Thursday, December 19, 2013

The Twelve Weeks of Obamacare

On the first week of Obamacare, The government gave to me
A promise of good healthcare, for me and my family

On the second week of Obamacare, the government gave to me
A website that wasn’t working
And a promise of good healthcare, for me and my family

On the third week of Obamacare, the government gave to me,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family

On the fourth week of Obamacare, the government gave to me,
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the fifth week of Obamacare, the government gave to me,
Navigators that weren’t navigating
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the sixth week of Obamacare, the government gave to me,
Call centers that weren’t calling
Navigators that weren’t navigating
A notice that my individual plan needed replacing,
A tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the seventh week of Obamacare, the government gave to me,
More time to sign up
Because of call centers that weren’t calling
Navigators that weren’t navigating
To replace a plan that needed replacing,
Requiring a tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the eighth week of Obamacare, the government gave to me,
Eligibility for premium tax credits,
More time to sign up,
Because of call centers that weren’t calling
Navigators that weren’t navigating
To replace a plan that needed replacing,
Requiring a tech surge to start repairing
A website that wasn’t working
And a promise of good healthcare, for me and my family.

On the ninth week of Obamacare, the government gave to me,
More information on my health plan choices,
Eligibility for premium tax credits,
More time to sign up,
With help from call centers that started calling
Navigators that started navigating
To help me replace a plan that needed replacing,
With a tech surge to start repairing
A website that had begun working
And a promise of good healthcare, for me and my family.

On the tenth week of Obamacare, the government gave to me,
No lifetime limits on my coverage,
More information on my health plan choices,
Eligibility for premium tax credits,
More time to sign up,
With help from call centers that started calling
Navigators that started navigating
To help me replace a plan that needed replacing,
With a tech surge to start repairing
A website that had begun working
And a promise of good healthcare, for me and my family.

On the eleventh week of Obamacare, the government gave to me,
A plan with no pre-existing condition exclusions,
And no lifetime limits on coverage,
Selected from a menu of health plan choices,
With eligibility for premium tax credits,
And with more time to sign up,
And help from call centers that started calling
And navigators that started navigating
I was able to replace the plan that needed replacing,
Thanks to a tech surge that was successful in repairing
A website that finally was working
So I could have good healthcare, for me and my family.

On the twelfth week of Obamacare, the government gave to me,
Confirmation that I had actually enrolled!
In a plan with no pre-existing condition exclusions,
And no lifetime limits on coverage,
Selected from a menu of health plan choices,
With eligibility for premium tax credits,
And with more time to sign up,
And help from call centers that started calling
And navigators that started navigating
I was able to replace a plan that needed replacing,
Thanks to a tech surge that was successful in repairing
A website that finally was working
So I now have good healthcare, for me and my family.*
*As promised

To the readers of this blog, I hope you enjoyed my tongue-in-cheek adaption of the Twelve Days of Christmas to describe the roll-out of Obamacare.  I will be taking the next two weeks off for vacation and the Christmas and New Year’s holidays, so this will be my final post of 2013. 

As always, I have enjoyed sharing my thoughts in this blog about the latest in health care policy, and I appreciate hearing back from you (yes, even when you don’t agree with me).  For what it matters, according to http://www.blogger.com, this blog got approximately 573,000 page views in 2013, and 1,870,621 since I started writing it in July, 2007, not counting this post.  Thank you!

Today’s question:  No question, just my wishes to you for a Happy Holiday and New Year!

Tuesday, December 17, 2013

What Should Physicians Expect When the ACA goes live on January 1?

Starting on January 1, the ACA will begin to transform how millions of Americans get health insurance coverage, although most of us will find that the plans offered by our employers are largely unchanged because they measure up to federal standards.  To the extent that some employers are imposing "negative changes, which include higher premiums, co-pays and deductibles, they've all been happening for more than a decade" because of employers wanting to curtail their health benefit costs. "Nor are there any signs that the Affordable Care Act has accelerated the trend."

Yet Obamacare will continue to be blamed for any changes in healthcare that the public dislikes.  Critics of the law will continue to stoke groundless fears in their relentless efforts to oppose and undermine it.  It will be important for supporters of the ACA to provide accurate information on what the law does including the better consumer protections it offers most of us that have insurance, like no lifetime limits on coverage, and access to affordable coverage for millions of uninsured persons--while acknowledging that not everything will be hunky-dory on January 1. 

There will be problems and unintended consequences, especially in the early start up months.  Physicians especially, need to be prepared for concerns and problems that will occur in the new year as patients show up with insurance that differs from what they had before, if they even had insurance before the ACA.  Especially for the heretofore uninsured, learning what health insurance does, and doesn't do, for them will be a steep learning curve.

Here are five things physicians need to be prepared for that can or will happen on or after January 1:

1.  There will be more Medicaid patients, a lot of them, many of them won't have a personal physician so will be looking for a physician who will agree to see them. They will be very low income people who were uninsured before, so this is good news overall, but it remains to be seen how many physicians will be available and willing to accept larger numbers of Medicaid patients.  How many there are will also be highly variable, depending on whether the physician and patients are in a state that is going along with the Medicaid expansion.  This is one reason that ACP is asking Congress to extend the Medicaid primary care pay parity program, set to expire at the end of 2014, for at least two more years. This program, created by the ACA, pays primary care physicians and some medical specialists no less than the Medicare rates for designated services provided to Medicaid enrollees.

2.  Patients who select silver and bronze plans will have substantial cost-sharing requirements (60-69% of the value of the covered benefits for bronze, 70-79% for silver).  For previously uninsured people, even a plan with high deductible/co-pays is better than having no coverage at all, and for their physicians, it is better than the care they provide to these patients being entirely uncompensated.  Also, the high deductibles are mitigated to some degree by first-dollar (no cost to the patient) coverage for USPSTF preventive and screening tests and procedures. Total out of pocket expenses are capped at approximately $12,600 for a family, and $6,300 for an individual, with reduced cost sharing for those with incomes up to 250% of the FPL.  (And of course the uninsured who are now able to get Medicaid generally will pay little or nothing out of pocket).  Also, most of the people buying coverage through the exchanges will get tax credit subsidies that limit the amount they must pay for premiums, pegged at a silver plan level. Still, for some patients, especially those who are new to health insurance or who had lower deductibles under their "cancelled" individual insurance plans, the high cost sharing could be problematic, and they may not realize that they have to pay their physician out of pocket until the deductibles or total out of pocket limits are reached.

3.  The prescriptions their physician has ordered for them may not be on the formulary exchange plan they chose.  This is particularly a concern for patients who must receive treatment for an ongoing chronic condition, like HIV, or an acute condition like a cancer patient getting chemotherapy.  Health plans offered through the exchanges should be transparent in what is included in the formularies and the criteria they use for making such determinations, and have an exceptions or appeals process for patients whose drugs are not covered, similar to what exists under Medicare Part D.  The administration's request to insurers that they continue to cover such drugs for patients with acute conditions may help, but a regulatory fix may be needed.  At the same time, it is not realistic to demand that all prescriptions be covered if the evidence does not support their effectiveness compared to other available prescriptions. And since many insurance plans in the traditional individual insurance market did not include any medication coverage, patients overall will benefit from the ACA's requirement that all plans cover medically appropriate drugs in all categories.

4.  Physicians or their hospitals may not be in the network of the exchange plan the patient chooses.  We don't know how often this will be the case, and narrow networks are becoming increasingly common under Medicare Advantage and private insurance unrelated to the ACA.  There should be an exception process to treat a physician as an in-network provider for patients who are undergoing treatment for an acute condition, especially if the physician is willing to accept the network payment rates.  There needs to be transparency in how insurers make these decisions.  The federal government and states should ensure that the ACA's network adequacy standards are being met, not just the letter of the law but in spirit.  Physicians should be able to challenge being "de-selected." And patients should have real time and accurate info on participating network providers when they choose a plan through the exchange.

5. Some patients may think they successfully signed up for insurance but their insurance company doesn't know it.  This could be the case if the patient didn't pay the premium by December 31, the new deadline set by the administration.  Or it could be the case if the federal government's troubled www.healthcare.gov didn't provide accurate enrollment information to the insurance company, a problem the federal government insists is mostly solved but the insurance industry says continues to a problem.  In this case, physicians may not know for several weeks if their patient had insurance, and who to bill for services provided during the interim.

I brought many of these issues up at a White House meeting that ACP's CEO Dr. Steve Weinberger and I attended last month, and we will continue to seek answers and solutions. The administration subsequently took steps to work with the insurance industry to mitigate some of these and other issues.  But more will likely need to be done as we learn what issues arise on or after January 1.

The fact that not everything will go exactly as was intended by the ACA when most of its biggest changes start to go live at the start of the new year should surprise no one.  Health care is complicated, our health insurance system is even more complicated, people--even the usually well-informed--don't understand it, and the ACA is trying to put in place complicated changes in coverage to close gaps in this very complicated and complex system, even as many are doing everything they can to make it fail. But the policies it is trying to implement are necessary and appropriate as a matter of social justice: no one in America should have to go without health insurance because of their age, their health status, their gender, where they live, where they work, and how much they make.  In a less polarized political environment, the mantra as problems arise with ACA implementation would be fix it, not nix it.  Until we get to that point, we'll have to muddle through, documenting problems as they come up and seeking the most feasible solution available given the political constraints. 

Today's question: what do you think will be the biggest "nuts and bolts" challenges for physicians and patients when the ACA's coverage expansions start to go live on January 1?

Thursday, December 12, 2013

Congress Takes Giant Step Toward Repeal of Medicare SGR

At a time when Republicans and Democrats, House and Senate, can't seem to agree on anything, Medicare physician payment reform is the exception to the rule.  Today, the House Ways and Means and Senate Finance committees reported out nearly identical bills to repeal the Medicare SGR formula and begin to move Medicare more rapidly toward paying physicians based on quality improvement activities--the closest Congress has ever gotten to reaching a bipartisan, bicameral accord on permanently repealing the SGR.

Today's action is not the end of the story, though.  The House recesses on Friday for its annual holiday break and the Senate will recess next week.  When Congress returns in January, the House must first reconcile the Ways and Means bill with an earlier (but similar in many respects) bill approved unanimously in July by the House Energy and Commerce Committee, which shares jurisdiction with Ways and Means on Medicare physician payment issues. Then, the House and Senate must reach agreement on an identical bill that can pass both chambers.  And perhaps the biggest hurdle is to find about $120 billion in offsets (cuts or higher fees to someone else) to pay for it all--a difficult task that will test the fragile bipartisanship that has gotten Congress to this point. 

In the meantime, Congress was also expected to pass a three month bridge to prevent the near 25% SGR cut scheduled for January 1, 2014--replacing it with a 0.5% update through March 31, 2014.  The thinking is that this will give Congress time to wrap up agreement on the permanent SGR legislation and budget offsets during the first quarter of next year.

ACP supports the bills reported out today, even as we will continue to seek improvements.  We had a direct hand in developing many of the policies behind them, getting positive changes in them throughout the process, and rounding up votes for them. We organized coalition letters with AAFP and AOA, and the Internal Medicine coalition letter. 

The bills are not perfect--what is?  We haven't gotten everything we want--who does? But compared to current law--which has resulted in scheduled (and growing) cuts year after year, for more than a decade now--the bills reported out today are a huge improvement.  Here are ten reasons why. The bills:

1. End the SGR cuts forever.
2. Add $120 billon to physician pay over the next 10 years.
3. Cancel the 2016 PQRS Meaningful Use penalties.
4. Provide a 5% bonus to physicians in new alternative payment models, such as PCMHs and ACOs.
5. Create options for physicians to earn positive updates for participating in a new Value-based payment program.
6. Combine and harmonize the existing Medicare PQRS, Meaningful Use, and Medicare Value Modifier Index into a single VBP reporting program.
7. Establish a process to improve the accuracy of relative value units (RVUs).
8. Provide funding to help smaller practices successfully participate in the new value-based payment program or in alternative payment models.
9. Increase federal funding for development of quality measures
10. Helps ensure that Medicare patients will continue to have access to physicians, the most important of all the changes it makes from current law.

And finally, there is now a chance that 2014 will finally be the year that we can move on from constantly having to re-fight the SGR battle, so we can concentrate on other things--like addressing administrative requirements that take time away from the patient-physician relationship.  Now, wouldn't that make for a happy new year?

Today's question: What is your reaction to the steps Congress took today to enact permanent repeal of the Medicare SGR?

Tuesday, December 3, 2013

Why I Fight for Obamacare

Readers of this blog and my tweets know that I am a passionate advocate for the Affordable Care Act, or Obamacare if you prefer.  It isn’t that I have a Pollyannaish view of the law itself, or the tortured political process that produced it—far from it. The ACA is an imperfect law, created by imperfect people through an imperfect process, with imperfect results. After almost 34 years of experience in Washington advocating with Congress and federal agencies, no one needs to tell me about the difficulties involved in successfully legislating and implementing the kind of sweeping changes required by the ACA. 

Yet, I will continue to fight for successful implementation of the Affordable Care Act, warts and all, and against efforts in Congress or by the states to undermine, block, defund or repeal it.  Here’s why:

First, my employer, the American College of Physicians, supports the ACA, and I am professionally obligated and personally committed to doing everything I can do to advocate for the policies established by our Board of Regents.  If I was unable or unwilling to advocate in support of the ACA, I would seek different employment.

Second, and more to the point, I am proud to work for a physician organization that has championed the cause of universal health insurance coverage for more than two decades now, and which today views the ACA as the best chance this country has had to ensure that nearly all Americans will have access to coverage.  That the College would be in favor of a law that has the potential to expand coverage to up to 95% of all U.S. resident should have come as no surprise to anyone who has followed ACP policy. 

In May, 1990, ACP said that, “A nationwide program is needed to assure access to health care for all Americans, and we recommend that developing such a program be adopted as a policy goal for the nation. The College believes that health insurance coverage for all persons is needed to minimize financial barriers and assure access to appropriate health care services.”

In 1992, the College editorialized in the Annals of Internal Medicine that, “No one should go without medical care for lack of money.  As physicians, we struggle daily against the chaos of illness and injury, whether in the context of clinical, laboratory, or administrative practice.  We try our utmost to restore or to preserve health, yet the lack of access to care for many Americans increasingly frustrates our best efforts.  In this issue of Annals, the American College of Physicians proposes a plan to ensure high-quality care for everyone.”  The editorial was accompanied by a policy paper that proposed specific policies to achieve universal coverage. 

ACP later went on to support the Clinton health care plan, and after that plan failed to get through Congress, promoted incremental steps to expand coverage. Then, in 2002, ACP proposed its own plan to get everyone covered through tax credit subsidies to buy private health insurance plans offered through state marketplaces and by expanding Medicaid to everyone below the federal poverty level (sound familiar?), phased in over seven years.  ACP’s plan was the basis of bipartisan legislation introduced in consecutive Congress’s by Senators Jeff Bingaman (D-NM), Steve LaTourette (R-OH), and Marcy Kaptur (D-OH).  ACP’s proposal was updated in 2008 to recommend giving the states more options to develop their own plans for universal coverage.  Then, in February, 2009, ACP called on newly elected President Obama and the 111th Congress to “provide affordable and accessible health care to all Americans.”   On January 15, 2010, ACP offered Congress detailed recommendations on the bills making their way through Congress to deliver on President Obama’s commitment to enact guaranteed coverage for all Americans, which later became the Patient Protection and Affordable Care Act (Affordable Care Act).  One month before the ACA became law, ACP issued a statement of overall support for the bill, citing the many specific policies in it that were aligned with the College’s own policies. 

The version of the Affordable Care Act that passed Congress a month later was almost identical to ACP’s own proposals, going as far back as 2002, to expand Medicaid to all persons at or near the federal poverty level, to require that large employers provide coverage, and to provide tax credit subsidies for people to buy qualified coverage through state-run marketplaces.

So why, then, do I fight for the ACA?

Because it is the position of the American College of Physicians—developed over many decades of analysis, and consensus--that every American should have guaranteed access to health insurance coverage, no matter where they work or live or how much they earn.

Because universal coverage is a moral and medical imperative.

Because the ACA comes close to providing universal coverage.

Because the ACA’s key policies, including tax credits to buy qualified health plans and Medicaid expansion, are identical to the College’s own proposals.

Because if the ACA fails, we will have turned our backs on the tens of millions of our fellow Americans who are at greater risk of living sicker and dying younger, simply because they lack health insurance.

Oh, and one more thing:, this is personal.  I have spent my entire professional life fighting to expand coverage for the uninsured, only to see it fail, time and time again, because of unrelenting political and ideological opposition. I first started working as an advocate for internal medicine at the American Society of Internal Medicine in January, 1979.  Since then, I have seen the cause of universal coverage fail under successive administrations and congresses.  I have seen it fail despite all of the well-meaning reports and commissions that challenged us to do better.  I have seen it fail as the number of uninsured has grown, year after year, decade after decade. I lived through the debacle of President Clinton’s failure to achieve universal coverage, and then I saw it put aside for another 16 years, until President Obama vowed to try again.  I lived through the contentious debate preceding the ACA’s enactment in March, 2010.  I am living through the ongoing political wars to block, defund, or repeal it.  I am living through the challenges created by the law’s troubled implementation. 

But if I have any influence whatsoever, I am not going to watch it fail this time, not when we are so close to providing affordable coverage to nearly all Americans, the  moral and medical imperative described by the American College of Physicians almost a quarter century ago. 

Today’s questions: Is the ACA worth fighting for? Why? Or why not?