tag:blogger.com,1999:blog-8512362.comments2024-03-10T13:59:19.230-04:00xpostfactoidAndrew Sprunghttp://www.blogger.com/profile/17601269968798865106noreply@blogger.comBlogger2260125tag:blogger.com,1999:blog-8512362.post-78061044298405167392022-12-30T01:40:00.373-05:002022-12-30T01:40:00.373-05:00Thanks for an excellent article.
As you know, I f...Thanks for an excellent article. <br />As you know, I favor much more aggressive tactics against predatory medical entities. For example, the names of predatory billers should be published in daily newspapers....let them deal with the hits to their reputation.<br />The fines against them should be large and immediate. <br />There should also be a federally-funded Health Law Advocates branch in every state. They should be threatened with the loss of their medical license as well.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-63175156207327773552022-12-11T16:17:19.048-05:002022-12-11T16:17:19.048-05:00The $796 million in hospital savings and $179 mill...The $796 million in hospital savings and $179 million in non-hospital savings were over 4.5 years, 2014-2018. https://downloads.cms.gov/files/md-allpayer-finalevalrpt.pdf Not sure from what baseline the 4% claim in the independent report was derived. It would seem to suggest $20 billion in hospital Medicare spending in that time frame.Andrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-36411721366486460852022-12-11T13:11:08.860-05:002022-12-11T13:11:08.860-05:00Excellent post exploring one of the key issues wit...Excellent post exploring one of the key issues with Value Based Payment models. I think the answer ultimately lies in robust quality measurement. Without being able to hold providers responsible for the quality of the care delivered and the outcomes of their patients, the incentives that you outline here could cause real problems.Charlie Estabrookhttps://www.blogger.com/profile/01753373451758010109noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-27165682059018298732022-12-11T08:58:38.660-05:002022-12-11T08:58:38.660-05:00I am not an expert here, but I read the numbers to...I am not an expert here, but I read the numbers to say that Medicare hospital spending in MD was about $80 billion over 10 years. If the caps saved $800 million, that is one per cent not four per cent. <br />That is better than the out of control growth we saw in the early years of Medicare, I suppose.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-2576611598796257732022-12-10T14:47:11.137-05:002022-12-10T14:47:11.137-05:00Bob: 1) Right, the hospital care savings (~ $800 m...Bob: 1) Right, the hospital care savings (~ $800 million) amounts to 4% of Medicare hospital spending in Maryland. That's according to this independent evaluation of the program (p. 12). https://innovation.cms.gov/data-and-reports/2021/md-tcoc-imp-eval-report That's a really significant savings, much bigger than in other CMMI pilot programs. 2) the Maryland program "adjusts Medicare payments to hospitals based on total cost of care (not just hospital care) over the year for each hospital’s attributed Medicare FFS beneficiaries." "Lower use of post-acute care facilities is a stated goal. Andrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-40306920667137420312022-12-10T14:05:52.565-05:002022-12-10T14:05:52.565-05:00Thanks for raising an important issue. Here are a ...Thanks for raising an important issue. Here are a couple of comments:<br /><br />1. I looked up the data on annual Medicare spending. Hospital care only accounts for about 30 per cent of all Medicare spending -- doctors, equipment, drugs, and home care are also very large spenders.<br />This surprised me. I have been reading about Part A trust funds etc for so long, I had the impression that this was the main part of Medicare.<br /><br />2. According to govt data, Maryland Medicare spends about $10 billion a year on hospital care. Thus, saving $1 billion over 8 years is not earth shaking.<br /><br />3. The fighting over post-acute care is really a nursing home issue. And it is very important, but I don't think doctors have much to do with it.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-20411322720922678642022-12-03T20:41:10.347-05:002022-12-03T20:41:10.347-05:00Not a big deal, but a family making $98,512 (at th...Not a big deal, but a family making $98,512 (at the top end of free child coverage) does not have a problem paying $575 for an abortion. They probably paid $575 to stay at a hotel and go to a Giants football game.<br /><br />The California coverage for all the undocumented is repulsive to me, though I don't expect any congratulations for my views. Free health insurance is a marvelous magnet to draw all the poor people of Central America to the USA....where some of them will stay on welfare for many decades. Liberal nations like Germany and Sweden are agonizing over this problem right now.<br /><br />Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-22925626278947331092022-12-03T09:07:44.025-05:002022-12-03T09:07:44.025-05:00Thanks Andrew. A good read as usual.Thanks Andrew. A good read as usual.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-14117085820880767092022-11-22T07:11:11.554-05:002022-11-22T07:11:11.554-05:00Thanks for posting. Being from Minnesota, I strong...Thanks for posting. Being from Minnesota, I strongly favor programs like ConnectorCare, which bridge a lot of gaps for middle income persons without employer coverage.<br />One item to keep in mind that an assessment of 8.5% of income for subsidized coverage is (I believe) 8.5% of pretax income. If your pretax income is $70,000, the premium costs about $6,000 a year. But your after tax income might be just $55,000 a year. Then the "8.5%" really stings.<br />Your info on how ConnectorCare is funded is very interesting.<br /> Assessment on employers? How did that happen?<br /> And a Medicaid waiver? what bureaucratic cleverness put that together?<br /><br /><br />This is notBob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-45722830356969317622022-11-17T09:15:56.943-05:002022-11-17T09:15:56.943-05:00Andrew:
Thank you for the commentary on the Massa...Andrew:<br /><br />Thank you for the commentary on the Massachusetts plan. Did not know this information and it is far simpler than the ACA. Good luck on your Substack.Bill Hnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-41830327540556091232022-10-30T11:12:44.714-04:002022-10-30T11:12:44.714-04:00Thanks for wading into this difficult arena. My ex...Thanks for wading into this difficult arena. My experience in an insurance agency was that the people who did not purchase Advantage plans were pretty ignorant of how traditional Medicare really operated. If they were to receive an OOP cap tomorrow -- and that is fine with me -- they would not change their behavior in any material fashion. The Advantage insurance companies create whatever controversy exists.<br /><br />Medicare part A has no out of pocket costs for the first 60 days of a hospital stay. Does anyone stay in hospital over 60 days any more? I am not sure. The ugliest disputes in my experience arose over post-hospital long term care.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-86521724805105214212022-10-12T16:22:36.127-04:002022-10-12T16:22:36.127-04:00I cannot get as far into the weeds on this issue a...I cannot get as far into the weeds on this issue as you can, Andrew, so thanks for your exposition.<br /><br />I will comment that if the insurers really cared about saving money for Medicare, they would make their low bids and do the work, and not expect the extra money that is sent their way by Washington.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-61629985524646959902022-10-06T18:09:23.584-04:002022-10-06T18:09:23.584-04:00Now, Andrew, are you trying to tell me that the sa...Now, Andrew, are you trying to tell me that the same people who produced these forthright straight-for-the-truth Harry and Louse ads https://www.youtube.com/watch?v=Cd_xPNT1Fh8 back in 1993 are not showing similar moral rectitude now? I just don't believe you.<br /><br />Please stop your leftist agitating.<br /><br />(Reference on the people are the same: https://en.wikipedia.org/wiki/Harry_and_Louise )Norm Spiernoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-40023065567023560262022-10-06T08:31:30.939-04:002022-10-06T08:31:30.939-04:00Excellent article on this subject in Kaiser Health...Excellent article on this subject in Kaiser Health News.....<br /><br />https://www.modernhealthcare.com/post-acute-care/medicare-advantage-plans-increasingly-ending-members-coverage<br /><br />Part of the problem is that so few Americans have long-term care coverage. Medicare has been kind of a band-aid with its 21 or so days of post-acute care payments. <br />Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-73526940295389395942022-10-01T19:18:36.381-04:002022-10-01T19:18:36.381-04:00Oops, I meant the Gap Plan, not Part B, and I see ...Oops, I meant the Gap Plan, not Part B, and I see this issue is addressed in the second part of this series.<br /><br />On another note, I will add that my disabled adult child has FFS Medicaid (there is also an HMO option that we turned down), and it is the best health coverage anyone in our family has had. He sees doctors in a university-affiliated system and hasn’t had a hoop (eg, prior autos, etc.) to jump through yet. No copays or deductibles needless to say. Really, the rallying cry should be Medicaid for all, not Medicare for all.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-69635196059589693552022-10-01T19:03:03.292-04:002022-10-01T19:03:03.292-04:00Several years ago, when I turned 65, I chose tradi...Several years ago, when I turned 65, I chose traditional FFS Medicare, in part because of an article I read that warned that once you go to MA route, you may never be able to switch to FFS. Because your pre-existing conditions would be held against you by Part B underwriters — and you really can’t go without Part B coverage. They could turn you down or charge prohibitive rates.<br /><br />The scenario where you’d want to switch to FFS is of course when you have acquired an awful medical condition and need very specialized care not available in your MA plan. Just the sort of condition a Part B underwriter might not like.<br /><br />I just hope that I’ll continue to be able to afford FFS in the fixed income years ahead.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-56598795287396357612022-09-30T09:51:04.701-04:002022-09-30T09:51:04.701-04:00Thanks for the research. Fascinating, that the mos...Thanks for the research. Fascinating, that the most contentious issue for plans is post-acute care. Believe me, the typical 65 year old choosing plans is not thinking about post-acute care that they might need when they are 90.<br />(I had an elderly aunt who had a big fight with her MA plan about post acute care.)<br /><br />The commission discrepancy is awfully stupid. Why the rates are not either standardized across all plan types, or just free-market, is completely baffling to me.Bob Hertznoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-38321712204785838362022-09-29T15:22:49.146-04:002022-09-29T15:22:49.146-04:00Not a big deal, but the RevUp program does not fo...Not a big deal, but the RevUp program does not focus poor patients, and used frequent interventions to minimize hospitalization (affordable or not).<br /><br />https://mdrevolution.com/md-revolution-rolls-out-revup-now/Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-39815342030560885912022-09-28T07:02:10.733-04:002022-09-28T07:02:10.733-04:00I assume that the doctor would be requesting prior...I assume that the doctor would be requesting prior authorization, not the enrollee. The doctor would not say, "I believe you need a transplant, why don't you check with your MA insurer before I schedule it." <br />I remember a series of studies about 10-15 years ago that looked at a bone marrow procedure which several insurers denied for breast cancer sufferers. The studies concluded that the procedure really wasn't much good, although by that time the insurers were all castigated as heartless villains,Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-63804900130448601502022-09-27T12:06:06.824-04:002022-09-27T12:06:06.824-04:00P.S., didn't realize I posted the above 9/26 c...P.S., didn't realize I posted the above 9/26 comment anonymously!Ted Doolittlehttps://portal.ct.gov/ohanoreply@blogger.comtag:blogger.com,1999:blog-8512362.post-61683394544324734522022-09-27T10:13:34.252-04:002022-09-27T10:13:34.252-04:00KFF has a list of services for which MA plans are ...KFF has a list of services for which MA plans are likely to require prior auth, ranked by the percentage of plans that require the service, here https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-premiums-out-of-pocket-limits-cost-sharing-supplemental-benefits-prior-authorization-and-star-ratings/ Maybe the more salient question for an enrollee is how onerous the prior auth process is likely to be, rather than for which services it's required.Andrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-15505928354466092952022-09-27T09:49:49.076-04:002022-09-27T09:49:49.076-04:00I mentioned that I have never had even the hint of...I mentioned that I have never had even the hint of a denial with my MN Med Ad plan.<br />Here is a summary of the conditions that do require prior approval in my plan (and thus be more vulnerable to denial)....<br /><br />Cardiology (ablation, stress test, advanced imaging, diagnostic and implantable device services)<br />Medical oncology (chemo and supportive medical specialty medications treating active cancer diagnosis)<br />Molecular lab (Breast Cancer (BRCA) gene testing, fetal chromosomal testing, molecular pathology)<br />Musculoskeletal (spinal injections for pain management; knee, hip and shoulder surgery; fusions)<br />Radiation therapy (surgical procedures such as mastectomy; radiation procedures such as 3D CRT and IMRT; surgical or radiation treatment of cancers)<br />Radiology advance imaging (MRI, MRA, PET, CT, and Nuclear Studies)<br />Sleep (sleep study, machine and supplies; apnea testing)<br />Transplant services<br />Some surgical procedures <br />Some behavioral health assessments and treatments<br />Certain medicines including injectables and intravenous therapies<br />Prosthetic supplies <br />Some medical equipment and devices including oxygen and wheelchairs<br />Some services may require a prior authorization to continue receiving the service after a set number of visits, such as acupuncture and home health visits<br /><br />Personally I have had a stress test, and not much else on this list. Thus my hassle-free experience, perhaps.<br /><br />The actual mechanics of a capitation system are probably a lot more complex than I would appreciate.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-34038120343461982602022-09-26T17:06:21.219-04:002022-09-26T17:06:21.219-04:00Thanks -- I kept meaning to link to this series. M...Thanks -- I kept meaning to link to this series. My impression was that in their last rebuttal, Halvorson and Donald Crane punted, effectively conceding that the model they tout -- incentives to keep per-enrollee costs low -- really only works in the 18% of MA plans that in turn pay providers on a capitated basis. And that model -- in which all parties are paid to keep enrollee costs low -- sets against the opportunity to reduce low-value care the heightened risk of reducing high-value but expensive care. Finally, in this piece, the authors emptily cite support for MA and ACO reach from the House of Representatives, CMS and CMMI, as if those institutions are disinterested, not addressing the possibility of regulatory capture. https://www.healthaffairs.org/content/forefront/medicare-advantage-emperor-s-clothes-reply-berwick-and-gilfillanAndrew Sprunghttps://www.blogger.com/profile/17601269968798865106noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-50858658347950763342022-09-23T21:26:07.933-04:002022-09-23T21:26:07.933-04:00George Halvorson published three longish articles ...George Halvorson published three longish articles on Med Advantage in The Health Care Blog in the spring. I have followed George since his days running health plans where I live in MN. He is very rarely wrong. I will have to re-read the articles. He is very pro-Medicare Advantage.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.comtag:blogger.com,1999:blog-8512362.post-4068655862191221522022-09-21T12:10:02.097-04:002022-09-21T12:10:02.097-04:00I have been in a Blue Cross MA plan for about 9 ye...I have been in a Blue Cross MA plan for about 9 years. I have had three surgeries in that time.<br />I have never paid more than $100 out of pocket for anything. I had the choice of 98% of the drs and hospitals in MN when needed. I believe I could have accessed providers in other states with no hassle.<br />I have not had to test the drug coverage....the costs would be high for specialty drugs, but that is true for all drug plans I believe.<br />When I did have a complaint about a provider overcharging me, a Blue Cross rep got on the phone with me and solved the issue in my favor.<br />Now I am always wary of generalizing from one's own experience... so I eagerly await your next article.Bob Hertzhttps://www.blogger.com/profile/08889826739646491269noreply@blogger.com