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Analysis: Senate’s Latest Health Blueprint Cuts Costs At The Expense Of Chronically Ill

The latest Senate health proposal reins in costs by effectively splitting the individual insurance market, with healthy people diverted into stripped-down plans and chronically ill individuals left with pricey and potentially out-of-reach options, insurance analysts said.

This draft — a fresh attempt by the Republican Party to undo the Affordable Care Act — injects more uncertainty into plans for people with preexisting conditions such as cancer, asthma, diabetes or other long-term ailments. Those people, insured through ACA marketplaces now, could be more isolated than in an earlier version of the Senate bill.

For such patients, “I would be pretty nervous,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “You will have separate pools — one that only healthy people can get into and one for you. That pool is liable to get increasingly expensive — in fact, very expensive over time.”

The two biggest insurer trade groups went further on Friday, saying in an unusually strong-worded letter that “millions of more individuals will become uninsured” if the proposal becomes law.

Plans sold to individuals and families through the Obamacare exchanges cover some 10 million people, many with chronic disease.

Use Our ContentThis KHN story can be republished for free (details).

A draft bill released Thursday added a proposal from Texas Sen. Ted Cruz that would let insurers sell health coverage outside the ACA exchanges with no provisions for prescription drugs, mental illness, hospitalization or almost any other benefit.

Such plans would be far cheaper than comprehensive coverage and almost certainly draw younger, healthier people away from high-benefit insurance, analysts said.

Without healthy customers subsidizing the sick, premiums and other costs would soar for plans that accept chronically ill patients, experts said. The Senate draft includes $70 billion over a decade to help pay those costs, but it’s far from clear that would be enough.

Insurers were struggling last week to grasp the implications of the legislation, studded with ambiguous language. One big takeaway: The Senate’s version of health care would undermine historical assumptions and drastically shift risk in the individual market.

Letting carriers sell low-cost, low-benefit plans to healthy consumers “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association, two lobbying groups, said in a Friday letter to the Senate.

The Republicans are nowhere near success with this plan. Already two of the 52 Republican senators — Kentucky conservative Rand Paul and Maine moderate Susan Collins — have said they won’t support the bill. One more defection would sink it, and a delay caused by the surgery of Arizona Republican John McCain gives opponents more time to build resistance.

Senate leaders had scheduled a vote for this week but postponed it to give McCain time to recover from treatment of a blood clot near his eye.

Meanwhile, the nonpartisan Congressional Budget Office is likely to issue its assessment of the bill this week. The CBO had said an earlier Senate bill would increase the number of people without health insurance by 22 million by 2026.

The Republican plan offers a freer insurance market — something the party has long favored — while purporting to protect those with existing illness. Insurers selling stripped-down plans would be required to also offer traditional Obamacare plans covering preexisting conditions.

You will have separate pools — one that only healthy people can get into and one for you.

Sabrina Corlette, Georgetown University’s Health Policy Institute

But such coverage risks becoming a high-cost ghetto for the chronically ill, experts said. It would likely become unattractive to carriers and unaffordable to members who could face paying thousands of dollars for premiums and thousands more out-of-pocket before coverage kicks in.

Even though insurers selling unregulated plans would be required to offer full-coverage plans to all comers, they could limit their risk with time-tested maneuvers to repel the sick, said Ana Gupte, who follows health care stocks for Leerink Partners.

“They usually find ways to minimize enrollment” such as jacking up premiums or cutting broker commissions for certain coverage, she said.

Nor would there likely be much choice in high-benefit Obamacare plans, she said. Under the Senate bill, carriers seeking to sell skimpy coverage would have to offer only one high-benefit “gold” plan and a medium-benefit “silver” plan as traditionally sold under the Affordable Care Act.

Even then, the legislation would allow state officials to alter Obamacare standards for out-of-pocket maximums and essential health benefits.

That even could allow richer plans intended for the chronically ill to drop coverage of prescription drugs, mental illness, maternity care or other items.

The bill includes two measures intended to keep costs in high-benefit Obamacare plans from spiking out of control. One is the $70 billion in federal subsidies to help cover the expense of the pool of sick people.

“It seems to me it’s not nearly enough” to keep plans affordable for those with chronic illness, said Timothy Jost, emeritus law professor at Washington and Lee University and an expert on health reform.

The other is a six-month waiting period for applicants wanting to buy full coverage who don’t already have it.

That’s supposed to induce healthy people to buy high-coverage plans and help subsidize the sick. Otherwise they risk a coverage gap if they become gravely ill or hurt, raising the chance they would have to pay thousands out-of-pocket for any unexpected medical expense.

But that incentive to buy comprehensive coverage is far weaker than Obamacare’s mandate, which fined people for not having insurance, Jost said. The Republicans’ bills would scrap the mandate.

“I just don’t think it’s going to be terribly effective,” he said.

Calif. Hits Nerve By Singling Out Cardiac Surgeons With Higher Patient Death Rates

Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.

Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.

“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized,” said Koumjian, whose risk-adjusted death rate was 7.5 per 100 surgeries in 2014-15. “The surgeons that worry about their stats just don’t take those cases.”

Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon.”

This story also ran in the Los Angeles Times. It can be republished for free (details).

California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft.” The practice is controversial: Proponents argue transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.

“This is a hotly debated issue,” said Ralph Brindis, a cardiologist and professor at UC-San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information.”

Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.

California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure. State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.

“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody,” said Holly Hoegh, manager of the clinical data unit at the state’s health planning and development office.

Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged from six to 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.

In this year’s report, the seven surgeons with above-average death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica. Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“For the lion’s share of my career, my numbers were good and I’m very proud of them,” said Pellegrini. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases.”

During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.

Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.

Robertson said in a written statement that he had three very “complex and challenging” cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions.” They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.

“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results,” Robertson said. “Every single patient is different.”

The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.

State officials said that providing surgeons’ names can help consumers make choices about who they want to operate on them, assuming it’s not an emergency.

“It is important for patients to be involved in their own health care, and we are trying to work more and more on getting this information in an easy-to-use format for the man on the street,” said Hoegh, of the state’s health planning and development office.

No minimum number of surgeries is needed to calculate a rate, but the results must be statistically significant and are risk-adjusted to account for varying levels of illness or frailty among patients, Hoegh said.

She acknowledged that “a risk model can never capture all the risk” and said her office is always trying to improve its approach.

Surgeons sometimes file appeals — arguing, for example, that the risk was improperly calculated or that the death was unrelated to the surgery. The appeals can result in adjustments to a rate, Hoegh said.

Despite the controversy it generates, the public reporting is supported by the California Society of Thoracic Surgeons, the professional association representing the surgeons. No one wants to be on the list, but “transparency is always a good thing,” said Junaid Khan, president of the society and director of cardiovascular surgery at Alta Bates Summit Medical Center in the Bay Area.

“The purpose of the list is not to be punitive,” said Khan. “It’s not to embarrass anybody. It is to help improve quality.”

Khan added that he believes outcomes of other heart procedures, such as angioplasty, should also be publicly reported.

Consumers Union, which sponsored the bill that led to the cardiac surgeon reports, supports expanding doctor-specific reporting to include a variety of other procedures — for example, birth outcomes, which could be valuable for expectant parents as they look for a doctor.

“Consumers are really hungry for physician-specific information,” said Betsy Imholz, the advocacy group’s special projects director. And, she added, “care that people receive actually improves once the data is made public.”

But efforts to expand reporting by name are likely to hit opposition. Officials in Massachusetts, who had been reporting bypass outcomes for individual doctors, stopped doing it in 2013. Surgeons supported reporting to improve outcomes, but they were concerned that they were being identified publicly as outliers when they really were just taking on difficult cases, said Daniel Engelman, president of the Massachusetts Society of Thoracic Surgeons.

“Cardiac surgeons said, ‘Enough is enough. We can’t risk being in the papers as outliers,’” Engelman said.

Engelman said the surgeons cited research from New York showing that public reporting may have led surgeons to turn away high-risk patients. Hoegh said research has not uncovered any such evidence in California.

In addition to Koumjian, Robertson and Pellegrini, the physicians in California with higher-than-average rates were Philip Faraci, Eli R. Capouya, Alexander R. Marmureanu, Yousef M. Odeh. Capouya declined to comment.

Faraci, 75, said his rate (8.34 per 100) was based on four deaths out of 33 surgeries, not enough to calculate death rates, he said. Faraci, who is semi-retired, said he wasn’t too worried about the rating, though. “I have been in practice for over 30 years and I have never been published as a below-average surgeon before,” he said.

Odeh, 45, performed 10 surgeries and had two deaths while at Presbyterian Intercommunity Hospital in Whittier, resulting in a mortality rate of 26.17 per 100. “It was my first job out of residency, and I didn’t have much guidance,” Odeh said. “That’s a recipe for disaster.”

Odeh said those two years don’t reflect his skills as a surgeon, adding that he has done hundreds of surgeries since then without incident.

Marmureanu, who operates at several Los Angeles-area hospitals, had a mortality rate of 18.04 based on three deaths among 22 cases. “I do the most complicated cases in town,” he said, adding that one of the patients died later after being hit by a car.

“Hospital patients don’t care” about the report. he said. “Nobody pays attention to this data other than journalists.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

HHS Secretary Tom Price and CMS Administrator Seema Verma Address the Summer 2017 National Governors Association Meeting "The Future of Health Care"

HHS Gov News - July 15, 2017

Today, Health and Human Services Secretary Tom Price, M.D., and Seema Verma, Administrator of the Centers for Medicare & Medicaid Services addressed the future of healthcare at a meeting with governors at the Summer 2017 National Governors Association Meeting in Providence, Rhode Island.

Health and Human Services Secretary Tom Price, M.D.

Full Remarks As Prepared for Delivery

[Excerpts]

"Under President Trump’s leadership—and following his vision for a reformed and renewed federal government—at HHS and across the Administration we are eagerly embarking on a new era of partnership and collaboration with America’s 50 states. And we believe that the basis for a successful federal-state relationship ought to be open and frequent dialogue. 

“So, I’m pleased to be here, not only to talk to you about what’s going on at HHS, but more importantly to listen to—and to learn from—all of you. And you couldn't have picked a more important topic for this morning's conversation—“The Future of Health Care” in America. 

“I say that not because of what’s going on in Congress right now, but because—if you think about it—every time we talk about healthcare we’re talking about its future. In fact, every policy debate—whether we’re talking about healthcare or anything else—is invariably a debate about the future…”

“If someone had told the American people ten or twenty years ago that one of the first priorities of a new president would be setting up a panel on drug addiction and something called the opioid crisis, I think most would have been pretty confused.

“And yet here we are, with opioids being a pressing issue for nearly everyone in this room...States have led the dynamic response to a problem that most never dreamed would get this large or pressing…Of course, there is an important federal role here, too. We have defined five strategies for fighting the opioid epidemic:

  • Improving access to prevention, treatment, and recovery services, including the full range of medication-assisted treatment
  • Targeting availability and distribution of overdose-reversing drugs; 
  • Strengthening timely public health data and reporting; 
  • Supporting cutting-edge research on pain and addiction; and 
  • Advancing the practice of pain management.

“…The opioid crisis and our response to it thus far is a useful case study that ought to inform how we think about the future of healthcare in America, because we aren’t winning that battle—not yet. 

“States have responded aggressively, and Congress has belatedly taken action too. But we need to aim higher—we need to aim for more fruitful federal-state partnerships, more aggressive action on opioids, new approaches to everything from health insurance access to figuring out how to bring down the costs of medicines. 

"As some of you may or may not know, the NGA was founded to address a particular cross-border problem from the state level: the management of inland waterways. 

“You can think of the ever-changing nature of healthcare like a waterway: rivers never stay the same. Their banks, their currents, their level of flow are always shifting. Sometimes it’s imperceptible, but it ends up having huge effects.

“This is how we ought to look at the future of healthcare, and how to get it right: There are constant shifts, some we can see, some we cannot. The only way to address that is to have the most collaborative relationship possible between the federal government, states, and our private-sector and civil-society partners, and to empower those closest to the challenges we face. We look forward to making that a reality under this Administration.”

 CMS Administrator Seema Verma

Full Remarks As Prepared for Delivery

[Excerpts]

“…The Secretary is absolutely right that our healthcare laws and programs need to be able to adapt to the dynamic nature of medicine. And he’s absolutely right that this means we need to empower states with the flexibility and authority they need to create the kinds of policies that meet the unique health needs of their citizens.”

"…So now that I have the privilege of serving as CMS Administrator, my goal is to focus the Agency on offering you more flexibility, so that America’s governors come to see CMS as an ally rather than an adversary.

“That’s why one of the first things we did earlier this year was send a letter to the governors of all 50 states encouraging them to use State Innovation Waivers under Section 1332 of the ACA to develop new, innovative policies tailor made to meet the unique healthcare needs of their citizens. Then, in May, we released a checklist that helps simplify the process for states that are interested in applying for a State Innovation Waiver.

“So far, we’ve been very encouraged by the response. It is clear that many governors are eager to break free from some of the most restrictive federal healthcare regulations and come up with their own solutions that they know will help improve health outcomes for their citizens…”

“In addition, at CMS we are starting a major deregulation initiative that will make it easier for healthcare providers and states to spend more time and resources focusing on delivering high-quality care, and less time and resources trying to comply with complex regulations that don’t meaningfully improve care, quality, or safety.

“We have also been working with members of the Senate to outline new options for states to reimagine coverage in ways that allow Medicaid to work in tandem with tax credits available under BCRA, so that low-income Americans have access to high-quality, affordable coverage.

“Unfortunately, the data I understand was presented to this group does not consider the full-range of funding opportunities available under BCRA, including tax credits, the stability fund, and opioid funding, as well as federal dollars available through the Medicaid.  I take significant issue with this information. 

"BCRA also gives states unique opportunities for states to design systems that ensure their citizens have access to affordable, high-quality coverage.  As everyone in this room well knows, there isn’t a one-size-fits-all solution to every problem. Working with governors and state officials to create programs that address the unique needs of their citizens in a sustainable way has long been a passion of mine, and as CMS Administrator I look forward to continuing that work with all of you well into the future.

“As Dr. Price mentioned, the basis of any fruitful federal-state partnership must be open and honest dialogue, so with that let’s start the conversation. I look forward to answering your questions and hearing your ideas about how we can make healthcare better for your citizens. Thank you.”

HHS announces $80.8 million in grants for Adult and Family Treatment Drug Courts, and Adult Tribal Healing to Wellness Courts

HHS Gov News - July 14, 2017

The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) announces funding of up to $80.8 million over a period of three to five years for treatment drug court programs for people who are involved in the criminal justice system with substance use disorders and co-occurring mental and substance use disorders.

Treatment drug courts combine the sanctioning power of courts with effective treatment services to reduce further criminal justice involvement and promote recovery for people with substance use disorders and co-occurring mental and substance use disorders.  By reducing the health and social costs of substance use disorders for individuals, treatment drug courts improve public safety in communities.

“One of the five key strategies the Department of Health and Human Services (HHS) has identified for fighting America’s opioid epidemic is expanding access to treatment and recovery services, including the full range of medication-assisted treatments. Drug courts can play an important role in connecting Americans to treatment when they need it,” said HHS Secretary Tom Price, M.D. “As HHS has carried out a national listening tour on the opioid epidemic—one of our top three clinical priorities—we have heard from many Americans finding recovery through drug courts, and we are pleased to support such work.”

“Providing needed treatment services for people with substance use disorders and co-occurring mental and substance use disorders who are involved with the criminal justice system benefits everyone,” said Dr. Kim Johnson, director for the Center for Substance Abuse Treatment.  “Treatment drug courts improve health and recovery outcomes, reduce the burden on the criminal justice system, and help people recover in their communities.”

The grant programs included in this SAMHSA effort are:

Grants to Expand Substance Abuse Treatment Capacity in Adult Treatment Drug Court and Adult Tribal Healing to Wellness Courts

The purpose of this program is to expand and/or enhance substance use disorder treatment services in existing adult problem solving courts, and adult Tribal Healing to Wellness courts, which use the treatment drug court model in order to provide alcohol and drug treatment (including recovery support services, screening, assessment, case management, and program coordination) to defendants/offenders.

Forty-four recipients will receive up to $17.8 million per year for up to three years.

List of grantees

Grants to Expand Substance Abuse Treatment Capacity in Family Treatment Drug Courts

The purpose of this program is to expand and/or enhance substance use disorder treatment services in existing family treatment drug courts, which use the family treatment drug court model in order to provide alcohol and drug treatment (including recovery support services, screening, assessment, case management, and program coordination) to parents with a substance use disorder and/or co-occurring substance use and mental disorders who have had a dependency petition filed against them or are at risk of such filing.

Twenty recipients will receive up to $8.2 million per year for up to five years.

List of grantees

The actual award amounts may vary, depending on the availability of funds.

Information on SAMHSA grants in available at:  http://www.samhsa.gov/grants.

For general information about SAMHSA please visit:  http://www.samhsa.gov

 

On The Air With KHN: We Make Sense Of The Senate Health Bill’s Latest Twists

KHN chief Washington correspondent Julie Rovner and KHN senior correspondent Mary Agnes Carey dig into the latest version of the Senate health care bill with colleagues on television and radio, lending their expert insight to what may happen to the Affordable Care Act.

PBS NewsHour with Julie Rovner (July 13):

C-SPAN’s Washington Journal with Mary Agnes Carey (July 14):

KQED’s Forum with Julie Rovner (July 14):

https://kaiserhealthnews.files.wordpress.com/2017/07/forum20170714a.mp3

The Mitch Albom Show with Mary Agnes Carey (July 14):

https://kaiserhealthnews.files.wordpress.com/2017/07/mitchalbom-mac-071417.mp3

Podcast: What The Health? Senate Health Bill 2.0. Still On Life Support

Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Sarah Kliff of Vox.com and Margot Sanger-Katz of The New York Times discuss the changes to the proposed Senate health bill, and whether they can win the 50 votes needed to pass it.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: The Washington Post’s “Senate GOP effort to shield disabled from Medicaid changes would leave many kids on the outside” by Jordan Rau

Joanne Kenen: The Atlantic.com’s “The healthcare cost of homelessness” by Nicolas Pollock

Margot Sanger-Katz: Axios.com’s “Ankle industry rallies behind Medicare pay raise” by Bob Herman

Sarah Kliff: Vox.com’s “The Trump Administration just saved Obamacare in Alaska” by Sarah Kliff

Subscribe to What the Health? on iTunesStitcher or Google Play.

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