Robert B. Doherty, Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
With the first annual open enrollment period for the Affordable Care Act down to its final few weeks, you are going to hear a lot of spin about the numbers. The end of March will be the first real test of ACA enrollment, because as of April 1, most people will have had to enroll in a health plan that meets the law’s requirements or pay a fine (equal to 1 percent of their taxable income, or $95, whichever is greater).
By the end of March, will the administration be able to say that it met its latest marketplace enrollment target of 6 million (which was lowered from its original 7 million)? As of February 25, the administration reported that 4 million had signed up.
How many who selected a plan will have paid their premium, and if they haven’t, how many will end up being dropped from the enrollment totals? How many will receive tax credits to help them afford the marketplace plans? How many will choose a plan in each tier? Will there be enough younger and healthier people enrolled to offset the costs of covering older and sicker people? If that number falls short, will it lead to a “death cycle” in premiums because insurers will have to raise rates to everyone else?
Neil I. Goldfarb
A friend of mine whom I’ll refer to as Jasper (not his real name) is a 40-something year old male who was diagnosed a few years ago with Parkinson’s disease. Several months ago he gave me a call, knowing that I have a health benefits background. Jasper had learned from his physical therapist that he was approaching the limits his health plan placed on the annual number of physical therapy sessions. The physical therapist had told Jasper not to worry, when the limit was reached, the office would re-file his case under a new diagnosis, which would trigger a new benefit-eligible episode of care, allowing it to continue delivering service, billing for it, and getting reimbursed for it.
Jasper was relieved to know that clinical services that seemed to be helping him maintain his strength and physical activity would be continued, but he realized he would continue to be responsible for a 20% co-payment. “What do you think I should do,” he asked, “should I continue with my therapy?”
“Well, let’s start with the question of how willing you are to commit insurance fraud,” I asked. I explained that “filing under a new diagnosis,” when in fact it was just more service addressing the same old diagnosis, was fraudulent. Undoubtedly, being able to continue billing under a fee-for-service arrangement would benefit the provider, but I asked Jasper to think about whether the additional physical therapy visits would benefit him.
David B. Nash, MD, MBA, Founding Dean of the Jefferson School of Population Health
Health reform means, in part, practicing a different kind of medical care. This new care will focus on the care of entire populations that we serve, not just on individual patients. While every individual is, of course, important, the healthcare system will soon be held accountable for outcomes of care across larger groups. These populations may be defined by persons with the same insurance coverage, folks in the same zip code, or even everyone who has diabetes in a clinical practice. We know that the health of populations is largely determined by so-called “social determinants of health” – factors like socioeconomic status, crime, and pollution. Yet, we are just beginning to understand their full impact.
The United States, despite its outsize spending on health care services, ranks only 17th in the world with regard to our national health status. It seems clear to many experts that we are not getting the best return for the money we are spending!! Shifting the focus to population health may change that.
If you are interested in these kinds of critical issues, I urge you to attend the 14th Annual Population Health Colloquium to be held in Philadelphia on March 17 through the 19th at the Loews Philadelphia Hotel. Among the major national figures who will be speaking are Dr. Jeffrey Brenner of the Camden Coalition (recent MacArthur Genius Award Winner and fellow Field Clinic blogger), the CEO of Humana, the Commissioner of Health for the State of New York, and the President and CEO of Thomas Jefferson University and its health system. Since health care is one of the largest and most important “businesses ” in our region, we all have a stake in the transition to a population health focus. You can learn more about this important conference by visiting http://www.populationhealthcolloquium.com, or by calling 215-955-6969.
Janet Weiner, MPH and David Grande, MD, MPA
Last week, Gov. Corbett submitted his Medicaid expansion proposal to the federal government. By most accounts, this proposal, which entails work-search requirements, premium payments, and changes to existing benefits, faces significant obstacles to federal approval. Even if approved, Medicaid coverage for nearly 300,000 uninsured people will not begin until January 1, 2015 at the earliest.
Why didn’t Pennsylvania choose to expand Medicaid on January 1 of this year, as 26 states have done? According to Gov. Corbett, the current program (one of the costliest in the country) is too bloated and too inefficient to simply expand. “We need to reform the entire Medicaid system that already exists before we do this other,” he said.
But there’s a problem in this logic. Gov. Corbett’s proposal does little to address the reason that Pennsylvania’s Medicaid programs costs so much. It focuses on reducing the costs of working-age, non-disabled adults, both in the existing and expansion population. They are not the costliest Medicaid enrollees, however. Those are beneficiaries who are elderly and disabled, and the costliest services that they receive, long-term care, are not part of the proposal.
Elizabeth A. W. Williams, Senior Vice President & Chief Communications Officer for Independence Blue Cross
As recently as last year, nearly 50 million Americans didn’t have health insurance. With the implementation of the Affordable Care Act (ACA), this has started to change. Beginning January 1 of this year, millions of Americans, including hundreds of thousands in the Philadelphia region, have gained access to health insurance for the first time.
But the reform law is just a first step. The U.S. health care system still faces significant challenges — first among them, inconsistent quality and costs that continue to rise. These problems are so large and complex they cannot be addressed with yesterday's solutions.
In fact, finding sustainable solutions to raising the quality and lowering the cost of health care requires a level of change and innovation that the law simply does not provide. Fortunately, this region has all the right components to create the health care innovations needed to tackle these challenges: world class universities, renowned teaching hospitals, talented and dedicated physicians, a strong health and life sciences economy, and an active entrepreneurial community.
Donald Schwarz, MD, MPH, Deputy Mayor for Health & Opportunity and Health Commissioner for the City of Philadelphia
If Pennsylvania were looking for new slogan, it might consider this: “Our state needs workers!”
In 1950, there were 8.7 working adults in Pennsylvania for every person aged 65 and older. Today, that number has dropped to fewer than four.
It’s clear from this demographic shift that Pennsylvania should be doing everything it can to retain and increase its workforce. Our tax base and our economy depend on it.
Antoinette Kraus, Director of the Pennsylvania Health Access Network
Last week, headlines read: "Devastating News for Obamacare: Over Two Million Workers Will Lose Jobs,” and Obamacare will push two million workers out of labor market." Contrary to these fear-inducing, sensationalized storylines, instead of losing jobs by the millions, Americans, for the first time, will enjoy the freedom and flexibility of leaving the workforce voluntarily. The CBO report that incited critics of the healthcare law actually makes it clear that the decline in workforce participation is not due to employers cutting jobs, but rather to workers choosing to work less.
The CBO report finds that the Affordable Care Act markedly increases the number of Americans with health insurance. The law gives individuals and their families the ability to access healthcare beyond the restrictions of employer-sponsored coverage. This coverage is portable and affordable, meaning that workers now have the freedom to choose -- they're free to take a risk and start a small business, free to take two years out of the workforce and get that college degree they never got a chance to finish, free to simply scale back their hours and spend more time at home with the kids.
Earlier this week, we met a mother of five from Philadelphia who, for years, had worked both a full-time job and a second, part-time job just so she could have health benefits. The 60+ hour work weeks exacted a heavy toll on her, keeping her away from her young children, and leaving her with the anguish of choosing between the health care she needed and seeing her children grow up. Frustrated and exhausted, she chose her family, and left the part-time job, knowing that it would mean gambling with her health. That was in 2012 -- she's been uninsured ever since. On March 1st, her new Marketplace health coverage will kick in and she'll have the peace of mind that comes with being covered.
David B. Nash, MD, MBA, Founding Dean of the Jefferson School of Population Health
After four years of medical school, physicians enter that “twilight zone” known as residency training. This intensive, hazing-like program of on-the-job training is characterized by very long hours and increasing levels of responsibility. I’m sure many readers have been in the great teaching hospitals that are bursting at the seams with residents. However, even the most educated people oftentimes have no idea that they are not only paying for this training, but they’re sometimes getting a raw deal to boot!
Post-medical school training, called Graduate Medical Education, or GME, is primarily funded with public money, to the tune of $10 billion dollars a year, paid by Medicare. Your tax dollars, in part, go to pay the salaries of physicians in training. Currently, the average resident makes $112,642 per year, but on an hourly basis, that’s about on par with an unskilled laborer without a high school diploma.
GME is divided into two components. Direct GME takes up about one-third of the dedicated Medicare funding; that pays for the trainees and the supervising faculty who watch over their work in the hospital. The other two-thirds is called Indirect GME. This compensates teaching hospitals for the higher costs associated with training new physicians and for the “lower clinical efficiency” - these new doctors tend to order more tests and are not as efficient as their older, more experienced colleagues.