Monthly Archives: June 2013

Health Wonk Review Is Up: A Superb Summary of Provocative Healthcare Posts

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The latest edition of Health Wonk Review is now up on Wing of Zock.

 Sarah Sonies and Jenifer Salopek have done a superb job of summarizing some of the most provocative healthcare blog posts of the past two weeks. 

Here are just a few of the questions these posts  raise:

—   Should states mandate nurse staffing ratios in acute care hospitals?

— What can we learn about early Medicaid expansion in some states?

—   Why do we need more research into the value of colonoscopies?

I won’t try to summarize the posts. Just go to Wing of Zock                    

If You Buy Your Own Insurance in the Exchanges, Will You Receive a Government Subsidy? How Much Will it Be for Couple, or a Family of Five?

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ACA tax credits

 

 

 

 

 

 

Source:

No doubt you have read that if you are single, and earn less than 400% of the Federal Poverty threshhold (roughly $46,000 for an individual or $94,200 for a family of four) you will be eligible for a tax credit to help you cover the cost of insurance premiums.

But most of us don’t fit into one of those two categories. What if you are a couple, or a family of three? What happens if you have four kids?.

As the table above reveals, if a couple has  four children  and earns less  than $126,360 (400% of the FPL), they will be elibigle for the tax credits. Note: these credits are available only if you are self-employed, unemployed, or work for a company that does not offer affordable, comprehensive insurance. “Affordable” is defined as individual coverage that costs less than  9.5% of your income.

The credits are designed to make sure that no one who purchases their own insurance is forced to spend more than 9.5% of their income on health care. For instance, according to the Kaiser Family Foundation’s (KFF’s) new subsidy calculator, coverage for a 35-year-old couple with three children might cost $13,101./(This is an estimate; actual premiums will vary depending on where you live. Healthcare is much more expensive in some states than in others. ) If the parents earned roughly $100,000 a year, they would be asked to pay $9,500 toward their insurance and would receive a tax credit of $3,626.

This assumes that they purchase a “silver plan” which pays for an average of 70% of covered benefits. The family would owe the other 30% in  the form co-pays and deductibles. But keep in mind that preventive care is free, there are no co-pays and the deductible does not apply.

Assuming they need care other than preventive care, total out-of-pocket spending would be capped at $12,750, even if the entire family wound up in a car accident, three of them were hospitalized, and two needed surgery.

If they preferred, the family could purchase a less expensive Bronze plan which would pay for 60% of covered benefits. Their co-pays and deductible would be higher, but once again, preventive care would be free, total cost sharing still would be capped at $12,700, and the premium for a Bronze plan would be lower: KFF estimates that a family of five earning $100,00 would still receive a subsidy of $3,626 and their share of the premium would be just $7,253.

Why is the Government Subsidizing Households That Earn more than $125,000?

 If people choose to have four children, that certainly is their business. But why should I help pay for their healthcare?

The answer is two-fold:

First, people don’t necessarily choose to have 4 children –or more. Some couples are surprised (not to mention overwhelmed) when they disccover that they are having twins or triplets. 

Secondly as a society, we care about children. We don’t want any child to go without needed care.

But there also is a pragmatic reason for supporting large families. If those children don’t receive preventive care such as dental checks as well as  timely treatments when they are sick, down the road, we as a society will pay the price. The health of the population will play a major role in determining how productive we, as a nation, are.  

 

 

 

 

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Obamacare: In 2014 Will Workers Be Able to Afford the Health Benefits Their Employers Offer?

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Recently AP floated a story that spread like a virus. Within a day it was picked up by Yahoo!,  the Wall Street Cheat Sheet, and the Washington Post  where it was headlined “Affordability Glitch.”

Thanks to a “wrinkle” in the law, the story warns, Obamacare may hurt many of the people it is supposed to help, by making “health insurance unaffordable for . . . workers employed by restaurants, retail stores, hotels, and small businesses.”  The law is explicit, AP explains: “companies that employ 50 or more workers must offer ‘affordable’ coverage to those working more than 30 hours per week — or face fines. ‘Affordable’ health insurance, as defined by the legislation, means that premiums can cost no more than 9.5 percent of an employee’s income. . . .    . . . For low-wage workers, many of whom live paycheck to paycheck and earn barely enough to cover basic necessities 9.5% represents a lot of money.”  

True, but the fact that the law says premiums can equal 9.5% of income doesn’t means that employer-sponsored insurance will cost 9.5% of a worker’s pay.

Nevertheless, Yahoo! conjures up a hypothetical employee who will be left out in the cold: “Take, for example, a restaurant worker who makes $21,000 per year. A premium that costs 9.5 percent of this income would run $1,995 for the whole year, or $166.25 per month.  How could this employee possibly shell out nearly $2,000 a year for insurance?”  

He will have to turn down his employer’s offer, and then the government will demand that he pay a penalty because he didn’t buy insurance!
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Will Obamacare Kill Jobs? More Fictions and Facts

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— Fiction: No doubt, you’ve heard that Obamacare will cripple small businesses, the “engine of job growth in America.” In 2014 employers with more than more than 50 full-time workers will have to provide insurance—or pay penalties. If more than 30 of their workers go to the individual Exchanges and receive government subsidies in the form of tax-credits, the business will have to help cover those subsidies by paying a fine of $2000 to $3000 per employee.

Obamacare’s critics speculate that many employers will stop hiring, so that they have no more than 49 full-time employees.

–Fact: As of 2010, there were roughly 5.7 million small employers in the U.S. (defined as those with fewer than 500 workers.) Ninety-seven percent of them have fewer than 50 employees. In other wrods, Obamacare’s employer mandate applies to only 3% of small businesses.

And 99% of those  with more than 50 employees already offer insurance. The employer mandate will affect just a tiny sliver of small companies.  Lawmakers understood this when they wrote the legislation.

–Fiction: In 2014, many small employers will trim full-time workers’ hours and we will become a nation of part-time employees.  Small business owners know that if they have fewer than 50 full time workers (averaging 30 hours a week) they won’t have to pay a penalty, and their workers can go to the Exchanges where individuals can purchase their own insurance, and receive those generous tax credits.

–Fact: This bit of fear-mongering overlooks the fact then when the government counts “full-time employees” it doesn’t just count heads, it counts hours.The law says that the firm must offer insurance if it has 50 full-time “or full-time equivalent employees.”

Here is how the rule works: If a business has 50 full-time employees working 30 hours a week and cuts 10 back to 15 hours, it will have only 40 full-time employees. But it will have to hire more part-timers to cover holes in the weekly schedule.

Assume the company hires 20 new part-time employees, each working 15 hours a week. Because they will be putting in 300 hours a week the government will count them as ten “full-time equivalents.” Add those ten to the remaining 40 full-time workers, and the company then will have 50 full or “full-time equivalent’ -employees.

The business won’t have to insure the 20 part-timerswho work only 15 hours, but it will have to insure the 40 who work full-time—or pay the penalty..

This fiction also overlooks why employers offer benefits.   Research reveals that when a business insures workers, it enjoys higher productivity, better morale and lower absenteeism.

This explains why roughly 95% of companies with more than 30 employees provide health insurance.

 —Fiction: Chain restaurants, retailers and hotels can easily cut thousands of workers to part-time so that they don’t have to insure them.

— Fact:  Organizing a  company’s  hiring and staffing around making sure that it won’t have to offer health benefits is hardly a brilliant business plan

Imagine what cutting full-time workers’ hours will do to morale and productivity– not to mention customer service. 

 Consider this  Wal-Mart has stopped hiring full-time employees, and is relying on part-timers and temps. As a result, Forbes reports that Wal-Mart is experiencing  “complaints about understaffed stores with empty shelves and inventory piling up in warehouses and back rooms.”. 

“It seems even Wal-Mart can’t operate on such a lean staff,” writes Forbes contributor Laura Heller, who describes herself as “a retail geek/expert.”

“Dirty stores, parking lots in disarray and out-of stock products don’t bode well for sales and stores can’t operate that way for long periods.”

Meanwhile, Target, one of WalMart’s chief competitors, continues to offer health care benefits to part-time employees, even though the ACA doesn’t require that it insure them.
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Obamacare– Fear-Mongers Poison Minds; Hatred Blinds

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Judith Mayer Lynn, uninsured and battling breast cancer, should be a fan of the Affordable Care Act. Instead, Bloomberg  reports, she know little about it. When Bloomberg interviewed the 56-year-old she was unaware of subsidies in the law that will help people like her buy coverage in 2014,. “Lynn didn’t know the Affordable Care Act requiresthat insurers to pay for prescription drugs, hospital stays and other services she’s spent the last two years scrimping to afford. Nor did she realize she can no longer be denied a policy due to her illness”.

When told of the benefits, “Lynn remained unconvinced, skeptical of insurers and government alike. ‘It’s a joke,’ she said. ‘There’s going to be loopholes in all of these provisions.’”

If you showed Lynn the list of “essential benefits” that insurers will have to include in the policies they sell to people like her, could you persuade her to read the list—and explain where she saw the holes? Probably not. Her mind is closed.

In an interview at an Access to Healthcare office in Las Vegas, Lynn said she was unaware of those benefits — and didn’t trust Obama to produce them anyway.

                                            The Poison: Hatred

Perhaps I shouldn’t be surprised. We live in a nation where in 2009,  a U.S. Congressman felt free to shout out “You Lie” during a  televised presidential speech to a joint session of Congress.   

(President Obama had just said that the legislation would not mandate coverage for undocumented immigrants. This is, of course, correct.  South Carolina Rep. Joe Wilson (R) later apologized.)

Yet that didn’t stop another Congressional Republican from calling out the President earlier this month. In a scathing speech on the floor of the House, Rep. Jim Bridenstine (R-OK) derided President Obama as a “dishonest, incompetent, vengeful liar” who lacks a “moral compass.” Bridenstine cited HHS Secretary Kathleen Sebelius’ efforts to promote enrollment in the Affordable Care Act as one reason that President Obama is “not fit to lead.”

Bridenstine didn’t apologize. Instead, the next day he told a talk show host that he had “gotten great encouragement” for his remarks from fellow Republicans. /

I have followed U.S. politics for many years. Never have I seen a president so hated—not Nixon, not LBJ at the height of the War in Vietnam..

       Politicians Are Not Alone in Teaching Americans Not to Trust Obamacare

Lynn recalls one of her surgeons telling her that he was leaving the business because the health-care law dictates what he can charge patients. This, Bloomberg notes, is “something the legislation doesn’t do. “

Why would a surgeon claim that the Affordable Care Act will be setting his rates? Presumably he reads newspapers.  How could he be so uninformed?

“There is a lot of distrust,” Sherri Rice, chief executive officer at Access to Healthcare explains. When her nonprofit group began asking members about the ACA last month, about half knew little about its provisions and another quarter were “furious” about it, she told Bloomberg.

Such anger makes it difficult to think clearly—or take in information.  This may explain why Lynn’s surgeon thinks that under the ACA he will be told what he can charge patients. Perhaps he, too, is so “furious” that the facts don’t register. Hatred blinds.

 
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Medicare Fraud and For-Profit Hospitals- A Story That Never Ends

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Sunday, CBS’ Sixty Minutes took a close look at Health Management Associates (HMA) a for-profit hospital chain that, according to its employees, has “relentlessly pressured its doctors to admit more and more patients—regardless of medical need—in order to raise revenues”

“We talked to more than 100 current and former employees and we heard a similar story over and over,” CBS correspondent  Steve Kroft reported.  Emergency room physicians were told “that if they didn’t start admitting more patients to the hospital, they would lose their jobs.” The orders came from the top:

With 71 hospitals in 15 states, HMA is the fourth-largest for profit chain in the country. Last year it raked in revenues of nearly $5.8 billion;  half of that came from Medicare and Medicaid. In other words, taxpayers were footing the bill for a large share of those unnecessary hospitalizations.

Patients also paid. As one doctor observed: “If you are put into the hospital for reasons other than a good, justifiable medical reason, it puts you at significant risk for hospital-acquired infections and what we would refer to as ‘medical misadventure’” (i.e. “preventable medical errors)

     :                           “Putting Heads on Beds” –An Old Story

 The piece was shocking. But it is not a new story. It is an old story. To be more precise, it is a never-ending story. In Money-Driven Medicine: The Real Reason HealthCare Costs So Much, I profiled several for-profit hospital companies that did just what Health Management Associates has done: “put heads on beds”– even though the patients didn’t need to be hospitalized.

At Tenet, in Redding, California, patients weren’t just hospitalized, they underwent heart surgery. An investigation would reveal that in many cases, they “had no serious cardiac problems whatsoever.”

 A FBI affidavit estimated that in one-quarter of all cases, Tenet’s two “rainmaker” heart surgeons were slicing  open patients who should never have been on an operating table. Other doctors tried to alert the hospital’s administration. They were ignored.

Some of those patients did not survive. Others were crippled. All suffered psychological trauma. 

                    HCA:  Florida Governor Rick Scott’s Back-Story                       

In 1997, Health Corporation of America (HCA) made headlines when FBI agents swarmed HCA offices in five states, and found evidence that at HCA, executive salaries hinged on meeting financial targets such as “growth in admissions and surgery cases.”
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Haggling for Health Care

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Below, a guest post by Naomi Freundlich. Long-time readers will remember Naomi as the person who helped me write HealthBeat before we both left The Century Foundation in 2011. She now has her own excellent blog,  Reforming Health

In this piece, she describes what it is like to live with a high-deductible health plan and find yourself bargaining with doctors when trying to get care.

Let me add that beginning in January of 2014, comprehensive, affordable insurance will be available in the Exchanges– along with subsidies. This should mean that no one will have to sign up for a plan with a $4,000 deductible ($8,000 out of network) plus co-pays.

(Though I realize that some upper-middle-class families who earn just a little to much to qualify for a subsidy may have a hard time finding affordable insurance in the Exchanges. But so far, the pricing in states like California and Colorado is encouraging. I’ll write more about this as we find out more about how much insurance will cost in other state Exchanges) 

Nevertheless, next year some health care providers may try to charge patients more than the insurer will pay. This is called “balance billing.” In that case, patients will need to shop for physicians who accept the insurers’ reimbursement as payment in full.

My guess is that most heatlh care providers will discover that there just are not enough very wealthy patients out there (even in New York City), able and willing to pay more than either Medicare or an insurer will pay.  

by Naomi Freundlich

I’m not a big fan of bargaining and my half-hearted attempts to get a better price for a used car, garage sale find or contractor’s service have been mostly unsuccessful. There’s always that nagging feeling that the seller is laughing with delight once I’m gone, thinking, “I really pulled one over on that rube!”

And so it has come as somewhat of a shock to me that medical care has become the new garage sale, as far as haggling goes.

First we found out that hospitals have “chargemasters” that hold the list prices for everything from knee replacements to aspirin tablets, and that these prices differ wildly between hospitals; even those in the same city. We also know that insurers, both private and Medicaid and Medicare, never pay these list prices but instead bargain with hospitals to pay substantially discounted prices. The only ones not getting in on the discounts are the uninsured or under-insured people who get hit with the full list price of hospital care.

The same thing happens with doctor bills. If you’ve ever compared what your doctor bills your insurer with what your insurer actually agrees to pay, it’s clear that there is a lot of bargaining going on. If the list price of an office visit is $125, the insurer pays $60; for a $200 lab test, the insurer reimburses $70, and so on.

A recent New York Times article,  “The 2.7 Trillion Medical Bill,”  focuses on the cost of colonoscopy to help explain how health care spending can be so much higher in the U.S. than other developed countries. In the article, patient bills for their colonoscopies ranged from a hefty $6, 385 to a whopping $19,438. Meanwhile, their insurers all negotiated the price down to about $3,500. As Elizabeth Rosenthal of the Times notes, ” this is still far more than the “few hundred dollars” that a routine colonoscopy costs in Austria or Italy.

Why do we have such price inflation here in the U.S.? Our for-profit health care industry has a lot to do with it, as does the maddeningly unregulated nature of the business.  Rosenthal writes: “A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor.”

David Blumenthal, president of the Commonwealth Fund tells the Times; “In the U.S., we like to consider health care a free market.” He adds, “But it is a very weird market, riddled with market failures.”

Now back to haggling. In the last year, my family—like many others in the nation—has been covered by a high-deductible insurance plan. Before our plan kicks in to pay for doctor bills, prescription drugs or diagnostic tests, we must meet a $4,000 in-network deductible. After that, we still have co-payments and also face an out-of-network deductible of $8,000. Now responsible for so much out-of-pocket health spending, I’m face to face with Blumenthal’s “weird market.” It’s a market where no one tells you the price of office visits beforehand, doctors have no idea how much an MRI they’ve just ordered is going to cost, and you end up paying dearly for not being an aggressive shopper.
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Workplace Wellness Programs– Making Insurance Too Expensive For Those Who Need It Most

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Note to readers: before reading this post, you may want to read the post below which questions just how effective workplace wellness programs really are.

Often, Workplace Wellness Programs use financial carrots to reward employees who participate.. In some cases, workers  will not have to contribute as much to their health care insurance premium if  they “get with the program” and meet specific standards related to their health. Typically, these “outcome-based wellness programs” offer discounts to employees who quit smoking, or who meet specific metrics for blood pressure cholesterol or body-mass index.

Meanwhile some companies charge workers higher premiums if they continue to smoke, or do not participate in a wellness program. 

Even if a company doesn’t use financial “sticks,” the carrots can mean that some employees contribute far less to the cost of their insurance.. The employer must make up the difference, and as a result, he is likely to make the “standard” employee contribution that much higher. Thus, employees who don’t receive the discount help subsidize the carrots for their co-workers.

                                                  Is This Fair? 

Last week, the Obama administration issued new rules which say that under reform, wellness program rewards can equal 30 percent of the cost of coverage, defined as the total amount that employer and employee contribute to premiums (Under current law, discounts are limited to 20 percent.) The regulations also allows a reward of up to 50 percent for employees involved in programs designed to prevent or reduce smoking.

The new rules, issued by the Labor, Treasury and Health and Human Services departments, gives this example of a permissible wellness program: “The annual premium for coverage in an employer’s group health plan is $6,000, of which the employer pays $4,500 and the employee $1,500. The employer offers a $600 discount to employees who participate in a wellness program focused on exercise, blood sugar, weight, cholesterol and blood pressure. 

 At the same time employers will be able to hike premiums for smokers by 50 percent .

Penalties Could Mean That Workers Will Be Forced to Opt Out of Insurance

“This could make insurance unaffordable for some workers, and  keep the sickest workers from affording the care they need,” Alan Balch, vice president of the Preventive Health Partnership, an alliance of the American Cancer Society, the American Diabetes Association, and the American Heart Association, recently told Business Week. In that case “Wellness Program” penalties could undermine a major aim of the Patient Protection and Affordable Care Act—ensuring  that all  Americans  have access to insurance.
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A RAND Report on “Workplace Wellness” Is Quietly Buried for Five Months—Why?

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Did you know that in the U.S. “Workplace Wellness” has become a $6 billion industry?  That’s how much employers pay vendors who sell workplace wellness programs designed to encourage employees to lose weight, lower their cholesterol, or stop smoking..  

Today, firms lay out an average of $521 per employee per year on ‘wellness incentives’ such as gift cards for employees who shed pounds. That is more than double the $260 they spent in 2009 according to a recent survey by Fidelity Investments and the National Business Group on Health. 

 At first blush, this sounds like progress: Enlightened employers are doing their best to encourage employees to take care of themselves.  There is just one catch: we have no hard evidence that these programs either improve health or lower health care bills.

Even Bruce Elliott, manager of compensation and benefits at the Society for Human Resource Management, the largest professional organization that represents benefits managers, is concerned. As employers chase Wellness, “the one things that does worry me is the utter lack of metrics and really, the utter lack of thought” Elliott recently told Bloomberg News, pointing to the “herd mentality” that seems to have overtaken the idea of “workplace wellness.”  

      A Rand Report Appears Briefly Online—and Disappears                   

Two weeks ago, Reuters broke a story about a RAND report on Wellness programs that was supposed to come out last winter. The report was mandated by the Affordable Care Act, and RAND delivered the analysis to the U.S. Department of Labor and the Department of Health and Human Services last fall. 

 According to Reuters’ reporter Sharon Begley, “Two sources close to the report expected it to be released publicly this past winter.”  She added that “Reuters read the report when it was briefly posted online by RAND before being taken down because the federal agencies were not ready to release it, said a third source with knowledge of the analysis.”

RAND had collected information about wellness programs from about 600 businesses with at least 50 employees and analyzed medical claims collected by the Care Continuum Alliance, a trade association for the health and wellness industry.

Reuters revealed that the results were disappointing:  “The programs that try to get employees to become healthier and reduce medical costs have only a modest effect. Those findings run contrary to claims by the mostly small firms that sell workplace wellness to companies ranging from corporate titans to mom-and-pop operations.”
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