Bifurcation of America

Minnesota and New York are getting to the levels of universal coverage that most European nations have. They are tweaking their systems and prepping waiver requests to extend coverage to currently excluded populations and improve affordability.

We get graphs like the following:


And then we have Texas (via the Texas Tribune)

For the first time in more than a decade, Texas’ uninsured rate dipped below 20 percent, analysts said Wednesday following the release of U.S. Census data.

Slightly more than 5 million Texans were uninsured in 2014 — a 700,000 decrease from the year before. That represented a 3-point dip in the percentage of Texans without health insurance, to 19 percent — the largest gain in health care coverage in Texas since 1999, according to the left-leaning Center for Public Policy Priorities….

the Census sampling, known as the American Community Survey, lends new credibility to earlier claims that Texas continues to lead the nation in the raw number — and rate — of people without health insurance.

We have a framework that can reduce the ranks of the uninsured to near OECD (Organization of Economic Cooperation and Development — the industrialized countries of the world) standards.  It can be implemented and it can work.  It mainly requires political elites to give a shit.


The Medicaid managed care value proposition

Raven asked a  good question in comments:

I don’t understand that privatized Medicaid stuff — what value do the care management firms add? But they do take a cut…

This whole idea that a business bureaucracy is somehow more cost-effective than a government bureaucracy strikes me as a load of bullocks. What’s the business model — underpaying the office staff?

Mayhew Insurance has a Medicaid managed care organization (MCO) contract.  I have spent quite a bit of time in the past two years working on MCO projects, so take that as you will.

What is the value proposition for a state to go the MCO route?

I see several.

  • Cost predictability
  • The ‘Bob’ or the external evil bastards
  • Preventative care improvements

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SEP verification and a privilege check

This is a continuation of the Special Enrollment Period verification conversation from earlier in the week.  I am of the opinion that the new CMS requirement for eligibility verification for the four major qualifying events is a reasonable accomodation to insurer’s needs to promote a more stable market and for people with legitimate qualifying events, not a significant barrier.  Someone I greatly respect disagrees.


The five major QE’s that make up 75% of the SEP triggers that now need verification are:

  • Loss of minimum essential coverage
  • Permanent move
  • Birth
  • Adoption, placement for adoption, placement for foster care or child support or other court order
  • Marriage.

From my perspective, the triggering event produces official paperwork in four of the five scenarios and that paperwork arrives very quickly.  It is not a case of an individual needing to find an original birth certificate from halfway across the country.  Is my middle class privilege overwhelming reality here?  I don’t think so, but I need a reality check

The loss of minimum coverage triggers a COBRA eligibility letter if the loss of coverage is because of a job loss that had ESI.  If an individual makes too much for Medicaid or otherwise loses Medicaid/CHIP, a termination letter with appeals rights is sent.  If the loss is due to the non-payment of premium, termination letters are sent.  This is recent paperwork.

Birth of a new baby produces lots of poop and a birth certificate.

Marriage produces a marriage license.  Divorce produces a divorce decree.  Both of those documents are freshly produced after 1/1/16.

Adoption, foster care, adoption placement, and child support produces reams of legal documentation and orders.  And again, this is fresh documentation after 1/1/16.

The hardest one to prove for some people is permanent move.  Middle class individuals can easily produce a signed lease or a mortgage or several bills at a distinct address.  However, people who are far less connected to the system may be using informal housing arrangements without leases or documentation, and they may only have a few bills and no bank account.  Those bills could be paid online and thus it would not matter if they all still went to a parent’s address 2 states away as they always were thrown away.  This is a challenge in my mind, but that is the only QE that is not guaranteed to produce recent verification documentation.

Does this make sense?

Congress working

The Senate is actually working on a real solution to a real problem where technical experts are being listened to, bi-partisan coalitions have been formed with Senators from opposing parties seeking to find ways to solve a common problem.

Someone please pass me the smelling salts as this is actual good news:

From the Pittsburgh Post Gazette:

The bill was introduced by Sens. Pat Toomey, R-Pa., and Rob Portman, R-Ohio. Sens. As primary co-sponsors, Bob Casey, D-Pa., and Sherrod Brown, D-Ohio, also have been shepherding it through Congress….

As part of an effort to prevent opioid abuse, lawmakers are teeing up legislation that would limit Medicare Part D beneficiaries to a single pharmacy and a single provider for narcotics….

The GAO estimates that 170,000 Medicare enrollees have engaged in doctor shopping, where they go to multiple doctors who then typically unknowingly write duplicative prescriptions that are then filled at multiple pharmacies for the very same painkiller,” Mr. Toomey said. “It’s an easy way for people to find commercial-scale quantities of opioids which they can then sell on the black market.”

Medicaid has a lock-in program which limits individuals who are identified through claims and prescription data as engaging in doctor shopping behavior.  The criteria varies by state.  In mine, it is seeing enough doctors to organize a pick-up basketball game and filling those prescriptions at several pharmacies that trigger the red flag.  The idea behind lock-in is that it forces an individual who has been doctor shopping to choose a single provider who sees on their medical records that this person has a history of opioid seeking behavior.  The single pharmacy restriction allows a pharmacist to see the same faces and act as a backstop when usage becomes an outlier which would suggest significant diversion.

As long as there is a reasonable national criteria for what constitutes opioid seeking behavior in the Medicare population, this bill makes a good amount of sense to reduce but not eliminate a pressing national problem.

This is a win.  The challenge is getting this bill to President Obama’s desk without it being tied up in half a dozen other pieces of legislation which contain unrelated poison pills.

Not observing games

PPACA has been attempting to bend the cost curve by penalizing stupid and avoidable errors.  One class of errors that has been amenable to reduction has been Medicare beneficiaries getting  re-admitted to hospitals  after their initial admission for a set of circumstances.  As soon as data started to be collected and before penalties started to be imposed, the readmission rate crashed.  Since penalties have been imposed, the rate is still going down but at a slower pace.  This does two things to the cost curve.  First, it reduces direct Medicare expenses as Medicare is not paying for another hospital day.  Secondly, changes in practices and procedures that result in lower Medicare readmission rates tend to diffuse throughout a hospital and all of its patients so people who are not covered by Medicare also benefit from the improvement in practice.

This sounds great.  We save money, save Grandma as hospitals are where old people die, and get better quality care.

However, wonks have worried that any quality measure that has real money attached to it can and will be gamed.

The easiest way to game a re-admission measure is to redefine admissions.  Hospitals have the ability to put people on “observation” status where to anyone but the billing and quality metrics department, the person looks like they are admitted.  They get the uncomfortably flimsy robe, they get the wrist band, they get poked and prodded and monitored just like an admitted patient.  They can stay in observation status for a time period including one midnight.  Yet these individuals are not part of the “admitted” or “re-admitted” population universes.

There was a possibility that a significant chunk of the seemingly great decline in readmission rates was really a bureaucratic shift of people getting moved from short term admissions to observation status.

That is not the case.

The New England Journal of Medicine  * has an interesting study on this matter:

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