So Many News Events, So Little Blog

Why Not Fast Track the ACA to the Supreme Court?

The Disease Management Care Blog asked the same question as Senator Nelson in this quixotic post weeks ago. The real news is that as a lawyer, the Senator has shown there is an exception to every algorithm.

Career Management 101

The DMCB understands the best time to exit any position is while your reputation is high and before things start going bad. That may be the intentional or unintentional thinking behind Dr. Blumenthal's decision to exit, but that doesn't make it any less true. As studies begin to show that the EHR stampede is not leading to higher quality or lower costs, explaining that sorry news will become the duty of a third HIT Czar.

A Vice President for Patient Centered Medical Homes

All well and good, says the DMCB, but the PCMH will not have truly achieved the pinnacle of corporate medical-industrial success that it so richly deserves until a major health system identifies a Chief PCMH Officer, or CPCMHO for short.

This Is How We Make a Health Law Better?

There's the cost of the ACA and then there is the revenue necessary to fund it. Repealing the 1099 provision addresses only half of the problem. The DMCB fears having Congress oversee the fiscal integrity of the ACA is like having Charlie Sheen emcee a spring break party.

1000 Posts!

Last week, the DMCB broke the 1000 post barrier. Really.

Why Appeals on the Constitutionality of the Affordable Care Act Will Not Be Fast-Tracked to the Supreme Court

The Disease Management Care Blog agrees with the spouse on one key observation about human and organizational behavior: if moms were put in charge, a lot of societal problems would be fixed - and pronto. For starters, war involving their children would end. Our nation's schools would work. 535 legislators would be looking for new employment. Taylor Swift's media ubiquity would cease.

If only.

The DMCB suspects the moms would also favor dismantling all of the lower court legal motions and appeals surrounding the constitutionality of the Affordable Care Act's individual mandate. It's going to end up at the Supreme Court anyway, so it'd be smart to just fast track it, right?

Alas, the moms aren't in charge. After researching the toxic legal issues and partisan undercurrents, the DMCB developed this handy decision tree posted above that amply demonstrates how our Republic can look forward to years of additional legal wrangling before we'll know for sure.

Email the DMCB if you want a pdf!

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Affordable Care Act. No Time For Amateurs. Shenanigans Inevitable.

The Obama Administration is dealing with the many unintended consequences of the Affordable Care Act's (ACA) medical loss ratio (MLR) limits. As readers may recall, setting the MLR at least 80% to 85% was intended to assure that 80% to 85% of the insurance premium was dedicated to paying for medical services. That limited commercial insurers' administrative expenses to 15% to 20%.

Things are not going quite as intended, reports Reed Abelson in an informative article published in The New York Times. A surprising number of health insurers have asked to have that MLR requirement waived by HHS and there may be more on the way. The good news is that the Administration is applying the "special circumstances" granted to it under the ACA to permit waivers if there could be significant market disruptions. While the White House clearly hopes that much of the market turmoil is a function of transitioning between now and 2014, there is the specter that some insurers will be unable to continue in certain markets, period.

All well and fine says the DMCB. The ACA is the law of the land and the Administration is doing what it needs to do on a case-by-case basis. It has only two concerns:

1) The DMCB heard from an NAIC official that the persons in the Obama Administration with all that authority over the waivers are still on a steep health insurance learning curve. In particular, there was a scary anecdote that when news of insurer exits from the "child only" market hit, officials couldn't quite grasp what a death spiral was all about. This is no time for amateurs.

2) It will be very difficult for well-connected lobbyists, insurers and politicians to resist seeking waivers, less on the merits of "insurance" and more on the basis of connections, pull and relationships. The ACA apparently grants huge "special circumstances" power to HHS and the likelihood of shenanigans, given the government's track record, is high. It may even be inevitable.

The DMCB hopes the two concerns are overblown. If not, you read it here first.

Star Wars' Master Yoda Advises President Obama on Health Care Reform: Communicating, The Role of Experts & Top 100 Lists

The virtual Disease Management Care Blog has learned to navigate the duality that bridges particles and waves, channel dark matter and access the cosmic video game that governs humankind's Sim-like existence. It is in that polymension that the DMCB discovered that President Obama and Yoda have communicated.

This exchange was plucked from a bosonic mimetic string and is shared as a DMCB exclusive for your reading pleasure.....

Mr. Obama: Master, my poll numbers on health care reform are in the crapper. I've blamed the insurers and the conservatives again to try to generate better support, but it's not working. What is your advice?

Master Yoda: As wily Cato described has, using the Force is the product but the pitch not. To recognize the flaws in the Affordable Care Act and seek to correct them, you need, young knight!

Mr. Obama: But, Master, I don't have time for that. Midterm elections are a less than a parsec away. What do you think about giving some more speeches in a tour of the heartland, like the Great Communicator?

Master Yoda: The difference learn between communicating and oratory, you must. Yes, hmmm.

Mr. Obama: But President Reagan....

Master Yoda: Silence young one! Speak the name of the greatest Jedi Knight that ever lived, do not. A rare Gladwell Academy Outlier he became.... spent decades writing and giving speeches training his superb communication talent. Many thousand hours at Earth poultry dinner gatherings helped him his skills hone. Just a rookie novice you are. Yeesssssss.

Mr. Obama: Hey, let me remind you that you're just a mix of green latex and computer animation, while I'm President of the United States and Number 1 on this list of the 100 most powerful people in health care.

Master Yoda: Silly, are you. Other insider insurance execs, ivory tower policymakers, politicians and bureaucrats in a closed information loop on that list, see you, hmmm? A way to retread old news and generate web traffic, "Top 100" lists are. Little green droppings on them, I leave. Blah!

Mr. Obama: Hey, now you're sounding like the party of no that got us in this mess in the first place!

Master Yoda: Work on me, your tired rhetoric will not [whack with weenie cane here]. Advise to jettison your mistaken notions into deep space, you I do. Best find advisors who on that Top 100 list are not.

Mr. Obama: But my administration's policy making is being formulated by the brightest folks this country has to offer!

Master Yoda: Of great danger, over-reliance on experts is. Commune exclusively on Planet C-SPAN do they, pretending that Federal healthcare Jabba the Hut is not. Lack day-to-day understanding of patient care, they do! Publish in journals that are read by few. Instead, hologram message view you must from New York Times about the future of publishing, using the wisdom of crowds this is.

Mr. Obama: You are truly wise, Master Yoda. My last question is how I can get the First Lady to don Princess Leia garb.

Master Yoda: Ahhh, brazen young pilgrim. Eternally wise DMCB also frequently that asks. Thinks its spouse looks better than a new star drive when sport she twin buns of hair, says it. When the answer to that find, a true Force become, shall you!

The Affordable Care Act and HHS Oversight of Unreasonable Health Insurance Rates: Is It Good Versus Evil?

Check out this New England Journal July 21 "Truth and Consequences" article that reviews the Affordable Care Act's (ACA) language on the Fed's new oversight of "unreasonable" health insurance premiums. Regrettably, it portrays the folks at Health and Human Services (HHS) as the White Knights come to rescue America from the Black Empire of the Health Insurance Companies. Think of the derring do of a ray-gun toting Princess Leia versus a sociopathic Darth Vader. The good news is that because you read the Disease Management Care Blog, even the Journal's one dimensional storyline can be turned into a short efficient learning opportunity.

If you go online to the ACA and look at Section 1003, you'll see that the HHS Secretary is supposed to establish a "process" to annually review or "monitor" the "justification" for any "unreasonable" health insurance premium increases. This process will not only include the health insurers, but the State Insurance Commissioners. To help them on their way, the Commissioners are invited to dip into a pool of $250 million and, in exchange, give the Secretary their recommendations, including whether an insurer should be listed on their exchanges.

According to the Truth and Consequences article, the ACA is a stand against the insurers' "disproportionate" profits, will buttress the outmatched Commissioners' ability to review rate hikes and provide enlightened and disciplined consistency across the States' regulatory efforts. Yet, the article notes, the ACA ultimately does NOT give the Secretary the power to deny insurance premium increases, which is described as a "lack of regulatory teeth." Another problem is that, now that there's a new HHS sheriff in town, insurers will be tempted to keep premiums down by taking it out on physicians with decreased fees, more administrative hassles, utilization management, a potential return of 1990's style managed care and capitated fees with the inevitable accusations that medical care is being withheld.

The Secretary is now gearing up for this with the announcement that comments are being accepted to help craft the specific regulations that will clarify the "process," "monitoring," "justification" and "reasonableness" language. The DMCB thought it was quite clever when it actually found the web site that is accepting the comments, until it realized that about 230 other groups and individuals have already taken advantage of it.

The DMCB recalls that Ms. Leia could be unpleasant at times. Furthermore, didn't Darth ultimately turn out to be a cuddly saint of a man? Let's look at the world through his black helmet goggles......

The health insurance industry may be making gazillions of dollars but its overall return on investment has been quite anemic. States view the regulation of insurance as one of those powers included in the Tenth Amendment and it still remains how much control they'll cede to the HHS Secretary's potentially intrusive overtures. Critics may charge that health insurers can abandon a State but there are examples of States' wrecking the marketplace with unsustainable demands for low premium levels. The terms "process," "monitor," "justify" and "reasonable" are vague and the final regulations that define them promise to be an overlawyered miasma that will do little to stem our national appetite for more health care. Finally, the insurers were mostly defanged in the 1990's. It'll ultimately be up to the physician community to figure out how to deliver higher healthcare value. If the docs are not up to the task, Plan B won't be the managed care insurers or an evidence-base courtesy of the wise editors of the New England Journal. It'll be the judgment of distant Medicare mandarins holding court in windowless rooms just outside of Baltimore.

Somewhere between all that white and black is a color called grey. To get a sense of that, check out the comments web page mentioned above. The submissions make for interesting reading and run the gamut from pleas to rely on actuarial soundness (the insurers) to demands that they be put out of business (cancer survivors). Hopefully the Obama Administration will put aside its public hostility to the insurers, recognize the Journal's Truth and Consequences article for what it is and steer a middle path.

We'll see.

Getting All Americans Covered Falls By The Wayside

The Disease Management Care Blog gained one major insight during its recent Washington DC health care conference.

In all the talk about "health reform," there was very little discussion about one of the past leading justifications of the Affordable Care Act (ACA): that by giving tens of millions of Americans insurance, there'd be more preventive and screening services, earlier care for chronic illnesses and better access to hospitals after unexpected illness. It was argued that disease detection would be increased, and disease progression would be decreased and avoidable high-cost complications would be... well... avoided. The expensive and shameful "hidden tax" of unnecessary and inefficient cost-shifting would be replaced by enlightened and cost-effective public financing.

There may be merit of the argument, but it's conspicuous absence at a D.C. conference and, by the way, in many of the health journals, policy media and blogs makes the DMCB think that many of the cognoscenti silently doubt it. Ask policymakers and academics about bending the cost curve today and what you'll get is a refrain consisting of bundled payments (that intelligently capitate physician services), primary care medical homes (that shift health services to a cheaper level of care) and accountable care organizations (that align all the economic incentives).

The DMCB sees the merits of each of those concepts. Congress obviously did also when it mandated them in a variety of demos and pilot programs. What's more, the ACA is remarkable for the power it gives to the HHS Secretary to rapidly expand them, and to do so without Congressional approval.

Which is the rub. While the Secretary's flexibility is a good thing, the one thing that is standing in her (or his) way is that the pilots/demos really have to show cost savings. While many of my colleagues believe that is a mere formality, the DMCB recalls many in the disease management industry felt the same way about Medicare Health Support Demo. It didn't quite work out as planned.

Which brings the DMCB to the ultimate question: if the pilots and demos don't work, just what is "Plan B?" The answer at the Conference, for Medicare at least, was across the board delays in any scheduled fee schedule increases and/or reductions. Yikes.

Which is the insight. The discussions about the possibility of across-the-board cuts may have greater visibility today than merits of extending insurance to the uninsured. It's not out there in the media. so you read it here first.

The DMCB will continue to monitor this.