Envisioning 2.0

Some proponents of Massachusetts’ efforts to ensure all residents have health insurance have long complained that some people will ignore the state’s requests to get covered because the “stick” is too small.  In 2007, those who could afford insurance, but opted to forgo it payed a $219 fine.  Some may have decided that this penalty was less burdensome than the annual cost of health insurance, which could reach $4,600 for a 60-year-old Boston resident.

Now public officials are tweaking the plan to make the stick much bigger.  According to the Boston Globe: “Penalties for Massachusetts residents who can afford health insurance but do not purchase it in 2008 could quadruple compared with the maximum penalty in 2007, according to draft regulations released by the Department of Revenue yesterday.
The maximum penalty for those who flout the law and do not buy health insurance would be $912 a year, compared to $219 in 2007.”

Massachusetts’ efforts are being closely watched as presidential candidates Hillary Clinton and John Edwards are proposed similar national plans that would require all citizens to sign up for insurance.

What’s most clear from this effort is that individuals are being asked to manage their health dollars in ways that were unimaginable to many in the early 1990s.  As more residents become insured and must pay for their care, look for efforts to provide them with information about healthcare cost and quality to accelerate.

Over the past few weeks, Mark Senak, who writes Eye on FDA, has been writing an excellent series focusing on where each presidential candidate stands on healthcare – especially as it relates to the pharmaceutical industry.  He not only talks about what each of them proposes to do, but points out where they could do better.  Take his analysis of Senator Barak Obama’s position on prescription drug pricing as an example:

“More than any other candidate, his site addresses each of the domains with particularity.  While the candidate gives a nod to the need for profits for drug companies for future research, when it comes to the fact that Americans are charged more for products than other countries on his importation policy, it does not take into account a global pricing structure that at this point, requires that more developed nations subsidize access for lesser developed countries.  That is an essential component for any commentary on drug pricing in America.”

Senak has done us all a great service by putting together this series.  Hurry over to his blog to learn more.

In a fascinating interview published on Maggie Mahar’s Health Beat Blog, Robert Blendon, professor of health policy and political analysis at Harvard’s Kennedy School of Government, had some sobering words for those seeking radical reform of the health system.  Blendon is well-known in health policy circles for tapping into the American mindset regarding reform.

First, Blendon looked at the current status of Massachusetts’ plan to cover the uninsured.  Policymakers hoped that more than 220 thousand uninsured citizens would sign up for a heatlh plan.  To date, only 15,000 have enrolled despite the threat of a fine.  Blendon described the Massachusetts effort as “the canary in the coal mine,” . . . if it’s not breathing in 2009, people won’t go in that mine.”

Following are a few excerpts from his interview, which I believe are instructive.

Include All Relevant Stakeholders In The Conversation

“Reformers need to ask ‘what are the points that are absolutely critical to various interest groups if we want them to find reform acceptable?’  You want many people to feel that they have had a major say. Then they should develop a very general plan.”

Don’t Try To Be Perfect The First Time

“The very best plan for reform would be polarizing . . . Every interest group would oppose it, and it would never pass. What reformers need to do is to decide which groups they can bargain with. In Massachusetts they decided they could make a deal with the insurers. But reformers will need to work quietly behind the scenes . . . finding concessions they can live with—or fix later.”

Remember, Middle Income People With Insurance Are Risk Adverse

“Middle-income people with insurance are risk adverse . . . Legislators need to be very careful about how they try to re-arrange coverage for the middle-class. Even if these people say they are dissatisfied with the present system, they think they have a lot to lose—especially if they haven’t been seriously sick and tried to actually use their insurance.”

Maher’s post has ignited quite a debate and is fascinating reading.

I received an interesting e-mail recently from the Kaiser Family Foundation (KFF). Earlier this year, the organization launched an in-depth Website focusing on health care reform. The site was useful before, but now it borders on indispensable. KFF has released a new tool that enables visitors to their Website to conduct side-by-side comparisons of the health reform plans of the presidential candidates. I played around with the tool this morning and found it very informative. (See screen shot of tool above listing the reform proposals of the major Democratic presidential candidates. Click to enlarge.)

This tool is a must-use for anyone looking to keep up with canidates’ competing proposals. Who knows which ones will get through the legislative meat grinder, but it’s fun to watch the debate!

Recently, academics and attorneys at George Washington University had this to say about efforts by insurance companies to rate physicians: “[D]one properly, physician rankings should not raise legal concerns, either for those who are pushing the standards, or those being measured.”

Insurers are not the only ones rating physicians, sites like RateMDs.com have exploded in popularity.  Clearly, insurers and patients want to choose physicians who are not only high quality, but personable and responsive.

Will this analysis change physicians’ minds about rating services?  Not likely.

Image Source: American Academy of Family Physicians

Yesterday, the Wall Street Journal published a very interesting article focusing on the practice of care-management. According to the Journal: “[A] growing number of employers and health insurers are turning to services that essentially audit an employee’s health care and look for ways to both improve outcomes and save money.

But critics contend that some of these programs intrude into the private relationship between patients and their doctors, and that they add yet another layer of bureaucracy, while saving money mostly by denying or switching specific drugs and procedures.”

A few key ways that care managers work with patients is by offering them second opinions on their care and switching or nixing treatments that don’t conform with evidence-based medicine.

From a health policy perspective, care management makes sense as it can help to alleviate practice variation: the sometimes stark differences in how physicians treat patients in across the country or in the same hospital.

However, care management can also spurn resentment. Despite our (apparent) march toward consumer-driven healthcare, the physician-patient relationship is still sacred. Decisions that are made in the physician’s office are very sensitive and I can understand why people become upset when a third party is injected into the process.

This is another in a great series of articles the Journal has been writing focusing on the mechanics of the healthcare system. I highly recommend this one.

John Bell, who writes the blog Digital Influence Mapping Project, has an interesting post about a subject near and dear to my heart: health literacy.  He outlined an idea  for helping consumers understand health information better.  I’ve reproduced some of the points he made in his post below:

“There is a terrific opportunity to provide health literacy programs to help all consumers get smarter about the healthcare options available to them. . . .

This new health literacy program is the perfect initiative for a brand-conscious, consumer-committed pharmaceutical company. Each of the pharmas struggle between ambitions to make their corporate brand meaningful to consumers and their need to build product brands and sales. . . .

The U.S. Government has an initiative afoot under HHS’s Health Resources and Services Administration. They will have an event at the end of October which is apprently Health Literacy Month. NIH has it’s own effort, as well. We should not leave this up to the government. A smart pharma could make this their signature CSR (corporate social responsibility) effort.”

For more about his idea, please click here.

 

A new poll released today by Harris Interactive indicates that when it comes to healthcare, most Americans want the candidates to focus on ensuring that everyone has access to insurance.

They also feel that the US does a good job of making sure that the very poor and the very rich can access care.  However, they believe that the middle class is being left behind.  According to the Wall Street Journal: “Across party lines, there is widely held belief that the U.S. health-care system works better for the very poor and the wealthy than it does for the middle class.”

What’s great about this presidential election cycle is that the candidates are focusing heavily on this issue.  Some would like to use the tax code to encourage people to purchase health insurance.  Others think that mandating that every American purchase insurance is the way to go.  However, as we enter this debate about how to increase access, we should be looking toward the states for information and knowledge about what works – and does not. There’s a lot of innovation happening at the local level that can inform our decisions about what the health system of tomorrow will look like.

 

Yesterday, the Wall Street Journal Health Blog cited a “closely watched” survey focusing on the predictable annual rise in health insurance premiums.  Digging past the headlines, Jacob Goldstein noted that “high deductible [health] insurance plans tied to special savings accounts continue to lag behind expectations, despite being praised high and low as a tool to slow the rise in . . . costs.”

You can learn a lot about why a product or service is not gaining ground by reading comments left on blogs, online bulletin boards and other sources.  Many of those commenting on the Health Blog’s story cited poor administration and mass confusion as reasons high-deductible plans have not taken off.  Some relevant comments are below.

Without Information I Can’t Make Good Decisions

“I have tried the consumer approach to health insurance. It is very difficult to obtain pricing or exact information from insurance companies or providers. How can you be an active shopper of health care if your ill and no one will provide the information to create an informed decision? You will not be having success connecting the consumer or provider until one can truly negotiate and understand the pricing.”
-Paul Brunner

Incompetence Ruined My Experience 

“My last job was with a Fortune 100 company. Their HSA administrator was completely incompetent. I had claims denied several times that clearly fell within the guidelines (contacts and eye exam, for example) while they were giving me excuses as to why they didn’t. Reimbursement checks were “lost in the mail”. In the end, it just seemed like a scam to take my money and my time. I did lodge a formal complaint with our HR department who told they had similar complaints and not many people sign up for a second year.”
-AMC in Florida

High Deductibles, Poor Service Keep People From Coming Back

“If someone actually needs the funds for health care, they offer few advantages except for a lower premium cost because the coverage starts after a high deductible. Duh. For a medical practice as a business, they are nightmares. Patients usually do not know how much is in their accounts and how providers are paid. We rarely have a clue as to how much we will be paid and how much the patient will owe. We need to bill the third party, wait until they adjudicate the claim and then try to collect from (often disappointed) patients.”
-Eric Einstein

This week a number of interesting stories have run in the New York Times and Wall Street Journal focusing on access to health insurance. I won’t comment on these articles, but I’ve summarized two I think provide food for thought.

-Battle Over Children’s Health Insurance Rages: This week, the Bush Administration issued a letter to states outlining a policy that would sharply reduce efforts to expand access to the federally funded children’s state health insurance program. According to the Times:

“The Bush administration, continuing its fight to stop states from expanding the popular Children’s Health Insurance Program, has adopted new standards that would make it much more difficult for New York, California and others to extend coverage to children in middle-income families.

Administration officials outlined the new standards in a letter sent to state health officials on Friday evening, in the middle of a monthlong Congressional recess. In interviews, they said the changes were intended to return the Children’s Health Insurance Program to its original focus on low-income children and to make sure the program did not become a substitute for private health coverage.”

-Managed Care Companies Create New Insurance Packages, But Some Think They Are Too Skimpy: Yesterday, the Wall Street Journal outlined efforts by managed care companies like Humana to encourage young people to sign up for health insurance. The policies, which carry low premiums but high deductibles are being praised by some. However, others charge that they are too skimpy, as some do not cover childbirth. According to the Journal:

“Health insurers are targeting the two groups of people least likely to be covered by insurance at work — young people in their 20s and 30s, and early retirees who don’t yet qualify for Medicare.

Companies including Aetna Inc. and WellPoint Inc. have recently begun offering individual health-insurance packages tailored for young adults, the fastest-growing population of uninsured Americans. Besides basic medical coverage, the packages also often include such benefits as teeth whitening and gym-membership discounts, because insurers say many young people are especially concerned about looking good. But to keep the policies affordable — Humana Inc. packages start at $26 a month, for example — the plans usually have high deductibles of as much as thousands of dollars a year and strip out some coverage that could be important, such as maternity care and brand-name prescription drugs.”