by George Chapman, GW Chapman Consulting

ACA Update.  Five Republican and five Democrat senators put aside politics and gave their “common ground” testimony before the Senate’s Health, Education, Labor and Pension committee. In doing so, they encouraged the entire Congress to do the same and fix the ACA together. The 10 senators jointly recommended: funding the cost sharing reduction payments (that the President has threatened to terminate);  re-enforce the individual mandate and encourage more younger and healthier people to buy health insurance; give states greater latitude to experiment and tinker; and, finally, address soaring costs. In the meantime, the Senate’s parliamentarian has ruled that the fast track “filibuster proof” approach  used by Republicans to repeal the ACA, known as budget reconciliation, expires  September 30 which means (as this article goes to press) there probably won’t be a repeal do-over till October 2018.

Obesity progress.  After several years of rapid increases, national  obesity levels have leveled off in 2015 and 2016. Industry observers worry that the relatively “good” news may cause policy makers to become complacent and ease up on the accelerator. Efforts to help us lead healthier lives must be kept up at full speed. Colorado had the lowest obesity rate at 22% while West Virginia had the highest rate at 38%.  Obesity is defined as a Body Mass Index (BMI) of 30 or more. I BMI of 30 is about 30 pounds overweight. The highest concentration of obesity is in southeastern states.

ER usage.  Most payers and regulators have historically placed a lot of blame for our high cost of care on unnecessary or avoidable emergency room visits.  A recent study published in the International Journal for Quality in Healthcare has debunked the myth that too many people use emergency rooms needlessly. Researchers studied 115,000 records representing  424 million visits over a 5 year period and concluded just  3% of the total ER visits were “avoidable”.  A number of these visits were for things most ERs are not equipped to deal with like dental or mental health problems. About 7% of the avoidable visits were for alcohol or mood related disorders and about 4% of the avoidable visits were for dental issues. The researchers defined an avoidable visit as one that did not require diagnostic tests, screening procedures or medications. Researchers  concluded that the vast majority of  us do not use ERs for primary or routine care and that we need to focus on access to dental and mental conditions after normal business hours.

Physicians treat all the same.  Historically, government plans like Medicaid and Medicare have not paid  physicians as well as most private payers. (Although in recent years private payers have tended to drop their rates closer to Medicare rates.) It would seem that people with poorer paying plans might receive less or worse care than people with better paying plans. While “you get what you pay for” is true in most industries,  it is NOT in healthcare.  The vast majority of physicians treat the patient, not their insurance plan. While your plan may not pay for a certain test or procedure, it is of no concern to the physician who is going to do what is best for you in his/her clinical judgement.  A recent study proves this, even if in a roundabout way. The study was published in the Journal of the AMA Internal Medicine. It  found no difference in the rates that low value services were provided to Medicaid covered patients versus commercial/private covered patients. Physicians tend to order the same low value (almost useless) tests and services indiscriminately. Also, it does not appear that Medicaid patients are forced to see “lower quality” providers. While the bad news is providers are still ordering “low value” tests and services, the good news is that none of us are being discriminated against because of our health plan. Just about all providers make it clear up front what insurances they accept, so once you’re in the exam room your insurance is moot.    

CVS and Walgreens sued.  Consumers are claiming the two large pharmacy chains failed to inform them that it would be cheaper, less out pf pocket, to simply pay cash for certain medicines versus going through their insurance. Insurance copayment amounts often exceeded the actual cost of the drug.  This fraud is called a “clawback”.  For example, the consumer has a $50 copay on prescriptions, but the drug only costs $30.  According to the lawsuit, the pharmacy chains are in cahoots with the pharmacy benefits manager Express Scripts.   

Hospitals fail to meet expectations.  A report published by Kaufman, Hall and Associates revealed only 8% of 125 healthcare organizations surveyed met consumer expectations. The report found that while almost all organizations say improving the patient experience is a high priority, just 30% have the capability to do so. Only 15% are making a concerted effort to improve patient access with diverse locations and digital connectivity and less than 10% see price transparency as a high priority, The managing director of Kaufman concluded that in the age of Netflix and Amazon, consumers expect a lot more from their providers and “consumerism” should be a core capability as it will be a key to long term sustainability. (In fairness to healthcare organizations, they are highly regulated and have nowhere near the access to capital that Amazon and Netflix have.)

Aetna and Apple.  The health insurance and consumer technology giants are considering making the Apple watch available to Aetna’s 23 million members. Aetna already subsidizes the cost of an Apple watch for its 50,000 employees. This may be no more than more of a marketing ploy by Aetna to attract younger more tech savvy members than as most studies of person wearable fitness devices are at best inconclusive when it comes to showing any improvement in the health of the device wearer.  Proponents feel that anything that makes people more health conscious is a good thing while critics are concerned about the invasion pf privacy and the potential nefarious use of date derived by the insurer.

Aging.  The state of Washington leads the country when it comes to helping its seniors “age in place” according to a study by AARP and The Commonwealth Fund. Everyone prefers to live at home for as long as possible and to avoid a nursing home for as long as possible. The average cost of home care is $128 a day nationwide. The average cost of a nursing home is $230 a day nationwide. Washington State has made support for home and community based care a priority. It provides a adult day care, assisted living and even foster care as options for the infirmed elderly. This is far preferable to family care givers as well. Washington also empowers home health aides to provide more care. Through its “No Wrong Door Program”,  highly trained staff either answer your questions or direct you to the right place. Washington provides more housing alternatives to  nursing homes than most states. Nationwide, about 52 of 1,000 people over 75 reside in an assisted living facility. In Washington, it’s double that.


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