Wednesday, December 11, 2019

Greed Outranks Compromise in Congressional Attempts to Fix Surprise Medical Bills

There are few things in our health care system that are more unfair than surprise medical bills. Consumers think they have good coverage and are getting treatment in their health plan network only to get a huge unexpected bill in the mail because it turned out that something like the anesthesiologist at their recent surgery wasn't covered.

How were they to know that? As you're sitting on the gurney about to be rolled into surgery do you need to do a provider roll call asking each to confirm their network status?

The worst of these examples often has to be with air ambulances sending patients bills for tens of thousands of dollars they had no reason to expect. As the patient lays there with burns over 60% of their body and they need to be transferred to the regional burn center, are they supposed to say, "Before you put me on the helicopter, what is this going to cost?

Now, every politician I know of says that all of this needs to end.

But, they are yet to end it.

Both sides on this issue have legitimate concerns.

Insurance companies, employers, and union plan sponsors (payers) find themselves caught between their customers and health care providers in these circumstances. Some of these providers actually have business strategies to purposely not be in a network looking to charge anything they want in these situations. That is not to say health plans couldn't be doing a lot better in making their networks clear to patients––Why in this world of real time data can't health plans and providers confirm that all providers who are part of my procedure are in the network at point of service?

Hospitals, doctors, and other providers worry that some of the proposed solutions would de facto toss them into the payers' networks at the network's typical payment rates thereby disenfranchising them from being able to negotiate what their payment rates should be.

Like everything else in the American health care system, it's complicated.

When you have two sides offering legitimate but diametrically opposed arguments the solution can only come through compromise. And, I will suggest, when such a circumstance occurs in a matter involving public policy, it is the role of the legislature to impose a compromise that, as its first priority, meets citizen needs.

Last Sunday, led by Senate Health Committee Chair, Lamar Alexander (R-TN) and the House Energy and Commerce Chair Frank Pallone, Jr. (D-NJ) and ranking member Greg Walden (R-OR), it sure looked to me like a powerful bipartisan group in Congress did just that.

They offered a solution to this problem that was responsive to both sides arguments and would end up holding patients harmless from all of this.

If a patient is out of network and the provider refuses to accept the plan's payment:
The provider would have to accept a minimum payment reflecting the plan's market-based median in-network negotiated rate for the service in the geographic area where the service was delivered.
This compromise would force the provider to accept a payment amount but it would be the median of all amounts that had already been negotiated in good faith in that market with a large number of providers.

But, providers could still have a reasonable objection arguing they should be able to negotiate their own rate and perhaps their circumstances justify a higher rate than the median.

Of course, they can always enter negotiations with the payers to be in their network in the first place.

But failing that, the proposed compromise would also give providers an out:
If the median in-network rate payment was above $750, the provider or the insurer could elect to take the matter to binding arbitration with an independent dispute resolution service. To keep people from gaming the system, a party could not go to arbitration for the same service more than once in 90-days.
This is what I would call a compromise. Neither side gets all that they want, both get something reasonably resembling what they have asked for (payers wanted a median rate, providers wanted arbitration), and the consumer/patient caught in the middle no longer has to suffer from all of this.

So, what has been the response to this so far:

Insurance companies, employers and union plan sponsors don't like it––the Coalition Against Surprise Medical Bills––said anything with arbitration wasn't good enough, "The result of arbitration is that consumers, employers, unions, and taxpayers pay the price" pointing to what they said was abuse by providers in an existing New York arbitration system.

On the other side, providers generally objected. The American Hospital Association said the proposal would, offer an "arbitrary...reimbursement rate," jeopardize patient access to hospital care," and "provide a huge windfall to commercial insurance companies at the expense of community hospitals."

Under pressure from the payer lobby on one side and the provider lobby on the other, leading members of Congress have been leery of supporting the proposed compromise. For example, the ranking Democrat on the Senate Health committee, Patti Murray (D-WA), didn't join in support of the bill reportedly because Democratic Senate Minority Leader Chuck Schumer (D-NY), responding to hospital lobbying in his state, waived her off.

Much has been made of the current toxic political environment in Washington, DC and the inability to get things done because of it.

But here is an example of bipartisan leaders in Congress hammering out a reasonable compromise in spite of that.

But so far, and with time running out on this Congress being able to get something done this year, when year-end must pass pending bills provide a vehicle for passage, old fashioned special interest greed politics still out ranks finding a solution for regular people.

I sure hope none of these politicians, more interested in carrying the water for the special interests than worrying about their constituents, don't need an air ambulance over the holidays!

Monday, December 9, 2019

The Trump/Republican 2020 Health Care Plan

The Republicans don't yet have a health care plan less than a year before the 2020 elections.

But based upon their 2017 Obamacare repeal and replace efforts, as well as a major document recently issued by the House Republican Study Committee, what might a Republican plan look like?

Monday, December 2, 2019

Elizabeth Warren Backs Into the Public Option and Effectively Takes Medicare for All Off the Table for Democrats in 2021

Medicare for all is dead because Democratic voters aren't buying it.


Fixing Obamacare and adding a public option is the health care policy territory first staked out by Democratic Presidential candidate Joe Biden.

Writing about Biden's plan recently on this blog, I said:
IF the Democrats capture the White House, keep the House, and take over the Senate, no matter who they elect as President, this Biden health care outline, not Medicare for all, will likely be the plan Democrats embrace in 2021.
Not even I thought Elizabeth Warren would act so quickly to move off her only days-old detailed Medicare for all plan and onto about the same place all of the leading Democratic candidates, save Bernie Sanders, sit on health care––just fixing Obamacare and adding a public option.

Tuesday, October 29, 2019

Medicare for All––the Bernie Sanders and Elizabeth Warren Health Care Plans

The Question That Single-Payer Medicare for All Advocates Need to Answer


You are probably thinking that question is, How are you going to pay for it?

Ultimately, yes.

But, I will suggest there is another critically important issue that is part of the overall question about how it will be paid for––What will your plan do to our existing health care system?

Medicare and Medicaid cost less than commercial insurance because Medicare and Medicaid pay providers––doctors, hospitals, and other health care providers–– a lot less for their services.

Advocates argue their single-payer Medicare for all health care system will overall cost us all a lot less. They are right that their systems can be a lot less expensive by expanding Medicare to everyone––primarily because government payment rates are so much smaller.

But here's the hitch––paying Medicare rates on behalf of all patients would literally bankrupt the system we have.

Wednesday, October 23, 2019

The Public Option's Silver Lining?

Joe Biden's Health Insurance Plan Would Fix the Individual Health Insurance System and Have the Potential to Politically Stabilize the Entire Private Health Insurance Market for Decades to Come

Biden's Public Option


In a prior post, I argued that the Biden health plan directly takes on the most problematic parts of Obamacare by making individual market coverage affordable––and would therefore make the individual insurance system much lower in cost and therefore financially sustainable.

A lower cost individual market would also make the entire private insurance market more politically sustainable––if people find their coverage affordable why move to a complete government takeover such as Medicare for all?

As part of his plan, Biden also calls for a "public option."

Monday, October 21, 2019

Joe Biden's Health Insurance Plan Would Fix the Individual Health Insurance System

IF the Democrats capture the White House, keep the House and take over the Senate, no matter who they elect as President, this Biden health care outline, not Medicare for all, will likely be the plan Democrats embrace in 2021


The Biden health care proposal directly takes on the big things that haven't worked in Obamacare.

Wednesday, October 16, 2019

Obamacare is "Stable" at an Incredibly Unstable Place

The Democrats Want to Move Beyond Obamacare Because We Have No Other Choice

 

Before I start talking about the presidential candidates' health care plans, let's review just exactly where we are with the Affordable Care Act (Obamacare).

Monday, October 14, 2019

There is Now No More Support for a Medicare For All Single-Payer Health Care Than There Was in 1977, or 1993, or 2009

Buy HMO Stocks––They're a Bargain

The more things change the more they stay the same.

With many of the Democratic presidential candidates' flirtation with Medicare for all, the topic is once again front and center going into the 2020 presidential campaign.

Just like it was when Jimmy Carter ran on a Medicare for all platform in 1976––and it turned out there weren't the votes for it in 1977 even though Carter had a filibuster-proof 61 Democrats in the Senate and a whopping 292 Democratic House seats. In fact, Carter failed to move any significant health care legislation.

In 1993, the Clintons didn't even try to move a single-payer plan even though the Democrats controlled 57 Senate seats and 258 House seats because only about half of the House Democrats favored a single-payer system.

The same for 2009 when both Hillary Clinton and Barack Obama ran on health care platforms during the primaries that looked a lot like the eventual Obamacare because again only about half of the House Democratic caucus favored a single-payer program.

Now in 2019 we are in the very same place we were in 1977, 1993, and 2009––only about half (118 as of September 6th) of the House Democratic caucus now supports the Medicare for all proposal introduced by Progressive Caucus Chair Pramila Jayapal (D-WA).

Wednesday, January 16, 2019

Is the Drug Industry an Existential Threat to the Private Health Insurance Business?

At a time when many Democrats are calling for a single-payer health insurance system, are the drug companies inadvertently driving the system on a course to that end?

Consider this.

Thursday, November 8, 2018

What Neither the Republicans Nor the Democrats Understand About Obamacare

The 2018 Elections Were Not About Obamacare--They Were About Health Insurance Security 

 

The 2018 midterm elections weren't a tsunami for Democrats--more like a blue wave hitting a red wall.  

 

Democrats are claiming the election vindicated Obamacare because they were successful in gaining control of the House of Representatives by criticizing losing Republicans for their votes to repeal the Affordable Care Act--including its key consumer protections.

 

My sense is that both Democrats and Republicans have missed the critical point.

Both sides don't understand that this was not about Obamacare. It was about health insurance security.

Friday, May 11, 2018

The Simple, Obvious, Time Tested Way to Reduce Drug Costs

I give the President great credit for shining his spotlight on the ridiculous place the U.S. finds itself over drug prices. They are way too high, the private market has proven incapable of dealing with it––PBMs have only made the drug market more opaque, and the biggest drug purchaser in the world, the U.S. government, has been politically unwilling to deal with it.

All while other industrialized countries have nowhere near the problem.

What is even more frustrating is to see an easy solution that has worked for years in these other industrialized countries that, rather than being a single-payer government-run solution, is as American-style free market as it could be.

Thursday, March 8, 2018

The CIGNA - Express Scripts Merger––So Much for Price Transparency and Competition

CIGNA just announced that it will buy pharmacy benefit manager (PBM) Express Scripts for $67 billion. In December, CVS said it would buy Aetna for $69 billion.

Already, UnitedHealth, through its Optum data technology and OptumRx pharmacy benefit manager subsidiaries, has detailed health care utilization information on over 115 million consumers, four out of five hospitals, 67,000 pharmacies, 100,000 physician practices, 300 health plans, and government agencies in 34 states and D.C.

Remember the good old days when we complained about the health insurance company oligopoly with just a few players controlling most of the market share in any given market?

We appear to be quickly on the way to a new and different kind of oligopoly controlling an even wider swath of the market with these new health care system aggregators being created.

Wednesday, January 31, 2018

Bezos, Buffett, Diamond, the Latest Newbies on the Health Care Block

I found it incredible that health care stocks tanked on Tuesday in response to an announcement from the Amazon, Berkshire Hathaway, and JPMorgan Chase CEOs that they were, as employer payers, going to become game changers in the health care market.

I have seen this movie before. Dozens of times over the last twenty-five years. The first time was when the leading employers in the Minneapolis-St. Paul market began the same effort in the early 1990s. That, and any other such initiative I have seen over the decades, went essentially nowhere.

But, this week, reporters were agog with the notion that these titans of business were going to wade in and change the health care world. After all, together these companies had a combined population of a million-people covered under their health benefit programs.

That is about as many people as Rhode Island and Delaware Blue Cross combined cover. So, I am not quite sure how these CEOs will bring a game changing critical mass to any provider bargaining table.

Wednesday, November 15, 2017

GOP's Obamacare Tax Scheme Will Create an Insurance Nightmare for the Middle Class

Senate Republicans just announced that the repeal of the individual mandate (in the form of reducing the penalty tax to zero) will be in the Senate Finance Committee's version of tax reform.

The individual mandate has never been successful toward the objective of attracting people to the program. There are much better ways to do that.

But killing the mandate while simultaneously opening up the market to cheaper stripped down alternatives would combine to create unintended consequences the Republicans haven't appeared to comprehend.

Thursday, October 19, 2017

The Outlook for Stabilizing Obamacare in 2018 and the President Who Can't Shoot Straight

The Alexander-Murray bipartisan effort to stabilize the Obamacare individual insurance markets will not pass the Congress on its own. 

The only chance it now has is to be added to a must-pass legislative deal, such as the one needed to fund the government by the December 8th deadline in order to avoid a government shutdown.

Also sitting in the queue, and certain to pass at some time, is the Children's Health Insurance Program (CHIP) reauthorization bill. The Congress is currently struggling over the pay-fors for this reauthorization but there is wide bipartisan agreement that it must be funded before the states start running out of money, which will begin in a few weeks. CHIP now covers nine million kids.

Conservative Republicans are adamant that they do not want to pass an “insurance company bailout” bill like Alexander-Murray. Particularly in the House, where Republicans were able to pass a "repeal and replace" bill, these members have already taken a controversial vote to cut Medicaid and insurance subsidy support and after that tough vote don't now want to have to explain why they have backtracked to "bail out" Obamacare with the Alexander-Murray short-term patch bill.

Sunday, October 15, 2017

Donald Trump Doesn't Know the Diffrence Between an Unfunded Mandate and a Bailout

By killing the cost sharing reduction (CSR) subsidies has Trump stopped what he has called an "insurance company bailout"? Or, has he created an unfunded mandate?

The Obamacare statute requires the health plans to provide cost sharing reduction subsidies to reduce the deductibles and co-pays in the Obamacare compliant individual health insurance market for those who make less than 250% of the federal poverty level. It is a mandate. Funding a mandate is not a bailout. In Washington, DC we call failing to fund a mandate an unfunded mandate.

What Trump's Obamacare Cost Sharing Subsidy Rollback Means to Health Insurers and the Middle Class

My NPR All Things Considered Interview with Michel Martin:

MICHEL MARTIN, HOST:
We have one more conversation about healthcare. As we just heard, health insurers are trying to figure out what to do without the [cost sharing reduction] reimbursement from the government that the Trump administration says will no longer be paid. The question is, will insurers raise their rates or withdraw from the health exchanges created by the Affordable Care Act? For perspective on this, we called Robert Laszewski. He's a former insurance executive who's now a health policy consultant. Mr. Laszewski, thanks so much for speaking with us.

ROBERT LASZEWSKI: You're welcome.

MARTIN: So based on your knowledge of the industry, what are the options that insurers are considering to deal with the lack of these subsidies?

Wednesday, September 20, 2017

The Republican Senators' Cassidy-Graham Conundrum

If you were a Republican Senator today, would you rather risk losing your Senate seat because the base was angry with your failure to pass an Obamacare repeal and replace plan, or because you did pass it but blew up the insurance system?

See my op-ed at CNBC.com

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