Medicaid Is Different…Isn’t It?

By Kim Bellard, March 14, 2013

Let’s be honest: since its inception, Medicaid has been the unwanted stepchild of the health care system.  It serves a diverse set of populations that other public and private programs have historically ignored, its health outcomes are no better and possibly worse than not having insurance at all, its payments to providers generally rank lowest of all payors, and its coverage varies widely between states and all-too-often is skimpy despite its broad coverage requirements.  And yet ACA wants to pour more people into this creaky vessel, sweetened by the inducement of increased subsidies to the states for the first few years. 

Some states are thinking there has to be a better way.

Supporters of ACA are crowing about the fact some prominent Republican governors, such as Arizona Gov. Jan Brewer or New Jersey Gov. Chris Christie, have come out in support of expanding their Medicaid programs as allowed by ACA (with a nudge from the Supreme Court).  They should be looking harder at states like Arkansas and Ohio.

Arkansas asked CMS if they could use the expansion dollars to fund buying private insurance, in the exchanges, for its Medicaid population.  No just the newly eligible population, mind you – the entire eligible population.  Much to some experts’ surprise, CMS approved this approach, citing premium support flexibility allowed by ACA and previous laws.  This approach still has to be approved by the Arkansas legislature, which so far has been receptive. 

Other states are not far behind.  Ohio, whose Republican Gov. John Kasich drew national headlines by supporting the expansion, is proposing a hybrid model that would put only the newly eligible population into private insurance via the exchanges, so that anyone over 100% of the federal poverty level can get coverage there.    

Wisconsin has an even more unusual twist.  Its Medicaid coverage already covers many residents over 100% of the poverty level, but is frozen to new adult enrollees due to budget issues.  Gov. Rick Walker wants a trade-off: Wisconsin would cover everyone under 100% of poverty in its Medicaid program, while anyone above that – including those now eligible for Medicaid – would get coverage (and subsidies) through the exchanges.  Connecticut is considering a similar move.

States like Florida are watching closely.  Its Governor, Rick Scott, shocked supporters by reversing his position and coming out in favor of the expansion.  The Florida legislature was not too thrilled about this seeming support for Obamacare, but finds the Arkansas approach intriguing.  Florida had already moved to putting its Medicaid enrollees in managed Medicaid plans, so the Arkansas approach is a closer fit philosophically.

In theory, CMS can approve such approaches if the cost and the coverage are comparable, but early indications are that they are taking a liberal (or would that be conservative?) interpretation of those requirements.  The Kaiser Family Foundation just released a brief outlining the various requirements and options for the premium assistance model, in case anyone is that deeply interested.  Some pundits think that if the Arkansas approach is implemented, that approach will spread quickly.

Two things I liked about ACA – and they may be the only two things – were that it ensured anyone could get coverage and that all of the lowest income people had subsidized coverage.  The way it did so, though, made an already complicated situation worse.

Consider a person scraping by just under the poverty level.  They now manage to get Medicaid coverage, with its limited cadre of participating providers and specific set of benefits.  That coverage is increasingly likely to be delivered through a private managed Medicaid plan.  Then they get a raise and start making enough money to get above 138% of FPL – so they are off Medicaid, and have to switch to another insurer through the exchange, with some public subsidies to help defray the cost.  They probably will lose some benefits, such dental or vision, but also probably would have a much broader set of providers from whom they can get care.  Then maybe they get a new job, whose employer offers health benefits.  They lose their exchange coverage, as well as the subsidies, and there’s no guarantee that the employer coverage will either be as good as the exchange coverage or that the employer subsidies will be anywhere close to the exchange’s subsidies (especially for dependent coverage).  If they lose that job, well, it may be back to the Medicaid coverage.

Honestly, Rube Goldberg would have enjoyed this set-up.

A recent analysis by HealthPocket suggests that less than 2% of health plans meet the recently released essential benefit standards.  I suspect that many of those plans may have been individual policies rather than plans offered by large employers, but ACA requirements like pediatric dental and vision are virtually never offered by even the best health plans (although may be available via accompanying dental or vision coverage).  It is not clear to me why someone who earns 137% of poverty should get dental and vision for all family members, while someone who earns 139% and lacks employer coverage gets only the pediatric coverage for children, and someone with employer coverage may lack those benefits entirely.  Is this coverage important or not?

I’m not advocating that all plans should include full dental and vision, but, come on, this jumping back and forth between sources of coverage/type of benefits/amount of premium subsidy is crazy. 

We have to remember that Medicaid really serves three distinct populations (as illustrated by this nice Kaiser Family Foundation graphic): the poor (some of them, anyway), the elderly needing custodial care, and individuals with severe disabilities.  Most of the spending goes to the latter two populations.  Maybe we should be thinking of splitting out the ongoing care support aspects of the program from the more traditional health insurance components of the program.  That would allow for a much more seamless source of coverage and care. 

When I read that the supposedly simplified, one-step application process may require a 21 page application, it feels like the canary dying in the coal mine: I fear the whole thing is going to crumble under its complexity.  I don’t know if the Arkansas approach of putting everyone in the exchange will end up being implemented, or if it would prove to be actuarially equivalent, but it makes a lot more sense to me than the patchwork quilt of coverage ACA sets in motion.



High Deductible PPO Plans Versus CDHPs

By Clive Riddle, March 8, 2013

United Benefit Advisors has just released results of their annual health plan survey, with responses from 11,711 employers sponsoring 17,905 health plans nationwide, with results applicable for small to midsize companies. The survey includes a focus on Consumer Driven Health Plan (CDHP) vs. PPO comparisons of premiums, deductibles and enrollment. Their study found that “Consumer-driven health plans (CDHPs) -- high-deductible health plans (HDHPs) often paired with health savings accounts (HSAs) or health reimbursement accounts (HRAs) -- are not achieving long-term savings greater than what would be reached by raising the deductible on traditional PPOs.”

Unlike most national large employer benefit consulting firms, UBA – whose survey concentrated on smaller firms – is not bullish on account based plans, and would rather place their bets on straight PPO plans with a higher deductible. Although one could argue, it might be easy to make a stripped down high deductible PPO health plan yield immediate lower costs than a CDHP that has account administration costs, up-front wellness benefits and other bells and whistles. That doesn’t necessarily mean the PPO HDHP would be the best long term solution for an employer’s and employee’s objectives, unless immediate premium costs is the only concern.

UBA CEI Thom Mangan tells us “Employers are turning to CDHPs as a cost-cutting solution against the relentless upward spiral of health care costs. However, our research shows that small-to midsize businesses in particular, who may be considering these plans may first want to consider increasing the deductible on the plans they already have to achieve the same initial savings. Or, prior to implementing a CDHP plan, employers should build a culture of health and wellness in their workplace that drives employee behavior towards quality, low cost medical care and prescription drugs.”

Here’s some of the data UBA has shared from their findings:

  • Nearly 60 percent of the 11,711 employers surveyed said they plan to offer a CDHP in the next five years
  • PPOs remain the dominant plan type with 61.7 percent of U.S. employee enrollment
  • The greatest savings of a PPO over a CDHP was achieved with a deductible of $2,000-$2,999, where PPO cost per employee was $7,811 and CDHP was $8,859, a savings of $1,000 per employee.
  • Savings created by CDHPs over the plans they were replacing or HSA, averaged 1.75 percent in 2012, a significant reduction from prior years.
  • Enrollment also decreased to 15.6 percent (a 1.8 percent decrease from 2011), and nationwide enrollment among employers with 1,000 or more employees dropped substantially from 15.9 percent in 2011 to 11.3 percent in 2012.
  • The area of the country that has seen the biggest increase in CDHP growth is Minnesota, which saw the percent of employees enrolled in CDHPs increase from 15.5 percent in 2010 to 37.1 percent in 2012, a rate 18.4 percent higher than the national average in those same years.
  • Other areas with rapid CDHP growth include Indiana, Virginia and the Northeast region. The only western state to see CDHP popularity increase was Oregon, where percent of employees enrolled in CDHPs increased from 12 percent in 2010 to 20.3 percent in 2012.
  • Overall, CDHP enrollment in the west is the lowest in the country with only 7.7 percent of employees covered, a slight increase from 7 percent in 2011 and 4.6 percent in 2010. HMOs account for 31.3 percent of the market in the west.

Involved But Not Committed

By Kim Bellard, February 28, 2013

There’s an old joke about the difference between bacon and eggs: the chicken is involved, but the pig is committed.  Perhaps the problem in health care is that when it comes to being engaged in our own health, most of us are chicken.  Maybe the wrong people have been cooking.

Patient engagement -- along with its many synonyms, such as shared decision-making or consumer-directed care – continues to be a favorite strategy for many health pundits.  I am biased towards it myself, although exactly what it means, or will mean in the future, is not entirely clear.

The prestigious journal Health Affairs recently devoted an entire issue to the topic.  In one study, Judith Hibbert and colleagues reported that patient activation scores help predict costs: lower activation levels were tied to higher costs, even after adjusting for risk.  A separate study, also by Hibbert, reviewed the literature and concluded that patients with higher activation levels had better health outcomes and care experiences, although the evidence was more inconclusive about the effect on costs. 

The trick, of course, is how to “activate” patients – is it all self-motivation, or can providers and other third parties (such as employers) encourage it?

One common method to influence patient engagement is an employer wellness program.  A recent National Business Group on Health survey reports that almost 90% of employers offer wellness-based incentives, spending an average of over $500 per employee on the programs.  Employers are getting tough too: 15% directly tie health plan eligibility to a health activity such as taking a risk assessment or biometric screening.  Almost two-thirds already tie employee contributions to completing such activities.  And 41% include, or plan to include, outcomes-based measures (e.g., lowering blood pressure) as part of the program.

Another strategy employers are using is increased employee cost-sharing, such as in consumer-directed health plans (CDHPs).  Critics accuse them of simply shifting costs to employees, but there are plenty of studies that indicate they may actually change employee behavior and help control costs.  For example, Cigna recently claimed that their CDHP members improved their health risk profile 12% while their health cost trend was 13% lower than traditional members.  Cigna CDHP members were also more likely to take health risk assessments, to use cost and quality tools, to choose generic drugs, and to seek preventive care. 

Consumers may be starting to take cost into account, but they don’t like it.  A study by Sommers, et. alia, reported on focus groups of insured patients.  The focus groups indicated that patients don’t like cost considerations to be part of health care decisions, and revealed that several stereotypes remain all-too-common, including that more expensive care is better care, and choosing more expensive care is some sort of victory over insurance companies (not realizing that, in the end, they and other insureds pay for that care).  Patients still don’t really know how to weigh risk versus cost. 

We treat health care costs much like we treat the deficit: costs come from other people, cuts should come from other people, other people should pay, and, oh-by-the-way, let’s think about it tomorrow.  That has to change. 

One thing that offers new hope for patient engagement is that the options for it have never been broader or more robust – mobile, electronic records, telemedicine, and social media, to name a few.

There are estimated 40,000 mobile health apps.  It seems you can get an app to do just about anything you can think of, plus many things you probably hadn’t.  The health apps vary widely not only in purpose but also in audience and quality.  A company called Happtique has just introduced a certification for health apps that will hopefully give consumers a better comfort about which apps to use, or for physicians to know which to recommend to patients.  They see the program not as a rating mechanism but as kind of like a Good Housekeeping seal of approval, assuring that at least a set of minimum standards have been met.  This could spur adoption.

It does appear that physicians are joining the mobile revolution, according to CompTIA.  Their recent survey indicated that one in five physicians is using a medical or health-related app daily, and 62% expect to be regular users with a year.  The trick will be how they incorporate them into their practice, for patient care and/or patient engagement.

EHR/PHRs provide yet another option to engage consumers.  To date, consumer adoption of PHRs have been disappointing, to say the least – even when they are available.  A recent study by Ritu Agarwal and colleagues, aptly titled “If We Offer it, Will They Accept?”, explores this issue and concludes that use depends on a number of factors – not just existing consumer preferences but also satisfaction with the patient-provider relationship, provider support for patient use of the PHR, and specific communication strategies to encourage use.  HITECH funding and “meaningful use” requirements may drive availability of patient EHRs, but persuading patients to use them will require some effort.

Telemedicine seems be exploding, both in terms of easing of regulation and in terms of payor coverage, so it is not surprising that there are a plethora of companies making their mark in this space.  These include American Well, Cardiocom, HealthSpot, NowClinic, or Virtuwell, to name just a few.  These may not provide your personal physician, but they offer physician expertise at your convenience – 24/7, from your house or even mobile device, not restricted to a physician’s hours.  That’s got to help improve patient engagement.

The IOM just hosted a workshop on partnering with patients, and one of the conclusions was that physicians and health systems need help in developing those skills, plus they may need additional incentives to engage in the kind of dialogue patient engagement requires (why am I not surprised?).  When you think about it, though, relying on physicians, or even nurses, to drive patient engagement doesn’t seem realistic.  We can spend time and resources on training them, but we still face the barrier of the projected shortages in both professions (physician, nurse), especially with the baby boomers just starting to crash the Medicare barrier.  Primary care providers may just be too scarce, especially in rural and other already underserved areas.  Not everyone agrees with these dire forecasts, but the point remains, though: the health professional to patient ratio doesn’t scale well into an era of higher patient engagement.

And maybe it doesn’t need to.  Maybe it really is up to us as patients to take responsibility.  Fortunately, we still don’t have to go it alone.

Social media, for example, may not even rely on a provider-patient model.  Health care providers are still trying to figure out social media.  An infographic by Demi & Cooper advertising/DC Interactive Group suggests that only 26% of hospitals use social media (most commonly Facebook), while over 80% of individuals 18-24, and 45% of those 45-54, would share health information via social media.  Meanwhile, Patientslikeme has been breaking new ground for social media use in health care for many years now, using patient-to-patient expertise and experience.  We’re only begun to scratch the surface of what patient engagement looks like in a social media world.

Artificial intelligence could be the real game changer in patient engagement.  IBM has made a big bet on AI in health care via Watson, and a recent study from Indiana University reaffirms that use of AI has the potential to both improve outcomes and lower costs.  Widely available health content on the Internet started this ball rolling, but health care professionals start to look like just another option – a preferred option, to be sure, but no longer the only option – to getting health information, advice, perhaps even diagnoses.  And I’ll have to save discussion of robotic surgery for another blog…

We’re already got a mobile stethoscope app, remote monitoring options for conditions like diabetes or blood pressure, medication and other reminder apps, and increasing ability for AI to evaluate and diagnose.  Who needs health coaches or even physicians to drive patient engagement?  Maybe in the not-too-distant future the model for patient engagement will increasing look like patients simply using their mobile devices: i.e., when Siri marries Watson.

At the end of the day, the person who has to be committed to patient engagement has to be the patient.


AHIP Announces Launch of new Health System Change Initiative

By Claire Thayer, February 25, 2013

The AHIP Foundation has announced the launch of a new Health System Change Initiative - the Institute for Health Systems Solutions (IHSS). The priorities of the new Institute will focus on:

  • Access: Using innovation to improve health care delivery and payment reform
  • Innovation: New ideas to improve access
  • Smart Regulation: Regulation that creates the fewest unintended consequences

More information, including links to Insights & Resources and News & Activities may be found here:


The Numbers Behind Plastic Surgery

By Clive Riddle, February 21, 2013

The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has just released results of their annual membership study, which provides a wealth of information about what goes on their world.

Let’s take a peek, with some excerpts compiled from their study:

Cosmetic Procedures: The survey indicated 73% of all procedures were cosmetic  (versus reconstructive) in 2012, up from 62% in 2011. Non-surgical treatments made up two-thirds of all 2012 cosmetic procedures. The most common cosmetic non-surgical procedures remain BOTOX® and hyaluronic acid fillers, with the top three areas of the face most treated by injectables being the forehead (42%), cheeks (35%) and the lips (18%).

Volume and Fees: Member surgeons report performing an average of 945 facial cosmetic surgical, cosmetic non-surgical, reconstructive and revision procedures per surgeon in 2012. Facelifts command the highest average fee per procedure ($7,453, on average), followed by: hair transplants ($7,182), revision surgery ($6,542), and rhinoplasty ($5,541).

Women: 80% of all surgical procedures and non-surgical procedures are performed on women.  Two-thirds of women having procedures are mothers, primarily in their 40's and 50's. In 2012 the most common cosmetic surgical procedure for women was facelifts, followed by blepharoplasty, and rhinoplasty. The most common non-surgical cosmetic procedures among women were BOTOX®, hyaluronic acid injections and microdermabrasion, respectively.

Men: Rhinoplasty remains the most requested surgical procedure overall among men.  On average, 20% of male patients request plastic surgery as a result of their significant other having received plastic surgery. Men had a significant increase in Botox  (up 27% from last year - with hyaluronic acid fillers and microdermabrasion also among the most popular maintenance treatments ) while the number of Botox procedures among women was similar to 2011.

Age Groups: 28% of Facial Plastic Surgeons have seen an increase in cosmetic surgery or injectables in those under age 25. For both female and male patients under the age of 35, the most common procedure performed was rhinoplasty (53% females; 70% males), followed by BOTOX® (30% women; 13% men). For all procedures, except rhinoplasty, the majority were performed on patients between the ages of 35 and 60.

Race: The 2012 survey revealed that African Americans and Hispanics were most predisposed to have received rhinoplasty (80% and 65% respectively). Asian Americans were most likely to have blepharoplasty (44%) or rhinoplasty (41%), while Caucasians were more likely to have facelifts (40%) or rhinoplasty (39%).

Consumer Selection: Most patients get their information about plastic surgery online (57%) and are most concerned with the results of the surgery (40%) followed by concern over the cost (33%)  and recovery time (21%)when making their decision to undergo facial plastic surgery. Last year just 7% of prospective patients used social media to research doctors and procedures, down from 35% in 2011. However, there was a 31% increase in requests for surgery as a result of social media photo sharing.  Surgeons report that, on average, 22 women and 12 men that were dissatisfied with previous rhinoplasty surgery from a different office requested corrective surgery.