Obamacare Isn’t The Problem…It’s The Insurance Companies

Primary Care Doctor Explains: “Obamacare Isn’t The Problem…It’s The Insurance Companies”
Posts by cpowell
Blue Dot Daily
July 15, 2017

With premiums increasing for those with coverage through the ACA marketplace, a lot of people are criticizing Obamacare. But many doctors and healthcare professionals are saying that isn’t really the problem. Cathleen London is a primary care physician in Milbridge, a rural town in Maine. She claims the problem isn’t Obamacare itself, but rather, the entire health insurance system and insurance companies are to blame.
Writing for the Portland Press Herald, London explains she is a a primary care physician who is on the front lines every single day, as  her town is very remote, which means it takes 30 to 40 minutes to get to the emergency room, which is why her office operates as an urgent care facility as well as a family medical practice.
It’s takes an ambulance about 20 minutes to get to her clinic and specialist care about 2 hours away, so Dr. London is trained to handle about 90 percent of medical problems.

Dr. London explains the following, which will show you exactly what’s wrong with health care:

One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.
Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.
I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.
I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.
The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).

Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.

Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.
I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.
I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.
My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.
Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.
This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies. Remember lifetime caps? Remember denials for pre-existing conditions? Remember the retroactive cancellation of insurance policies? Returning to that is not an option.
Indeed it is not an option, Dr. London.  If Republicans get their way eventually by repealing Obamacare, it may be where we end up again. If Republicans really get their way, it’ll be even worse than it was before.

Kaiser, which has long claimed to practice preventive medicine, to raise rates 9.2 per cent, on reinstated policies

Apparently, Kaiser Permanente wasn't so interested in preventive medicine as it claimed. When required to provide preventive care, it raises rates.

Kaiser to raise rates on reinstated policies
The proposed 9.2% boost would cover higher costs associated with Obamacare
By Kristen Consillio
Star Advertizer
Nov 30, 2013

Kaiser Permanente Hawaii plans to boost rates by an average 9.2 percent for 11,000 individuals who were earlier notified their health insurance policies would be canceled at year's end because they did not meet the minimum requirements of the federal Affordable Care Act.

The state's largest health maintenance organization said it filed the proposed rate hike this week with the Insurance Division to cover higher projected medical expenses next year, costs associated with an aging population and taxes and fees related to the federal Affordable Care Act...

Why are American doctors paid so damn much?

Chart: Why are there so few doctors in the US?

Because the medical establishment has intentionally limited the number of doctors in this country--so doctors could make more money by serving more patients. Of course, this has resulted in poorer medical care.

"This is yet another reason not to shed too many tears for doctors. They've basically brought this on themselves. If the market were allowed to produce as many doctors as there's demand for, they'd already be getting paid less. Right now they're enjoying the substantial rents that come from squeezing their own supply, and they've fought like lemmings for decades to keep it that way." -- Kevin Drum

Why Are American Doctors Paid So Damn Much?
By Kevin Drum
Mother Jones
Nov. 20, 2013

Conservatives have picked up today on a Kaiser Health News piece reporting on doctor complaints that insurers plan to pay them less for Obamacare patients than for other patients:

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors. But many primary care doctors say they barely have time to take care of the patients they have now.

Matt Yglesias is unsympathetic. He says American doctors are very well paid and should quit griping: "If we ever reach the point where American doctors have been squeezed so badly that they start fleeing north of the border to get higher pay in Canada, then we've squeezed too hard. Until that happens, forget about it."

That's pretty cold. But if you really want to know what's going on, take a gander at the chart... [above]. It's from the OECD, so it includes all of the world's relatively rich countries:

That's damn peculiar, isn't it? If Econ 101 is to be believed, higher pay should produce more doctors. And yet, even though the United States pays doctors far more than any other country on the globe, we're in the bottom third. We have more doctors per capita than poorish countries like Mexico and Poland, but far fewer than Belgium and Britain and Germany—all of which pay doctors considerably less than we do here. So what's going on?

As Matt says, the basic answer is that U.S. doctors operate as a cartel. They artificially limit their own ranks, which drives up their compensation.

What we really ought to be doing is working to further pressure the incomes of doctors through supply-side reforms. That means letting nurse-practitioners treat patients without kicking a slice upstairs to an M.D., letting more doctors immigrate to the United States, and it means opening more medical schools. Common sense says that since the population both grows and ages over time, there should be more people admitted to medical school today than were thirty years ago. But that's not the case. Instead we produce roughly the same number of new doctors, admissions standards have gotten tougher, and doctors have become scarcer.

This is yet another reason not to shed too many tears for doctors. They've basically brought this on themselves. If the market were allowed to produce as many doctors as there's demand for, they'd already be getting paid less. Right now they're enjoying the substantial rents that come from squeezing their own supply, and they've fought like lemmings for decades to keep it that way. You can hardly blame them for that, but there's no reason the rest of us should put up with it. It's time to fight back.

A safe, effective vaccine for cancer that some insurance companies don't cover

A safe, effective, cancer-fighting vaccine shunned
By Katy Waldman
Slate.com
August 5, 2013

Why aren't more teenage girls getting vaccinated against the human papillomavirus?

The New York Times reported recently that vaccination rates for the disease, the most common sexually transmitted infection and “a principal cause of cervical cancer,” failed to improve from 2011 to 2012.

This despite the fact that the rates at which people get “new vaccines typically increase by about 10 percentage points a year,” according to Thomas Frieden, director of the Centers for Disease Control and Prevention. And despite that experts have recommended since 2007 that girls receive the triptych of shots at age 11 or 12.

Every year, HPV causes about 19,000 cancers in women (mostly cervical) and close to 8,000 cancers in men (mostly throat). Yet, reported the Times, “only 33 percent of teenage girls finished the required three doses of the vaccine in 2012 ... putting the United States close to the bottom of developed countries in coverage.”

This distressing news launched a fleet of theories: that teenage girls go to the doctor less frequently than toddlers, leading to fewer opportunities for vaccination; that patients — or their parents — are embarrassed to ask for a vaccine for sexually transmitted infections, and doctors are reluctant to broach the topic; that neither doctors nor patients are well-versed enough in immunization literature to get the ball rolling.

A study in the (delightfully named) Morbidity and Mortality Weekly Report, however, rules out hypothesis No. 1. Teenagers are receiving plenty of other inoculations. (“If HPV vaccine had been administered during health-care visits when another vaccine was administered,” the authors of the study wrote, “coverage. ... could have reached 92.6 percent.”)

The vaccination flat line may flow from a combination of underinformed families and inconsistent doctors. “Providers give weaker recommendations for HPV vaccination compared with other vaccinations recommended for adolescents,”

researchers found. Plus, “the HPV vaccine is controversial,” says Tai Warren, a receptionist at Washington Pediatric Associates in Washington, D.C. “A lot of parents don't want them for their children.”

Warren couldn't say whether parents most often object to the vaccine because they perceive it as a license to have sex, because they are concerned about safety, or for some other reason. (More than seven years of study can attest that the procedure is safe, as well as effective.)

Sadi Bhattarai, a nurse at Chevy Chase Pediatrics in Washington, D.C., was not aware of any stigma surrounding the HPV vaccine. The procedure does prove slightly inconvenient.

“We often have to call after the first round and remind families to get the second and third shots,” she said.v Still, “at our practice, everybody gets vaccinated — boys and girls — when they come in for a physical and if they're the right age.”

Bhattarai ventured that plateauing rates “are both doctor- and patient-driven,” since not all clinics have adopted the immunizations as a standard part of their procedure, and not all families know to ask.

But Chris Griffiths of the Columbia, Mo., Health Department, said institutional lethargy is not wholly to blame. She senses a lingering wariness.

“As a nurse, I bring (the vaccine) up to people, and they associate it with promiscuity,” she said.

While her clinic makes a point of recommending the shots, other facilities in the state do not. Funding plays a role — to administer vaccines, a practice needs a separate locked refrigerator kept at a specific temperature and may rack up other expenses — but it is only part of the story. Patients and their families may also be dissuaded by insurance policies that fail to cover HPV inoculation. (The triplicate shot can cost up to $140 per dose.) Doctors may not want to incur a backlash by suggesting the vaccine.

Whatever the reason, we've trekked too far into the 21st century to be dithering over safe, easy, cancer-blasting vaccinations for children. Though the explanations behind the plateau may be complicated, the solutions are simple: Insurance companies should cover HPV shots. Doctors should promote them. Patients and their families should embrace them.

Anthem Blue Cross Drops Cedars-Sinai, UCLA From Health Plan

Anthem Blue Cross Drops Cedars-Sinai, UCLA From Health Plan
Bob Herman
Becker Hospital Review
September 24, 2012

Anthem Blue Cross in California is shutting out two of the largest healthcare providers in the Los Angeles area — Cedars-Sinai Medical Center and UCLA Health System — from one of its health plans because the health systems are "too expensive," according to a Los Angeles Times report.

All physicians affiliated with Cedars-Sinai and UCLA will be eliminated from Anthem's Select health plan, effective Jan. 1, which is offered to roughly 60,000 employees and dependents in Los Angeles. The city said Anthem's plan would save $7.6 million in annual premiums. It is expected that roughly 2,200 city employees and family members will lose in-network access to their physicians, according to the report.

In response to the move, the health systems said their high costs are associated with their medical research and innovative treatments that "benefit the entire community," according to the report. Cedars-Sinai and UCLA also said Anthem's maneuver will only shift costs onto those who still receive care at the facilities.

Trouble In Mitt Romney's Socialist Hospital Paradise

In 2010 Romney himself acknowledged the need for Obama's health care law (before he began pursuing the Republican presidential nomination):

"Look, it doesn't make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way."

Trouble In Mitt Romney's Socialist Hospital Paradise
10/27/2012
Arthur Delaney and Jamieson
Huff Post

In the early hours of May 1, D.C. bartender Mike Boone came to the aid of a young woman who was being mugged.

Boone had offered to walk her home from the bar, Trusty's on Capitol Hill, since the immediate neighborhood is not known for having the safest streets at night. A man jumped from behind some bushes and grabbed the woman's purse. Boone also grabbed it, and the two men started fighting.

"We were punching each other pretty hard," Boone recalled. It wasn't until blood gushed from his body and the woman screamed that the bartender realized what had really happened.

"He was punching me with a knife," Boone said.

Boone passed out on the sidewalk. He woke up the next day in a hospital bed, recovering from eight stab wounds and a collapsed lung.

Like nearly 50 million other Americans, Boone lacked health insurance. A pre-existing condition -- in his case, a broken back he suffered in 1993 -- prevented him from obtaining affordable coverage. President Barack Obama's health care law prohibits insurance companies from discriminating against people with pre-existing conditions, but that reform doesn't go into effect for adults until 2014.

Republican presidential nominee Mitt Romney has vowed to repeal the health care law entirely if he's elected. In America, Romney has said, we don't let people die in the street simply because they lack health insurance: Hospitals are there to care for the uninsured.

"We don't have a setting across this country where if you don't have insurance, we just say to you, 'Tough luck, you're going to die when you have your heart attack,'" Romney said in an interview with The Columbus Dispatch on Oct. 11. "No, you go to the hospital, you get treated, you get care, and it's paid for, either by charity, the government or by the hospital."

Indeed, the health care system did not let Boone bleed to death on the sidewalk. But it did bury him in life-altering debt. After four days in the hospital and two surgeries, the 39-year-old -- hailed as a hero on Capitol Hill and beyond for his actions -- is staring at $60,000 in medical bills so far. And they haven't stopped rolling in.

Well-wishers, moved by media reports of his story, have donated $17,000 to help Boone cover his expenses, and he's hoping a public fund for crime victims could defray as much as $25,000 more. But Boone, who said he expects to earn only about $15,000 this year, figures he'll still be looking at nearly $20,000 in debt, all for risking his life for a fellow human being.

His story is one that plays out with troubling regularity in the bar-and-restaurant business, where a high quotient of workers go without health coverage. Post-tragedy fundraisers are common in the industry. The events serve as vivid examples of the private sector's safety net in action.

These fundraisers can defray some of the costs of emergency care, as they have done for Boone, but often they don't provide nearly enough. Paying for health care isn't as efficient or just as Romney suggests. Instead, much of the cost is borne by health care providers and insurers and, ultimately, the insured. We all pay.

"At first, I was like, man, this is really great, this could take care of it," Boone said of the charity he has received. "And then the big bills started coming."

A FORM OF SOCIALISM

Douglas Zehner is the senior vice president and chief financial officer at MedStar Washington Hospital Center in northwest Washington, where Boone was treated. He said Medstar gave $22.1 million worth of care to uninsured or underinsured patients and forgave $85.1 million in debt last year. But that charity isn't free. The only way the hospital can recoup its losses, Zehner said, is by negotiating with private insurance providers for higher prices, a process known as "cost-shifting."

"I have to price my services with insurance carriers because that’s the only group I'm even in the room talking to about how much they're going to pay me for my services," Zehner said. "So the way the cost-shifting works is you basically back into how much [money] you need to run that service [for all patients] and apply it to the expected number of people that are coming in that have insurance to get that service."

The fewer people who have insurance, the greater the burden on those who do have coverage. In order to cover the costs of treating the uninsured, premiums go up. The American Hospital Association estimated that U.S. hospitals performed $39.3 billion worth of uncompensated care in 2010, the most recent year for which numbers are available. That's 5.8 percent of total expenses.

This is a problem that Obama's health care law seeks to address and one that Romney himself has acknowledged in the past, before he began pursuing the Republican presidential nomination.

"Look, it doesn't make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way," he said in 2010.

In 2007, he used even starker language: "When [uninsured people] show up at the hospital, they get care. They get free care paid for by you and me. If that's not a form of socialism, I don't know what is."...

Consumers have "no meaningful information about the quality of care," but the same can't be said for Leslie Michelson

Why do consumers have "no meaningful information about the quality of care"? Because businesses are the ones buying the insurance, not the patients. And insurers have no stake in long-term results.

September 21, 2012
Leslie Michelson: Doctor to the 1% (and Maybe Someday to You)
By JOSEPH RAGO
Wall Street Journal

The rich are different than you and me. Not only—yes, yes—do they have more money, but they've also heard of, and many have hired, Leslie Michelson.

...So the health-care delivery system, to the extent it qualifies as a system, "has no quality control, no integration, no coordination." Doctors "tend to operate in an independent and isolated way, and even specialists who've been treating the same patient for years and years typically never, ever speak to one another."

Private Health is designed to backfill these gaps whenever one of its patients has a medical emergency or complex condition, say, a traumatic brain injury or newly diagnosed cancer. A personal-care team parachutes in, led by a clinician employed by the company, and compiles a brief on the patient. They centralize and digitize the patient's medical records, usually dog-eared paper piles that can run to thousands of pages. Research scientists immerse themselves in the latest findings and treatment regimens for the particular condition involved.

Tests are double-checked—biopsy tissues are sent to an outside pathologist, MRIs to another radiologist. For an era of targeted therapies, Private Health runs a full battery of molecular diagnostics "to sequence the entire three billion base pairs of somebody's DNA in a couple of hours," Mr. Michelson marvels.

The goal is to ensure an accurate diagnosis and lay out all the treatment options. Private Health functions as a kind of running, independent second opinion. It operates in the twilight zone where there isn't a "best practice" for when and how to treat, but a continuum of risks and benefits that vary from patient to patient.

The clinician helps locate the right experts, Mr. Michelson says, and then works to "fuse together all these multiple specialists in a single team with a single objective." There are "no redos, no lost scans, no ambling around going from specialist to specialist, trying to figure out what's going on." The most frequent reaction is: "This is how medicine was always supposed to be practiced."

The idea for Private Health came to Mr. Michelson when he was running the Prostate Cancer Foundation, the multibillion-dollar philanthropy Michael Milken set up in 1993. Prostate cancer is a common disease but treatment isn't straightforward. Surgeons end up recommending surgery, radiation specialists radiation, still others "watchful waiting," etc.

Mr. Michelson says people started asking him for advice, which led to the prototype for Private Health. Eventually he decided to improve his process across more diseases and help more people.

One irony is that for all its white-glove extras (a research department, genetic profiling), a lot of what Private Health does are core functions that patients would value and providers or insurers ought to be doing but rarely do (case management, using computers). Why is that?

Cost is part of it. "It's too expensive for us to do it for everybody right now," Mr. Michelson says. Another part, he thinks, is that "the incentives are attenuated because of the structure of insurance," namely, job-based coverage.

Since businesses are the customers, not the individuals who change jobs every three years on average, insurers "act rationally" and don't invest in services with "short-term costs and long-term payback." Mr. Michelson thinks the better option is for businesses to convert to cash vouchers so their workers can buy portable policies. Right now, there is "no meaningful information about the quality of care, virtually no information about price, and no sensitivity to price," but that would change if the insurance industry built "an enduring relationship with consumers," he says.

"I understand that it is woven into the fabric of our society that employers can and should continue to pay for health insurance for their employees," Mr. Michelson declares. "But why, circa 2012, should HR departments be selecting and administering one or two or three plans for a thousand or a hundred thousand workers and their dependents? You don't need a Ph.D. in economics to understand that you will guarantee suboptimization."

Taking A Risk To Secure Health Insurance

Taking A Risk To Secure Health Insurance By Randy Dotinga KaiserHealthNews.org Henry J. Kaiser Family Foundation JUN 12, 2012 When it comes to medicine, I usually do as I'm told. Take a pill? Sure. Blood test? Absolutely. Surgery? If you think so, doc. But I've been acting against medical advice since January, and I'll keep on ignoring it until July. Let me explain. Last January, I cancelled my existing, very expensive individual coverage through California's state-run high risk plan and became insurance-free to gain eligibility for the federal alternative. That means that if I get a cancer diagnosis tomorrow, I'll end up with huge medical bills. I did this because I want to take advantage of the federal government's efforts to help people like me who have pre-existing conditions and no access to a group plan. Those two words -- pre-existing condition -- explain why I find myself in this circumstance. Back in 1996, when I was 27, my heart started to beat funny. The diagnosis was lone atrial fibrillation, a kind of irregular heartbeat that appeared for no apparent reason and, in my case, couldn't be fixed. Even getting "cardioverted" didn't help. A daily beta blocker keeps my heart from pumping too fast, and my risk of any complications is low. Even so, no one will insure me on the individual market. And since I'm single and self-employed as a freelance writer, I don't have access to guaranteed group coverage, except for a plan for artists and writers that would cost me at least $31,226 a year. That's why, for the last few years, I have made do with the state's high-risk insurance plan. California, where I live, is one of 35 states that offer health insurance to people with pre-existing conditions who otherwise wouldn't be able to get individual coverage. But for me, access to California's high-risk plan is expensive -- the PPO plan would cost me $748 a month this year, close to $9,000 a year -- and the coverage is thin. The annual spending limit is just $75,000, hardly enough to cover a major health crisis. And the lifetime benefit limit is a paltry $750,000. As a result of the 2010 federal health law, I now have another possibility: The federal high-risk plan would cost me just $265 a month -- $3,180 a year -- and offers unlimited annual and lifetime benefits. That sounds like a great deal cost-wise, and the lack of coverage limits is much better for me in the long run if I get diagnosed with an expensive disease. But there's a rub: I'm not eligible for the federal plan unless I go six months without any coverage at all. That's just what I decided to do. To me, the prospect of affordable and unlimited coverage -- at least from July 2012-December 2013 -- is worth the risk of going without coverage for the allotted time. "You're responding in an understandable way," said Harold Pollack, a University of Chicago professor who studies health care. "Any program that requires people to be actively uninsured creates a very paradoxical and painful set of incentives and encourages people to do what you're doing." But I'm taking a major risk by going without insurance for so long. This would be the absolute wrong time to get hit by the proverbial bus. Or, as happened a few weeks ago, hear a dermatologist ask "Have you had that looked at?" while I lounge at a hotel pool. (Don't worry. I'd previously had it looked at, and it's nothing to worry about.) My decision to go coverage-free did not go over well up in Sacramento when I mentioned it to staffers at the California Managed Risk Medical Insurance Board, which oversees the state and federal high-risk plans here. A spokeswoman told me that the agency wouldn't cooperate with me on this story if I planned to embolden other people to make the same decision. Janette Casillas, the agency's executive director, put it this way: going without insurance in order to get insurance "is not something that we would encourage." The federal government could change everything by getting rid of that six-months-without-coverage rule. But if it did, it would need to find another way to limit coverage for high-risk patients so it doesn't cost more than the budgeted amount, Pollack said. "They'd have to have some other rationing requirement that would also create problems, since it's such a small program for such a huge need," he said. "Almost every deficit of this program comes down to the fact that Congress has not appropriated enough money to meet the need that is there." Even if I do land in the federal high-risk plan as of July 1 -- if space is available -- it's not a long-term fix for me or anyone else. The good news, for me at least: In 2014, the federal health law is scheduled to take full effect, including provisions that protect consumers who have pre-existing conditions from being denied coverage. The high-risk pool coverage won't be needed anymore.

Kaiser Permanente Dr. Paul Phinney Simple Doctor Extraordinaire!

Kaiser Permanente Dr. Paul Phinney Simple Doctor Extraordinaire!
Youtube video
Mar 21, 2012

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CARMEN BALBER, WASHINGTON, D.C. DIRECTOR

Carmen Balber is the director of Consumer Watchdog's new Washington, D.C. office, and its eyes, ears and voice on national public policy. She is also point person for research and advocacy that exposes the corrupting influence of cash and corporation on politicians. She coordinates Consumer Watchdog's public education efforts on medical malpractice and is a legislative advocate on issues ranging from financial system and healthcare reform to protecting the civil justice system and corporate accountability.

Bad news: if your doctor won't stand up for you to your insurance company, you're in trouble

New Year, New Deals? Breaking Down Health Plan, Doctor Alliances
by Dan Diamond
California Healthline Contributing Editor
January 04, 2012

The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)

But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:

Out: Physicians and insurance companies as mortal enemies.
In: Health insurers and physicians ... as partners.

Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.

Are these deals an industry blip or the beginning of a boom?

Check back at year-end. For now, it's too soon to know.

The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.

Changes Afoot for Everyone

It's old news that industry players are taking on new roles.

Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.

But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.

Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.

"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."

What's Driving the New Partnerships

UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.

Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.

But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.

One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.

Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.

California at the Epicenter

These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.

What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.

A good share of these new physician-payer deals are unfolding in California.

That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.

CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.

Reaction and Reassessment

Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.

Monarch also leaves behind a pair of jilted ex-partners.

Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.

That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.

If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.

Here's what else to watch as the new year begins.

In the States

CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).

Challenges to Reform

After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).

Inside the Industry

Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models. After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3)...

Consumer advocate Harvey Rosenfield takes on health insurers

Here's a biography of Harvey Rosenfield.

Consumer advocate Harvey Rosenfield takes on health insurers
Rosenfield, who used California's initiative process to regulate auto insurance rates more than two decades ago, is preparing a new initiative that would force health insurers to get state approval before they could raise premiums.
By Marc Lifsher
Los Angeles Times
November 26, 2011

The former "Nader's Raider" who used California's initiative process to regulate auto insurance rates is headed back to the ballot. This time he's spoiling to take on health insurers.

Harvey Rosenfield, the combative attorney and consumer advocate who wrote California's landmark Proposition 103 more than two decades ago, is preparing a ballot initiative that would force health insurers to get state government approval before they could raise premiums.

Stricter controls are needed to put some restraints on a industry that's reaping fat returns for shareholders and multimillion-dollar salaries for executives while consumers struggle to pay for coverage, Rosenfield said. In California, average premiums for family coverage rose 7.5% in 2010, according to the California HealthCare Foundation. They increased by 3% nationally for the same period. About 1 in 5 Californians, or 7.2 million, have no health insurance.

"Everybody knows the horror stories," said Rosenfield, founder of the advocacy group Consumer Watchdog. "Premiums are going through the roof. A lot of people can't get health insurance at any price. Benefits are going down. Company CEOs are getting rich."

Consumer Watchdog submitted a draft of its initiative to state authorities this month, a first step toward placing the measure on the November 2012 ballot. Getting it there won't be cheap. The Santa Monica group would need to gather signatures from at least 505,000 registered voters, a process that could cost around $3 million, according to election experts.

If approved by voters, the measure would give California the country's most stringent regulation of the 35 states that have some form of health insurance oversight.

Health insurers denounce the initiative as big-government meddling that could lead to higher rates and less coverage for everyone.

"Giving a politician the power to set prices does not address the real reason healthcare costs are increasing and could threaten patients' access to medical care," said Charles Bacchi, executive vice president of the California Assn. of Health Plans.

The industry could spend more than $100 million trying to defeat Consumer Watchdog's proposed initiative, said Michael Mattoch, a former insurance committee staffer in the state Legislature and current executive at auto insurer USAA.

But Rosenfield and Jamie Court, Consumer Watchdog's president, say they like their chances. Private focus groups and polling show 80% of voters queried would support reining in health insurers, they said.

Some independent analysts share their assessment.

"I imagine this would be quite popular going into a [national] election. Insurance companies are not exactly the most favorite institutions," said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a national healthcare think tank not related to the Kaiser Permanente health maintenance organization.

Rosenfield is no stranger to David versus Goliath battles.

Helped by his mentor, consumer activist Ralph Nader, Rosenfield in 1988 persuaded California voters to pass Proposition 103. That landmark ballot initiative slashed car insurance rates and forced auto insurers to get approval from state regulators for future premium hikes. The law also applies to rates for homeowners' and most other lines of property and casualty insurance.

Outspent by the opposition $120 million to $3 million, Rosenfield's tiny operation prevailed by tapping into the frustration of California motorists fed up with skyrocketing premiums. Despite dire predictions that carriers would flee the state, California's auto insurance market remains competitive. Premiums have declined by about 30%, saving Golden State motorists billions, according to the Consumer Federation of America.

Rosenfield said he's again resorting to a ballot initiative to allow California voters to do what the Legislature hasn't been able to do — rein in soaring health insurance premiums. Bills to give the state more authority to regulate rates have been bottled up in Sacramento for years; health companies and insurers have contributed millions to lawmakers to keep it that way, Rosenfield said.

Health insurance "fits perfectly with 103," Rosenfield said.

Insurance industry opponents counter that Rosenfield and his colleagues have other reasons for wanting to expand Proposition 103. Over the last two decades, they've reaped millions in legal fees and settlements from insurance companies while declaring themselves champions of the little guy.

Bacchi of the California Assn. of Health Plans criticized Consumer Watchdog as "a self-anointed consumer advocate," pursuing "yet another deeply flawed policy proposal that is ultimately designed to line their pockets with cash from expensive lawsuits."

Rosenfield, who has shaved his mustache, buffed up his physique and upgraded his wardrobe since his Nader's Raiders days in the 1970s and 1980s, said he welcomes insurer insults. That's "how I know we're doing our job," he said.

But the proposed health insurance initiative promises to earn Rosenfield more adversaries than usual.

Carefully inserted in the measure is a one-sentence "poison pill" that could nullify a proposed auto insurance initiative that's also aimed for the November 2012 ballot. The crafty tactic was aimed straight at Rosenfield's old nemesis: George Joseph, the chairman of Los Angeles-based Mercury General Corp., who is helping to bankroll the auto insurance measure.

That initiative, which would offer certain discounts to longtime insured motorists, would weaken Proposition 103, Rosenfield said, by effectively raising rates for drivers who were previously uninsured. Last year voters defeated a similar ballot measure, with the losing campaign costing Mercury $16 million. Undeterred, Joseph already has pumped $8 million into the new effort, which officially is sponsored by the American Agents Alliance, a trade group.

Rosenfield said his wording would restate and expand a controversial provision of Proposition 103 that previously uninsured drivers should not be penalized with higher insurance rates. It would take effect if both Rosenfield's and Joseph's measures were approved but Rosenfield's gets more votes.

The poison pill, insurers argue, is unconstitutional and is likely to be challenged in court on the grounds that initiatives by law can deal with only one subject.

Rosenfield contends that his measure would withstand such a challenge from insurers.

"We fight just as hard as we can for consumers," he said.

Why Are Customers of This Health Insurer So Happy?

Here's a puff piece about Kaiser Permanente. This is clearly not investigative journalism. The article doesn't mention the downside of Kaiser's "guidelines for treatment." The biggest downside is that Kaiser Permanente makes its profits by offering assembly-line care. It has lists of symptoms that it checks for and treats. But if you have symptoms that differ from the guidelines, you may well end up dead. Kaiser is playing the percentages. It sacrifices patients with problems that don't fit the pre-determined process.

Electronic records are interesting. They can be easily altered, and Kaiser takes full advantage of this when a patient presents with a problem that Kaiser doesn't want to deal with.

If Kaiser is at the top in customer ratings, there must be a lot of really bad plans out there.

Why Are Customers of This Health Insurer So Happy?
By Maggie Mahar
Time Magazine
October 18, 2011

Kaiser Permanente’s stand-out performance in Consumer Reports’ national rankings of some 830 insurance plans raises an obvious question: What makes Kaiser so different? In a word: collaboration.

Kaiser is distinctive among the major health insurers in that it’s not just a health insurer. While the non-profit Kaiser Foundation Health Plans provides coverage for its 8.8 million patients, Kaiser also offers an integrated network of doctors and hospitals. The insurer and the providers share one goal: keeping patients healthy over the long term.

(MORE: We’ve Been Wasting a Ton on Vitamins and Dietary Supplements)

Because Kaiser is both the insurer and the provider, it has a larger incentive to invest in preventive care, wellness classes and free smoking clinics. Many other insurers and health systems avoid sinking money into such programs because patients switch insurers so frequently that such spending winds up benefiting another company. But as the Consumer Reports’ ratings show, Kaiser patient satisfaction is high and patient turnover low, so it makes more sense for the insurer to invest for the long haul.

Founded in 1945, the California-based plan was one of the earliest “health co-operatives” that, instead of charging fee-for-service, accepted a lump-sum payment of, say, 85 cents per patient per month. The American Medical Association objected; it insisted that doctors should be free to set prices for each procedure, thus leaving total health care costs open-ended. The AMA had great clout: By 1950, most states had passed laws that barred the co-ops. Kaiser was one of the few that survived.

Today, Kaiser’s physicians are still on salary, treating patients in nine states, plus D.C. Each year Kaiser Health Plan (the insurer) and the Kaiser Permanente Medical Group (the doctors) in each region negotiate and agree on a lump sum that the Health Plan will pay the Medical Group on a monthly basis for each patient. Rather than compensating doctors for volume (fee-for-service) the goal is to hold physicians “accountable” for keeping patients well. If they succeed, fewer patients will need to be hospitalized or undergo expensive procedures, and the payment will turn out to be greater than the actual cost of necessary medical care. When that happens, the Medical Group, as a whole, shares in some of the surplus. Thus, rather than having an incentive to “do more” tests and procedures, Kaiser’s doctors have an incentive to “do less, and do it right.”

(MORE: Patients Prefer HMOs (And Other Healthcare Surprises))

Nationwide, many doctors prefer working fee for service, running their own business and competing for market share with an eye to increasing their income. But others compete for jobs at Kaiser: In California, Kaiser hires just 11 percent of the doctors who apply for positions. These tend to be physicians who don’t want the hassle of running a business.

Kaiser also makes very effective use of information technology in coordinating patient care. It maintains a single computerized record for each patient, so all physicians are looking at the same chart, where they can read their colleagues’ notes and know what they are thinking. In other healthcare “systems,” patients can often be seeing five doctors, none of whom have no idea what the others are planning or prescribing.

Perhaps just as important, Kaiser uses that electronic database of patients’ records to determine which treatments work best for which patients. By mining that medical evidence, it is able to create “guidelines” — they’re careful not to call them rules — for consistent standards of care. Without such guidelines, many experts agree, U.S. healthcare can be frighteningly idiosyncratic, particularly when doctors are working alone. It is impossible for any single physician to keep up on all of the newest research. But when doctors are working elbow to elbow in large multispecialty groups, they share their knowledge.

Over time, a combination of teamwork, guidelines and computerized records has helped Kaiser achieve remarkable results that go well beyond the Consumer Reports findings. For example, in Northern California, Kaiser has reduced death from heart disease among its 3 million members so significantly that it is no longer the leading cause of death. In fact, after adjusting for age and gender, death from heart disease is more than 30 percent lower among the Kaiser population than among Northern Californians who receive care through another insurer.

Maggie Mahar writes the HealthBeat blog for The Century Foundation, where she is a fellow.
Read other related stories about this:

Health-Insurance Plan Rankings from the NCQA Consumer Reports

Insurers Banking their Cash

Insurers Banking their Cash
By The Palm Beach Post
Sept. 30, 2011

Critics of the Affordable Care Act pounced last week on the news that health care premiums went up 9 percent this year. According to the Kaiser Family Foundation, the average family health plan in the U.S. now costs $15,073.

What the critics didn't say was that the year before President Obama signed the law, the cost of an average family policy rose 5 percent. That same year, 2009, the five largest U.S. health insurance companies earned a record $12.2 billion - as 2.7 million Americans lost their private health coverage in the worst year for the economy since the Depression.

This year, some insurers reported double-digit profit increases during the second quarter, and expect to exceed expectations for the year. One reason may be that fewer consumers are seeking medical care in the still-weak economy.

Some of the Affordable Care Act's key portions - the individual mandate, the marketplace-like exchanges - came from Republicans two decades ago. Gov. Scott and other current Republicans who want the health care law repealed say premiums will go down if insurers can compete by selling policies across state lines. Most insurers, however, already have licenses in multiple states. Blue Cross and Blue Shield of Florida recently gave its mental health policies for Florida residents to a Kansas-based company in which it has part ownership.

Objective analysts attribute only about 1 or 2 percentage points in premium increases to the new law's mandates, notably those that require insurers to provide preventive services at no out-of-pocket costs and add adult children to their parents' policies. Those are good changes.

Some analysts believe that insurers are charging more to hedge their bets for when the economy improves and more people seek treatment, and that companies are banking cash before next year, when the law requires them to justify increases. In this case, the health care law is more the target than the problem.

- Rhonda Swan,

for The Palm Beach Post Editorial Board

Health insurance premiums climb faster in 2011

Health insurance premiums climb faster in 2011
By Alina Selyukh
Reuters
Sep 27, 2011

The cost of health insurance continues to climb for companies and workers, with annual family premiums this year growing at a pace triple that of 2010 and outpacing wage increases, according to a survey.

As the United States continues to grapple with a stubbornly weak economy, family premiums in employer-sponsored health plans jumped 9 percent this year and single premiums rose 8 percent, compared with 2010's 3 percent and 5 percent, the Kaiser Family Foundation's annual study, published Tuesday, found.

"We're probably on a more modest side ... but even with a 5 percent increase in a premium (that our workers saw) this year, they didn't get a 5 percent raise," said Jeff Franck, a compensation and benefits manager at Altru Health System, which employs about 3,700 people in North Dakota and Minnesota and participated in the survey.

Health insurance, unlike other industrialized countries, is largely provided by employers. Although the latest Census found more Americans losing company-sponsored insurance, almost 170 million Americans were on employer-based plans in 2010.

Kaiser and the Health Research & Educational Trust surveyed 2,088 randomly selected public and private employers large and small earlier this year.

The survey found that, on average, employees are contributing 28 percent, or about $4,129, a year toward employer-sponsored family plans. That is 131 percent more than a decade ago.

Including employers' contributions, the overall premium has increased 113 percent since 2001 to $15,073 a year.

More workers, especially in smaller firms, continue to join high-deductible health plans. Thirty-one percent of covered employees this year have to pay at least $1,000 in single plans before coverage kicks in, up from 27 percent last year.

The survey also highlighted some early results of President Barack Obama's healthcare reform.

Under one of the few provisions already in effect, people under the age of 26 are now allowed to remain covered by their parents' insurance plans to curb historically high uninsured rates in that age group. The Kaiser survey estimated that U.S. companies have added 2.3 million young adults to their parents' family health policies.

Franck at Altru Health pegged much of the premium costs' increase at his company to adding children of his employees onto their plans.

That part of the healthcare reform was not meant to cut costs, and many cost-cutting provisions have yet to kick in, said Kaiser President and Chief Executive Drew Altman.

"There are a variety of factors that could have been responsible for (premium increases), but the major reason is not the healthcare reform," he said.

Although the survey did not study contributing factors, Altman echoed other analysts in suggesting that insurance companies had planned their premiums in expectation of more people going to the doctor or buying medications as the economy improved -- which did not happen.

Insurers have generally attributed the need to raise premiums to growing underlying medical care costs as coverage also continues to expand. Both have fed into a heated debate over the future of healthcare spending, which for several decades has grown faster per person than the nation's economic output, according to the Congressional Budget Office.

Slowing down those soaring costs is one of the main issues on the agenda of a bipartisan congressional deficit-reduction panel that is due to make recommendations by November 23 on how to slash the U.S. budget deficit by at least $1.2 trillion.

(Reporting by Alina Selyukh in Washington; editing by John Wallace)

Appeals court strikes down health overhaul requirement that most Americans must buy insurance

The way I see it, Americans shouldn't have to die or be physically damaged simply because they don't have healthcare. Also, they shouldn't end up financially devastated by illness or injury.

This means we all have to chip in to provide health care for all. Having everyone buy health insurance is one way of doing this. But if this isn't possible, then the only solution I can see is a single-payer system.


Appeals court strikes down health overhaul requirement that most Americans must buy insurance
By Associated Press
August 12, 2011

ATLANTA — A federal appeals court panel on Friday struck down the requirement in President Barack Obama’s health care overhaul package that virtually all Americans must carry health insurance or face penalties.

The divided three-judge panel of the 11th Circuit Court of Appeals struck down the so-called individual mandate, siding with 26 states that had sued to block the law. But the panel didn’t go as far as a lower court that had invalidated the entire overhaul as unconstitutional...

Medicaid improves health and budgets of poor

Medicaid improves health and budgets of poor
Jul 7, 2011
(Reuters)

Medicaid, a government health insurance program designed to help the poorest of the poor, is giving people unprecedented access to doctors and also improvihttp://www.blogger.com/img/blank.gifng their finances, a study co-authored by the Harvard School of Public Health has found.

The study, released on Thursday, showed that new recipients of Medicaid reported better physical and mental health and were less likely to go into debt to pay their medical bills.

The fate of Medicaid -- the health program for people and families with low incomes and resources -- has been hotly debated for its role in the ballooning U.S. deficit. The Obama administration's healthcare overhaul passed last year requires all U.S. states to extend eligibility to millions more people by 2014.

The study followed health outcomes a year after a 2008 Medicaid expansion in Oregon, where 10,000 uninsured low-income adults won coverage through a lottery.

The results show that Medicaid helps poorer Americans well beyond the default safety net options that exist for people without coverage, according to the researchers from Harvard, the Massachusetts Institute of Technology, the National Bureau of Economic Research and Providence Health & Services...

Kaiser is actively lobbying against AB 52, which will require health insurance companies to get state approval for rate increases.

Courage Campaign

This message is from Eennie Andrews, a 72-year-old Kaiser policyholder and Courage Campaign member who lives in the Central Valley. Eennie works as a caretaker for developmentally disabled people.



I don't have employer-provided health care coverage, so I buy my insurance myself from Kaiser Permanente. If my insurance rates were to increase greatly, I wouldn't be able to afford it.

That's why I'm concerned about Kaiser's decision to raiserates on 300,000 of its policyholders in California this year. And it's why I'm angry that Kaiser is actively lobbying against AB 52, which will require health insurance companies to get state approval for rate increases.

Tell Kaiser to put working Californians first and support AB 52.

Even though it's a "not-for-profit" company, Kaiser has made $5 billion in profits since 2009 and pays George Halvorson, its CEO, nearly $8 million a year.

On top of that, Kaiser executives are ignoring their own employees who are asking for adequate staffing levels at Kaiser facilities, and they're trying to cut benefits for caregivers.1

I signed this letter to Mr. Halvorson, asking him to support AB 52. This bill would give state regulators the authority to reject excessive and discriminatory rate increases.

Sign our petition to Kaiser execs to support real health care reform.

Kaiser has an opportunity to lead the industry by helping to reform health insurance in California, instead of raising rates on hundreds of thousands of us and lobbying to make sure they can do it again whenever they like.

Please join me in asking Mr. Halvorson and his team to stand for, not against, California.

Thank you for your help,

Eennie Andrews

Cancer costs put treatments out of reach for many

Cancer costs put treatments out of reach for many
By Debra Sherman
Jun 6, 2011
Reuters

The skyrocketing cost of new cancer treatments is phttp://www.blogger.com/img/blank.gifutting advances in fighting the deadly disease out of reach for a growing number of Americans.

Cancer patients are abandoning medical care because the costs are simply too high and medical bills -- even among the insured -- are unmanageable and risk bankruptcy, studies show.

"There's a growing awareness that the cost of cancer treatment is unsustainable," said Dr. Lee Schwartzberg, an oncologist who did a study examining the factors that contributed to patients quitting their oral cancer drugs.

Cancer is one of the most costly diseases to treat, largely because many patients are treated over a long term, often with expensive new drugs that are complicated to produce and not available in generic form. And as insurance companies cut all benefits, reimbursements on cancer treatments have also declined.

"When it's an expensive drug, we have to have the hard discussion about a very substantial out-of-pocket payment. I ask: 'Do you want to spend this money for an average improvement of just a few months of life?' I'm very uncomfortable having those discussions because I want to focus on the patient getting better," Schwartzberg, medical director of the West Clinic in Memphis, Tenn., said in an interview.

Schwartzberg's and other cost studies presented at the American Society of Clinical Oncology (ASCO) annual meeting come as U.S. lawmakers battle over ways to reduce the national debt, including cuts in healthcare funding. For full ASCO coverage see [nN05141382]

ASCO president Dr. Michael Link, a pediatric oncologist, said access to healthcare should be a national priority.

INSURMOUNTABLE BARRIERS

"We're thrilled with what we consider to be breakthroughs and wonderful new therapies ... yet the barriers for some patients to get them is insurmountable. It is an indictment of how we take care of patients in the United States," Link said.

Cancer is the second-leading cause of death in the United States, after heart disease. The incidence is expected to increase with an aging population.

The costs for cancer care topped $124 billion in 2010 in the United States, led by breast cancer, according to the National Cancer Institute (NCI). That number is expected to rise as more advanced treatments -- targeted therapies that attack specific cancer cells and often have fewer side effects -- are adopted as the standards of care. The NCI projects those costs to reach at least $158 billion by 2020.

Until recently, almost all cancer drugs were administered intravenously. Today, about a quarter of them can be given orally, which means fewer visits to the doctor. But pills are often more expensive, have higher co-payments, and are reimbursed by insurers at lower rates than IV drugs, he noted.

Using a database of pharmacy claims paid by private insurers and Medicare, he found, not surprisingly, that those with higher co-payments quit their drugs more often.

Patients with co-payments of more than $500 were four times more likely to abandon treatment than those with co-payments of $100 or less, Schwartzberg said. Claims with the highest co-payments had a 25 percent abandonment rate, compared with 6 percent for co-payments of less than $100...

Health Insurers Making Record Profits as Many Postpone Care

Health Insurers Making Record Profits as Many Postpone Care
By REED ABELSON
New York Times
May 13, 2011

The nation’s major health insurers are barreling into a third year of record profits, enriched in recent months by a lingering recessionary mind-set among Americans who are postponing or forgoing medical care.

Dr. Rebecca Jaffe, in Wilmington, Del., said that after years of resisting generic medicines, more patients were now requesting them to avoid paying hefty co-payments for brand-name drugs.

The UnitedHealth Group, one of the largest commercial insurers, told analysts that so far this year, insured hospital stays actually decreased in some instances. In reporting its earnings last week, Cigna, another insurer, talked about the “low level” of medical use.

Yet the companies continue to press for higher premiums, even though their reserve coffers are flush with profits and shareholders have been rewarded with new dividends. Many defend proposed double-digit increases in the rates they charge, citing a need for protection against any sudden uptick in demand once people have more money to spend on their health, as well as the rising price of care.

Even with a halting economic recovery, doctors and others say many people are still extremely budget-conscious, signaling the possibility of a fundamental change in Americans’ appetite for health care.

“I am noticing my patients with insurance are more interested in costs,” said Dr. Jim King, a family practice physician in rural Tennessee. “Gas prices are going up, food prices are going up. They are deciding to put some of their health care off.” A patient might decide not to drive the 50 miles necessary to see a specialist because of the cost of gas, he said.

But Dr. King said patients were also being more thoughtful about their needs. Fewer are asking for an MRI as soon as they have a bad headache. “People are realizing that this is my money, even if I’m not writing a check,” he said.

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn’t feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, “I can’t afford to use it.” Delaying care could keep utilization rates for insurers low through the rest of the year, according to Charles Boorady, an analyst for Credit Suisse. “The big question is whether it is going to stay weak or bounce back,” he said. “Nobody knows.”

Significant increases in how much people have to pay for their medical care may prevent a solid rebound. In recent years, many employers have sharply reduced benefits, while raising deductibles and co-payments so people have to reach deeper into their pockets.

In 2010, about 10 percent of people covered by their employer had a deductible of at least $2,000, according to the Kaiser Family Foundation, a nonprofit research group, compared with just 5 percent of covered workers in 2008.

Doctors, for one, say patients’ attitudes are changing. “Because it’s from Dollar 1 to Dollar 2,000, they are being really conscious of how they spend their money,” said Dr. James Applegate, a family physician in Grand Rapids, Mich. For example, patients question the need for annual blood work.

High deductibles also can be daunting. David Welch, a nurse in California whose policy has a $4,000 deductible, said he was surprised to realize he had delayed going to the dermatologist, even though he had a history of skin cancer. Mr. Welch, who has been a supporter of the need to overhaul insurance industry practices for the California Nurses Association union, said he hoped his medical training would help him determine when to go to the doctor. “I underestimated how much that cost would affect my behavior,” he said.

Dr. Rebecca Jaffe, a family practice doctor in Wilmington, Del., said more patients were asking for the generic alternatives to brand-name medicines, because of hefty co-payments. “Now, all of a sudden, they want the generic, when for years, they said they couldn’t take it,” she said.

The insurers, which base what they charge in premiums largely on what they expect to pay out in future claims, say they still expect higher demand for care later this year. “I think there’s a real concern about a bounce-back, a rebound, in utilization,” said Dr. Lonny Reisman, the chief medical officer for Aetna.

Because they say they expect costs to rebound, insurers have not been shy about asking for higher rates. In Oregon, for example, Regence BlueCross BlueShield, a nonprofit insurer that is the state’s largest, is asking for a 22 percent increase for policies sold to individuals. In California, regulators have been resisting requests from insurers to raise rates by double digits.

Some observers wonder if the insurers are simply raising premiums in advance of the full force of the health care law in 2014. The insurers’ recent prosperity — big insurance companies have reported first-quarter earnings that beat analysts expectations by an average of 30 percent — may make it difficult for anyone, politicians and industry executives alike, to argue that the industry has been hurt by the federal health care law. Insurers were able to raise premiums to cover the cost of the law’s early provisions, like insuring adult children up to age 26, and federal and state regulators have largely proved to be accommodating.

But 2014 and 2015 are likely to be far more challenging, as insurers are forced to adjust to the law’s greatest changes, like providing coverage to everyone regardless of whether they have an expensive pre-existing condition. “I think they’re going to go through a winter,” said Paul H. Keckley, executive director of the Deloitte Center for Health Solutions, a research unit of the consulting firm Deloitte.

And while the slowing down of demand is good for insurers, at least in the short term, the concern is that patients may be tempted to skip important tests like colonoscopies or mammograms. The new health care law will eventually prevent most policies from charging patients for certain kinds of preventive care, but some plans still require someone to pay $500 toward a colonoscopy.

In recent times, insurers have prospered by pricing policies above costs, said Robert Laszewski, a former health insurance executive who is now a consultant in Alexandria, Va. The industry goes through underwriting cycles where the companies are better able to predict costs and make room for profits. “They’re benefiting from a very positive underwriting cycle,” he said.

“Maybe managed care is finally working,” he said. “Maybe this is the new normal.”

Still, he emphasized, health care costs, even if they are rising at 6 percent or 7 percent a year, are increasing at a much faster pace than overall inflation. “We haven’t solved the problem,” Mr. Laszewski said.

Issa Watch: Holding the Oversight Chairman Accountable

Friday, February 11, 2011
Meeting Rena
by Rick Jacobs
Issa Watch

...Rena and her son were also both recently diagnosed long-term health problems. Their Congressman’s response was voting to allow their insurance provider to deny them coverage for these “pre-existing” conditions. Facing a spike in her health insurance costs, a choice between her own medication and medicine for her son, and the even the prospect of losing her coverage altogether, Rena decided to contact her Congressman.

Not for the first time, Rena called Issa's office asking to meet with him. Instead of getting a meeting, she was told that she won't ever get one.

Instead of meeting with Rena, Issa did make time for folks who shelled out $125 a pop to attend a Vista Chamber of Commerce event at the posh Shadowridge Country Club Friday night. While Issa was inside vowing to champion the cause of the DC Lobbyists he’s asked to help drive his committee’s agenda, Rena was outside for hours in the chilly night— hoping for just a few seconds to speak to her Congressman.

Tragically, Rena’s experience mirrors that of a growing number of Americans for whom the concept of a truly “Representative” government is almost always out of reach. A few weeks ago, Rena’s Congressman, Rep. Darrell Issa, sent letters to more than 150 corporate lobbyists who aren’t in his district to ask what he could do to make their lives a little easier. But Rena—one of the small business owners who create nearly two-thirds of the new jobs in this country and one of the 331,000 CA 49 residents with pre-existing conditions who are directly impacted by the new healthcare law -- couldn’t even get a meeting...