Category: Amusements

Health Wonk Review: Ideas of March Edition

published date
March 15th, 2018 by

Beware the Ides of March” –Soothsayer to Julius Caesar
Fear not the Ideas of March” –Health Business Blog to the wonkosphere

If you see something say something

Your friendly neighborhood drug dealer

Count on Drug Channels to make sense of even the most convoluted pharmacy business models –and convoluted they are. This time the topic is the emerging trend of point-of-sale (POS) rebates. Did you know that many pharmacy benefit plans act like reverse insurance, with the sickest members subsidizing the healthiest? POS rebates start to right this wrong and bring forth uncomfortable questions such as: Where have the rebates been going until now?

Crocodile tears

Managed Care Matters shares its perspective that the Administration’s efforts to undermine the ACA have yielded bitter fruit on the marketplaces. Some premiums are up by 30% and meanwhile Congress is doing little or nothing.

Two years ago you couldn’t read the news without hearing about the disastrous premium increases due to “Obamacare,” but the media is silent now.

So what’s going on? Our blogger has a theory: The media is being manipulated and chasing bright, shiny objects.

Skimpy is as skimpy does

InsureBlog likes CMS’s proposal to restore the maximum policy length of short-term medical plans to 12 months from three. That’s even though some news outlets call the plans “skimpy” and some healthcare policy analysts consider such plans to be leeches on Obamacare, because they may siphon the healthiest people out of the marketplace risk pool and drive up premiums.

Location location location

When my son was a toddler, we trained him to say “location location location” when asked, ‘what are the three most important things about real estate?’ I still remember him driving a realtor crazy when one tried to pitch us on a house we didn’t like.

Now, Workers Comp Insider has decided that location is destiny in healthcare, too, declaring ‘It’s the Zip Code Stupid.’ Insider cites a recent JAMA Internal Medicine study that shows geography is “the biggest X-Factor in today’s American Hellzapoppin version of healthcare.”

Location: Wonk zone

The Hospital Leader (not to be confused with the Dear Leader) helpfully explains that “We need creative solutions” really means “the problem we are trying to solve has no answer.” Case study: Hospitals, hospice and SNFs – The big deceit.

A pending bill seeks to establish a state-based individual mandate in New Jersey. But a provision targeting employees of small businesses could inhibit Association Health Plans from selling insurance that does not comply with small group rules. Xpostfactoid explains.

Who knew? Health Care Renewal informs us that the ostensibly libertarian Washington Legal Foundation has become a front for healthcare corporate leaders –and leaders from other fields— to operate with impunity. The foundation’s campaign to abolish the Responsible Corporate Officer Doctrine failed, but the damage was done. (Hat tip to Health Care Renewal for anticipating today’s theme by including “methinks” in its cover note.)

Local talent

The Health Business Blog is now a teenager. I ran the annual round-up of favorite posts by month.

CareCentrix CEO John Driscoll and I rant and rave about Amazon and innovation in the latest monthly episode of #CareTalk.

Singing from the himmnal

Health System Ed shares results from the 2018 US HIMSS Leadership and Workforce Survey, a survey of providers and vendors.

Top themes: privacy and security, process improvement and workflow, data analytics, business intelligence to inform clinical decision-making remain top of mind. 

Well that’s it for the Ideas of March edition. Watch your back today!

By healthcare business consultant David E. Williams, president of Health Business Group.

GOP ignores the Cadillac already in the garage

published date
June 5th, 2017 by
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Cadillac taxi?

The Wall Street Journal is a serious newspaper, so I had to laugh when I read GOP Senators weigh taxing employer health-plans. Apparently Senators are thinking about including a new tax in their Obamacare repeal bill in order to raise revenue, improve equity, and reduce the distorted incentives that divert taxable wages into non-taxable healthcare expenses.

We learn from the article that although it’s a solid policy idea and is being considered by many Republicans, “it could be politically risky, since it could expand the impact of GOP health proposals from Medicaid recipients and those who buy insurance on their own to the roughly 177 million people who get coverage through their employers.”

Republicans accused Obamacare opponents of not having read the Affordable Care Act before approving it in 2010. Seven years later it appears Republicans themselves haven’t read the law that they are now trying to overturn. If they did they would discover that Obamacare already includes this provision, an excise tax on high cost employer plans, nicknamed the Cadillac tax.

It’s far from perfect, but it’s not so bad either. It places a steep tax on corporate health spending above a certain high level, thus limiting the impact to the most serious cases, discouraging healthcare inflation, and phasing the tax in gradually.

So rather than wasting time discussing a new approach where consensus will be hard to forge, all the GOP has to do is leave the Cadillac tax in place. While they’re at it they might consider leaving the rest of the Obamacare in place, too, and working to improve the few areas that need a tune-up.

But I read the whole article in the print edition without finding any mention of the Cadillac tax. Someone must have pointed that out to the editor, because the online version tacked on two sentences at the end about it.

As I argued back in February (Can Congress agree on the Cadillac tax?) limiting the tax deductibility of employer sponsored health insurance is a good idea, but is opposed by a huge array of forces on the left and the right. I advocated then and am suggesting now, to leave the Cadillac tax in place.

By healthcare business consultant David E. Williams, president of Health Business Group.

What's wrong with Trumpcare (so far)

published date
March 3rd, 2017 by

 

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As a college student many years ago I had a summer internship at a top consulting firm, where I learned an important lesson from my boss: “Don’t come tell me about a problem without proposing a solution.” It went without saying that before speaking up I was expected to focus only on real problems, analyze the situation, and propose realistic, logically consistent solutions.

I’m reminded of this lesson pretty much whenever I hear Donald Trump say something, on subjects ranging from immigration to the environment to foreign policy. If he were a summer intern he would have been fired, and We the People should have known better than to hire him for his current gig.

Trump has no problem calling the Affordable Care Act (ACA) a “complete and total disaster” and saying everything should be thrown out the window and replaced with “something terrific.” But if you listen in recent days it’s become clear to me that Trump doesn’t even know what the Affordable Care Act includes. I’m sure if a reporter asked him to name five key elements of Obamacare he couldn’t do it, not that he could be bothered to try.

The things Trump says he wants to achieve are mainly in line with the objectives of the ACA itself. Furthermore, the ACA has achieved some or a lot of success in many of these areas. To the extent Trump has backed different approaches, they are either irrelevant, ineffectual, contradictory, or fiscally unsound.

Trump said in his speech to Congress that he wants to replace the ACA “with reforms that expand choice, increase access, lower costs, and at the same time, provide better healthcare.” He continued with talking points that he and Congressional Republicans have used in the past:

  • Allowing the sale of insurance across state lines –which unlike what Trump said, will not lead to a national market nor achieve the other goals. In any case, selling across state lines isn’t forbidden today but there’s little interest in it from health plans themselves because they would have to set up local networks and wouldn’t have leverage to negotiate with local providers. It’s just policy ideologues and ignoramuses who think this will work. (It also requires contradicting typical Republican views about states rights.)
  • Ensuring that people with pre-existing conditions have access to coverage is a cornerstone of Obamacare, and a successful one at that. So it isn’t something Trump or Republicans can take credit for and was never a GOP goal before the ACA. If we’re going to be pure about a full repeal of Obamacare, why leave this –and other popular provisions—in place?
  • “Giving our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.” –Well if making sure no one is left out is the goal then the states should accept the Medicaid expansion. Shifting to block grants may provide flexibility but won’t add resources
  • The use of tax credits and Health Savings Accounts to allow individuals to buy plans of their choice (not ones “forced by the government”) is just fancy words. Tax credits would have the same objectives as the current subsidies for premiums and out-of-pocket costs but they would probably be less efficient. If the credits aren’t refundable and/or they are based on age but not income, it won’t help poor people buy insurance. And if people can buy whatever plan they want it will help young, healthy people who want bare bones coverage but will make insurance more expensive for everyone else. Already, Trump’s instructions to the IRS not to penalize people who don’t buy insurance is undermining the Obamacare exchanges rather than helping them
  • Malpractice reform. Sorry, that will have no meaningful impact
  • “Bring down the artificially high price of drugs and bring them down immediately” –No word on how that would be done, certainly not immediately.

It’s notable that none of these so-called principles actually deals with improving the delivery of healthcare. They’re all about insurance and financing.

He concluded “On this and so many other things, Democrats and Republicans should get together and unite for the good of our country and for the good of the American people.”

Amen to that. A good way to start would be for Trump and the rest of the GOP to apologize for demonizing and undermining the implementation of Obamacare and then work on improving it. With hardliners from the ironically named Freedom Caucus likely to oppose pragmatic policies, it’s up to the GOP to persuade Democrats why they should go along.

By healthcare business consultant David E. Williams, president of Health Business Group.

Promises promises

published date
November 14th, 2016 by

Post-election Donald Trump is making healthcare promises he can’t keep. Here’s the transcript of Trump’s 60 Minutes interview from Forbes.

Stahl: And there’s going to be a period if you repeal it and before you replace it, when millions of people could lose -– no?

Trump: No, we’re going to do it simultaneously. It’ll be just fine. We’re not going to have, like, a two-day period and we’re not going to have a two-year period where there’s nothing. It will be repealed and replaced. And we’ll know. And it’ll be great healthcare for much less money. So it’ll be better healthcare, much better, for less money. Not a bad combination.

I would love to see great healthcare, that’s much better, and costs much less. But Trump has no idea how to make that happen and neither do his advisors nor the Republicans in Congress. I wonder if they believe their own rhetoric or if they realize it’s BS.

In any case, now it’s their responsibly to deliver.


By healthcare business consultant David E. Williams, president of Health Business Group.

Goodbye Obamacare? More like hello single payer!

published date
November 10th, 2016 by

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Once Donald Trump enters office, Republicans will be in a good position to repeal Obamacare, something they have been foaming at the mouth to do for quite some time. Democrats might be able to filibuster to prevent an outright appeal, although the majority has other ways to gut the law, such as the reconciliation process.

I say let them go ahead and repeal Obamacare without putting up a big fight. As Trump told 60 Minutes, “I am going to take care of everybody. Everybody’s going to be taken care of much better than they’re taken care of now.” He also promised to provide “quality, reliable, affordable health care.”

I look forward to hearing the great ideas revealed by Trump and the Republicans in Congress. If they can do what they say then I’m entirely in favor of it and will give them the credit that’s due.

Meanwhile, I’m going to feel free to criticize the stock initiatives of the Republican party, which were largely mirrored in Trump’s campaign statements:

  • Repeal Obamacare, by which they really mean keeping the popular pieces like making health plans accept members with pre-existing conditions without charging higher premiums, but at the same time jettisoning the unpleasant aspects such as the individual mandate and taxes that help subsidize coverage. Sounds nice, but without a mandate, plans will suffer from adverse selection, premiums will skyrocket, and people will be left uninsured
  • Let health plans sell insurance across state lines. This one is highly touted but in reality it’s a big yawn. The plans themselves have little appetite for moving across borders and even if they did, most new entrants won’t be able to establish strong enough negotiating positions in the markets to bring down premiums
  • Change Medicaid to block grants so states can do what they want with the money. This isn’t a terrible idea because it could allow states to more freely innovate and tailor Medicaid to meet local needs. In practice it’s likely to be used just as a way to screw the poor
  • Promote drug re-importation. Remember the senior citizen buses to Canada in the 1990s before Medicare Part D and the mail order pharmacies with drugs supposedly from Canada, that disappeared once Obamacare required drug coverage? Well, the GOP might bring these back. But the drug market has changed and the most pricey new meds won’t necessarily be attainable from abroad anyway
  • Let individuals who buy their own health insurance take a tax deduction the way businesses already do. Again, sounds great in theory but it’s a regressive approach that rewards higher income people who are in the top tax brackets. It also encourages premiums to rise and widens the budget deficit. The Cadillac tax or some variant that limits deductibility by businesses is more fiscally responsible
  • Expand Health Savings Accounts (HSAs), allow them to be shared among family members and passed on as part of one’s estate. Not a bad idea but hardly a game changer in its own right

Remember, thought, that the Republican ideas above were presented by conservatives, while Trump himself has been at least a liberal and frankly more of a socialist when it comes to health care policy, at least based on his earlier writings. Once he learns that the ideas of the conservatives in Congress won’t produce universal coverage, he may well go back to improving –instead of replacing– Obamacare, moving to a Canadian style single payer system, or opening up Medicare for all, just like Bernie and much more radical than Hillary.

I can’t wait to see how it all plays out.

Image courtesy of Thanamat at FreeDigitalPhotos.net


By healthcare business consultant David E. Williams, president of Health Business Group.