I have come to believe that fee for service (FFS), at least in its current incarnation, is an unsustainable model of financing health care. Pick up any newspaper or journal and you are likely to see that I am not alone. The reasons are as numerous as the faults of the present health care landscape – high costs, poor quality of care, unhappy patients, and unhappy providers. Continue reading Providers in the Insurance Game
There has been a lot of understandable outrage over the troubles plaguing Healthcare.gov, the federal website for purchasing individual or family health insurance under the Affordable Care Act (aka Obamacare). Opponents of the law (Republicans), recovering from their self-inflicted wounds over the government shutdown, see this as evidence of the fundamental unworkability of the law, and of the folly of a “government solution” to a complex problem. Supporters of the law (Democrats) are terrified that the difficulty in buying insurance will dissuade the so-called “young invincibles” (healthy young people who have limited needs for health care services) from buying coverage. Continue reading Functioning Health Exchanges
The irony continues. The federal government is “shut down” but health insurance exchanges at the center of the law that provoked Republicans to hold the country hostage have been up and running, and attracting a lot of interest. Although there have been some well-publicized (and expected) technical glitches, millions of people have visited State and Federal websites to learn more about their options for purchasing health insurance.
At the same time, the New York Times reported this week that millions of other citizens, who have incomes too low to qualify for subsidized private insurance on the exchanges, will continue to be uninsured. Remember that the Affordable Care Act was designed to expand health insurance coverage in two ways: for those with the lowest incomes, states were offered new funds from the federal government to expand Medicaid, which would have covered nearly all of the new expense at the outset, and about 90% thereafter. For those with higher incomes, the exchanges were created to provide new access to private insurance and subsidies based on income. Continue reading Week Two
October 1 marks what should be an important milestone in the implementation of the Affordable Care Act (ACA), informally known as “Obamacare.” Sadly, this has been overshadowed and even threatened by irresponsible and reactionary posturing by Republican members of the US House of Representatives.
Today was supposed to be the day that a signature element of the legislation was realized – the opening of Web-based “exchanges” through which individuals without employer-provided health insurance could purchase it from private insurance companies with progressive government subsidies based on income. Together with federal funds for the expansion of Medicaid, the patch-quilt of state health insurance programs for the poor, the goal of providing affordable (get it?) insurance to nearly all citizens was to be achieved. Instead, the news is filled with talk of a government shutdown or even a default on repaying federal debt, either of which would be a completely avoidable, self-inflicted wound to our prosperity. Continue reading Opening Day
I have been thinking more about the price of health care services. I have already shared some thoughts about this, but this time I have a more personal story to tell.
I recently had an echocardiogram. I would score the indication as “uncertain” (not clearly appropriate or inappropriate) according to professional guidelines. As a cardiologist myself, however, I would have ordered one in similar circumstances without hesitation. So I did not think the test itself was a problem — until I got the bill. Continue reading More on Prices
Physician groups, hospitals and health systems are feeling pressure, principally applied by private insurers and other payers, to figure out how to improve the quality of care we provide and lower its cost. Our intense efforts to do so, all too often coupled with a hefty dose of resentment and unhappiness that we have to, may make us less likely to notice that insurance companies are also trying to achieve the same ends by directly influencing the choices that patients make about their own care. These efforts come under the broad rubric of “value-based insurance design,” or VBID.
The basic idea of VBID is pretty simple: adjust the out of pocket costs (co-pays and deductibles) that patients face to “steer” them from one course of action to another. The concept is not particularly new, and is probably most familiar in the realm of pharmacy benefits, where reduced co-pays for generic drugs or selected drugs of a given class have been prevalent for years. Continue reading Value-Based Insurance Design
A recent study in the New England Journal of Medicine (N Engl J Med 2013;368:1713-22) has been getting a lot of press lately, and not because it reported on a new blockbuster drug. Rather, it reported the results of an unusual – and unintended – experiment about the utility of Medicaid.
A little background: one of the cornerstones of the affordable care act (aka “Obamacare”) is the expansion of Medicaid eligibility to include more low-income individuals. Since Medicaid is a state-run program partially financed with federal funds (as opposed to the “fully federal” Medicare program), eligibility has traditionally varied widely by state with much more generous eligibility and coverage in states like New York (read “blue states”) than say, Alabama. Continue reading The Oregon Medicaid Experiment: A Success or Failure?