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The Overlooked Mandate Issue

March 30, 2012
2:16 pm

While the U.S. Supreme Court was hearing oral arguments this week on the constitutionality of the individual mandate provisions of the Affordable Care Act, another serious concern about the mandate didn’t involve constitutional issues and stayed relatively unnoticed.

Is the individual mandate sufficient to achieve its intended goal, to bring healthy Americans into the health insurance pool?  In answering this question, the stakes are high.  If millions of currently uninsured Americans choose to remain without coverage, and simply pay the noncompliance penalty instead, serious questions are raised as to whether other insurance reforms can take effect – most importantly, eliminating pre-existing conditions as a barrier to coverage – without destabilizing the marketplace.

This is a legitimate worry.  In 2014, a person who chooses to remain uninsured would be penalized $95 or one percent of adjusted taxable income, whichever is greater.  And even when the penalty is fully implemented in 2016, the penalty will be the greater amount of $695 or 2.5 percent of adjusted taxable income.  These penalties will still be less than the cost of purchasing health coverage.

As University of Illinois law professor Richard L. Kaplan put it, accurately, “(A) person might choose not to buy health insurance, opting to wait until something medically unfortunate happens.  Insurance companies will not be able to refuse her at that point, a situation that might imperil the private insurance market.”

Even if the Court upholds the constitutionality of the individual mandate, lawmakers can’t complacently assume that it will be strong enough to move uninsured citizens into the insurance marketplace.  It would be worth studying the efficacy of other incentive programs, such as those used by the Medicare Part D prescription drug program.  Part D has utilized both limited enrollment windows as well as higher costs for those who delay enrollment.

The goal of incentivizing Americans to acquire health insurance is a good and necessary one.  It’s necessary, though, to keep in mind that the constitutionality of the individual mandate may be the most visible issue, but it’s far from the only one.

A Capitol Hill Briefing on Wellness

March 22, 2012
8:42 am

There is broad agreement that one of the keys to achieving a sustainable, cost-effective healthcare system is to emphasize wellness and disease prevention.  After all, with 75 cents of every healthcare dollar going toward the treatment of chronic disease, it’s essential that we curb the escalation of preventable illnesses in order to contain healthcare spending.   The question is, though, whether there is a cohesive game plan for doing so.

The Healthcare Leadership Council and the Congressional Wellness Caucus are hosting a briefing this Friday, March 23 on the innovative actions hospitals and health systems are taking to strengthen patient and community wellness.  Our speakers will include Baylor Health Care System CEO Joel Allison, Dr. Michael Roizen of the Cleveland Clinic, and Dr. Donald Hensrud of the Mayo Clinic.  Under Allison’s leadership, Baylor has been recognized as one of the top facilities in the country when it comes to medical research and innovative approaches to care.  Roizen is the author of books on wellness that have hit the top of the New York Times bestseller charts.  Hensrud is an author and recognized expert on nutrition, diabetes, and wellness.

The briefing is being held from 12:00pm-1:30pm in the Capitol Visitors Center, room SVC 203-02.  For more information, contact Teresa de Vries at 202-449-3436 or tdevries@hlc.org.

And for more information on the latest and most effective approaches to disease prevention in the private sector, take a look at the examples contained in the HLC Wellness Compendium.

What the Washington Post Gets Right…And Wrong

March 19, 2012
9:35 am

In this morning’s editorial, “This Cost-Cutting Reform Deserves a Chance,” the Washington Post paints opposition to the Independent Payment Advisory Board as largely political, or parochial, in nature.  Republicans, the Post argues, want to sink one of President Obama’s initiatives before it can get off the ground, while some Democrats take issue with a non-elected board carrying out responsibilities that belong to Congress.

In making these points, the Post editorial goes off the rails early by focusing too heavily on inside-the-Beltway political banter.  In fact, opposition to IPAB extends well beyond conventional White House-v-GOP partisan skirmishing.   As of today, over 400 patient, healthcare, employer, veteran and disability organizations from all 50 states have signed a letter to Congress urging an immediate repeal of IPAB.

That kind of strong grassroots sentiment transcends partisan gamesmanship.

That’s not to say the Post editorial is entirely offbase.  Actually, the opinion piece is right on the mark in saying that the Medicare status quo cannot stand and that Washington politicians have been negligent in not pursuing substantive change to address the program’s serious financial problems.

The newspaper is dead wrong, though, in asserting that IPAB represents a workable solution to this problem.  The editorial pulls out what have become, by now familiar canards – that IPAB will be made up of healthcare experts, that the law creating it specifically forbids any kind of healthcare rationing.  The simple fact is, though, that IPAB’s structure, in which changes must be made immediately in order to get program spending below an arbitrary level, will limit the board’s realistic options to cutting payments for healthcare services.

In some policy circles, chopping Medicare reimbursement levels is referred to as bringing greater efficiency to the program.  In the real world, though, it means fewer physicians seeing Medicare patients and less beneficiary access to new healthcare innovations.  The law may say that IPAB can’t recommend rationing, but reduced access to care is an inevitable result.

Why Our Emergency Rooms Will Be More Crowded

March 14, 2012
1:47 pm

There was a disturbing juxtaposition of news items this week.

First, the Congressional Budget Office came out with new forecasts showing that, under health reform, the number of Americans enrolled in the Medicaid program will be even greater than expected.  Even before these new numbers emerged, it was estimated that more than 15 million Americans would be moved into the Medicaid program because of the new eligibility thresholds established by the Patient Protection and Affordable Care Act.

We saw a preview of the potential impact of Medicaid expansion through a study issued by the Annals of Emergency Medicine.  The study, authored by Dr. Atil Ginde of the University of Colorado School of Medicine, found that, between 1999 and 2009, 39.6 percent of Medicaid patients visited an emergency room compared to just 17.7 percent of privately insured patients.

The reason, Dr. Ginde determined, that Medicaid patients are more than twice as likely to be in an ER is because not only are they in poorer health generally, but they are less likely to be seeing a primary care physician.   This situation is not likely to improve once health reform is fully implemented.  In fact, it could severely worsen.  As Dr. Ginde put it, “Our findings are particularly worrisome in light of the additional 16 million people who will be added to the Medicaid rolls over the next decade.  The shortage of primary care providers in the U.S. seems to affect Medicaid patients disproportionately and more harshly.”

And, I would add, Medicaid’s significantly lower reimbursement rates compared to private insurance make it even more difficult for physicians to see Medicaid patients.

If the CBO trends, showing fewer people receiving employer-based private coverage and more individuals enrolled in Medicaid, continue, policymakers are going to have to revisit the mechanisms being used to provide Americans with health coverage.

A Technological Answer to Healthcare Cost, Workforce Issues

March 08, 2012
3:32 pm

We’re all concerned about how our healthcare workforces will keep up with an increasing patient population.  Not only is Medicare growing at the rate of 7,500 new beneficiaries per day, but the Affordable Care Act will lead to millions more Americans having health coverage when fully implemented.

We’re seeing one answer in the form of technology that is helping to reduce hospital readmissions and enable health facilities to evaluate patient conditions and needs without requiring them to come to the doctor’s office.

This week, the Geisinger Health Plan and AMC Health announced the results of a two-year evaluation of a telemonitoring program developed by AMC.  Geisinger found that home telemonitoring of patients with congestive heart failure reduced 30-day hospital readmission rates by more than 40 percent.

Here’s how the system works.  Patients receive scheduled calls from an interactive voice response system.  The patients report their symptoms, with those responses immediately stored in their electronic health record and evaluated.  A determination is made whether the patient needs a follow-up with a nurse or a case manager.  96 percent of the Geisinger case managers said the system was allowing them to monitor heart failure patients more effectively.

This also bolsters our argument that there are better ways to address healthcare’s cost issues than simply axing dollars out of the system and consequently reducing patient access and care quality.  There are technological solutions, as shown in this innovative work by AMC Health and Geisinger, that can make the system more cost-effective while providing even better care to patients.