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Monday, August 22, 2016

ObamaCare in trouble? Coverage, cost, access problems...

I have no doubt you're aware that there's been a lot of fractious, angry news and blog chatter on the Internets lately focused on the broad overlapping topics pertaining to the intractably byzantine business of healthcare. And, as we head for the final approach to the 2016 Presidential election, GOP (and Libertarian) promises to "Repeal and Replace ObamaCare" have never been louder.
BTW, see my July 2015 book report on "ObamaCare is a Great Mess."
While driving home from last my last volunteer stint at, I listened to a very interesting KQED "California Report" segment, one concerning the "mental health" side of things:

Sorry, The Therapist Can't See You — Not Now, Not Anytime Soon

More than 43 million Americans have depression, anxiety, or another mental health condition. But more than half never get help. Recent laws were supposed to make it easier for Californians to access treatment, but many still face roadblocks, even with insurance...

We talk to a single mom looking for help in San Francisco, where there are lots of therapists. And we meet a young woman in Shasta County, where there aren’t.

We talk to the therapists who are trying to help. We explore the current state of enforcement. And we take a step back in history to understand how psychotherapy became a hobby of the wealthy rather than a critical service for those in need...

...[Natalie] Dunnege puts all her spare money into therapy for Strazh. She says it helps a lot. But Dunnege herself is struggling, feeling depressed and overwhelmed. She decided to look for her own therapist.

“One of the things that I’ve really had to wrap my head around is that I can’t change him. I can only change how I handle the situation,” she explains. “And not that I would want to change who he is. He’s a really good kid, but it’s a lot to handle, especially as a single parent.”

But when she logged onto her insurance website to find a therapist, she realized her copay for a mental health visit was going to be upwards of $75 – more than double her copay for other doctors’ appointments. Under a 2008 federal mental health law, those copays are supposed to be the same...

More than 43 million Americans suffer from depression, anxiety and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care. Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.

Recent health laws, the 2008 Mental Health Parity Act and the Affordable Care Act, were supposed to fix this...

But advocates say insurance companies are still finding ways to keep people who need care from getting it. Some are still not complying with the law. And some have found subtle, technically legally, ways to limit treatment...

There’s something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he spends training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants them to devote that education to taking care of people with serious mental illness.

But many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls “the worried well” –- people who enjoy the self-exploration of therapy but do not necessarily have a mental health problem...
Really good segment. Really disturbing. Then, there's this stuff, from THCB:
Aetna’s Obamacare Surprise

Did Aetna just pull a nasty, Trump-like move and up the ante on the Obamacare debate in advance of the election and exchange open enrollment for 2017?

The allegation is that the company withdrew from 11 state insurance exchange marketplaces for 2017 after the Justice Department failed to heed Aetna’s warning that it would do so if Justice didn’t approve its $37 billion purchase of Humana. The Justice Department announced last month that it was challenging that deal and Anthem’s proposed merger with Cigna, saying both deals threaten to sharply reduce competition in the health insurance marketplace...
Then, also at THCB, comes this creatively razor-tipped bit of anti-regulatory snark mocking the new MACRA initiative:
Value-Based Government (GACRA)

We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it  GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you,  The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

With GACRA, you will need to document every thing you do, but we will only pay for meetings and rules you make.

You will be paid for each meeting in this manner: You need to document the history of the meeting, what you discussed, how complicated the problem is, did you review any prior documentation, did you do an adequate review of the pertinent materials?  You will document a level 1,2,3,4, or 5 depending on the complexity, history etc. Don’t document a 4 if it was really a 3, that's fraud, so pay attention, its a complicated formula, but you have time to figure it out...
Read all of it. Below, this gave me the "ouch, lol" reaction:
To document all this, you must use the software that we certify, you cannot use your own. No customized software. We know better on what you need, not you. You may think you have a better way, but forget it. We don’t want innovation or new ideas, we want you to use old, one-size-fits-none software, that they will charge you a lot of money to buy and support. Sorry that its pricey and it doesn’t work well, it is what it is, don’t whine about it...
Well, you could use my Clinic Monkey ;)

In about a month, I will be joyful witness to the latest exuberant onslaught of all things cutting-edge Health IT and BioMedTech during the 10th Annual Health 2.0 Conference:

Been covering it every year since 2012. A high point of my year every year, as are the Health 2.0 WinterTech Conference that launched in 2015, and the yearly Lean Healthcare Transformation Summits.

In April I posted "Digital Health IT = "Better Care at Lower Cost." Right?" Prior to that I posted "The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"

All of the whiz-bang tech and progressive process QI in the world can be stymied by the Gordian Knot comprising the hopelessly partisan socioeconomic politics of the "Payment Side." See, e.g., my prior posts on the "shards" of health care, here and here. apropos, see also my May 16th post "EHRs and the ACA: Obama's diabolical plot to enslave physicians."


Just in from STATnews:
Are insurance policies saving patients money, or keeping them from the treatment they need?

As science makes once-unthinkable treatments available, patients are increasingly facing a harsh reality: Insurance companies are forcing them to try older, less expensive therapies for months before covering pricier ones.

Insurers have long relied on a cautious approach to control costs and spare patients from expensive medications they might not need. But in more than a dozen interviews with doctors and patients, a picture has emerged of insurers growing more aggressive as they respond to financial pressures.

The result is a reliance on what is known as “step therapy,” whereby patients are forced to try cheaper treatments before they graduate to more expensive ones, even when health care providers are confident the inexpensive treatments will not work...
 Interesting. STATnews reliably rocks.

This Princeton health economist thinks Obamacare’s marketplaces are doomed

I’ve spent the past week talking to lots of health care experts and economists about the future of the Affordable Care Act. Of all the people I spoke with, Princeton University health economist Uwe Reinhardt offered the most dire and pessimistic assessment of the marketplaces' future.

Namely, he believes they’ve already entered a death spiral and are heading toward total collapse...

More to come...

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