Wednesday, November 25, 2015

The NAIC takes on balance billing

Of all the dysfunctions of the U.S. healthcare system, perhaps the most egregious (besides leaving tens of millions uninsured) is the "balance billing" of insured patients at in-network hospitals by out-of-network providers.

Elisabeth Rosenthal has documented some particularly extreme examples -- e.g.,  a woman who arranged for surgery with an in-network surgeon and was billed $117,000 by an out-of-network assisting surgeon. Sarah Kliff found a particularly sharp illustration of the roulette-like character of hospital care, in which two women working for the same employer and having the same insurance gave birth within weeks of each other at the same hospital. One was billed $1600 for an epidural by an out-of-network anesthesiologist who happened to be at work that day; the other (who also had an epidural) was billed nothing.  A Consumers Union survey conducted this past March indicated that 30% of  privately insured Americans received a surprise medical bill in the past two years, with their health plan paying less than expected.

This week, the National Association of Insurance Commissioners (NAIC) adopted a model rule for health plan network adequacy that includes some protections for patients faced with balance billing. Such model rules are meant to serve as templates for state legislatures to adapt to local needs and political propensities.

I plan to write about the balance billing section of the model rule in some depth next week. This post is a sketchboard -- and an invitation for anyone with expertise in the area or a personal experience to relate to comment or contact me.

Saturday, November 21, 2015

HHS embraces high deductibles

It's funny how a trend impinges on your consciousness: you think something is new, then it gradually dawns that it's been going on for some time. Such is the case (for me) with an emerging mode of compensating for the unaffordability of healthcare at U.S. prices.

On Tuesday CMS, apparently stung by news accounts of ACA marketplace customers whose plan deductibles were so high they found care inaccessible, put up a blog post touting many plans' provisions of some services that are covered before the deductible is reached:

On Thursday, I took a look at the benefit structure provided by Centene's Ambetter, an insurer that has "cornered the silver market" in several large cities, including Miami, Chicago and Seattle. Ambetter plans feature high deductibles and a relatively broad array of services offered beneath the deductible:

Friday, November 20, 2015

Dollars to donut holes, Ambetter undercuts the competition (including UnitedHealthcare)

In late October, when first released plan prices for 2016, Jed Graham noted that Ambetter (parent company Centene) had "seized the pole position" in several of the federal exchange's largest markets, offering the cheapest bronze and the two cheapest silver plans in those markets.

Graham further pointed out, "By shrinking the cost of silver through its high-deductible strategy, Centene is lowering the subsidies available for all plans."  A few days later, Richard Mayhew wrote that Ambetter was "spamming" the exchanges by cramming a half-dozen barely-different silver plans into its lineup, all priced below the nearest competitor's cheapest silver.

Yesterday I took a close look at the way Ambetter has combined sticker-shock silver deductibles (e.g., $6,400 for silver unenhanced by CSR in Chicago) with a relatively broad array of benefits that kick in before the deductible is reached. Swiss cheese coverage is apparently the secret sauce by which the insurer has calculated it can undersell its rivals.

In all markets taken together, we're told that on average the unsubsidized price of benchmark silver plans has gone up 7.5% (CMS), and for the cheapest silver plans in each market, 7% (Kaiser).  Not surprisingly, in markets in which Ambetter competes, the base price of the cheapest silver plan has generally gone down -- at the same time that most most of their competitors have felt compelled to raise their prices.

Thursday, November 19, 2015

Ambetter's donut hole coverage: high deductibles alloy ACA silver

In pre-ACA times, many low income workers were enrolled in "mini-med" health plans that provided first-dollar coverage up to very low limits, and no insurance after those limits were reached. Such plans still exist, though they don't satisfy the ACA's "personal responsibility" requirement.

Also long available: "catastrophic" insurance that provides no coverage at all (or, post-ACA, preventive care only) until a high deductible is met. That's basically a stop-loss policy for people with enough assets not to be deeply indebted by by the time they reach the deductible. Many if not most bronze plans offered in the ACA marketplace are in this category: deductibles are usually north of $6,000 per person.

Yesterday, CMS touted an under-recognized fact: lots of marketplace plans offer some benefits before the deductible is met. Put this in the category of consolation prize:

Wednesday, November 18, 2015

In ACA exchanges, the key word is "exchange"

The Kaiser Family Foundation has published an in-depth analysis of rate hikes and their actual likely effects on users in the 2016 federal ACA marketplace (

Crunching the data for all of the counties in 36 states* in which last year's cheapest silver plan can be compared to this year's, Kaiser highlights the savings that many if not most current enrollees can realize by switching plans. The study focuses on the lowest-cost silver plan in each county, because those are the most popular plans.  Among the key findings:
  • The average unsubsidized premium for the lowest-cost silver plan for a 40 year-old in 2016 is 7% higher than for the cheapest silver plan in 2015.

  • In 73% of counties examined, last year's cheapest silver plan is not this year's.

  • The premium for last year's cheapest silver plan will rise an average of 10% for a 40 year-old earning $30,000, and 28% for a 40 year-old earning $20,000.
The 7% average hike bespeaks some pain for the federal treasury, and the volatility in plan price and rank spells trouble for many who auto-renew without comparison shopping. However: 

Tuesday, November 17, 2015

"A million bin Ladens will bloom"

Whatever else it offers, Twitter often serves up some remarkable juxtapositions.

Last night, someone posted one more demonstration that The Onion is our oracle of Delphi, except that it speaks unambiguously (cf. Bush's inaugural: "our long national nightmare of peace and prosperity is finally over"). On March 23, 2003, the paper published a Point/CounterpointThis War Will Destabilize The Entire Mideast Region And Set Off A Global Shockwave Of Anti-Americanism vs. No It Won’t. Startling verification of one of those representative opinions also turned up on Twitter yesterday.

The Onion's "point person" argues that an attempt to impose democracy by force on a foreign culture is doomed to fail. It includes a prophecy:

Monday, November 16, 2015

A month of "yes buts"

For some reason, in the past month or so I've found myself pushing back against, or at least qualifying, assertions about the ACA by people with deep expertise in healthcare, or economics, or healthcare economics. They all know a good deal more than I do, but touched on areas that I've been preoccupied with.

These posts aim to put a corrective lens on...not myths, but partial truths that in some cases leave a misleading impression. Specifically: