Why should physicians do prospective evaluations?
Most plans that have done prospective evaluations have taken one of two approaches: Using their existing physician network, or using mid-level practitioners who live in the same general area as the members to be evaluated.
Although they have been significantly more effective than network physicians in these programs, there is a better way.
It is possible to recruit physicians evaluators who can travel to the area of the project and devote their full day to the evaluations. They bring a number of advantages.
All in all, the traveling physician model works.
Further Evidence that Part D is Working
New data shows that seniors enrolled in Medicare Part D will pay about $30 in monthly premiums in 2012, 76 cents less than they do now and about 44 percent lower than originally projected in 2003. Indeed, since 2007, premium costs in Medicare's Part D program have increased by about $8, according to CMS.
The program continues to be a shining example of how the Federal government can create a new market for insurance from a green field, imbue it with fierce competition among private companies, and regulate the hell out of it to achieve a major public good. Part D has come in well over $100 billion cheaper than anyone thought it would on the Hill in 2003, and the vast majority of beneficiaries are happy with their choice of plan. The program has also been shown to reduce the incidence of unnecessary hospitalizations among those enrolled.
Sounds like a blueprint for health reform. Our government hasn't exactly demonstrated lately that it can learn from its mistakes; maybe we'll have more luck learning from our successes.
What Happened to the Crack-berry?
This amazing letter was written to RIM leadership by a ranking exec about the woes of their flagship product line, which you know and love as BlackBerry.
It's not often that a company* can appropriate a 1000-year-old word and completely change its meaning in the culture. It's a testament to the way RIM changed--one could say created--the smartphone category with its product. You always remember your first: mine was in 2003: the 6200, the last greenscreen model, which I promptly traded for the 7200 (color!) a year later. RIM's woes since then have been well documented and are fascinating. They go something like this: guessed wrong, got lazy, became out of touch with the market it created.
It's the last point I find most interesting. RIM defined the smartphone market by convincing businesspeople that responding to emails while on the toilet at 11pm was completely acceptable behavior. But they swiftly lost touch with this category by missing the implication of what they had created: that email and phone use were precursors to the real game, which was putting a computer in everyone's pocket. That was where the category was always headed--- it's easy to see now. But at the time, just the addition of a phone was so radical that when Blackberry first added it to its handheld--which was an overgrown two-way pager, they didn't even include a numbered keyboard.
Medicare Advantage is in a similar moment. While CMS gets credit for creating the category, seniors are now comfortable with managed Medicare. This coming generation even more so. But will the product be left behind by ACOs or other forms of integrated care? By MSAs? By something really cool that we don't even know about? Will MA learn how to integrate a phone? And will we forget to put the numbers on it?
*A CANADIAN company, at that!
A Way Out of the Healthcare Cost Explosion? Look North
According to a study by the University of Toronto in Health Affairs, US health care spending could be cut by billions a year if doctors spent the same amount of time and money dealing with insurance plans as their Canadian counterparts. Because Canada has a single-payer system -- essentially Medicare for all -- and because of our patchwork quilt of financing healthcare here, US doctors spend nearly $83,000 per physician per year dealing with insurance companies, compared to around $22,000 for doctors in Ontario, the study found. Staff in US doctors' offices also spend around 10 times longer per physician per week dealing with health plans than their Canadian counterparts.
The findings are similar to those found by a US Government Accountability Office study commissioned by my old boss, US Rep. John Conyers, back in 1991:
"If the universal coverage and single-payer features of the Canadian system were applied in the United States, the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured."
I acknowledge the political impossibility of enacting a single-payer system here in the US. But in our tough economic times, the financial death spiral we are in on healthcare costs, and watching the ongoing sumo match around the ACA, I do wish President Obama had stepped in front of the cameras a couple years ago and said "It's time all Americans had Medicare, with a choice of high-quality health plans."
This is also a family issue for me: my younger brother, one of the most brilliant physicians I have ever seen, actually fled to Canada 12 years ago in a fit of pique about the administrative burdens of medicine in the US, our litigious culture and the epidemic of drug-seeking patients. Today as an intensivist running the biggest ICU in Quebec, he's never been happier. Sure, there are plenty of affluent Canadians coming across the border for elective procedures they were stuck in a queue for back home, but at the end of the day, Canada kicks our ass in coverage, most major health indicators, and notably, physician satisfaction.
It's getting harder for the US to continue its jingoistic tune that we have the best healthcare in the world. We do -- but only if you can pay for it, and can find doctors who will see you.
Hey Star Czars: Look Here
Medicaid Came This Close to Deep Cuts in the Debt Battle
Keeping Medicaid from automatic cuts was a priority of the Obama administration in the final, ugly days of the debt ceiling fight. It was the one major concession the President and the Democrats won in the whole nasty sausage-making exercise.
Politico did a great job telling how the deal was done, and the tense moment when Obama staffers threw down the gauntlet:
[T]he atmosphere was tense as the hours slipped toward the deadline. By Saturday night, discussions over the trigger had bogged down, and a call between [Senate Minority Leader Mitch] McConnell's staff and senior White House aides turned heated when GOP negotiators demanded that Medicaid be added to the mix of programs that could face cuts.
Gene Sperling, chairman of Obama's National Economic Council, was in mid-sentence, trying to calmly explain why the White House wouldn't allow that, when Office of Management and Budget Director Jack Lew interrupted.
"No!" the typically mild-mannered Lew yelled. "The answer is simply no! No, no!"
In earlier plans passed by House Republicans, Medicaid had been subject to automatic cuts. At least the Dems won one for the little guy.
Debt "Deal": Not As Bad for Medicare as Expected, Medicaid Spared
So we have a deal on the debt ceiling. The President is now authorized to raise the debt ceiling by at least $2.1 Trillion. The roughly $2.5 Trillion in cuts over 10 years represents 5% of expected Federal spending over that time period. $917 Billion in cuts are made up-front. A joint bipartisan committee will then decide on an additional $1.5 Trillion in cuts by November 2011 for a December vote.
If the evenly divided committee failed to agree to the required amount of cuts, Congress would either have to approve a balanced budget amendment to the Constitution (which doesn't stand a chance of being ratified), or accept an across-the-board cut in spending, with 50% coming from defense programs beginning in 2013 (military pay and veterans' benefits are exempt). Medicare would also sustain cuts, but only up to a point. Medicaid and Social Security were exempted.
Putting "sacred cows" on the chopping block, like national security for Republicans and Medicare for Democrats, was to provide a strong incentive for the joint committee to avoid gridlock and deliver a plan that could pass Congress. I could see these "incentives" working on Democrats, who just folded AGAIN to the demands of the far-right House GOP. The Tea Partiers just showed they're willing to flirt with global economic ruin -- what's a few billion to the Pentagon or the Department of Homeland Security to them? Expect another budgetary "High Noon" right around the holidays.
Physicians and other providers could see an additional 2 percent pay cut on top of double-digit Medicare reductions already slated for 2012 under the "deal". The now-29% pay cut for physicians is scheduled to go into effect this year unless there's a fix to Medicare's Sustainable Growth Rate formula, as well as an 11 percent regulatory hit to home health agencies.
The White House said last night the Medicare cuts would hit providers but would not directly affect beneficiaries, but of course they do -- mainly in providers' willingness to continue to accept Medicare patients. There wasn't specific mention of Medicare Advantage or Part D plans -- but if the "doc fix" doesn't happen, that 29% cut in traditional Medicare could translate into a 7% hit to Medicare Advantage rates in 2013.
What to expect in the coming months? Two of the proposals in the Bowles-Simpson bipartisan deficit reduction committee's December 2010 report will get more attention: increasing the Medicare eligibility age from 65 to 67, and moving dually-eligible beneficiaries into health plans, which would curry huge state support. As a general proposition, the Administration will likely bend over backwards to provide states with greater flexibility in how Medicaid dollars are spent through the state waiver process.
It's hard to call this anything but a political rout for Obama and the Democrats. A few weeks ago they had the Republicans over a barrel on the Ryan Medicare reform plan. Now they've handed the Tea Party several opportunities where they can create a global financial crisis unless the President caves, and he's now shown for a third time that he will.
My favorite wonk, WaPo's Ezra Klein, called this a "terrible, horrible, no good, very bad deal" and I couldn't agree more. He went on to say that "Today, the markets are breathing a sigh of relief because Washington managed to agree before it sparked an unnecessary financial crisis. But we could be celebrating an agreement that actually did what was necessary to speed the recovery now and reduce the deficits that matter. Congress may be patting itself on the back because it didn't needlessly wreck the global financial system, but that's not evidence of success. It's evidence of how terribly they have failed us. And the fact that so many are celebrating this deal only goes to show how used to their failures we have become."
Poll: Cut the Deficit, but Not Medicare
Half of all Americans say the deficit should be reduced by cutting spending on government programs and services, but there is strong opposition to cutting entitlements, according to a poll released Thursday by the Kaiser Family Foundation.
Kaiser's July Health Tracking Poll found that 62 percent of people don't want Social Security cut, 59 percent don't want Medicare cut and 48 feel the same way about Medicaid.
There was majority support for "closing tax loopholes for large businesses," "closing tax loopholes for wealthy Americans" and "increasing taxes for wealthy Americans." Only 23 percent of poll respondents supported increasing taxes for all Americans.
What Happens to Medicare and Medicaid If We Default, continued
The Bipartisan Policy Center tried this week to break down the daily cash flow in the days following the Aug. 2 deadline to give an idea of what could get paid.
On Aug. 3, a day when there will be a $20 billion shortfall, $2.2 billion in Medicare and Medicaid bills will vie with $23 billion in Social Security payments, $1.4 billion in payments owed to defense vendors, and $500 million in federal salaries and benefits. Health spending's place in Accounts Payable at Treasury would change daily depending on what bills come due and the amount of revenue available.
States get their federal matching money for Medicaid in quarterly payments on the first of the month, so Sept. 1 would be the first big date for the program.
Amidst all this uncertainty, the only thing that's clear is that the country would be in uncharted territory if there's no deal before Aug. 2.
Blowing up the "Health Insurance" Service Model
In the 15 months since ACA passed, MA plans have scrambled to improve their Star Rating. Nothing motivates like the promise of a 5% premium bump in an era otherwise marked by dramatic payment decline. Also motivating: CMS appears to be making initial steps towards delivering on intimations that low-rated plans will have their contracts terminated.
Early efforts in the Stars focused on HEDIS scores and for good reason. Much of domains I and II are process and outcome-based HEDIS measures. But with C and D ratings taken together, less than 20% of the ratings are actually driven by these clinical targets. So where's the beef?
It's the service model. HEDIS aside, fully half the measures can be traced directly back to the service model--- and we're not talking call center hold times. The reliance on subjective survey measures for much of the Star scoring and the role of the service center in driving member compliance with clinical activities point to the increasing value of the relationship members have with the plan--- for better or worse.
This week, noted power point gurus Accenture released the results of a consumer survey regarding health insurance. The report shows that nearly half of insurance customers would be willing to pay more for health insurance that caters to their needs. Two specific items stood out to me:
- 85 percent of those surveyed rated interaction with knowledgeable employees as highly important, yet fewer than 50 percent were satisfied with current experience;
- More than 80 percent said dealing with one contact to resolve issues was important, but 60 percent said they currently were transferred to multiple contacts to resolve issues.
This sounds like the best very best rationale for the "Concierge" customer service model we've put in place at a few plans over the years. In the Concierge model, every member is paneled to a specific Rep, who also is tasked with making frequent, targeted and data-driven outreach to their panel. In other words, don't wait until the customers are unhappy until you talk to them. And while Concierge programs have proven to be no more expensive than traditional inbound models, this survey implies that your members would even pay more for it.