ObamaCare signups: More than just the exchange numbers

All that hyperbole for nothing!

All that hyperbole for nothing!

President Obama just announced that 8 million people signed up for coverage on federal and state health insurance exchanges during the initial open enrollment period for the Affordable Care Act, aka ObamaCare. That’s higher than originally projected, and much higher than how things looked when the glitch-filled healthcare.gov sputtered out of the gate. Cynics will pick at that accomplishment, claiming that it overstates the law’s impact by counting people who already had insurance, and those who don’t end up paying their premiums.

ObamaCare is a complex law (remember the big excitement about how many pages it takes to spell out) and it’s much more than just the exchange websites.

Focusing just on the 8 million who have signed up through the exchanges actually seriously underestimates ObamaCare’s impact on the number of people with insurance. Consider:

  • Close to 4 million people have signed up for Medicaid since October. It would have been more if opponents hadn’t blocked Medicaid expansion in so many states
  • Millions have signed up for private health insurance outside of exchanges: through brokers or directly with the health insurers
  • Many formerly uninsured young adults are insured through their parents up to age 26 instead of being dropped

There’s also another way to look at the folks who already had insurance who have signed up on the exchange. ObamaCare opponents have made a big deal out of people having their plans canceled because those plans didn’t meet the new law’s requirements. We’re suddenly told how everyone loves their existing plan –something I never heard touted prior to ObamaCare. Considering the hassle involved in getting a policy through an exchange, one could reasonably assume that people are getting better, cheaper coverage than what they had before. Even if that doesn’t increase the number of insured people, it improves the overall level of insurance within the population.

 

photo credit: Fresh Conservative via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

Zohydro ban: Disagreeing with Governor Patrick

Massachusetts Governor Deval Patrick is trying to ban Zohydro ER, a new prescription painkiller, under a state of emergency he’s declared to combat opiate abuse. I agree with the Governor that opiate addiction is a huge problem in Massachusetts (and many other places) but the attempt to ban sales of Zohydro is a bad idea that’s likely to have a negligible impact on the addiction crisis while potentially harming one of Massachusetts’ most important industries.

The argument against Zohydro ER (the ER stands for “extended release”) is that it promotes abuse by providing a higher dosage in one pill than comparable immediate release products and that it lacks tamper resistant features that could make the pill harder to abuse. That’s probably why the FDA’s own advisory panel voted overwhelmingly against approval and why the drug has taken so much heat.

Historically states don’t attempt to interfere with the FDA approval process, but Patrick argues that approval is only a minimum requirement for sale and that states are free to impose additional restrictions beyond what the FDA mandates.

Here’s why I think Patrick is misguided:

The drug does address an unmet need and has real benefits

  • It allows some people who need round-the-clock pain relief and who currently use immediate release drugs such as Vicodin to take fewer pills and to avoid Tylenol (aka acetaminophen or APAP) that is typically combined with hyrdocodone and which can harm the liver

The harms presented by this drug are not unique, and the formulation technologies available to deter abuse are not especially effective

  • Some painkillers –such as Oxycontin and Opana ER– have been reformulated to make them harder to abuse, but others including the generic version of Opana ER are available without tamper resistance
  • Search Google for how to defeat tamper proof Oxycontin and you’ll find simple and effective methods to do so. Sure there’s some value to adding such technologies but it’s no cure-all

It would be bad news to establish the precedent that states could place additional restrictions on approved drugs

  • It really perplexes me that Patrick would promote the idea that FDA approval is insufficient to allow a drugmaker to sell its product throughout the US. Is he nuts? It’s a novel idea, laughed at by the first judge –but who knows how other judges will rule and what other states will seek to do if the principle is established
  • It’s expensive and difficult to get a product from lab to market as is. And, regardless of the merits of the Zohydro ER situation, it’s a bad idea overall to make marketing a new drug even harder. Add more uncertainty, cost and hurdles and it will reduce investment in R&D and may eventually have an adverse impact on the availability of new products for patients. Massachusetts is home to many pharmaceutical and biotechnology companies, so I’m especially surprised Patrick would take this step, which is so contrary to the state’s economic interests

The FDA’s decision to approve Zohydro surprised me and many others. It may or may not have been the best decision. But it’s a bad idea for individual states to try to overturn the approval through unilateral actions.

By healthcare consultant David E. Williams of the Health Business Group

ICD-10 delay –I’m quoted in AIS Health

ICD-10 is grounded again

ICD-10 is grounded again

I was surprised –like many others– that the latest temporary “doc fix” bill also delayed the implementation of ICD-10 coding for a year or more. Everyone I know had expected the real deadline to be October of this year. We were told as much by CMS leader Marilyn Tavenner in her keynote address at #HIMSS14 in late February:

“There are no more delays and the system will go live on October 1. Let’s face it guys, we’ve delayed this several times and it’s time to move on.”

But she doesn’t run Congress and they decided to do their own thing.

AIS Health (Health Plans Are Not Happy After One-Year ICD-10 Delay Slipped Into ‘Doc-Fix’ Bill) asked me for my perspective on the delay:

David Williams, co-founder of the Health Business Group and MedPharma Partners consultancies and author of the Health Business blog, tells HPW that he thinks the consistent and public drumbeat of negative news that has come with the Affordable Care Act (ACA) rollout has something to do with the congressional action on ICD-10. “I think it actually ties into the challenges of the implementation of the ACA….People are wary of sudden switchovers after seeing the various delays in mandates of the ACA.”

If I had been lobbying for a delay (I wasn’t), I would have pointed to the disastrous launch of the federal –and some state– insurance exchanges under ObamaCare and said we don’t want to see something like that for ICD-10 in October, just before the elections. Delaying for a year or more will provide more time for testing, something the exchanges seemed to have skipped. I would also have pointed out that the administration has repeatedly pushed back deadlines, some at the last minute. That line of reasoning could have been persuasive to those on both sides of the aisle, and it’s my guess that such logic was employed.

Whoever paid their lobbyists to pursue this outcome must be pleased with their investment. I wonder if they’ll try for a further extension next year. If so, they’ll have to reveal themselves and face some strong counter lobbying by ICD-10 proponents, who won’t be caught sleeping twice.

photo credit: Chris Devers via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

GetWellNetwork CEO speaks about patient engagement

Michael O'Neil, CEO of GetWellNetwork

Michael O’Neil, CEO of GetWellNetwork


Michael O’Neil had the misfortune to contract non-hodgkin’s lymphoma while in graduate school. His medical outcome was good but his experience as a patient was not. He founded GetWellNetwork (GWN) to provide an interactive patient engagement solution to help patients move from dependence to independence in the course of their care. The company’s solutions are found in 200 hospitals and are credited with lowering readmissions, increasing staff responsiveness, and increasing patient satisfaction with pain control.

I caught up with Michael at #HIMSS14 in Orlando and asked him to tell his story.

By healthcare consultant David E. Williams of the Health Business Group

Should step therapy and prior authorization be outlawed?

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In ‘Fail first’ fails patients in the Boston Sunday Globe, a patient with depression decries his health plan’s use of “step therapy,” which requires members to try less expensive drugs before switching to pricier products.  This is a brave article –the author is going public as a transgender man and as someone who suffers with depression– and I agree that he should not have to endure what he’s been going through. In his case the drug that worked for him was put onto the list of drugs requiring prior authorization. He had to spend endless time with the insurance company and get his doctor to advocate for him to keep him on his therapy.

The author would like to see insurance companies barred from using step therapy and prior authorization, “particularly when insurance companies are still turning profits on our premiums.” That’s a simple solution that will appeal to many readers. After all, the insurance company is standing in the way of what’s best and also inconveniencing the patient and doctor along the way. Yet this solution too simplistic and ignores the broader context in which this situation is unfolding.

As a society we’ve handed health insurers much of the responsibility for controlling costs, while also imposing a series of constraints on them that limit their scope of action. ObamaCare, which I support, takes this approach even further and puts the rest of the US in a similar position to where we are in Massachusetts.

In a more typical insurance business –like life insurance or liability insurance–  the insurance company succeeds by refusing to insure customers who are likely to file claims, increasing rates after claims are filed, and writing policies in such a way as to exclude most things that are likely to happen. There is regulation, but in general you’ll struggle to get life insurance if you’re about to die or if you flunk your medical exam, and your car insurance rates will rise if you get a speeding ticket or cause a crash. In many parts of the country, health insurance has worked like this as well.

But under RomneyCare and now ObamaCare, health plans can’t charge more for people with pre-existing conditions –such as depression– and can’t refuse to accept business even from customers who will definitely be unprofitable. Not only that, but even when insurers do a good job of controlling costs, their profits are capped due to minimum medical loss ratio regulations. If they don’t spend enough on medical costs then the excess premium is returned to the customer.

Before we place yet another restriction on cost containment methods for health plans, let’s look at the broader picture.

First, rising health care costs are a huge problem for employers, individuals and taxpayers. Have your raises been low for the last several years? It’s probably because your employer is paying more for health insurance instead of giving you a salary boost. Is your town having trouble balancing its budget and struggling to find funds to build new schools or hire teachers? A big driver is the rising cost of employee and retiree health care. So it’s really important to bring healthcare costs under control. Step therapy and prior authorization are reasonable ways to do it.

The price differences and impact on premiums are not trivial. The May 2014 issue of Consumer Reports compares prices of drugs before and after they go off patent. Two of the eight drugs on the list (Cymbalta and Abilify) are used for depression. One just went generic and the other will be generic next year. After three years off patent, Cymbalta is expected to cost $27 per month for the generic v. $538 for the brand, and Abilify $45 v. $900. In other words, these drugs will be 95% cheaper once the generic market kicks in. As someone paying insurance premiums, I would rather have someone use a product that costs 5% if it works just as well, including drugs that are generic right now.

Naturally, pharmaceutical companies will push newer, higher-priced products. That’s their job as profit-maximizing companies, and they have a wide array of marketing and sales tools available to them to make it happen. (Unlike health plans, pharmaceutical companies’ profits are not capped.) On the other side, the health plan needs a set of tools to deploy to keep things in balance. In today’s world of biologic drugs that cost tens or hundreds of thousands of dollars it’s prudent to expect most patients to step through a process of trying less expensive treatments first, especially when those treatments may work just as well or better and be less dangerous. If we want –as the author does– to have fully unrestricted access, then that would require some regulation of the price of drugs. Take that too far, however, and the incentive to develop new and innovative medicines will be compromised.

Step therapy and prior authorization are legitimate and even necessary tools. This doesn’t mean that these approaches shouldn’t be scrutinized. In particular, the author implies (although doesn’t come right out and say) that he went through a series of drugs before finding the one that worked for him. If that’s the case, then he shouldn’t be forced to go back and try ones that have already not worked for him. But it’s not clear that this is what’s happening.

Balancing cost, quality, access and convenience in today’s healthcare system is not easy. Making things better requires something more than legislating further restrictions on health insurers.
photo credit: torbakhopper via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

Give Boomer Esiason a break on birth comments

Retired football star and current radio host Boomer Esiason has opened the floodgates of righteous indignation by suggesting that the Mets second baseman should have encouraged his wife to have a scheduled C-section before opening day. That would have prevented him from missing the first two games of the season when he flew home to be with her.

Esiason got the blowback that he should have expected, and made a lengthy apology for his comments today.

I’m happy though, that this mis-step has turned into an opportunity to educate people about the dangers of early elective delivery. There’s actually been a major, successful effort underway to reduce the use of early elective deliveries. Such deliveries –either induced or scheduled C-sections before 39 weeks– represented 17 percent of births in 2010 (as high as 25 percent in some states). As of 2013 the rate has fallen dramatically, to less than five percent according to the New York Times.

It turns out babies born at 37 or 38 weeks have a lot more health problems then those born at 39 or 40  weeks, even though it doesn’t seem that such a short time difference should be so important. So I hope the reaction to Esiason helps to get this message across.

Esiason is getting the word out. Here’s what he said:

I’m very grateful to my many friends over at the March of Dimes who graciously reached out and re-educated me that if a pregnancy is healthy, it is medically beneficial to let the labor begin on its own rather than to schedule a C-section for convenience. In fact, babies born just a few weeks early have double the risk of death compared to babies born after 39 full weeks of pregnancy. As their promotional campaign says, ‘Healthy babies are worth the wait.’ And as a proud father, I couldn’t agree more.

I find it quite interesting how societal expectations about fatherhood have changed in the recent past. A generation ago, the notion of a father being in the delivery room was unheard of. Fifteen years ago I had a job interview with a large financial services company. The hiring manager (in his early 30s at the time) told me the job required an all out commitment, and that while he hoped to be present at the birth of his child, that wasn’t really the way things were prioritized there. I didn’t agree with that sentiment then, but it was the norm in many places.

So it’s interesting to me that Esiason took it for granted that the player would be present for the birth –he didn’t seem to question whether work should come first.

Esiason said the wrong thing, but I think we should cut him some slack. First of all, being a football quarterback is different from being a baseball second baseman. Baseball teams play 162 games per season, NFL teams only 16. A star quarterback plays every game, whereas even star baseball players get a day off from time to time. So maybe we can accuse Esiason of lack of empathy for thinking about how he would have behaved, not what a baseball player would do. But I understand his point about not wanting to miss a game.

Esiason is 52 and times have changed. He gets part of the new way of thinking –dad should be there for the birth. But he screwed up by suggesting unnecessary surgery. And while I don’t fault him for not knowing that earlier births aren’t good for babies, at least it gives people a chance to bring it up and make it known to a wider audience of would-be fathers who might otherwise not be paying attention.

By healthcare consultant David E. Williams of the Health Business Group