For today’s post I just want to share some highlights of NHPC14, which I attended two weeks ago. The conference speakers all provided fascinating perspectives on current trends and future directions, but if I had to single only one I would pick Mark McClellan, formerly FDA Commissioner and CMS administrator, and now a Senior Fellow at the Brookings Institution, who gave the plenary speech on Tuesday (February 4).
Let’s start in reverse order with McClellan’s speech. He used the plenary to discuss the just-released report of the RWJF Commission to build a healthier America, which he co-chaired with Alice Rivlin, former White House OMB director and Fed Vice-Chairman, and now also Senior Fellow at the Brookings Institution like McClellan. The Commission makes the following recommendations (all quotes are from the executive summary):
- Prioritizing early childhood development, including: “creat[ing] stronger quality standards for early childhood development programs, link[ing] funding to program quality and guarantee[ing] access by funding enrollment for all low-income children under age 5 in programs meeting these standards by 2025” as well as “help[ing] parents who struggle to provide healthy, nurturing experiences for their children.”
- Linking community development and health, including “support[ing] and speed[ing] the integration of finance, health and community development to revitalize neighborhoods and improve health.”
- Connecting health and health care, for instance by “adopt[ing] new health “vital signs” to assess non-medical indicators for health”, “creating incentives tied to reimbursement for health professionals and health care institutions to address non-medical factors that affect health,” and “incorporate[ing] non-medical health measures into community health needs assessments.”
Here are a couple of initiatives that caught my attention:
- “In Salt Lake City, Goldman Sachs, United Way of Salt Lake and the J.B. and M.K. Pritzker Family Foundation have formed a partnership to create the first-ever social impact bond designed to expand access to early childhood education through the early Childhood Innovation Accelerator.” (More information here.)
- “Oklahoma has offered universal access to pre-kindergarten since 1998 and has one of the highest enrollments in the country, with 74 percent of the 4-year-olds attending a pre-K program.” (Way to go, Oklahoma!)
- “Educare is a network of state-of-the-art, full-day, year-round schools across the country that provide at-risk children from birth to age 5 with comprehensive programs and instructional support that build skills and lay the foundation for successful learning… Four Educare schools include or are directly adjacent to on-site health clinics. Additionally, two Educare schools are linked to elementary schools with on-site health clinics.”
- “The Healthy Futures Fund developed by Morgan Stanley, the Kresge Foundation and the Local Initiatives Support Corporation is encouraging community development organizations and community health care providers to collaborate using Low Income Housing Tax Credit equity and an innovative New Markets Tax Credit structure to drive economic development that helps improve health outcomes. The project will support development of 500 housing units with integrated health services and eight new federally qualified health centers through a $100 million initial investment.”
You can read the executive summary here and the full report there. The findings echo a theme I’ve heard repeated many times throughout the conference, both by speakers and by attendees. Broadly speaking, the issue is that improving Americans’ health is not going to happen only through healthcare payments, no matter the incentives for efficient and early care (although obviously healthcare payments that incentivize good care are better than healthcare payments that unwittingly encourage wasteful spending or counterproductive behavior), but also through social payments, for instance free pre-kindergarten care.
Shannon Brownlee, formerly of the New America Institute and now of the Lown Institute on Monday (February 3), gave the other plenary speech, which also touched upon social payments. She is best known for her book Overtreated: Why too much medicine is making us sicker and poorer, after the publication of which she said some physicians refused to stand in the same room as her. The three action items she recommended in her speech – “keep patients out of the hospital, redeploy resources from hospitals into the community and begin building infrastructure” – would not have seemed out-of-place among the conclusions of the RWJF report.
Another speech I enjoyed was the talk Jeffrey Kang of Walgreens gave as part of a panel on primary care access. His focus was on the role of pharmacists and nurse practitioners (Walgreens operates 8,200 retail pharmacies, 30,000 pharmacists and 2,000 NPs). Did you know that 2/3 of Americans live within 3 miles of Walgreens and in particular 3/4 of the minority population? Walgreens stores are open at least 14 hours a day and some 1,500 stores are open 24 hours a day. This puts Walgreens in a position to play a key role in providing Americans community-based access to health care. (According to Kang, the chain is the largest provider of flu shots in the country.) Challenges include states’ “scope of practice” statutes, some coverage and reimbursement issues, and the fact that there is NO e-discontinuation order between the primary-care provider and the pharmacy, so that the pharmacy doesn’t know a prescription has been discontinued. The most common medication error is in fact that a doctor has discontinued a medication but the patient is still taking it at home.
I also liked the description of WA’s Healthplanfinder and the Washington Health Benefit Exchange in a breakout session on health insurance exchanges. Challenges in implementation have included call center volumes and wait times, Medicaid renewals, pending applications (including some people who enrolled but did not pay, presumably switching to a private carrier in the meantime), reconciling enrollment reports to carriers. Successes include the large enrollment, stabilized system performance, marketing and outreach, stakeholder support and infrastructure development. Total new enrollments in Washington State including Medicaid were at 323,000 when the presentation was prepared and Medicaid renewals were at 233,000.
While not everything went smoothly (wait times to the call center averaged 39 minutes at some point), the speaker, Richard Onizuka, referring to the color code of green, yellow and red commonly used in project management to describe tasks that are on schedule, borderline and beyond schedule, threatening project due date, explained that “we always knew it wasn’t going to be a green project, it was always going to be a yellow project.” The Seattle Times has a blog post about enrollment numbers as of January 2014, apparently not including Medicaid. Premera BlueCross and its subsidiary LifeWise (the only company that offers a state-wide plan) have captured about 2/3 of the new enrollees, totaling almost 43,000 between the two of them. (This incidentally means that the 323,000 number is above is predominantly due to Medicaid expansion.)
The blog post provides the following statistics: “More than 77 percent of people buying insurance on Washington’s exchange had incomes low enough to be eligible for tax breaks that reduce the cost of the monthly premiums. The majority of exchange shoppers bought so-called “silver plans,” which provide middle-of-the-road coverage. These silver plans also qualify for additional cost-sharing subsidies that can bring down the amount people spend out-of-pocket for their health care, again based on their income.”
A note of concern regarding the Washington State plans available on the exchange, though (emphasis is mine): Seattle Children’s Hospital announced in January that “it has treated approximately 125 patients who lost contracted access to Seattle Children’s when new plans on Washington’s Health Benefit Exchange became effective at the beginning of the year. Those patients… were all treated by Seattle Children’s regardless of their Exchange plan coverage, but continued access to the hospital remains in question.
“This is a dire situation for our patients,” said Dr. Sandy Melzer, senior vice president and Chief Strategy Officer, Seattle Children’s. “We can’t continue providing services to these patients without reimbursement from their insurance companies. Eventually, these patients will have to seek care elsewhere, and for the treatment of many conditions, there is nowhere else to go in the region.”” These kids had coverage before. Why can’t they have coverage now? How does that help anyone to refuse them access to a nationally ranked pediatric hospital that has the most in depth knowledge for their condition?
(This is a serious problem. Seattle Children’s sued in October “over the state Office of the Insurance Commissioner’s “failure to ensure adequate network coverage” in several health plans being sold through the state’s new online insurance marketplace, called Washington Healthplanfinder. Most plans available through Healthplanfinder for coverage in 2014 do not include Children’s among their in-network providers, which hospital officials say could significantly disrupt and delay care for children in need of the hospital’s services. In King County, seven insurers are offering plans through the exchange. Only two — Group Health Cooperative and Community Health Plan of Washington — include Seattle Children’s in their provider network.” (About 20% of the new enrollees ended up picking these two plans.) More information in this Seattle Times blog post, from which the previous quote was excerpted. In fact, according to the article, Seattle Children’s is left out of the top two health plans mentioned above, Premera Blue Cross and LifeWise, although Premera later agreed to cover services only available at Seattle’s Children at a network benefit level. Call me opinionated if you wish, but insurers who don’t put the leading regional children’s hospital in their network in order to cut down costs are just taking the lazy way out.)
I’ll throw in another insightful article about the ACA, that one about insurers dropping out of the marketplaces: “Causes, effects of marketplace drop-outs unclear.” The article states that “marketplaces in at least 17 states and the District of Columbia offer plans from four or fewer insurers… [and some] prominent insurers have decided not to sell plans in the marketplaces of states where they already have a presence.” For instance, “high-profile marketplace departures have included Aetna dropping out of its Connecticut home state marketplace and United Health Group—the nation’s largest private insurer—opting not to offer plans in the California marketplace, which is expected to be the nation’s largest ACA marketplace.” While the article explains this is due to uncertainty regarding rates needed for the plans to remain solvent or the state regulators’ rejection of those rates, I wonder whether those insurers’ not wanting to have some of their already insured population switch to cheaper plans they would offer on the marketplace played a role, a risk touched upon in this other HFMA article.
Finally, a quote by a panelist about the ACA: “It’s like getting a library card. That doesn’t mean people will have libraries nearby. That doesn’t mean they will have access to books they like.” With the latest open enrollment deadline pushed back to March 31, we may not see for a while longer how it all turns out, but the consequences on insurers, including this year’s claims and next year’s rates and new entrants or dropouts, promise to be fascinating.