Health Wonk Review Is Up

David Harlow, author of David Harlow’s Health Care Law Blog hosts the newest edition of HWR.  Harlow offers a meaty summary of some of the most provocative healthcare posts that have appeared in recent weeks.  

–On Healthcare Collaboration, Dr. Kenneth Cohn suggests that if you want to herd cats, you probably have to let the cats figure out how to herd themselves: “Most physicians enjoy bottom-up processes more than top-down edicts.  They prefer being inspired to being supervised.  The only way that I know to develop a common culture is to allow physicians to play a role in shaping it. I agree. You can’t bribe them. You can’t bully them. They have to want to do it because they realize that if they work as a team, they and their patients will be better off.

Over at Managed Care Matters Joe Paduda reports that recent analysis indicates that some states’ active efforts to hinder enrollment are working,, and are partly responsible for the shortfall in Exchange enrollment
He also points out that  CMS may require health insurers selling via the federal exchanges to make sure at least 30 percent of “essential health providers” are in-network in 2015.  This in response to some complaints about networks that are allegedly too narrow.
Paduda’s note: “Which is kind of ridiculous; smaller networks are better at controlling costs and that’s a BIG part of the success criteria for health reform.”  I agree. Moreover, if you Google “Consumer Reports,” and “NCQA” and “HMO’s” you will find that the best HMOs deliver higher quality care than open-ended plans.

–Writing on Colorado Health Insurance Insider, Louise Norris explains that folks purchasing health insurance on the exchanges need to be sure they understand drug formularies. An important point.

–As the demand for high tech and mobile surges, Julie Ferguson of Workers’ Comp Insider reminds us that more and more cell tower workers are being killed. The intense pressure to meet unrelenting deadlines is undermining workers’ safety.

Brad Wright, at Wright on Health, wonders if we can make health care prices transparent so that patients can “comparison-shop.”  Wright  worries (rightly, I think, pun intended,) that even with better information, consumers aren’t likely to change their behavior much, because health care economics does not operate according to traditional market principles. When you’re sick, you’re not bargain-hunting. Most people assume (wrongly) that health care that is more expensive must be better.

Folks from the Brookings Institution have a piece up on the Health Affairs Blog, titled “Paying For a Permanent, or Semi-Permanent, Medicare Physician Payment Fix. They emphasize  that a plan that includes “off-sets for physician payment reform that support improvements in care as well as lower costs . . . could assure beneficiaries and other health care providers that these savings are not just payment cuts that must be absorbed, but steps to help reduce spending through reforms that improve care.”

This is just a small sample of some of the best recent posts. You’ll find more here.


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Reverse “Sticker Shock”—Why are Insurance Rates in the State Marketplaces Lower Than Expected? — Part I


Even Forbes’ columnist Avik Roy is recanting.  Earlier this month he acknowledged that under Obamacare, many Americans who buy their own coverage in 2014 will find that insurance is significantly more affordable than it was in the past:  “Three states will see meaningful declines in rates: Colorado (34 percent), Ohio (30 percent), and New York (27 percent).”

Colorado, Ohio and New York are not unique. As states announce the prices that carriers will be charging in the online marketplaces (or “Exchanges”) where Americans who don’t have health benefits rate at work will be purchasing their own coverage, jaws are dropping. Rates are coming down, not only for those individuals, but for some small business owners who will be buying insurance for their employees in separate SHOP (Small Business Health Options Program) Exchanges.

What may be most surprising is that premiums will be lower, not only in liberal Blue states but in some Red states that are opposed to Obamacare.

What is making health insurance more affordable?

First, the majority of individuals shopping in the Exchanges will be eligible for government subsidies that will go a long way toward covering premiums. In the past I have written about how these tax credits will help young adults (18-34).  But older Americans also will benefit. Fully 30% of those who receive tax credits will be 35-54, and 12.5% will be 55 or older.  This is important because in the Exchanges, insurers  in every state except New York and Vermont will be allowed to charge a 60-year-old three times as much as they would charge a 20-year-old for exactly the same policy.  Without subsidies many would find insurance totally unaffordable.

The second reason premiums are significantly lower than expected is that as I have explained on  in the state marketplaces insurers are forced to compete on price. All policies sold in the Exchanges must cover the same essential benefits, and follow other rules that will make the plans look very much alike. The only way for a carrier to distinguish himself from the crowd will be to charge less—or have a better network of providers. But the younger customers that carriers covet care far more about price than about the network.

Third, in many cases, state regulators have been clamping down. In Portland Oregon, for example, regulators forced insurers to cut their proposed rates by an average of nearly 10%. Three of the 12 insurance companies in that market had to lower their rates by more than 20% f

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Is Obamacare “Medicaid for the Middle Class?” –A Muddled Argument

Yet another catchy phrase, “Medicaid for the middle class,” is popping up in conservative propaganda.  What are Obamacare’s opponents trying to say?

Those who have latched onto this catchphrase make two very different arguments. The arguments actually contradict each other, but they have one thing in common: Both are untrue.

#1 ) Obamacare isn’t good enough because the coverage families will receive in the exchanges will limit them to a tiny network of providers.

Originally, conservatives claimed that Obamacare would be too expensive. Americans who tried to buy insurance in the exchanges would experience “Sticker Shock!”  Now that states have begun to announce premiums, it’s becoming apparent that this isn’t true.

So conservatives have regrouped. In an about-face, they are acknowledging that some plans offered in the exchanges may be affordable, but this, they say, is because insurers are limiting their networks to providers who will accept lower fees.

Reform’s critics insinuate that “narrow networks” will exclude top-notch doctors and hospitals. The Citizens’ Council on Health Freedom (CCHF) calls exchange coverage “second-tier Medicaid for the middle class.”

Nevertheless, CHCF says, “Many people are expected to choose narrow-network plans that offer a limited choice of doctors, clinics and hospitals … because the cost will be less.”

Note that, while grousing about “limited choice,” CHCF predicts that patients will “choose” narrow networks.

When you’re fibbing, it’s easy to begin contradicting yourself. The truth is that people who have not been able to afford insurance in the past are far more interested in price than they are in the size of the network.

Moreover, many Baby Boomers already have embraced HMOs: they charge less when a patient stays “in network,” and the best focus on keeping patients healthy. I

In fact, when Consumer Reports published NCQA ratings of quality and customer satisfaction HMOs out-ranked other insurers.

“Narrow” Doesn’t Necessarily Mean “Not As Good”

Everything turns on who is included, who is left out – and why.

In the exchanges, insurers will be competing on price. As a result, carriers are pushing back against providers that over-charge – including brand-name hospitals that demand far more for very simple procedures.

The push-back could help rein in health care inflation: “As narrow networks continue to exclude high-priced, academic hospitals … we expect they will consider re-pricing,” says Jenny Kerr, Market Analyst at HealthLeaders-InterStudy.

Both insurers and “employers are sending a message that they are no longer willing to pay for hospitals that charge higher rates for routine services to cover costs of their teaching and research missions,” Kerr adds.

 For example, employers (in this case the city of Los Angeles)   as well as exchange insurers are rejecting LA’s pricey Cedars-Sinai Medical Center. Cedars-Sinai boasts a reputation as “hospital to the stars.”

Among the nation’s 50 top-grossing non-profit hospitals, it ranks third.  But this does not necessarily mean that it provides superior care. In 2012 when the Joint Commission released its list of the Top Performers on Key Quality Measures, Cedars-Sinai did not make the cut.
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