• Avoiding the health care run-around

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    You’ve all experienced it: There’s a problem with your health care bill, or you have difficulty getting coverage for the care you need. Your doctor or hospital tells you to talk to your insurer. Your insurer tells you to talk to your doctor or hospital. You’re stuck in an endless runaround.

    A small patient advocacy industry has sprung up to help, but that help can cost several hundred dollars an hour. Is there a way to get the customer service we deserve?

    Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems, according to results from a recent study by me; Garret Johnson, now a medical student at Harvard; and Zoë Lyon, a research assistant at the Harvard T.H. Chan School of Public Health.

    Our conclusions are based on analysis of Medicare Advantage plans — private insurance alternatives to traditional Medicare. Medicare Advantage plans are offered by major insurers like UnitedHealthcare, Humana, Aetna, BlueCross BlueShield affiliates and others. But nearly one-quarter of the plans are issued by hospitals or health systems. These provider-offered plans are more likely found in dense, urban areas in the Northeast and the West.

    The government collects data on health care quality from surveys and medical claims, then aggregates them into ratings of plans. These are publicly reported in units of stars: Five stars represents the highest quality, and one the lowest. Our study, published this month in the health policy journal Health Affairs, found that provider-offered plans have higher quality ratings.

    Plans offered by insurers have average ratings of just over 3.5 stars for both nondrug and drug service. An average provider-offered plan has quality ratings that are about one-third of a star higher for both, after adjusting for factors that could confound the comparison, like socioeconomic status and the types and number of doctors where plans are offered.

    Our study dug deeper to examine the kinds of quality enhancements available in provider-offered plans. Some aspects of quality are clinically focused. For instance, measures of preventive screening — like that for colorectal cancer — or management of chronic conditions assess the quality of care delivered by doctors and hospitals in a plan’s networks. Provider-offered plans perform somewhat better than insurer-offered plans in such areas.

    Other aspects of quality pertain to customer service. In measures of complaints, responsiveness to customers and the enrollees’ overall experiences, provider-offered plans really shine. In each area of customer service we examined, provider-offered plans are rated one-half star higher than insurer-offered ones. (This is a big difference. For comparison, over half of plans are within one star of each other in overall quality.)

    These results make some sense. When a customer has an issue — like a problem with a hospital bill — the easiest thing for a health plan to do is pass it off to the hospital. Likewise, the hospital’s easiest course of action is to blame the health plan. The patient, stuck in the middle, is not likely to rate his plan (or hospital) highly for customer service in this case.

    However, when the plan and hospital are one and the same, neither can pass the buck to the other. Problems may be resolved faster; they may be less likely to develop in the first place. This could lead to the higher customer satisfaction reflected in the quality ratings.

    If the higher ratings are enough to interest you in trying a provider-offered plan, how would you find one? Unfortunately, there’s no readily accessible source to inform consumers (or researchers) about this feature of plans. Sometimes the plan’s name gives away the relationship. The UPMC Health Plan practically has the health system that offers it right in the name — UPMC stands for University of Pittsburgh Medical Center. In other cases, consumers can identify the relationship on plans’ or health systems’ websites. For example, the Vital Traditions plan website identifies as its parent company the largest nonprofit hospital system in Texas, Baylor Scott & White.

    But in many cases, it’s not so easy to figure out. In fact, this is why there has been so little analysis of provider versus insurer plans. For our study, we had to scroll through hundreds of websites, news articles and documents to build a research data set on provider-offered plans from 2011 to 2015. Because of the work involved, there are very few studies on the subject. Another, published in Health Service Research by me, Roger Feldman of the University of Minnesota and Steven Pizer of Northeastern University, found a similar quality relationship when examining 2009 data.

    That earlier study also found that provider-offered Medicare Advantage plans charge higher premiums. But a recent study of marketplace plans found that provider-offered ones are not necessarily the most expensive. For some, a higher premium may outweigh the benefits of greater quality, but for others it may not.

    From our study, we can’t be certain that provider sponsorship of plans causes higher quality. It could be that higher-quality providers are the ones that choose to offer plans. Nevertheless, such tight integration between plans and providers is at least a signal of higher quality, even if it doesn’t cause it.

    Recent trends suggest more health systems are offering plans in other health care markets for the working-age population, not just in Medicare Advantage. Not all markets may be hospitable to provider-offered plans, however. Some systems that did offer plans are pulling back. According to The Wall Street Journal, Catholic Health Initiatives, which runs over 100 hospitals across 18 states, is divesting itself of some of its health insurance plans. After struggles with profitability, Tenet Healthcare and several other health systems have said they will do the same.

    Provider-offered plans may increase convenience for consumers. But the financial risk it confers on the organizations that offer them may be more than some can handle.


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  • AcademyHealth: Traditional Medicare is cheaper

    Hold on to your hat: Medicare pays lower prices than commercial market insurers. Yeah, OK, you already knew that. But what are the implications for access to care? I answer that question in my latest AcademyHealth post.



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  • If Obamacare exits, some may need to rethink early retirement

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It also appeared on page A10 of the February 28, 2017 print edition.

    Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early.

    Americans reaching 65 become eligible for Medicare. Before reaching that age, some can get retiree coverage from their former employers. But not very many companies, especially small ones, offer medical insurance to retirees. If early retirees are poor enough, they could turn to Medicaid. To retire early, everybody else would need to turn to the individual health insurance market. Without the subsidies and protections the A.C.A. put in place, health care coverage would be more difficult to obtain, cost consumers more where available, and provide fewer benefits than it does today.

    That means that if the A.C.A. is repealed, retiring early would become less feasible for many Americans.

    This consequence is called job lock — the need to maintain a job to get health insurance. One of the arguments in favor of the A.C.A. was that it would reduce or eliminate job lock. With repeal of the law on the agenda of Congress and President Trump, there is renewed concern about how health insurance could affect employment and retirement decisions.

    These relationships have been examined extensively by scholars. Though not all studies have found evidence of job lock in the pre-Obamacare era, a majority of high-quality studies have. That’s the conclusion of systematic reviews conducted by the Government Accountability Office and several health economists.

    Because people approaching retirement age are more prone to illness and high health care costs, employment-based insurance is particularly valuable to older workers — so much so that many studies document that it influences retirement decisions. One study found that workers whose employers offered retiree health benefits were 68 percent more likely to retire early than those who lack employer-based retiree coverage.

    Another study found a smaller effect, 47 percent. But that study also found that workers in poor health who had retiree health benefits were 88 percent more likely to retire early compared with similar workers lacking retiree health benefits. Both those studies used data that are now several decades old. But a 2014 study that incorporated more recent data — though still pre-A.C.A. — also found that retiree health benefits encourage early retirement. The inference from these studies is that coverage options in the A.C.A. marketplaces would similarly encourage early retirement.

    Deferring retirement because of health benefits is just one form of job lock. Another example: Many studies show that spouses are much more likely to work if their partners do not have employer-based family coverage. Other studies show that workers with cancer are more likely to continue working if that’s how they get health insurance.

    Two studies led by Cathy Bradley of Virginia Commonwealth University examined working women with breast cancer diagnoses. Both studies found that those who depended on their employment for coverage were more likely to remain working.

    If not for job lock, we’d probably see greater job mobility and entrepreneurship. According to one analysis, two million more people would change jobs if it weren’t for job lock — presumably finding work that makes them happier or to which they are better suited. One study found that 25-to-55-year-old married men with no other coverage options are 22.5 percent less likely to switch jobs compared with those who have alternatives. Another study, examining 24-to-35-year-old married men, estimated smaller effects, between 10 and 15 percent.

    The evidence of sticking with jobs instead of starting a business is mixed, but the preponderance of it suggests this kind of “entrepreneurship lock” exists, affecting up to four million people. Workers without coverage from a spouse — therefore, more reliant on their own employers’ coverage — are a few percentage points less likely to become self-employed, according to one study. Similarly, self-employment spikes when workers turn 65 and obtain Medicare coverage.

    From the late 1980s to the early 2000s, tax deductibility of policies for self-employed workers was phased in, making those policies more affordable. Two studies provide evidence that this change increased self-employment. One found that it rose 10 percent among women without health coverage from a spouse versus those with such coverage. Another found that the tax change explained as much as half the total increase in self-employment between 1999 and 2004.

    All of these studies suggest that job lock would be alleviated by more available and affordable coverage outside work. Whether Obamacare did that is less clear. Many policy experts expected the A.C.A. to reduce job lock. An analysis by the Urban Institute, conducted before the health insurance reforms were implemented, estimated that the self-employed would increase by about 1.5 million individuals as a result of the law. In 2014, the Congressional Budget Office anticipated that the A.C.A. would reduce the size of the labor force by at least two million people by 2024.

    One post-A.C.A. study found that the prohibition of pre-existing condition exclusions for children increased job mobility for their parents. And in the months after the insurance market reforms rolled out, voluntary part-time work increased and the growth in the number of workers over age 55 slowed, both consistent with alleviation of job lock. But more rigorous studies of part-time work did not find an impact from the A.C.A.

    According to a review of scientific papers by the economists Jean Abraham and Anne Royalty, for the University of Pennsylvania’s Leonard Davis Institute of Health Economics, few other studies have found solid evidence that the A.C.A. reduced job lock or had other effects on the labor market. For instance, studies have not found that allowing children to stay on their parents’ insurance until age 26 has influenced the labor market choices of young adults. Nor have they found that the A.C.A. increased early retirement or employment more generally.

    One reason studies might not have found an impact on job lock could be because the law is relatively new, and there isn’t enough data available to researchers to tease out all its effects. It could also be because the law has been under siege on multiple fronts since passage, rendering its status uncertain. This may have raised doubts in workers’ minds about the wisdom of relying on it as a substitute for employer-offered coverage.

    But it is clear that with A.C.A. repeal on the table, people contemplating early retirement may need to reconsider.


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  • The health care system treats patients like garbage

    I started and stopped writing this post many times because it’s mostly whining. But, dammit, it’s a consumer’s right to whine, so here it is: in my experience (YMMV) — and that of many others I know — the health care system largely treats patients like garbage.

    I was reminded of this fact during my recent experience dealing with my daughter’s broken arm. It started well enough. Our pediatrician has late hours and an X-ray machine, so we were able to skip the Friday night (and more expensive) emergency department visit for our initial diagnosis, and therefore missed all the attendant waiting and frustration.

    Upon viewing the X-rays, the pediatrician conveyed that it was not a bad break and didn’t need to be addressed immediately. A brace, which she provided, was good enough for now. Fair enough. But what was our next step? “The X-rays need to be examined by a radiologist before I can tell you that,” my wife was told. OK …

    I wonder how long we would have waited for that to happen. By the middle of Saturday, we became too uncomfortable to find out, so I called the pediatrician’s office. Now, and with no further consideration of the X-rays, they were wiling to give us some recommendations for orthopedic clinics. Why couldn’t those have been given to us on Friday?

    Naturally, one clinic was closed on the weekend. But, the other, hospital-based one, had Sunday hours. Great! A call to that clinic got me a voice-mail. I left a message. I have never gotten a call back, but I didn’t wait for one. I called again later and got a person who told me they had 7AM walk-in hours. Just go to the main hospital entrance and ask for the walk-in orthopedic clinic, I was told.

    This was bad advice. After dragging my broken-limbed daughter through every door that plausibly seemed like the main entrance, we finally found someone who said we should go through the ED entrance. That was the right answer, but not what we were told on the phone.

    After waiting and registering, we finally saw the orthopedist. He was great. It was, in fact, not a bad break. Now it is safely casted. All is well. But not before we had to do a lot of legwork — and received a lot of wrong answers, promises of follow-ups that didn’t happen, etc. Meanwhile, our pediatrician has not (yet) checked in on her patient.

    I get it. She’s busy with more urgent matters. It makes sense, but it sucks, and all the more knowing that we spend a fortune for such treatment. No other business would treat customers this way. In health care, inconvenience, uncertainty, lost records, lack of follow-up and coordination, the necessity of self-advocacy, and lots and lots of waiting is the norm.

    Of course, there are some examples of good customer service in health care. I’ve even experienced them. But every tasty crumb I’m tossed just reminds me how awful the rest of the meal is.

    In his most recent article, Atul Gawande related an example of good customer service in health care. The patient, Haynes, had experienced a lifetime of frequent, debilitating migraines. None of the more standard treatments worked, so his doctor, Loder, got creative.

    The most exotic thing they tried was Botox—botulinum-toxin injections—which the F.D.A. had approved for chronic migraines in 2010. She thought he might benefit from injections along the muscles of his forehead. Haynes’s insurer refused to cover the cost, however, and, at upwards of twelve hundred dollars a vial, the treatment was beyond what he could afford. So Loder took on the insurer, and after numerous calls and almost a year of delays Haynes won coverage.

    That’s what I’m talking about! This should be standard, but it isn’t. More typically, the patient is left holding the bag. You want the treatment you need, go fight your insurer for it. The health system is not going to help you, because it is not in most stakeholder’s interest to do so. It also should be noted that such inconvenience keeps health spending down — and I completely appreciate the need to be prudent with spending — but it still sucks for patients.

    Perhaps concierge medicine is the answer, or paying more for your own care. We’ll see, because we’re running that experiment right now. I’m not seeing a lot of movement, but maybe it’s too early or I’m unlucky. I could just be a whiner.


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  • Upshot Extra: “Without Obamacare, maybe I can’t retire early”

    “I hope to retire early, but if Obamacare is repealed, where would I get health insurance?” Erkan Baloglu asked me at a New Year’s Eve party. To attend graduate school, he immigrated to the U.S. from Turkey two decades ago and now searches for new, potential drugs at a small, Boston-area biopharmaceutial company. Like most employers, and the vast majority of small ones, his does not offer health insurance to its retirees.

    “Without Obamacare, maybe I can’t retire early,” Erkan said. This is “job lock,” the topic of my Upshot post today. Go read it.

    One option available to Erkan, but not to most Americans: “I could go back to Turkey, where everyone is covered,” he said.


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  • AcademyHealth: Adverse drug events

    Adverse drug events are a big deal, impacting half of hospital stays for adults 65 years old and older. My latest AcademyHealth post covers some of the other stats and issues.



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  • AcademyHealth: Some lessons about opioids

    A NEJM paper last year by Nora Volkow and A. Thomas McLellan offers several important lessons about opioids. My latest AcademyHealth post covers some of them.


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  • AcademyHealth: Polypharmacy

    Multiple chronic conditions and the taking of many prescription medications to treat them — polypharmacy — are common among the elderly. Studies have found an association of polypharmacy with adverse outcomes. An important question is, to what extent does polypharmacy cause bad outcomes? And, if it’s causal, what can be done?

    Read my latest AcademyHealth post for more.



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  • Longer lifespans largely not to blame for rising health care spending

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It also appeared on page A3 of the print edition on January 26, 2017.

    American life spans are rising, and as they are, health care spending is, too. But longevity is not contributing to the spending increase as much as you might think.

    The median age in the United States will rise to about 40 by 2040, up from 37.7 today. That’s partly because the average American lives three years longer today — reaching nearly 79 years old — than in 1995. The Congressional Budget Office credits population aging for a substantial portion of its projected increase in health care spending — from 5.5 percent of the economy today to almost 9 percent by 2046.

    But research suggests that living longer, by itself, isn’t a big driver of rising health care spending. Because the baby boom generation is so large — members of which are now in their 50s to late 60s — the average age of Americans would rise even if life expectancy didn’t. For every 100 working-age American today, there are about 25 Americans over 65. By 2040 there will be 37.

    Older people need more health care, and they spend more. Compared with the working-age population (people 19 to 64 years old), those 65 to 74 spend two times as much; those 75 to 84 spend four times as much; and those 85 and older spend six times as much. And the growth in health care spending is faster for retirees than for younger Americans.

    The real culprit of increased spending? Technology.

    Every year you age, health care technology changes — usually for the better, but always at higher cost. Technology change is responsible for at least one-third and as much as two-thirds of per capita health care spending growth. After accounting for changes in income and health care coverage, aging alone can explain only, at most, a few percentage points of spending growth — a conclusion reached by several studies.

    Some health care technology helps us live longer. The vast majority of the seven years of life expectancy gains in the latter half of the 20th century were because of better — and more costly — treatments for premature infants and cardiovascular disease, according to analysis by the Harvard health economist David Cutler and his colleagues. But recent work led by the Stanford economist Raj Chetty reminds us that factors outside the health system — like smoking rates and education levels — also influence longevity.

    Just how much longer life spans boost spending depends on how many of those extra years are spent in good health versus poor health. Several studies warn that Americans will spend more of those years in poor health and with disability, which would push health spending higher.

    But other analysis suggests that the leading causes of death, including cancer, heart disease and stroke, are being pushed off until later in life, giving us more years of good health. A recent study by Mr. Cutler and researchers from Harvard and the National Bureau of Economic Research found that between the early 1990s and the late 2000s, the elderly population gained more disability-free years than years with disability.

    Perhaps some of the additional money we pour into the health system each year is doing some good. “Certainly we must address the problems associated with financing health care spending and health disparities,” said Michael Chernew, a Harvard health economist and a co-author on the study. “But we can take some solace in evidence that more people are living longer and better.”

    These findings are consistent with other work showing that higher health care spending by older patients has more to do with their proximity to death than with their age. One study found that hospital expenses grow 1,000 percent in the last five years of life, but increase only 30 percent from 65 years old to 80. Another study found that a majority of Americans over age 85 have no limitations to their daily activities because of health, which suggests that age is a poor marker of health and its associated costs.

    A decade ago, in a study published in Health Policy, two German health economists calculated how much incorporating the effect of shifting the spending near death could reduce health care spending projections. They took an extreme approach by assuming all of the increase in health care spending as one ages is in the proximity to death (none to greater age). So imagine that instead of incurring high costs and dying at, say, 75, one lives five more years in relative health, shifting those higher costs to just before age 80. The effect, according to their study, is to reduce estimates of health care spending because of aging by 40 percent.

    In other words, living longer doesn’t increase health care spending so much as it delays the large amount spent near death. Some health care spending is associated with those intervening, relatively healthy years, just not much compared with that spent in one’s final years.

    Living longer offers many benefits. That it isn’t, by itself, a major contributor to health care spending is a nice bonus.

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  • AcademyHealth: Private vs. public prices

    The prices private health insurers pay hospitals have long been above those paid by Medicare and Medicaid. But in recent years, the difference between public and private prices has grown tremendously. Why? Read my latest AcademyHealth post for more.



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