I was interviewed yesterday about medical cost trends for Real Money with Ali Velshi. The show airs tonight on Al Jazeera America.
The Affordable Care Act requires employers to provide coverage for full-time employees but not part-timers. That sounds like a straightforward and reasonable provision, but as usual the devil is in the details. ACA opponents have taken up the argument that this provision is a “job killer” because it will cause employers to limit employees’ hours, thereby pushing people into part-time roles to deprive them of benefits. That view strikes me as simplistic, since in my experience companies are in business to make money, not to hammer their employees.
I had an opportunity recently to chat with some HR heads from big employers –retailers and restaurants—that employee many part timers as well as full timers. I asked them for their take on the controversy. Unsurprisingly they provided a pragmatic, non-political view of the situation.
Here are the main takeaways:
- Prior to the ACA, each company had its own definition of full and part time. As a rule they knew who they intended to pay benefits to and who not
- The ACA is causing them to track hours of part-timers closely, with the goal of not inadvertently having to pay benefits to someone they don’t consider full time
- The result is that work hours are being spread around more evenly among part-time workers whereas in the past some part-time workers got a lot of hours while others had fewer
- From the standpoint of corporate HR, this is a good result, because part-timers who are assigned more consistent hours are more likely to stay. This increase in retention is good for productivity and profits. In this case the ACA is reinforcing an HR best practice that companies have started to implement in any case
- Companies have not been trying to take away benefits from those who had them prior to ACA implementation
It’s arguable that the losers here are the few part-time employees who used to get lots of hours because their managers preferred them. Some of those are likely to make the jump to full time. Others may seek opportunities elsewhere.
These discussions are about the short term. Longer term it’s possible that employers will take the ACA into account when designing the structure of their workforce. Still, it’s just one factor among many.
House calls by physicians have gone the way of the dodo bird. It used to be the norm for doctors to visit their ailing patients at home, but that model gave way long ago to office based practices, a setting which enables a physician to see many more patients than would be possible in the old time model. If anything it would seem like house calls by physicians would be even less tenable in an era of team-based care, which seeks to leverage the scarce physician resource with mid-level providers, nurses, and administrators.
And yet at least a few solo physicians are making house calls again, and a column in HealthLeaders argues that it could even make sense for hospitals to offer house calls as a new service line.
I like the logic.
The office setting is convenient for the physician, but it’s inconvenient for patients, especially the sickest ones, for whom getting out of the house and into the office is a major ordeal, especially for those who require help with transportation and logistics. In an era where prevention of hospital admissions and readmissions is seen as a key strategy to reduce healthcare costs, and where accountable care organizations are focused on outcomes rather than volume, there may be a new role for doctors in the home. And indeed, a doctor featured in the HealthLeaders article discusses his ability to keep even quite sick patients out of the hospital.
Diagnostic and information technology is evolving, too, in ways that help physicians be productive on the road. In fact the “Bring Your Own Device” phenomenon of doctors bringing their own iPads into the hospital demonstrates that physicians don’t have to make any information technology tradeoffs when they leave the office. New portable ultrasound machines are another example of technology that can easily be brought into the home.
When a physician visits a patient at home he or she can gain a much better sense of the overall context for the patient’s health. An empathetic, astute, holistically oriented physician should be able to turn that information into a better care plan and prevent unneeded escalation to an acute setting.
Another potential benefit is that patients can avoid sitting in a germy waiting room and potentially being exposed to dangerous infections as a byproduct of their doctor visit.
Of course, much of the same logic that applies to house calls for doctors applies to nurses as well. But it’s reassuring that the economics support the reintroduction of such highly trained professionals into the home.
I’m quoted in the Springfield Republican today about the closure of North Adams Hospital and the implications for healthcare in Massachusetts more broadly. The article draws heavily on a report we contributed to about the challenges facing lower and middle income communities as a result of how healthcare is financed in this state.
HealthLeaders (‘Vicious Cycle’ Flagged in MA Hospital Financing Disparities) reports today on a white paper we contributed to about the impact of hospital price differences in Massachusetts. We built on previously publicized price data to highlight the implications for middle class and lower income communities: they effectively subsidize their richer brethren who pay the same premiums but get their routine care from pricier providers.
One of the things that surprised us is that Medicaid managed care plans, which are hired by the state, pay teaching hospitals much more than they pay community hospitals.
The report includes four recommendations to address the disparities:
- Require high-cost providers to hold cost growth below the general benchmark under Chapter 224 of health reform
- Consider each provider’s payer mix when setting Medicaid (and possibly commercial) rates
- Implement a Medicaid Accountable Care Organization (ACO) to contain costs and encourage quality, rather than relying on cutting unit prices
- Encourage commercial health plans to design products that reward members who use low cost providers
I’m quoted in the article.
Two medical bills arrived in the mail over the weekend. One requested $525 for a specialist office visit, another $250 for a routine colonoscopy at a hospital. Since I don’t think we owe for either of these and the numbers are pretty big I decided to tackle them.
The specialist bill was odd because it didn’t appear that the insurance company had been billed. We go to this specialist frequently and have had the same Blue Cross Blue Shield of MA plan for a long time so I wondered what happened. After going through the phone tree, being kept on hold and listening to a recording about “higher than normal call volume” I was connected with a customer service rep. She said, “actually looks like insurance just paid. Your balance is $5.” On the one hand I was happy but on the other hand if I had just waited for the next bill it sounds like I would not have had to call at all. I’m still not sure why they sent the bill to me without any indication of billing the insurance company.
For the colonoscopy I decided to call my health plan first to check whether I had full coverage. They had “higher than normal call volume,” too, which I think must be normal. They were surprised to hear about the request for $250 but then looked at the bill and said it had been submitted as an outpatient surgical procedure (for which I would owe $250) rather than as a routine preventive screening.
I then called the hospital and had a long wait on hold, although they didn’t say anything about it not being “normal” call volume. I explained the situation, the rep then went to do a bit of research and came back to tell me it was billed properly –but not as a routine colonoscopy– and could I please pay the $250. I said no, hung up the phone, and spoke to the patient who assured me it was in fact a routine, every 5 year screening.
Not exactly what to do next, I decided to send an email to the hospital (conveniently, there is a billing email on the bill) presenting the information I have. I was happy to receive a reply within one business day letting me know they were checking with the physician to look into it.
So bottom line: I spent about 45 minutes on these bills and don’t have a lot to show for my effort so far. On the other hand I have helped drive up administrative costs by prompting action from my specialist’s billing office, health plan customer service, hospital billing office and now a doctor.
CVS’s decision to stop selling cigarettes is a smart one. Cigarette sales are incompatible with the company’s positioning as a health care provider. With the reduction of smoking rates, growing restrictions on where people can smoke, and increasing numbers of localities banning cigarette sales in drug stores it will probably make business sense over time as well.
I’ve been surprised that so much of the commentary on CVS’s decision has focused on what else the company should stop selling. Candy, gum and soda are bad for you, too, so maybe CVS should stop selling that. And the list goes on from there –maybe some of their toys are dangerous, for example.
Asking what else CVS should stop selling is asking the wrong question. Cigarettes cause an order of magnitude more harm than those other categories and are more addictive. That’s a good reason to stop selling smokes without having to stop selling other things that aren’t 100 percent healthy.
I’d like to see a bigger emphasis on reducing the availability of cigarettes more broadly and making them more expensive.
Cigarette taxes vary wildly by state. Missouri is the lowest at $0.17 per pack and New York is the highest at $4.35. (New York City tacks on an additional $1.50.) The federal tax is $1.01 and some places add other taxes including state and local sales tax. The average retail price for cigarettes is about $6, so tax represents a big part of the price.
These big differences provide a major incentive for smuggling. Although no one knows exactly what percentage of cigarettes are smuggled, it’s a lot.
Indian reservations are another source of low-tax cigarettes. High tax states like New York have seen considerable friction as non-Indians have sought out on-reservation stores for bargain prices.
The effects can be insidious. A friend told me recently about a public housing project in his area where a man goes door to door selling cigarettes he obtains cheaply on a nearby reservation. If the price were higher the rate of smoking in this price sensitive population would be likely to decline.
I’m not proposing a specific mechanism to address these challenges, but I would like to see the low tax states raise their tax rates, more enforcement effort devoted to stopping interstate smuggling, and more aggressive action to reduce the availability of reservation cigarettes. Although this will never happen, one approach could be fore the federal government to charge a tax of $6 minus whatever the states charge. That would provide an incentive for every state to raise the tax to a uniform, high amount.