How Can This Affordable Care Act/ACA Be Affordable?


Happy Day after Halloween!

Another debate down and there are no real solutions or reasonable strategies to our problems. The “debate”, if you want to call that travesty a debate, served no one and really didn’t give anyone a better picture of who to vote for or support. Although I still like Ben Carson, Chris Christie and Mr. Rubio for President and will support these possible candidates over the already crowned Queen Clinton.

However, this week I received my statement for my ophthalmologist visit last month and was appalled that my Medicare or my supplemental insurance covered none of my exam as billed by my ophthalmologist. So, once again we are witness to a system that doesn’t encourage wellness, instead makes it more expensive for the patient to have good heath care coverage.

Now add in the following progressive changes.

An analysis shows the monthly premiums for many people with Obamacare (i.e. the Affordable Care Act/ACA) policies will not much change in 2016. But the high increases of some policies are drawing fire.

Rob Colvin recently wrote that some health insurance companies are asking for big price increases next year, and that has again riled critics of the federal health care law. But early analysis shows those steep hikes may not affect the majority of consumers.

The numbers released last week came out of a June 1 deadline, under the Affordable Care Act, that requires insurance companies to tell government regulators when they’re requesting price hikes of more than 10 percent. Some officials opposed to the law, like Sen. Steve Daines, a Republican from Montana, decried the increases.

“Blue Cross Blue Shield, which is Montana’s largest insurer, is asking for an average increase of 23 percent for Montanans enrolled in individual plans,” he told colleagues from the U.S. Senate floor last week.

While that sounds scary, it turns out that Blue Cross Blue Shield in Montana is actually asking for large price hikes on just two plans it wants to offers in the state. While it’s not yet public how many they’ll offer in 2016, they currently offer 50 plans.

Caroline Pearson, vice president for health reform at the consulting firm Avalere Health, has been digging into available numbers on insurance pricing across several states. She says such price hikes are not the norm. She’s not seeing anything like a 20 percent average increase in the price of monthly premiums.

“Those are not necessarily the plans that hold the bulk of enrollment,” she says. “So, while some of those plans may be going up a lot in price, that doesn’t mean a lot of enrollees are necessarily affected.”

In the handful of states where data is available (Connecticut, Maryland, Michigan, Oregon, Virginia, Vermont, Washington state and Washington, D.C.), Pearson says the majority of people buying health coverage on exchanges won’t face serious sticker shock.

“We have seen that about 6 percent average rate increases are expected for 2016,” Pearson says.

As Avalere looks at the less expensive plans, she says, “We’re seeing anywhere from a 5 percent increase for the lowest-cost plan available, to a 1 percent increase for the second-lowest-cost plan available. So we’re really looking at very modest increases — very consistent with what we saw from 2014 to 2015.”

Pearson also points out that the price increases — big or small — are by no means final. They’re requests from insurance companies. And, in a lot of states, insurance commissioners have the ability to reject price increases they judge unjustifiable. The actual prices of health plans being sold on the exchanges will be final this fall.

Or look at what the Blues want to do.

Reported by Emery P. Dalesio and Emily Masters that North Carolina’s largest health insurer says higher-than-anticipated costs after two years of selling federally subsidized coverage has forced it to seek premium increases even greater than it thought would be necessary two months ago.

Blue Cross and Blue Shield of North Carolina said Thursday that it now seeks an average 34.6 percent higher premium for insurance sold under President Barack Obama’s health insurance overhaul law. The company said in June that it wanted to raise rates by an average of almost 26 percent starting in January, compared with this year’s allowed 13.5 percent increase.

The move comes as dozens of health insurers across the country have proposed increasing premiums for individual policies well beyond 10 percent for 2016. However, many of those insurers face pushback from state and federal regulators, and experts say it’s still too soon to say how things will turn out.

Blue Cross vice president Patrick Getzen says the program has not met expectations that healthier customers would enroll in the second year and that costs would level out after people who avoided doctors for years got treatment.

“Based on our data, neither expectation is proving true. Our claims and expenses are higher than our premiums and we need to take steps now to protect the sustainability of plans for our customer over the long-term,” Getzen said.

Consumers insured through their employers and those continuing individual coverage under policies taken out before the federal Affordable Care Act took effect will not be affected. With more than 3.9 million members in North Carolina, the insurer’s policies on the individual market represent a fraction of its overall business.

And it’s not clear whether any of these preliminary rate hikes will stick. Regulators in many states have the power to reject price increases, and many who don’t are expected to at least pressure insurers to soften their plans. Health insurance price hikes have been the subject of growing scrutiny for years.

Health insurance experts say it’s tough to draw broad conclusions about prices from the requests. The health care law only requires insurers to report proposed hikes of 10 percent or more. That’s only a partial picture of the market that tilts toward a worst-case scenario.

A recent study by the nonpartisan Kaiser Family Foundation found that while increases for 2016 are generally bigger than they were this year, consumers still should have money-saving options to choose from. The study looked at preliminary data on premiums in major cities across 10 states, plus Washington, D.C.

Researchers found that premiums for a type of lower-cost plan that’s used as a benchmark will increase an average of 4.4 percent for 2016. In most cases, consumers would have to be willing to switch plans to get a lower premium.

Blue Cross said it’s also retrenching offerings in 16 counties including the Research Triangle and Charlotte regions. The Chapel Hill-based insurer said it will no longer offer there its Blue Advantage and Blue Select plans, which offer broader networks of doctors and hospitals. Getzen said the 55,000 customers affected by the change will be switched to lower-cost, narrow network offerings.

Adam Linker, a health access expert for the North Carolina Justice Center, said he hopes the state’s Department of Insurance “takes a hard look” at this rate request.

“There is a question of whether these high rate increases are justified in the short term,” Linker said. “There is a lot of uncertainty nationally with insurance companies but I think that companies have a tendency to ask for higher rates than necessary so that they can sort of pad these losses.”

Linker said he’s concerned that people who are ineligible for federal subsidies will struggle to pay premiums. More than 90 percent of those in North Carolina who bought coverage through a federally run marketplace received federal subsidies that helped them pay the costs.

The federal law changed how health insurance is sold by requiring companies to accept anyone without ruling out some because of existing conditions or healthiness. Policies also were required to cover 10 essential elements including hospitalization and prescription drugs. In return, most adults are required to have coverage or pay a penalty.

Blue Cross in 2014 was the only insurer to sell ACA plans to residents of all 100 of North Carolina’s counties.

UnitedHealthcare and Coventry Health Care also offered marketplace policies in North Carolina this year and plan to do so again in 2016. Coventry, a division of Aetna Inc., requested rate increases of between 17.2 percent and 25.8 percent. UnitedHealthcare wants an average 12.5 percent rate increase.

Now put this into perspective regarding the overall health of the patient. The Institute of Medicine report Crossing the Quality Chasm identified timeliness as one of the fundamental aims of health care. Timeliness is increasingly recognized as an important factor in quality of care, and measuring wait times, or the amount of time it takes for a patient to have access to an appointment and see a clinician, has emerged as a key indicator of overall system performance.

At the extreme, extended wait times and delays for care negatively affect morbidity, mortality, and quality of life1- 3 as well as health care utilization and patient experience. National attention on the topic of timeliness reached a new level in 2014 with the discovery that 1700 veterans in need of primary care appointments in the Veterans Affairs (VA) Phoenix Health Care system had been left off the mandatory electronic waiting list, and 40 veterans died while waiting for an appointment.4 Although there is not enough evidence to conclude that the prolonged waits were the cause of these deaths, the VA investigation documented poor quality of care.

A new report from the Institute of Medicine (IOM), Transforming Health Care Scheduling and Access: Getting to Now,5 considers national evidence and practices on access, scheduling, and wait times. Anchoring its perspective that health care must be patient and family centered and implemented as a goal-oriented partnership, the committee that wrote the report examined evidence from published studies, including those related to the VA experience; held public meetings; and examined relevant findings from related systems-level approaches in other sectors. Despite the paucity of available evidence, the committee members shared their expertise, reviewed the literature, and heard presentations from nationally renowned, high-performing health delivery systems at a public hearing.

The committee identified examples of systems-level approaches in individual settings that improved scheduling and wait times while having either neutral or positive effects on quality of care and patient experience. These approaches included scheduling strategy models, team-based workforce strategies, and technology-based alternatives to in-person visits. For example, the Mayo Clinic in Rochester, Minnesota, used Lean and Six Sigma methods to implement a surgical process improvement intervention, which resulted in significantly fewer wait times at surgical admissions, significantly higher rates of on-time arrival to the preoperative area, and significantly quicker operating room turnover times.6 To improve discharge processes, Boston Medical Center implemented a program designed around nurse discharge advocates and clinical pharmacists. Results from a randomized study found that patients participating in the intervention, compared with usual-care patients, were significantly less likely to have a subsequent hospitalization and reported a higher follow-up rate with their primary care physician.7 These successful systems-level models have the potential to be adopted more widely and become a foundation for standards of care. The changes illustrated in these examples can be achieved without significant investments in personnel or facilities, relying instead on process reengineering, resource reallocation, and behavioral change strategies. Moreover, these changes can lead to real-time engagement of patient concerns.

The IOM committee found a number of commonalities among exemplary practices reflected in the literature and case examples. These represent a set of basic health care access principles for primary, specialty, and hospital and post acute care scheduling and also provide targets for expanded research and evaluation. They include

  • Supply-demand matching through formal ongoing evaluation
  • Immediate engagement and exploration of need at time of inquiry
  • Patient preference on timing and nature of care invited at inquiry
  • Need-tailored care with reliable, acceptable alternatives to clinician visit
  • Surge contingencies in place to ensure timely accommodation of needs
  • Continuous assessment of changing circumstances in each care setting

Committee findings touched on several key issues related to the timeliness of care. Access variation ranges from same day in some circumstances to several months in others. Consequences of delays include negative effects on health outcomes, patient satisfaction with care, health care utilization, and organizational reputation. The committee identified multiple delays in access to health care, including mismatched supply and demand, clinician-focused approach to scheduling, outmoded workforce and care supply models, priority-based queues, care complexity, reimbursement complexity, and financial and geographic barriers.

Strategies for improving access call for continuous supply and demand assessment and monitoring as well as implementation of alternatives to in-office physician visits. This will lead to process redesign to improve workflow and match patient needs with available staff skills. These changes can enhance patient volume and access and decrease the cost of care and the need to add personnel. It is also possible to influence supply and demand through electronic consultations, telehealth, and surge capacity agreements with other caregivers and facilities.

One of the most significant findings of the committee was the absence of standards for access. Standardized measures for timely access to health care are needed for reliable assessment and improved scheduling. However, available evidence to provide setting-specific guidance on care timeliness is limited, and reliable performance standards cannot be established without better data. To develop the evidence base, health care organizations will need reliable information, tools, and assistance from various national organizations with the requisite expertise—as well as interorganization coordination to ensure the harmony of reporting instruments and reference resources.

In order to make any progress in the care of our patients depends on active engagement of patients and their families in the design and implementation of access and scheduling approaches; a systems perspective based on continuous assessment of both supply and demand; and leadership at all levels. Efforts targeting access, scheduling, and wait times (by the VA and others) can foster transformative patient- and family-centered progress in system performance. Health care has yet to experience a call for action from its leaders—similar to those that occurred for enhancing patient safety and patient-centered care—to focus on improving wait times and access. It is difficult to reach these goals if we make it difficult for the patient to access the health care system by increasing the hurdles which they need to jump over…..i.e. the increasing health insurance premiums and out of sight deductibles.

How is the average caring patient today supposed to afford their health care if the premiums and deductibles keep that affordability for care outside of their grasp?

I, myself, am thinking of not going back for another routine eye exam because the health care coverage doesn’t cover that exam. Think about this thought process when it comes to severe disease such as cancers. I am already seeing the results where patients don’t come in to their doctors until it is too late to treat.

What a great health care system we offer through the ACA system. How can we care for our patients if we make it unaffordable except for the non-compliant and non-paying exchange based patients?

The other question is-Is this ACA health care system really sustainable?

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