Author Archive

EBRI’s First Look at HSA Account Balances and Distributions

The Employee Benefits Research Institute has just published its first analysis of HSA accounts, balances, and distributions, based on its own HSA database. This is an excellent report, in part because it also looks at other similar reports and discusses the strengths and weaknesses of each.

It is well worth downloading and saving the entire report and using it as a baseline to watch the growth of HSAs over the coming years.

Here are some of the bullet points –

  • This year marks the 10th anniversary of the creation of health savings accounts (HSAs) under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
  • Starting from scratch a decade ago enrollment in HSA-eligible health plans is estimated to range from 15.5 million to 20.4 million policyholders and their dependents, and it has also been estimated that there are 10.7 million accounts holding $19.3 billion in assets as of Dec. 31, 2013. Seventy percent of HSAs were opened since 2011.

Read More » »

Price Controls

Phil Gausewitz, MD, recently focused on the problem of price controls in medicine. He argues that the imposition of price controls have devastated quality and innovation in medical care and makes a compelling case that removing them would open up a new era of patient centered care and restore the physician/patient relationship.

With the removal of the price controls we can expect that, in addition to saving the enormous administrative costs they cause, the devastating effects of the physician shortage will be relieved. Patient care services will improve significantly as physicians compete for patients on service and fees. Medicare patients will regain the right to protect their lives, which they are denied now, by being able to freely contract with physicians who require fees greater than the government allows, and we will be spared the ridiculous spectacle of the “doc fix”.

Shortages caused by price controls protect less effective doctors who now have busy practices regardless of the quality of their service. The exciting new developments in diagnostic and treatment procedures, equipment, immunology, informatics and genetics will be brought more efficiently to patient care, without being inhibited by burdensome and needless financial regulations. The relationships between physicians and patients will improve as patients choose physicians with whom they are comfortable.

Value Based Payments

In Information Week David Carr writes about some of the current trends in health care, and especially about “value based payments.” He writes –

“Value based” is a catch-all label for Accountable Care Organizations (ACOs) and other ways of restructuring healthcare around payment for value delivered, as measured by metrics of healthcare quality or the aggregate health of a population rather than by the volume of visits, procedures, or hospital stays a healthcare organization records. In other words, it’s a highly data-driven vision of healthcare reform, intended to improve quality and efficiency while reducing costs.

He reports on a new study by Availity that says while 75% of providers currently participate in some form of “value-based payment model…fewer than 30% believe these schemes offer a good level of reward for the risk.” Generally, both physicians and hospitals are concerned about the additional administrative burden and expense needed to justify payment.

That concern is certainly borne out by an article titled “What is Value in Health Care?” from the New England Journal of Medicine sent to me by a friend. This was published in 2010 and written by Michael Porter of the Harvard Business School.

Read More » »

Population Health

I’ve been wanting to write about “Population Health” for some time now. It is a huge new trend that has risen under the radar of almost the entire population. Nearly every medical school now has a Department of Population Health or a Center for Population Health. Thomas Jefferson University has an entire school devoted to the subject — The Jefferson School of Population Health, founded in 2008.

The concept is kind of creepy, but it is getting even creepier. The Institute for Healthcare Improvement (IHI), Don Berwick’s old outfit, recently announced a conference on “Population Management” to be held September 28 to October 1 this year. Enrollment will cost $4,950 per person, so you know it’s a very big deal.

One of the reasons it is hard to write about this is there is no settled definition of what it is. A paper written in 2003 by David Kindig and Greg Stoddard in the American Journal of Public Health took a stab at it. They write –

Although the term “population health” has been much more commonly used in Canada than in the United States, a precise definition has not been agreed upon even in Canada, where the concept it denotes has gained some prominence.

Read More » »

Variations in Post-Acute Care Spending

A publication called “Becker’s Hospital CFO” recently ran a story based on data from a company called DataGen on “The Truth Behind Variation in Episode Payments.” The article claims it will explore “the regional variations in Medicare payments for 90-day episodes of care.” This is to prepare for the new era of bundled payments, which is supposedly right around the corner.

Toy Businessman on a Pile of MoneyIn fact, the article does two things:

  1. It completely fails to explain the regional variations it identifies, and
  2. It illustrates what a poorly thought-through idea bundling is, especially when designed by payers like Medicare.

The article defines four types of episodes that are likely candidates for bundled payment. These all start with an inpatient admission followed by post-acute care treatment –

  1. Acute Myocardial Infarction (AMI)
  2. Congestive Heart Failure (CHF)
  3. Pneumonia
  4. Major joint replacement

Read More » »

Demographics of CDHP Enrollees

EBRI has released the latest in its series of surveys on “Characteristics of the Population With Consumer-Driven and High-Deductible Health Plans.”

This is the ninth year in which Paul Fronstin has looked at the people enrolling in “consumer driven health plans” (CDHPs), which include both HRA and HSA models. He also surveys people with stand-alone “high deductible health plans” (HDHPs), and “traditional” plans, though I am not sure what traditional means anymore. It is defined as any plan with a deductible below $1,000 for an individual, so I guess it includes PPOs, HMOs, and POS plans.

In any case, as usual he finds that CDHP enrollees are very much like everybody else, with these exceptions — they are much better educated, have somewhat better incomes, and are slightly healthier. There are “statistically significant” differences in some other categories, but they are not great and they tend to bounce around from year to year. For instance, in 2013 70% of CDHP enrollees were married, compared to 63% for HDHPs and 61% for traditional. But in 2012 the rates were 78% for CDHP, 70% for HDHP, and 76% for traditional. It is hard to see much of a trend there.

But there is a definite trend in education levels. Here is the comparison of the completed education levels for enrollees of each type of plan for 2013, but the differences are similar for every year surveyed.


Read More » »

Can Anything Be Trusted in This Administration?

The new announcement that the Census Bureau is completely changing its Current Population Survey (CPS) questions about health insurance coverage (see previous post here) is devastating for those of us who do health research.

We have all known for years — decades — that the CPS count of the insured isn’t especially accurate. The questions it asks are about full-year coverage but people tend to answer based on their current status. It chronically under-reports Medicaid enrollment — the actual head count from Medicaid programs is always higher than indicated in the survey. The same is probably true for employment-based coverage. It has often been criticized for being weak on foreign language questions. Massachusetts, for example, has a significant population of people who speak Portuguese and that state thought the CPS failed to capture those people.

The Census Bureau recently (in 2007) revised its numbers because the software was misallocating people who reported that everyone in their family was covered. More on this below.

Read More » »

Zeke Goes Off the Rails

Ezekiel Emanuel, Rahm’s brother and one of the key ObamaCare advisors, has been on quite a roll lately. Consider some of the headlines just from the past few weeks or so –

  • “Insurance Companies as We Know Them Are About to Die” (New Republic)
  • “In Health Care, Choice is Overrated” (The New York Times)
  • “You Don’t Need a Doctor for Every Part of Your Health Care” (CNSNews write up of a Bill O’Reilly interview)
  • “Inside the Making of ObamaCare” (Wall Street Journal)
  • “Progress with Caveats: At least 12 million have received coverage directly through a provision of the law” (Wall Street Journal)

In every instance his message is that he knows better than you do what is good for you. He knows a better way to do insurance than you do, he knows that you don’t really need a choice of doctor or hospital, he knows that you don’t really need a doctor at all for most services, and he knows that “things are actually going well” for ObamaCare despite the fact that you and most Americans don’t like it.

One has to wonder what is going on with this guy. Why is he so confident in offending so many Americans? Either he is triumphant in the idea that what we think doesn’t matter anymore because Obama is firmly in control of our future, or he knows that ObamaCare is such a disaster that he can finally say any damned thing he wants because none of it will ever happen anyway.

Read More » »

Why Bundled Payments Aren’t Working

The New England Journal of Medicine recently ran an article by Clay Ackerly, MD, and David Grabowski, PhD, calling for “Post-Acute Care Reform.”

They use a (presumably) fictional patient to illustrate the problems with the current payment system:

Mrs. T. is an 88-year-old woman who lives alone, has a history of congestive heart failure and osteoarthritis, and has traditional fee-for-service Medicare coverage. One day, she was found lethargic and sent to the emergency department, where she was discovered to be in renal failure and was admitted to the hospital for fluids and monitoring. Her hospitalist concluded that she had accidentally overdosed on Lasix (furosemide). On hospital day 2, Mrs. T. was having difficulty ambulating, although her cognition and renal function had improved and she felt “back to her old self” and was eager to go home.

What to do?

Read More » »

HIT Apologia

Health Affairs recently announced its top 15 articles for 2013, and has made them available to nonsubscribers.

The top article was by a pair of RAND researchers updating what is known about the health information technology (HIT) roll out from the 2009 HITECH law, appropriating $20 billion to upgrade information technology throughout the health care system.

It doesn’t take long ― like just the abstract ― to figure out that people haven’t learned a blessed thing from flushing $20 billion down the toilet. Here’s the complete abstract with my comments −

A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually.

This original “study” was horrendously flawed. They deliberately chose (and said so) to ignore any contra information, basing their projections on a best possible scenario that couldn’t possibly come true in real life. In the latest report:

Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion.

I’m sorry, so sorry
Please accept my apology

Read More » »