Healthy buzz

[cornstein-blog]

More Medicare data released today: How I’d use it

This morning, in conjunction with Health Datapalooza, the Centers for Medicare and Medicaid Services is releasing data, by hospital, on charges for the most-common inpatient stays in 2012 and what Medicare paid for them.

It did so for the first time last year after an uproar about hospital prices triggered by Steven Brill’s “Bitter Pill” story in Time Magazine.

Predictably the conversation around this data will focus on which hospitals raised their list prices the most from 2011 to 2012.

While there’s no question that medical costs are important—and becoming more important as patients pay a greater share of the bill—this data has two big limitations. (I’ll explain later why I still think it’s useful)

First, what Medicare pays isn’t determined by what a hospital charges. Instead, the federal government sets reimbursement rates based on a patient’s primary diagnosis, the hospital location and certain patient characteristics. Second, almost no one pays a hospital’s list price (the charges it submits to Medicare.) Private insurance companies all negotiate lower rates, and many patients without insurance receive charity care discounts.

I took a quick look at the data comparing the number of patients treated by hospitals for different conditions in 2011 and 2012. What I saw were big percentage increases and decreases that should prompt local reporters to dig deeper.

Some hospitals, for example, billed for many more patients with psychoses. SUNY Health Science Center in Syracuse, N.Y., billed for four times more psychoses patients in 2012 than in 2011, 212 vs. 55.  Anaheim General Hospital in California had a similar increase, 310 vs. 82. Good Samaritan Medical Center in Brockton, Mass., saw a 248 percent increase in drug and alcohol abuse stays, jumping to 195 from 56.

I would want to know a few things: Did these hospitals hire new physicians to provide services in this area? Did Medicare change its reimbursement policies? Or did they see a spike in community need? Any of these could provide a good hook for a story.

Similarly, some hospitals showed big decreases. The number of lower extremity joint replacements at Jackson Purchase Medical Center in Kentucky dropped 90 percent from 2011 to 2012. Chest pain stays at Beth Israel Deaconess Medical Center in Massachusetts dropped 88 percent.  Psychoses stays at Rutland Regional Medical Center in Vermont dropped 86 percent.

I’d ask similar questions of these hospitals: Did they lose physicians in this area? Did Medicare change payment policies? Was there a change in community need?

I’d encourage reporters and researchers to look at changes in utilization by hospital more than changes in hospital charges. Simply take the 2011 and 2012 files from CMS’ website, match them together and see what you find.

[cornstein-blog]

On your mark, set, be careful.

The federal government will soon (any minute) release data on how much it pays physicians to treat Medicare patients. Here's why that's a good thing (as I explain in an op-ed for the Los Angeles Times). And here's why you should be careful (as I discuss in a blog post for AHCJ.)

[cornstein-blog]

Data on Medicare payments to doctors set to be released next week

As early as next week, the federal  government will release a massive database on the payments made to 880,000 health care professionals serving seniors and the disabled in the Medicare program, officials said this afternoon.

The data will cover doctors and other practitioners in every state, who collectively received $77 billion in payments in 2012 in Medicare’s Part B program. “With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers,” Jonathan Blum, principal deputy administrator of the Centers for Medicare and Medicaid Services, wrote in a blog post today.

“Providing consumers with this information will help them make more informed choices about the care they receive.”

The data will be released as early as next Wednesday.

CMS’ decision officially upends a policy dating back more than three decades that had barred the release of this very information. In 1979, a federal court in Florida granted an injunction that prohibited the U.S. Department of Health, Education and Welfare (the predecessor to the Department of Health and Human Services) from releasing data on how much physicians earned under the Medicare program.

In 2010, The Wall Street Journal wrote a series of articles called “Secrets of the System,” and its parent company Dow Jones filed a motion in Florida to overturn the injunction prohibiting the release of physician-specific payment information. In May 2013, a Florida judge issued an order vacating the injunction.

A few months later, after the window for appeals had ended, CMS requested comments from the public about whether it should begin releasing the information. Between August and September, CMS received more than 130 comments representing the views of 300-some organizations and individuals.

In a letter sent today to the American Medical Association, Blum wrote that for every health professional participating in Medicare, CMS would release the number of services provided, average charge, average Medicare payment and count of beneficiaries treated, as well as other fields. To protect beneficiary privacy, CMS plans to redact data if it applies to fewer than 11 patients.

“The Department concluded that the data to be released would assist the public’s understanding of Medicare fraud, waste and abuse, as well as shed light on payments to physicians for services furnished to Medicare beneficiaries,” Blum wrote in the letter.

He also wrote that much has changed in health care since the injunction was granted. “The physicians’ privacy interest in payment data is not the same as it was over 30 years ago or even 5 years ago,” he wrote.  

CMS has begun releasing more Medicare data in recent years. This includes payments made to hospitals and details on prescriptions written in Medicare’s drug program.

[cornstein-blog]

Why every metric for judging Obamacare's success is flawed

One day very soon, the focus on Obamacare will turn from signing up new enrollees to quantifying the law’s success—or failure.

The six-month open enrollment period, during which consumers sign up for health plans under the Affordable Care Act, is supposed to end today. But the U.S. Department of Health and Human Services, as well as many states running their own marketplaces, are giving some extra time to consumers who’ve had trouble signing up.

It’ll probably all wrap up by April 15. Then, the final numbers will be tallied and the pronouncements will begin. Politicians on both sides of the aisle will use the same data to proclaim that they were right about the law.

Last Thursday, the Obama administration said that more than 6 million people have signed up for coverage on the health insurance exchanges, meeting the projections set out by the Congressional Budget Office. Republicans have countered by questioning how many enrollees have paid their first month’s premium, the final step necessary for coverage to be in effect.

Dr. David Blumenthal of the Commonwealth Fund recently told me that any attempt to review the success of the law must go beyond those who sign up for coverage on the exchanges. It should include those who gained coverage through the expansion of state Medicaid programs for the poor, as well as young adults who are now able to stay on their parents’ health plans because of the law.

“I think the real success of the law will be judged over 5 years, not six months,” he said. “In fact, this president, President Obama, has until January 2017 to establish it as a fixture in the American social policy firmament.”

That may well be true, but now seems like a reasonable time to take stock. So, how should success—and ultimately the law itself--be judged? Here’s what some experts are saying about which metrics to use and the problems with each.

What percentage of previously uninsured people are finding coverage under the exchanges?

We can’t answer this question yet because we don’t know whether those signing up for coverage were previously uninsured.  In fact, some enrollees, perhaps many, had their insurance plans canceled at the end of 2013 because the plans did not meet the requirements set out by the ACA. Obama administration officials have not released any numbers on this.

That said, a recent report from the Leonard Davis Institute of Health Economics at the University of Pennsylvania and the Robert Wood Johnson Foundation compares enrollment data through the end of February (with one month left to go in the official open enrollment period) to the number of eligible uninsured people in each state.

Here’s what the researchers found:

“Overall, more than 4.2 million people have enrolled and picked a plan through the exchanges, about 14.8% of all potential eligibles. The enrollment rate varies from state to state, with a high of 54% in Vermont to a low of 5% in Massachusetts. We should note that Massachusetts had the lowest rate of uninsurance in the nation since its health reform in 2006; its previous success might mean that the remaining uninsured population could be especially difficult to reach.”

Here’s a graphic from the report showing the states in which the greatest share of uninsured received coverage (through February).

Did states meet estimates from the U.S. Department of Health and Human Services?

MarketWatch had a story last week comparing enrollment in each state to the HHS projections. By that measure, Connecticut led the pack, signing up 218 percent of its projected enrollment through the end of February. It was followed by Rhode Island, New Hampshire, New York and Maine.

(SOURCE: Marketwatch)

The problem with this approach is that the goals are “in many cases, based on little more than educated guesswork,” writes Charles Gaba, creator of ACASignups.net, which has become akin to the Bible for tracking sign-ups under the law.

He noted that CMS’ state-by-state projections were based on 7 million enrollees nationwide, the original projection of the CBO. That projection has since been revised downward to 6 million because of the problems with HealthCare.gov, the online sign-up portal for 36 states. In addition, some states provided their own figures while CMS simply sliced up the rest to fit the 7 million projection.

He elaborated in an email: “Ten states out of 50 gave their target numbers to CMS, but those numbers were higher than CMS was figuring, so they had to drop the other 40 states down so that the grand total fit the CBO's 7 [million] total. As a result, you get some absurd numbers--both NY and KY had the same 220K (actually, KY's was 220K, NY's was less at 218K) even though NY's population is much, much higher and so on.”

Gaba suggests an alternate measure more like the one used by the Leonard Davis Institute researchers, which looks at the percentage of eligible enrollees in each state.

What percentage of enrollees are young adults, aka the “young invincibles” who typically are regarded as healthier?

A number of news outlets have focused on the relative dearth of young people choosing plans through the end of February to point out that the insurance companies may not have so-called balanced risk pools, meaning enough young, healthy enrollees to offset the costs of older, sicker ones. The Washington Post noted this month:

“Strong participation by young adults is critical to the program’s success, because they tend to use less medical care. Because they are cheaper to insure, young people offset insurers’ costs of covering the sick, many of whom are eager to sign up for coverage. Under the health-care law, people with preexisting medical conditions can’t be rejected.

Initially, officials had hoped that 40 percent of the sign-ups would be adults under the age of 35, but only about 27 percent of February enrollments were young adults, about the same as in January. On Tuesday, administration officials said they were nevertheless encouraged and predicted more young people would enroll closer to the deadline.”

Drew Altman, president of the Kaiser Family Foundation, is critical of such efforts to equate young enrollees to healthy ones.

“Young people benefit the risk pool because they are healthier, but it’s really the percentage of healthy people that make or break the risk pool,” Altman wrote in a column last week. “Even if enrollment of young adults stays where it is – at about one-quarter instead of 40%, which our analysis shows they make up among potential enrollees – premiums would only increase by two to three percent. Though even that isn’t quite right, since many insurers expected this and already built it into their premiums.”

What we really need to know is what percentage of enrollees are healthy vs. sick. That will take time.

What will happen to insurance premiums in 2015?

Some experts are looking beyond this year’s enrollment numbers and are focusing on what the insurance rates will be for those renewing their plans this fall — or selecting plans for the first time. Scott Gottlieb, a resident fellow at the American Enterprise Institute, told me this month that he thinks attention will quickly shift from this year’s enrollment cycle to insurers’ rates for next year.

“The rates are going to come out early spring, so that’s going to be the next big story. And I suspect they’ll go up quite a bit,” he said.

That view was echoed by an anonymous insurance executive who talked to The Hill newspaper.

Dylan Scott at Talking Points Memo isn’t convinced they will uniformly rise. He also notes that insurance rates were increasing before Obamacare and will increase after the law.

“The real data for measuring Obamacare's success aren't in yet, but they eventually will be. At the top of the list: What happens with premiums in 2015? Plus: Do insurance companies leave the market or enter it? And the ultimate barometer: Has the number of uninsured Americans dropped significantly?” he wrote last week. “In simpler terms: Did Obamacare, in year one, create a sustainable insurance market for the long term?”

Another problem with looking at rates is that an insurer’s increase for 2015 may mean that it didn’t set the right price for this year, not that medical costs have increased dramatically.

***

In the end, some hints of the law’s success—or failure—will be available this year, but it will take longer to assess how much it has reduced the number of uninsured and moderated health care costs (the two key metrics of success).

An article Friday in The New York Times suggests that rather than judging the success of the law nationally, it may make more sense to look at it state by state. “A review of state-by-state enrollment data and other research, as well as interviews with patients, advocates, health policy analysts, elected officials, supporters and critics of the Affordable Care Act, suggest that, for consumers at least, the state of health care under the national law depends almost entirely on where a person lives,” the article said.

At the end of his column, Kaiser’s Altman wondered if the American public would wait for the facts to make up its mind: “The problem is that it will take time to learn if the mix of enrollees is healthier or sicker, and how premium increases vary around the country, and how people feel about their coverage,” he wrote. “Meanwhile Republican politicians will lambast the law and Democratic ones will offer lukewarm support and overall popularity of the ACA probably won’t change very much. Anybody willing to wait for a judgment based on the right metrics?”

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

Smokers fuming after glitch costs them Obamacare coverage

(Photo courtesy of Terry Wetherby)

Retired New Hampshire nurse Terry Wetherby doesn’t hide the fact that she smokes.

She checked the box on HealthCare.gov saying she uses tobacco and fully expected to pay more for her insurance policy under the Affordable Care Act. “It’s not a secret at all,” she said.

Wetherby dutifully paid the premium Anthem Blue Cross and Blue Shield charged her for January and again for February—and believed she had coverage effective on Jan. 1.

Then when Wetherby went to pay her March premium, she was told she couldn’t. A check arrived in the mail refunding her February premium with a two-word explanation: “Contract cancelled.”

It is unclear if the error affected smokers in other states served by Anthem.

Wetherby, 64, learned on Friday that her insurance was being reinstated, retroactive to Jan. 1, and that the original rate she was quoted—about $26 a month after a big government subsidy—would be honored throughout this year. She turns 65 in October and will then go on Medicare.

“When we were contacted by consumers who were experiencing application processing problems, we reached out to the carrier (Anthem), and worked with them to understand the factual situation,” said insurance department spokeswoman Danielle Kronk Barrick. “Ultimately, Anthem agreed that it would honor the originally quoted nonsmoker rates for the remainder of 2014, even though Anthem believes the glitch was not of its making.”

Still, for the past month, Wetherby has been scrambling to find out what happened and get it fixed. She contacted Anthem, her governor, her Congresswoman, her senator and state insurance regulators. She set up a Twitter account to try to get someone’s—anyone’s—attention.

“How can this be??” she wrote to me. “The ACA guarantees coverage. I went to the ACA website and received a rate. Anthem has taken my premium for 2 months and undoubtedly they have taken the corresponding US government subsidy dollars, yet they tell me I am not covered. I read where Obamacare is covering millions but when I speak to the NH Insurance department I am told many people have the same issue as I do.”

An official with the Centers for Medicare and Medicaid Services, which oversees HealthCare.gov, said “this was an error committed by Anthem” and that the insurer recently submitted revised data, which will soon be reflected in the online health plan comparison tool.

“CMS works to ensure the accuracy and completeness of the data issuers submit,” agency spokesman Aaron Albright said. “Issuers are also responsible for sending accurate and complete rating information to CMS."

Across the country, some of those signing up for coverage are finding out that their policies are not what they thought: Their physicians are not in their insurance network, their drugs aren’t covered, or their copays are higher than expected. But Wetherby’s case was different—she was left with no insurance at all.

While it is legal in many states to charge smokers more for insurance, it generally is not okay to cancel them based on an error made by the insurer.

Officials at Anthem, the lone Obamacare offering in New Hampshire, did not return multiple emails and phone calls seeking comment. In a letter last week to the insurance department about Wetherby’s case, an analyst wrote that “it was determined that when the policy was to be loaded there was a difference between the calculated rate and the quoted rate, so it was never effective.”

Wetherby is exactly the type of person the ACA is intended to help. Retired in 2013, she lives on Social Security benefits and had been paying $400 per month for high-deductible coverage last year.

Once HealthCare.gov began working again in November, she logged on and signed up for coverage. Because her income is barely above the federal poverty limit, she qualifies for a huge federal subsidy--$657 a month. She is also eligible for help paying her copays and deductibles.

While Wetherby said she is healthy, she said she was nervous about not having insurance. When she canceled her old policy four days before the new one took effect, “I wouldn’t leave the house. I was so afraid I was going to get hurt.”

Even after what’s happened, Wetherby said she remains a “boisterous” supporter of the ACA.

“It’s been a long hard journey but I still believe in it because I believe that everyone should have insurance,” she said. “The president has just put so much effort into this and I feel we still do have a lot of people in government who believe in this and I myself believe in it.”

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

As Obamacare deadline nears, conservative author finds little to praise

(Photo credit: American Enterprise Institute)

The final countdown is under way to sign up for health insurance under the Affordable Care Act before this year’s open enrollment cycle closes on March 31. Assuming the deadline is not extended by the Obama administration, most consumers won’t be able to sign up for health insurance again for many months.

After a disastrous rollout, enrollment via HealthCare.gov and state insurance exchanges has picked up, and recently surpassed the 5 million mark. But it’s unclear how many consumers have paid their first month’s premium (a prerequisite for having coverage) or how many were previously uninsured (the target demographic for the law).

In recent months, we’ve checked in with insurance consultants and officials at the Kaiser Family Foundation and Commonwealth Fund to get their views about how the law is working. Today, we check in with Dr. Scott Gottlieb, a resident fellow at the American Enterprise Institute. It’s no secret that Gottlieb, a physician and former deputy commissioner at the Food and Drug Administration, is critical of the law. He’s written lucidly about it for Forbes and others.

Q. You’ve written a lot about the problems with Obamacare, so let’s start off talking about things that have gone right. Can you name a couple things?

A. In terms of the rollout? Wow. I’m not sure anything has gone right with the rollout that’s really material. To me, the bottom line is there’s going to be groups of people who benefit from the Affordable Care Act, but even those folks who ostensibly should be getting a substantial benefit are having a hard time accessing it in my view. So I’m not sure what’s gone right with the implementation of this so far.

There were always going to be a lot of unintended consequences. You’re seeing those in terms of the effects on the broader market. Presumably, there was a group of people in my view who benefited substantially. The sweet spot of this law in my view is between 150 percent [$35,775 for a family of four] to a little bit more than 200 percent of the federal poverty level, where you have the benefit of the cost sharing subsidies that substantially reduce the out-of-pocket costs. But those folks are having a hard time getting access to the plans. And frankly, I think in many cases, the plans are more expensive than what people thought. So even with the benefit of the premium subsidies and the out-of-pocket subsidies, you know it’s not a substantial cost but there’s still some costs to a lot of those individuals, especially if they’re older.

Q. One thing that seems to be going right is that enrollment seems to be at the finish ticking up pretty dramatically.

A. Well, you’re always going to see a boost at the finish. The website is fixed. The front-end of the website looks good. When you go on to it, it’s a pretty good experience. The back end still doesn’t work. But to me, those are not really the key ways to assess the long-term viability of this. They had a flawed rollout. They were always going to be able to fix that, I think. The bigger issues are all these changes you’re seeing them make to the plan [the law] to paper over or forestall some of the hardships that Obamacare was always going to cause. By pushing out the inevitable, they’re making the plan itself less sustainable. This was the type of plan that was so complex that each part relied on another part. And so, as they pull out elements of Obamacare, other things get strained. This whole thing was a complex house of cards and they’re starting to dismantle their own program and make it harder for it to be self-sustaining.

Q. You recently wrote a piece for Forbes talking about the upside surprise that few people are talking about, namely those who are signing up for insurance plans not through the state or federal marketplaces but rather directly through the insurance companies. Explain why this is an upside.

A. These are typically going to be people who don’t get any subsidies [to lower the cost of their monthly premium]. In order to take advantage of the subsidies, at least upfront, you had to enroll through the exchange. So folks who are higher income who are transitioning into Obamacare--in most cases because their policies were canceled--a lot of them are going directly to the insurers. Probably 20 percent, when you look at the numbers that the insurance companies have put out. I think that will fully offset the number of people who enrolled through the exchange but don’t pay their premium. The administration keeps putting out these misleading numbers about the number of people who enrolled, but they don’t put out the number of people who’ve actually matriculated, who paid a premium. So we know there’s probably going to be 20 percent attrition. That attrition, I think, will be fully offset, and there may even be a net positive once you factor in the off-exchange enrollment. That said, the off-exchange enrollment aren’t the people that Obamacare targeted. They’re going to tend to be higher-income people who were previously insured. This isn’t the target market, but they will boost the overall numbers in the end. Very few people that I’ve seen have even talked about it.

Q. You wrote recently about ways in which folks can avoid paying a penalty if they don’t sign up for insurance under Obamacare. So while there has been a lot of talk about the bite of the individual mandate, it seems if you don’t want to pay it, you don’t really have to pay it.

A. First of all, the mandate this year was going to be a very weak mandate in terms of just absolute dollar values [of the penalty you pay for not buying insurance]. Even when you look at the mandate going out two or three years, when the full kick of the mandate goes into effect, it’s still a pretty low dollar-value mandate relative to what you’re asking the consumer to do. I always felt that the mandate was too small to really achieve what they wanted to, which is to coerce people into Obamacare. Obamacare relied on carrots and sticks. The carrots were these subsidies, but it relied on a lot of sticks. The biggest stick was the mandate, and I don’t think that that coercion was substantial enough relative to the cost of the plan that you were asking many consumers to buy. Especially young people for whom the pricing of these plans is not really a good economic deal.

There’s a lot of ways to get out from the mandate. They basically created this 14th category, a catchall category, if you experience any hardship at all in buying insurance. That could be any of us. We all experience hardship in buying insurance. And they extended that out all the way through 2017. So effectively the mandate is unenforceable all the way through 2017. I suspect it will be as simple as checking a box on a tax return. They’re not going to create a complex system to get out from under the mandate, based on what we have seen in the regulations.

Q. Another problem you’ve written about is the inability of consumers to find a doctor willing to talk exchange plans. How is this playing out?

A. The types of networks that are being formed in these Obamacare plans are very narrow networks, a lot like Medicaid. I don’t think there’s going to be a shortage of doctors, and I’ve written about that with Zeke Emanuel, but I think there’s going to be relative shortages of doctors depending on what insurance scheme you’re in. It could very well feel like there’s a shortage of doctors to you because your plan does not include a lot of specialists or even pediatricians. That’s what we’re seeing. The reason why it’s hard to make final assessments now is because these networks are very poorly formed. A lot of the doctors that are listed on the websites as being part of these Obamacare networks actually aren’t in them, and you see the complaints on the internet all the time. It’s going to take probably another year until we really understand what these networks look like. But every indication is that they’re going to be Medicaid-like networks. In fact the insurers are saying that. They’re calling it Medicaid-plus. That’s what we can expect.

It begs the question of how these plans got through the review process both at the state and federal levels if they didn’t even have their networks formed, because there had to be some network adequacy assessment. I think the reality is that they were rushed to do this and they basically waved everything through. There will probably be more stringent regulation in the future. I think they’re going to use the experience this year as their baseline in trying to learn how to do this regulation.

Q. When the calendar hits April 1 and open enrollment closes, what happens then?

A. I think open enrolment will probably be extended a little bit, but I suspect a lot of the discussion will start to focus on the premiums for next year. The big story this fall was going to be the canceled plans in the small group market. But that probably won’t happen in numbers that we thought because of the extended grandfathering [the Obama administration granted additional time before the plans must end]. So I think you’re going to see people start to focus on what the plans are going to look like for next year. The rates are going to come out early spring, so that’s going to be the next big story. And I suspect they’ll go up quite a bit.

Q. It seems the discussion about repealing the law, even with a replacement, isn’t going to go very far given the number of people now signed up for plans and for Medicaid. Do you agree?

A. I agree. I don’t think you can just repeal this without replacing it. I think Republicans made a bad mistake tactically over the years not talking about insurance as something that was a service that we should do more to try to provide to lower-income people. There’s something morally different about access to quality healthcare. You would never argue that every poor person should have a fancy car but you would argue that every poor person should have access to adequate health care, good comprehensive health care. And I think by not making that moral argument, conservatives conceded the debate to Democrats here. I hope they won’t make the same mistake again. I think you need to talk about what you’re going to do to provide coverage, make coverage available to everyone. And that doesn’t mean forcing everyone to buy coverage necessarily and it doesn’t mean necessarily guaranteeing everyone coverage. But it does mean providing an opportunity where everyone can get access to coverage, and that will mean some form of subsidies for a lot of people.

Q. Finally, people tend to blame everything on Obamacare—rising premiums, narrow networks—when a lot of factors and changes in the health care system have been going on for a very long time. How do you parse out what should appropriately be attributed to the law and what’s just a complex, and some would say malfunctioning, health care system?

A. The health care system certainly wasn’t a free-market utopia that worked well before Obamacare. I think that’s absolutely right. I think the insurance companies have either implemented things they’ve long wanted to implement or accelerated the implementation of certain changes under the guise of the dislocation created by Obamacare. And so there are things that would have happened, but probably happened a lot more slowly. There are certain things that they probably were reluctant to do but were able to implement here, for example businesses kicking spouses off of health plans.

It’s really hard to parse it. At the 10,000-foot level, the costs imposed by Obamacare forced people to take a hard look at their health care costs and created a reckoning in a lot of places. I think there are a lot of things going on that were already underway, that were accelerated by Obamacare, and then there are things that businesses long wanted to do but now they have the political cover to implement it. There clearly are things that are directly attributable. I think the rising premiums in the existing individual and small group market are very clearly attributable. The things that are directly related to mandates that they imposed and new regulations that’s causing premiums to go up is directly attributable. To me those are the most immediate negative impacts of the law.

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

How Prescriber Checkup came together

Today at #NICAR14, I led a session on Prescriber Checkup with my friend and collaborator Jennifer LaFleur. Here's a link to our slideshow. And here's a link to our User Guide.

[cornstein-blog]

A few of my favorite (health data) things

This morning, I will be on a panel at #NICAR14 about health data. I put together this handy tip sheet that discusses a few of my favorite health data sets. Do you have others that you like? I would love to hear about them.

Here are the slides from my co-presenter Peter Eisler. And be sure to check out the tweets from our third presenter Dan Keating.

[cornstein-blog]

Best reads on Obamacare enrollment

There have been a flood of stories, including one by me, about what we can learn from the Obamacare enrollment numbers released by the U.S. Department of Health and Human Services earlier this week. Here are some of the more-insightful reads:

A guide to understanding Obamacare's sign-up numbers, by Sarah Kliff, Washington Post

Implementing Health Reform: A January Exchange Enrollment Report, by Timothy Jost, Health Affairs blog

Subsidized exchange enrollment data and trends, by state, by Galen Benshoof, The Incidental Economist

Sorry, Conservatives: Based On The Latest Sign-Up Figures, There Won't Be An Obamacare Death Spiral, by Avik Roy, Forbes

Most states lag in health insurance sign-ups, by Ricardo Alonso-Zaldivar and Kevin Vineys, AP

For Many, Few Health-Plan Choices, High Premiums on Online Exchanges, by Timothy W. Martin and Christopher Weaver, the Wall Street Journal

One-Fifth of New Enrollees Under Health Care Law Fail to Pay First Premium, by Robert Pear, New York Times

Finally, be sure to check out the Kaiser Family Foundation's data. Way cool.

Happy reading

[cornstein-blog]

When a university hospital backs a surgical robot, controversy ensues

Flipping through the New York Times magazine a few Sundays ago, former hospital executive Paul Levy was taken aback by a full-page ad for the da Vinci robot.

It wasn’t that Levy hadn’t seen advertising before for the robot, which is used for minimally invasive surgeries. It was that the ad prominently featured a dozen members of the surgery team at the University of Illinois Hospital and Health Sciences System. “We believe in da Vinci surgery because our patients benefit,” read the ad’s headline.

(Photo by Paul Levy)

“While I have become accustomed to the many da Vinci ads, I was struck by the idea that a major university health system had apparently made a business judgment that it was worthwhile to advertise outside of its territory, in a national ad in the New York Times,” Levy, former chief executive of the prestigious Beth Israel Deaconess Medical Center in Boston, told me by email.

Ads for prescription drugs and medical devices are common, and some feature physician testimonials about why they believe the product works. Physicians also deliver promotional talks for drug and device makers, something we’ve covered extensively in our Dollars for Docs series.

But a whole hospital department? Levy wondered: Was this kosher?

“I was stunned that a public university would allow its name and reputation to be used in that way,” he wrote. “The next day, I did a little research on the university’s own website and confirmed that my initial reaction was correct: The ad violated the University’s code of conduct and administrative procedures, and likely state law.”

Da Vinci robotic systems aren’t cheap. The Wall Street Journal reported last year that they can cost up to $2.2 million each, and questions have been raised about their value. A study found that deaths and injuries caused by the robots are going underreported to the U.S. Food and Drug Administration. And the American Congress of Obstetricians and Gynecologists said in a statement last year: “There is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.”

Levy, who runs a blog called Not Running a Hospital, began writing a series of posts about the ad. The first, called Time to Fire Somebody, ran on Jan. 22. “The University has allowed its reputation to be used in a nationally distributed advertisement produced and owned by a private party, in benefit to that party's commercial objectives. This is not consistent with ‘exercising custodial responsibility for University property and resources,’” it said.

Levy subsequently wrote a post noting that some of those who appeared in white coats in the ad weren’t doctors; one wasn’t even a medical professional, instead serving as the administrative director of the University of Illinois at Chicago Robotic Surgery Training Center, according to her LinkedIn profile.

Levy found that the university’s campus administrative manual appears to prohibit such advertising: “In general, the University cannot permit its image to be used in any commercial announcement, in a commercial or artistic production, including the World Wide Web or in any other context where endorsement of a product, organization, person, or cause is explicitly or implicitly conveyed,” the manual says.

Subsequent posts focused on the hospital’s board of trustees, Intuitive’s disappointing earnings, and the compensation received by the dean of the University of Illinois College of Medicine at Chicago for serving on the board of directors of  drug maker Novartis. Levy forwarded the posts to the president and trustees of the university and suggested that they investigate.

Then, one day this month, Levy received an email from Thomas Hardy, the University’s executive director of university relations. It said the ad was paid for by Intuitive, the da Vinci maker, and that neither the university nor those pictured were compensated for appearing in the ad. Nonetheless, Hardy’s note continued,

“We asked Intuitive to suspend the ad, and the company agreed, immediately upon learning of concerns expressed about it. Our request was based on a business decision; we were concerned that the ad was not benefiting UI Health. Out of an abundance of caution, we decided to review circumstances surrounding the publication of the advertisement.  We will use this opportunity to conduct a methodical assessment of policies, guidelines, procedures and practices, and where corrective changes are required we will take the appropriate action.”

The president of the University of Illinois system asked his vice president for research to investigate the matter and report back to him by March 15 if policies had been violated.

By writing about the issue, Levy appears to have made an impact on how the university navigates commercial relationships.

But the university and Intuitive are not patting Levy on the back.

In response to questions from me, Hardy reiterated what he had told Levy and also pointed me to a Boston Globe opinion column that faulted Levy for lapses in judgment in a personal relationship with a female employee while he led Beth Israel Deaconess. Levy was fined $50,000 by the hospital’s board of directors.

When I asked Hardy how this was relevant, he wrote in an email, “I believe if you’re attributing claims and accusations to the blogster, your readers deserve to know his reported background so they can make an informed decision about his credibility…Wanted to make sure you have the pertinent information.”

Levy said he had admitted his errors publicly and apologized.

Intuitive spokeswoman Angela Wonson said in a statement that she believes the ad was appropriate and that the testimonials from university staff were unpaid.

“Medical schools and their affiliated hospitals are our customers and play an important role in training surgeons. In the past year, there has been much misinformation about robotic-assisted surgery, spread largely by plantiffs’ lawyers as well as segments of the health-care community threatened by our groundbreaking technology. Intuitive’s advertising campaign is intended to educate both the medical and patient communities by using factual information from independent, peer-reviewed studies that prove the safety of our system. The University of Illinois, which uses our technology, and the people featured in the advertisement agreed to appear without compensation. Those who use our technology see first-hand the outcomes resulting from its use. Their unpaid testimonials of da Vinci surgery are credible and sincere.”

Levy first questioned the value of the da Vinci in a blog post in 2007, but a year later, he wrote about how his hospital bought one anyway. “Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places,” he wrote.

Other medical device companies also use doctors in their ads and videos. Hologic Inc., which makes a 3D mammogram machine took out an ad in a trade journal last year featuring the staff of Methodist Hospitals in Merryville, Ind. And Accuray, which makes the CyberKnife, a competitor for the da Vinci system, includes physician testimonials in videos on its site. One video features a physician from Beth Israel Deaconess. The videos do not disclose if the doctors have been paid.

“Accuray does not typically reimburse physicians to participate in the video testimonials on the website and they are not considered company spokespeople,” the company said in a statement. “Some of the physicians and/or their institutions may have received payment for other activities, such as speaking at an educational or medical conference, or for conducting research.”

Beth Israel spokesman Jerry Berger said its doctor, Irving Kaplan, “was approved under the policy we had in place when the video was shot in 2011. He was not compensated for the appearance.”

Levy said he has a financial relationship with EarlySense, which makes equipment to monitor heart rate, respiration and patient movement. He sits on the company’s advisory board. It is not a competitor to Intuitive.

[cornstein-blog]

Obamacare’s market share mystery: Will the health law shake up insurance leader board?

Well before enrollment began in Obamacare’s new insurance exchanges, Blue Cross and Blue Shield of Rhode Island dominated the state’s individual insurance market, with a 95 percent market share in 2011.

Fast forward two years and little has changed. In the first four months of enrollment in Health Source RI, the Blue Cross plan has seen its market share grow, as hard as that is to believe—to nearly 97 percent.

Source: http://www.healthsourceri.com/press-releases/healthsource-ri-releases-enrollment-demographic-and-volume-data-through-feb-8/

A similar situation is playing out in California.

In 2011, Wellpoint’s Anthem Blue Cross had a 37 percent market share, followed by 20 percent for Kaiser Permanente and about the same for Blue Shield of California, according to the Kaiser Family Foundation, which crunched the figures.

In the first three months of enrollment under the Affordable Care Act, the same three insurers remained in the lead: Anthem captured 31 percent of the market, Kaiser had about 19 percent, and Blue Shield increased its share from about 20 percent to nearly 30 percent.

SOURCE: http://coveredcanews.blogspot.com/2014/01/milestone-enrollment-numbers-released.html

HealthCare.gov, the federal system that is handling enrollment for 36 states, has not yet released data on which plans consumers chose. In addition, some states running their own exchanges have not released their data. (It’s possible the Centers for Medicare and Medicaid Services will release plan-specific information when it releases its February totals, expected in the next couple days.)

Based on the states that have released the information (including California, New York, Washington, Rhode Island and Minnesota), experts are divided about how the market will ultimately shake out.

Some expect the new markets to closely resemble the ones they are replacing.

“Generally speaking, I'd expect the big plans in the individual market before the ACA to remain the big plans,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation (not affiliated with Kaiser Permanente). “They have brand recognition and the resources to put into direct-to-consumer marketing.

“The insurance market was highly concentrated pre-ACA and that's likely to continue, at least in the near future.”

Part of the premise of the Affordable Care Act was that it would make health care affordable and provide consumers with meaningful insurance choices, regardless of their health status. In the years before the law was passed, the individual insurance market was seen as dysfunctional—with few choices and high costs. In 2010, in 17 states, the insurer with the largest share of the individual market had more than 65 percent of enrollees in the state, a Kaiser report found.

The Huffington Post analyzed data from nine state exchanges and found that the “status quo is mostly holding in several states -- including Rhode Island, California and Connecticut -- where companies with the biggest market shares in 2011 are leading enrollments via the state's exchanges.”

Of course, the early data shows some successes by new players. Health Republic Insurance of New York, a nonprofit startup, garnered 16 percent of New York’s enrollees, second only to Empire Blue Cross, the established leader.

SOURCE: http://www.healthbenefitexchange.ny.gov/resource/december-2013-enrollment-report

Peter Newell, director of New York Hospital Fund's Health Insurance Project, told Modern Healthcare last month that Health Republic’s success was not a shock. “They had very competitive rates in almost every county they were in,” he said. “These co-ops are starting with zero covered lives. It's important for them to get enrollments early on, and it looks like Health Republic has done that.”

Caroline Pearson, a vice president at Avalere Health, a consulting firm that is tracking the rollout of the health reform law, said it’s too early to say what the final pattern will look like. “Thus far, the trend seems fairly consistent with what we expected,” she said in an email. “Regional plans, particularly Blues, are dominating the market. However, the sample is so small that it is hard to know how other plans are doing, especially in states where they priced competitively.”

Another challenge, Leavitt said, is that many insurance plans are also selling the same plans outside of the exchanges and the figures being released by states do not include these figures. Consumers who are not eligible for subsidies have little reason to purchase their coverage through the exchanges.

If an insurance company is not able to attract enough interest in 2014, the inaugural year of the exchanges, it may choose to drop out for next year, further reducing consumer choices.

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute in Washington, D.C., said he believes the insurers that choose to participate in exchanges will be those that also serve patients enrolled in state Medicaid programs. That is because they already have assembled networks of providers willing to accept payments lower than those paid in commercial plans.

“This is really structured like a Medicaid product with very broad mandates but low pricing, so you need to have a cheap provider network to service it,” Gottlieb, a former deputy commissioner of the Food and Drug Administration, wrote in an email. “I don't think the same insurers that provide commercial coverage and have better networks are also going to be able to simultaneously maintain cheap networks to service the government business and vice versa.”

This is already playing out, Gottlieb says, pointing to insurance giants like Aetna and Cigna, which are focusing on their commercial business and have relatively modest participation in Obamacare exchanges, compared with Wellpoint and Humana, both of which are investing more heavily in government programs.

“When this happens, what it will mean is that what remains in the employer sponsored insurance market, broadly speaking, will be white collar services employers, the kinds of firms that demand a better benefit and are willing to pay up for it,” he wrote. “This will mean the Cignas and Aetnas will have to move further away from the cheaper product they would have sold in the exchange to continue servicing this remaining employer segment.”

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

Epic fail: Where four state health exchanges went wrong

Much has been written (and will continue to be written) about the spectacular failure of health insurance exchanges in Minnesota, Massachusetts, Oregon and Maryland—all blue states that support the Affordable Care Act.

All were woefully unprepared for their Oct. 1 launch, and unlike HealthCare.gov, the federal marketplace, they are still having trouble getting back on their feet. As a result, enrollment in those four states has lagged behind other states, including many that actively oppose the health law.

The New York Times recently reported on how problems in these states could give Republican candidates an opening. “Last month, the Republican National Committee filed public-records requests in Hawaii, Maryland, Massachusetts, Minnesota and Oregon seeking information about compensation and vacation time for the exchange directors, four of whom have resigned. All five states have Democratic governors whose terms end this year. Three of them — Gov. Neil Abercrombie of Hawaii, Gov. Mark Dayton of Minnesota and Gov. John Kitzhaber of Oregon — are seeking re-election,” The Times reported.

One common element emerging in the coverage of these exchanges is that at least some state employees knew they were heading for disaster but didn’t take action early enough to remedy it. All the states have blamed some, if not all, of their problems on outside tech contractors. Here’s a sampling of what has been reported in each state.

Oregon

The Oregonian newspaper has done a great job chronicling the unfolding disaster with Cover Oregon. The state is the only one in which no one has been able to enroll using the website. In an article last month, the newspaper reported that a technology analyst at Oregon's Department of Administrative Services warned last May that managers at the exchange were being "intellectually dishonest" in claiming it would be ready Oct. 1.  

As the Oregonian set forth in its findings::

The project's significant flaws were well documented dating back to November 2011. Multiple independent analysts repeatedly raised questions about poor management along with strong doubts that it could be operational by the Oct. 1, 2013 deadline.

Cover Oregon leaders wavered between despair and an almost evangelical enthusiasm that they could complete the site. In the end they charged ahead, piloting an unfinished, largely untested exchange project right up to the Oct. 1 go-live date with no backup plan ready to go.

Senior officials in Gov. John Kitzhaber's office and elsewhere read at least some of these warnings but took no significant steps to intervene, apparently after being convinced by others the project was on track.

A key official in the massive IT project took steps to silence the critics. The Oregon Health Authority last January withheld payment from the company hired to monitor the project, claiming its persistent criticism was inaccurate and inflammatory.

The director of Cover Oregon left on medical leave in December. The Oregonian also has a good piece comparing Oregon’s failures with the successes of Kentucky, whose exchange has been lauded.

Minnesota

Blame is being spread around in Minnesota, where the MNsure exchange is sputtering and its call center is unable to keep up with demand. As news site MinnPost reported last month: “The vendors are blaming the state. Gov. Mark Dayton and state officials are blaming the private companies who built the faulty technology, and MNsure leaders are quick to point out that they weren’t around when controversial decisions were made. Republican lawmakers, meanwhile, are saying that the governor needs to take responsibility for the project.”

MinnPost reported that despite their efforts to blame vendors, state officials were responsible for key decisions:

Newly released contract documents suggest the state and MNsure leaders had a more direct role in the health exchange’s many missteps than they have publicly acknowledged.

In recent weeks, Gov. Mark Dayton and MNsure officials have increased their criticism of vendors, blaming the private technology companies for some of the underlying problems and glitches with the health exchange’s operation.

However, in early May, the state of Minnesota in effect took over responsibility from its lead contractor, Maximus Inc., for constructing MNsure’s technical infrastructure, according to contract amendments released to MinnPost by MNsure.

The new documents show that the exchange staff quietly made a significant change to its key contract for building MNsure — just months after making major revisions to the timeframe and size of the project.

Dayton later said he was unsure if senior MNsure staff were keeping him apprised of the serious issues with the exchange as soon as they came up.

The Star Tribune has reported on lengthy delays at the exchange’s call center and how officials in charge of the project received bonuses before its disastrous launch.

As in Oregon, the head of Minnesota’s exchange also resigned.

Massachusetts

In many ways, Massachusetts should have been a leader in setting up its own exchange. After all, its 2006 health reform law signed by then-Gov. Mitt Romney has been cited as the model for Obamacare. But the state’s exchange, the Massachusetts Health Connector, has fumbled.

The Boston Herald reported last month that, “State officials overseeing the Health Connector website knew as early as February 2013 — some nine months before launch — that parts of the $69 million Obamacare gateway would probably be delayed, public records obtained by the Herald last night revealed.”

The Boston Globe followed up with another report:

Massachusetts officials knew in July, three months before the launch of the state’s ill-fated health insurance website, that the technology company in charge was far behind on building the site and that there was “a substantial and likely risk” it would not be ready, according to a state official’s memo.

The website launched on Oct. 1 was incomplete and riddled with errors that frustrated consumers, blocked some from getting coverage, and required the state to move tens of thousands of people whose applications could not be processed into temporary insurance programs.

The head of the Massachusetts Health Connector Authority, which runs the insurance marketplace, was copied on the July memo. But the executive director, Jean Yang, and her staff never told the Connector board during its monthly public meetings that the project was off track, according to meeting minutes.

The Globe reported in a separate story how an untold number of people who “applied for Connector plans without financial assistance have not gotten coverage, because their payments were lost or somehow never linked to their accounts.”

John J. Monahan, a columnist for the Worcester Telegram & Gazette, put it like this last weekend:

Massachusetts' universal health care program was the model for Obamacare. And now, it seems, the Obamacare website fiasco has been modeled by Massachusetts. The state contracted with the same software company that messed up the launch of the Obamacare website to redesign its Health Connector website for people to buy insurance. It was scheduled to be working Oct. 1 to renew insurance for Jan. 1. It still isn't working.

Maryland

The Maryland Health Connection, like the exchanges in other states, knew well in advance that it wasn’t ready to launch, but the problems weren’t fixed in time.

The Washington Post reported last month how “senior state officials failed to heed warnings that no one was ultimately accountable for the $170 million project and that the state lacked a plausible plan for how it would be ready by Oct. 1.”

Over the following months, as political leaders continued to proclaim that the state’s exchange would be a national model, the system went through three different project managers, the feuding between contractors hired to build the online exchange devolved into lawsuits, and key people quit, including a top information technology official because, as he would later say, the project “was a disaster waiting to happen.”

The repeated warnings culminated days before the launch, with one from contractors testing the Web site that said it was “extremely unstable” and another from an outside consultant that urged state officials not to let residents enroll in health plans because there was “no clear picture” of what would happen when the exchange would turn on.

Within moments of its launch at noon Oct. 1, the Web site crashed in a calamitous debut that was supposed to be a crowning moment for Maryland officials who had embraced President Obama’s Affordable Care Act and pledged to build a state-run exchange that would be unparalleled.

Weeks later, the Baltimore Sun’s Meredith Cohn wrote a piece about just how much trouble she personally had trying to enroll:

For a chunk of two recent days, I tried to buy insurance on the Maryland health exchange.

My editors asked me to do this because Gov. Martin O'Malley recently told a national television audience that the "website is now functional for most citizens."

They wanted to know what "functional" meant, especially after hearing stories from consumers about a glitch-prone website created under the Affordable Care Act for the uninsured and underinsured. Marylanders have described frozen screens, lost information, error messages and even mistaken identity.

My own enrollment took 5 hours and 22 minutes over two days, two calls to the exchange's call center, seven times entering my personal information, two computers and two web browsers.

Maryland’s exchange director resigned in December. Last week, Maryland Gov. Martin O’Malley signed a law that would provide a backup method for hundreds of residents to get coverage effective Jan. 1 if they can show that they tried unsuccessfully to get coverage from the exchange.

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

My health beat daily reading list

I’m often asked by colleagues how I stay abreast of health news and developments across the country. It takes time and it takes work. I start each day plowing through a slew of emails that summarize and aggregate health news from around the country, each with a different bent. So focus on the politics. Some focus on the policy. Others are state focused. While it may not be realistic to sign up for all of the email lists I do, here’s what I read.

I’m sure this list isn’t complete. Do you read anything else? Drop me a note at [email protected].

Daily

HealthLeaders Media: (I get the Daily News and Analysis)

Kaiser Health News: (I get the Daily Health Policy Report)

National Journal Health Care Edge

The Morning Consult

American Hospital Association News Now

California Healthline

iHealthBeat

Advisory Board Daily Briefing

Politico Pulse

American Health Line

Wonkblog

HHS Inspector General

Government Accountability Office

MedPage Today

McKnight’s Long Term Care News

Health Law360

Robert Wood Johnson Foundation:

  Weekly

AHCJ Weekly Newsletter:

Reporting on Health:

Health News Review (sign up at the bottom of the page):

[cornstein-blog]

As the media gets bored with Obamacare, is the public starting to get on board?

We have now passed several key milestones in the open enrollment cycle for the Affordable Care Act: The deadline to sign up for coverage that was effective in January, the due date to pay for that coverage, and the deadline to enroll in coverage that is effective this month. The latest update from the Obama administration is that more than 3 million consumers have signed up for coverage on the federal and state insurance exchanges. Unknown is how many have paid for their plans and how many of these enrollees are newly insured (as opposed to people whose coverage was canceled).

Periodically during this open enrollment cycle, I’ve checked in with experts to get past the sound bites so endemic in this heated political debate. This week, I talked to Dr. David Blumenthal, president of the Commonwealth Fund, a New York foundation that conducts health policy research and whose mission is to “promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable.” While the foundation does not endorse legislation, it is generally seen as supportive of Obamacare’s goals.

Blumenthal was previously the national coordinator for Health Information Technology in the Obama administration. He is the brother of U.S. Sen. Richard Blumenthal, D-Conn.

The Commonwealth Fund has recently issued reports exploring Americans’ experiences with the health insurance exchanges and how states are implementing the act. The fund has a wealth of data that’s worth exploring. My Q&A with Blumenthal has been edited for length and clarity.

Q. It almost feels like after such a disastrous launch, folks have a bit of Obamacare fatigue. Is that a fair way of putting it?

A. I think that folks who cover this closely like you and the media, and maybe us in the cognoscenti world, may have a little bit of fatigue, but I think the American public is just learning about this law really. They’re getting past all the superficial characterization and the caricatures and beginning to understand what’s really in the law, whether it makes sense for them to seek coverage, and whether they are eligible for coverage. I actually think the uninsured still have a lot to learn about it, particularly in states where there has been a mass amount of misinformation and a conscious effort to prevent people from learning about the law. In fact, I think we’re not at the point of fatigue. We’re at the beginning of trying to introduce the public to the serious details of this legislation.

Q. Come March 31, what do you need to see to call this period a success?

A. First, let me say that I think the real success of the law will be judged over 5 years, not six months. In fact, this president, President Obama, has until January 2017 to establish it as a fixture in the American social policy firmament. I think that we are close to being able to say that the March 31 open enrollment period is already a success. And let me break it down for you. We have 2.2 million people who’ve already selected plans through the exchanges [as of the end of December], which is about 30 percent of what CBO [the Congressional Budget Office] predicted. We have about 6 million people who have been found eligible to enroll in Medicaid, and we have 3 million young adults who weren’t previously insured who are now insured under their parents’ policies. …You’ve got about 11 million people who’ve been touched by the law, maybe as many as 15 million. That’s really quite an astonishing number for the first six months.

If you want to just focus down on the exchanges and enrollment through the exchanges, I would say that if there are 5 million folks who have chosen plans through the exchanges by the end of March -- 5 million of the 7 million that CBO projected -- that would be a strong accomplishment for the law and the administration could claim success for the private exchanges. But as I said earlier, I think they are on the verge of being able to claim success for the law as a whole.

There’s a whole other part of the law which you’re aware of which most Americans are unaware of, which has to do with the [health care] delivery system reforms, and they have been moving along at a fairly deliberate pace as well.

Q. You talk about the 5 million people who may gain coverage in the exchanges, but what about people who had their insurance plans canceled? CBO didn’t anticipate a net change in the number of people insured through the individual insurance market.

A. There is obviously a number of people, we don’t know exactly how many, who have been told that their policies don’t meet the basic minimum standards set out under the regulations implementing the law. Some of them are now getting new policies through the exchanges and some of them are now having their plan continued at the discretion of state insurance commissioners. There was an unanticipated effect on the currently insured that the administration is trying to juggle. That was obviously not a great success story, but my view of most social legislation and indeed most programs undertaken by government of any kind is that they all have unanticipated effects. They are all born imperfect and they all need to be modified over time. The question is on balance do they do more good than harm and is the administration--whichever administration, the administration that passed the law or the administration that’s managing the law after its passage--nimble and effective in adapting the statute and the regulations to the reality that’s discovered. No legislation is perfect. The most revered programs in our social portfolio--Medicare, Social Security, you name it--have undergone massive changes over time as they experience problems that were either unanticipated or different from what was expected. That should be what happens to this program as well.

Q. What needs to happen for you to call it a failure?

A. If over the next three to five years, there are not significant reductions in the number of uninsured and underinsured Americans at a cost that the nation can afford, then I think it would have fallen short of expectations.

Q. There’s a lot of rhetoric on both sides and it seems almost shifting predictions too. Are both sides of the debate posturing so that the ends match their political aims?

A. Sure. My view of the current discussion about the Affordable Care Act, if you can call it a discussion, is that it’s a continuation of the 2012 election and a prelude to the 2016 election with a brief stop along the way for the 2014 midterms. I see this debate as quite fundamental to politics and policy in the United States. It reflects deep-seated, longstanding disagreements about the role of government in general, the role of government in health care, and it would be surprising to me if those debates didn’t continue and if the arguments made on either side didn’t change in order to gain the advantage in advance of those important upcoming electoral challenges. 2016, I think, will be the ultimate and probably final judgment on the law, and the question will be whether a Democrat who supports the law is elected or a Republican who opposes the law is elected. And then if it is someone who opposes the law, whether they decide they want to fix it or try to dismantle it.

From a historical perspective, there are some parallels to what happened in 1968, when Richard Nixon was elected president following the Great Society programs and their enactment, which the Republicans vigorously opposed. Nixon, in a different era with a different Republican party, decided he had to make the law work, and as you know there have been continuous reforms to Medicare under both Republican and Democrat administrations since. But it became clear that too many people depended on it to repeal it or to try in any way to undermine it.

Q. How are state Medicaid programs adapting to the huge influx? We hear a whole lot less about consumers who are receiving coverage in this way but we also hear that it’s hard to keep track of exactly how many have enrolled.

A. We know that there have been roughly 6 million Americans found eligible through the exchanges or through other devices for Medicaid in the 26 states that have agreed to expand Medicaid, that’s out of the 9 million that CBO projected through 2014 as enrolling in Medicaid. We don’t know how many have actually enrolled but it’s going to be in the many millions. Your question gets at whether that’s a burden that the states are having trouble managing. From what we can tell, the Commonwealth Fund works with state Medicaid directors actively, there’s no concern about managing this influx of new enrollees. There is concern about financing going forward. That is whether the federal government will sustain its commitment. There is also concern about the underlying efficiency of the health care system that serves both Medicaid and non-Medicaid patients.

Q. You recently released a report saying that 63 percent of those who are potentially eligible for the law’s health coverage options are aware of the new marketplaces. Around the same time, the Kaiser Family Foundation released a survey showing that unfavorable views now outnumber favorable views among the uninsured by roughly a 2-to-1 margin. How do you reconcile the different findings?

A. I think first of all, the uninsured are becoming aware of the law but I don’t think they yet understand it. I think it’s an extremely difficult law to understand. And I think there are a large number of uninsured in places like Texas and Florida where there has been relentless negative characterization of the law. I was just in Orlando for a meeting and watching a television and up comes an incredibly negative advertisement funded by a group opposed to the Affordable Care Act.

As they become more aware of it, they’ll go through a period where they’re concerned about whether it’s good for them. Now that the website is up and running and can accommodate a surge of new enrollees, the administration has a chance to get a new message out as do the insurance companies that stand to benefit from new enrollees. We’ll see what happens.  One thing you might conclude is that it’s not likely to get any worse than it already is from the standpoint of people’s attitude toward it.

Q. Any final thoughts?

A. One general point I want to make and it’s easy to get lost. The Affordable Care Act was passed to rescue the private insurance market, which was unraveling prior to the enactment of the law. That’s why insurance companies are so supportive of it and that’s why so many people who had lousy insurance policies are now finding that in a new regulated world with consumer protections, they’re finding that their old policies were not sufficient and that they needed to be upgraded. Going back to the world before the Affordable Care Act is not a viable option. That’s the background, that’s the substrate with which we’re dealing right now. We’re in the process of creating a new insurance market for the individuals and the small groups, and that process is going to have bumps, but it was a necessary change to preserve the private insurance market in the United States.

Has your insurance been canceled? Have you tried signing up for coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

Can't get through to your health insurer? Vent on Twitter

Fed-up consumers, armed with questions and concerns about their new health insurance under the Affordable Care Act, are flocking to social media websites to seek answers and vent their frustrations.

For some, it’s because they can’t get through on the phone. For others, it’s a way of getting attention right away before trying phones or email.

This digital equivalent of line-jumping appears to be working.

A week ago, New Jersey writer Jen A. Miller sent a tweet asking:

Anyone else having problems with the @horizonbcbsnj site? I'd LIKE to pay my bill, but they don't seem to want to take my $$.

— Jen A. Miller (@byJenAMiller)

January 23, 2014

A representative of Horizon Blue Cross Blue Shield replied the following day and asked for more information.

@byJenAMiller We'd like to help. Email [email protected] w your ID#, contact info and issue.We'll have someone call you to assist.

— Horizon BCBSNJ (@HorizonBCBSNJ)

January 24, 2014

“After an email exchange, HorizonBCBSNJ called and figured out that a ‘glitch’ delayed the mailing of the February bills,” Miller told me in an email. “I ended up paying over the phone.”

Miller said she turned to Twitter first because the last time she had an issue with Horizon—with her website login—“it took 40 minutes and two calls (including the part where the first person I talked to gave me the wrong number to call).”

“So when I had this issue, I tried Twitter first.”

Thomas Vincz, a spokesman for Horizon, wrote that the insurer has been deluged with new enrollees. More than half of its enrollment from HealthCare.gov, which is handling sign-ups for New Jersey, came between Dec. 15 and Dec. 24. “This crunch required intensive work in subsequent days and weeks to address many back end issues with enrollment verification and payment processing,” he wrote. 

Horizon extended its hours, tripled its customer service staff and delayed payment deadlines, and things are returning to normal, Vincz said. “But we’re maintaining higher levels of customer service staffing to better assist our members during this busy time.”

The slew of health insurance complaints has drawn the attention of the Chicago Tribune and the Philadelphia Inquirer.  

Companies across the country are feeling the heat. This from Michigan:

@mikecampau We're sorry to hear your frustration & would like to help. Could you pls email your question to us at [email protected]?

— BCBSM (@BCBSM)

January 27, 2014

And this from Illinois:

@sds52 We know the hold time is lengthy and we're sorry- is there something we can answer for you?

— BCBSIL (@BCBSIL)

January 27, 2014

@faramir22 We know this has been frustrating- we see your call to customer service and that representative is working on it for you.

— BCBSIL (@BCBSIL)

January 27, 2014

Among companies receiving the most scorn is Anthem Blue Cross. Earlier this week, we reported how the company had canceled the policies of some consumers in California, then switched them into new plans and deducted the premiums automatically from their bank accounts. Needless to say, consumers who chose other insurance options were none too pleased.

Way to blame the Affordable Care Act for the reason why you won't pick up the phone during business hours, @AnthemPR_CA. Classy.

— kevinwchat (@kevinwchat)

January 28, 2014

@sleepminded Please email me your name, birthdate, phone # & city of residence so we can assist. [email protected]

— Anthem Blue Cross (@AnthemPR_CA)

January 28, 2014

@Uma3055 Please email me your name, birthdate, phone # & city of residence so we can assist. [email protected]

— Anthem Blue Cross (@AnthemPR_CA)

January 27, 2014

The man who responds to those messages, spokesman Darrel Ng (@AnthemPR_CA), told me in an email that the insurer’s customers are interacting with companies in ways beyond the traditional phone call. “In response to this new demand, we created our customer service twitter account @AskAnthem several years ago to assist members. As consumers themselves started proactively contacting our other twitter accounts, we started directing these inquiries to customer service for assistance.” 

The insurance company Aetna has a dedicated Twitter account, @AetnaHelp, to assist with customer service queries—and it’s been busy lately.

@typeis4lovers Thanks for your email. We have reviewed your request and a response has been sent via email. Have a great Night! ^ TL

— Aetna (@AetnaHelp)

January 28, 2014

Spokesman Matt Wiggin said the beginning of the year is a busy time for the insurer and is particularly so this year because of the Affordable Care Act and its changing deadlines.

“There have been some instances where call volumes have been heavy and if people have not been able to get through or been able to get the information we need, they’ve either reached out to us through social media or other means available,” he said. “It’s just another way for folks to engage with us.”

Sometimes, Aetna’s tweets are even proactive. When a customer of Anthem Blue Cross tweeted dissatisfaction and said her business was up for grabs, Aetna’s customer service team chimed in.

@AdrianaK Hi. If you have questions about Aetna plans please let us know. Thanks! ^ TL

— Aetna (@AetnaHelp)

January 27, 2014

The California Health Care Foundation has been tracking Twitter sentiment around the Affordable Care Act. In a report released last week, the foundation found that in general, there has been much less discussion about the law recently than there wasin October when HealthCare.gov, the federal marketplace, didn’t work. In December, the conversation shifted somewhat to the affordability of options.

Catherine Teare, a senior program officer for health reform and public programs at the foundation, said she doesn’t have data about consumers interacting with their plans on Twitter, but added that an uptick makes sense.

“I don’t think these tweets give us necessarily a way to grade either the performance of the insurance companies or of the exchanges, but we certainly didn’t see the complaints about insurance companies back in November because people weren’t that far through the process,” Teare said.

Even state insurance exchanges themselves are getting into the act, responding to Twitter queries lobbed their way. This from California:

@MamaEdits A household is what you claim it to be on your taxes.

— Covered California (@CoveredCA)

January 27, 2014

@KristineHolst Unfortunately, you'll have to get through to the Service Center to get that fixed.

— Covered California (@CoveredCA)

January 24, 2014

Anne Gonzales, a spokeswoman for Covered California, said the exchange has a social media team that monitors its Twitter feed, Facebook pages and Instagram account around the clock.

“We actively respond to consumers using social media to answer their questions and to help them through the process,” Gonzales wrote. “We get as many as 500 Facebook posts a day, and the social media team answers up to 50 questions a day, so it's becoming a valuable tool for people in need.”

 Gonzales said the exchange’s Facebook and Twitter followers help each other out and compare notes. “People root each other on to get covered, and congratulate others on successful enrollment,” she wrote. “We recognize that social media is the resource of choice among younger, more tech-savvy consumers, and we are using it as a tool to get consumer feedback and to reach out to those experiencing difficulty in enrolling or getting information.”

[cornstein-blog]

Consumers with canceled insurance plans shifted to new ones without their permission

When California pharmacist Kevin Kingma received a letter last fall notifying him that his high-deductible health plan was being canceled because of the Affordable Care Act, he logged into his state’s health insurance exchange and chose another plan beginning Jan. 1.

Thanks to a subsidy, Kingma’s monthly premium went down, from about $300 to $175, and his benefits improved.

But this month, Kingma logged into his bank’s website and saw that his old insurer, Anthem Blue Cross, had deducted $587.40 from his account and had enrolled him in another of its insurance products for this year —he says without permission.

Hundreds of other consumers are caught in the same predicament, insurers acknowledge. And the California Department of Insurance said it is exploring whether any laws were broken when insurance companies withdrew money from consumers’ accounts for plans they didn’t select.

Here’s what happened to Kingma and others: When they received letters last fall, they were informed that their plans had been canceled. But within the letter, it also said that if they did nothing, they would be switched over to a different plan and if they had set up their payment to autodraft from their account, it would continue to do so.

Kingma said he didn’t read the whole letter, just enough of it to know his old plan was being canceled.

Once he noticed the withdrawals from his account this month, Kingma said he tried calling Anthem’s customer service hotline but couldn’t reach anyone because of “high call volume.” Dozens of consumers have reported long phone waits trying to reach Anthem.

Kingma then repeatedly faxed and contacted the insurer through its website. An Anthem representative first told him that he may only receive reimbursement for about half of January, until the date he actually canceled the new policy. Since then, it appears the insurer canceled his policy at the end of 2013. But as of Friday afternoon, it hadn’t refunded Kingma’s money, he said.

“I and a number of other former Anthem policy holders are stuck in Anthem's Kafkaesque nightmare as part of healthcare reform,” Kingma, 57, wrote to me in an email.

Darrel Ng, a spokesman for Anthem Blue Cross, said in an e-mail that insurers across California had moved members from canceled plans to new ones that comply with the law “and that transition retained their payment preference.

“In cases where members neglected to inform insurers that they had selected a new plan or informed insurers too late that they had selected a new plan, members are receiving a full refund for any amount paid.”

Kaiser Permanente spokesman Chris Stenrud confirmed that his insurer has also found cases similar to Kingma’s.

“Unfortunately, about 500 of our existing members in California who had automatic payment set up for their current plans were inadvertently charged before our systems recognized their enrollment in new plans through Covered California,” the state’s exchange, he wrote in an email. “We have identified the affected members and are in the process of contacting them to make them aware of the mistake, and of course, our commitment to refund the extra charge.

“We take this seriously, and want to assure our members that we will make them whole,” he wrote.  

These actions may not fully satisfy the California Department of Insurance. Janice Rocco, deputy commissioner for health policy and reform, wrote in an email that insurers have cooperated with her agency and refunded premiums when questions arose, so “we hadn’t been focused on what the potential legal violations might be.”

She said insurers may have violated the law in two ways by deducting funds from customers’ bank accounts electronically. “Moving a policyholder from one product to another would be considered a ‘material change’ that would trigger a requirement in law to provide information about how to cancel the electronic funds transfer agreement. We did not see any notice of how to cancel an electronic transfer of funds in the policy cancellation notices, so there may be some violations of law in this regard.” 

Beyond that, Rocco said, some of the new products used by two health insurers were technically “sold by one of the insurer’s affiliated companies with which that policyholder had no prior electronic funds transfer agreement, so that might be another area of potential legal violations,” she wrote.

It isn’t known whether similar complaints have been lodged outside of California. But insurers in a number of states sent consumers letters saying they would be moved to new plans unless they said otherwise. (This letter was posted online by Politifact.) The Associated Press reported last month that at least 4.7 million people were told their old health plans were going away because they didn’t meet the coverage standards of the Affordable Care Act.

In the meantime, consumers have taken to Twitter to voice their frustration. Here’s a sampling of their tweets (ProPublica has not verified their claims):

@AnthemPR_CA I've been on the phone for 2.5 hours to cancel part of a plan I never purchased. Can you please help cancel it?

— gregmachlin (@gregmachlin) January 24, 2014

@AnthemPR_CA It looks like you had charged me for a cancelled plan, please refund.

— mortanyong (@mortanyong) January 18, 2014

@AnthemPR_CA Been trying to cancel my policy for a month. You stole money from my bank acct. Can't get anyone to help. What do I have to do?

— Kathi Kruse (@kathikruse) January 20, 2014

Kingma said the whole situation has left him frustrated.

“No business conducts fair business that way,” he said in an interview. “In December, they should be telling customers, this is the plan you will be converted into, this is the cost. I don’t put anything past large corporations.”

Has your insurance been canceled? Have you tried signing up for coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

[cornstein-blog]

My predictions: How Medicare will release physician payment data

(Above: A snippet of the data ProPublica was given on prescribing in Medicare's massive drug program.)

The federal government’s announcement last week that it would begin releasing data on physician payments in the Medicare program seems to have ticked off both supporters and opponents of broader transparency in medicine.

For their part, doctor groups are worried that the information to be released by the Centers for Medicare and Medicaid Services will lack context the public needs to understand it.

"The unfettered release of raw data will result in inaccurate and misleading information," AMA President Ardis Dee Hoven, MD, said in a statement to MedPage Today. "Because of this, the AMA strongly urges HHS to ensure that physician payment information is released only for efforts aimed at improving the quality of healthcare services and with appropriate safeguards."

On the other hand, healthcare hacker Fred Trotter has raised concerns about CMS' plan to evaluate requests for the data on a case-by-case basis. That isn’t much of a policy at all, he wrote, giving federal officials too much discretion about what to release and what not to.

So, how is this all going to shake out?

Three recent examples offer some clues.

The first involves the Wall Street Journal and the Center for Public Integrity. The news organizations sued the government in 2009 to obtain records on physician claims in Medicare. They received the information they were seeking in a legal settlement, but had to agree not to publish physicians’ names in most cases. The data they received was so vast that it took data experts months just to load it into a computer, organize it and analyze it.

The news organizations never did receive a complete set of Medicare payment data. Instead, they received a 5 percent sample of the Carrier Standard Analytic File, which includes records of Medicare Part B (outpatient) billings and payments.

And that in itself was huge: In 2008 alone, it had about 42 million rows, each with 612 variables. It was about 38 gigabytes even before being imported into a database, data journalist Maurice Tamman wrote in a legal declaration. At the time, Tamman was a WSJ news editor. Tamman’s declaration was included in a successful lawsuit filed by Dow Jones (the Journal's parent company) to lift a legal moratorium that had prevented Medicare from publicly releasing data on payments to individual physicians.

The second example is the project that my colleagues at ProPublica and I have been working on to examine how doctors and other health professionals prescribe medications in Medicare’s drug program. Instead of seeking individual medication claims, we sought aggregate records for each prescriber, grouped by drug. We gave up some information we wanted, such as characteristics of the patients, but we also were not subject to any limits in terms of our ability to name doctors.

The result is our Prescriber Checkup news application that lets consumers look up their doctor and see how he or she compares to others in their same specialty and state. Our stories identified examples of risky prescribing, high rates of name-brand prescribing and patterns that suggested fraud.

Even though we did not have individual details on every drug claim filled—more than 1 billion a year--the files we had were also vast: more than 70 million rows of data on the drugs prescribed by 1.6 million providers in 2011 alone. In cases in which a provider wrote fewer than 11 claims for a particular drug, the data were redacted.

Processing the data took us months, as well.

Finally, healthcare hacker Trotter obtained data from Medicare on referrals to and from providers within Medicare. He sought and received statistics on the number of patients who saw one doctor (Doctor A) within 30 days of seeing another doctor (Doctor B). He’s created DocGraph to show these referrals visually.

According to his website, Trotter received nearly 50 million pairs of referring parties involving about 1 million providers in 2011. Like the data ProPublica received, Trotter did not receive information on referrals in which fewer than 11 patients were involved.

Here are my takeaways:

1) Medicare is far more likely to release aggregate information than data on individual claims. This is mostly to protect patient privacy, but also because officials have grown increasingly comfortable writing programs to aggregate the data (as was the case with ProPublica and Trotter).

I would not be surprised, for instance, if Medicare released information on the number of times each provider billed for different procedures and services last year, as well as the number of patients each doctor treated, but few details about the patients themselves.

2) Expect redactions. It’s safe to assume that Medicare will redact data in which fewer than 11 patients are involved. 

3) Medicare likely will not create a glamorous news application in which consumers can view the data. When the government released information on hospital charges last year, it released a big spreadsheet and left it to news organizations and others (see here and here) to come up with clever ways of displaying it. I see no reason why this will change.

4) Medicare, likewise, is unlikely to put together tip sheets and other context for interpreting the data. While the program should—and probably will—release basic information about what is being released, I don’t think officials will tell consumers how much weight they should give it. That’s up to the media and physician groups. If these groups, including the AMA, are dissatisfied with the media’s presentation of the data, they are welcome to create their own site with the data and the context they believe is important.

5) There will be far more requests for Medicare physician data than there will be Medicare staff assigned or available to fulfill them. This is a process that will take time and everyone should be patient.

6) Those wanting every morsel of Medicare data to be released will likely be disappointed. This is a massive, immensely complicated program with many interrelated parts. I would expect more information to be released each year, but it won’t happen overnight.

7) Finally, few news organizations or research groups are equipped to deal with such large data sets and produce meaningful content quickly. As noted above, all of this will take time.

All that said, let the data releases begin.