21 Ideas for Addressing the Affordable Care Act

The future of the Affordable Care Act is at the top of the news. Frequently, it is said that there are no credible proposals on the table for an effective replacement. This writer feels it is time to focus on costs, as I have stated in the past.

What follows is a series of detailed suggestions, with some commentary, with the goal of reducing costs. Some promote increased competition, some suggest increased regulation in markets that are too thin to support competition.

There are 2 broad philosophies behind these points- first, that health care is a right (with some exceptions), but PROVIDING health care is the privilege. I feel we have it backwards in this country, where providers of all types have the right to provide services, and we are lucky if we have the privilege of seeing them.

Second, I feel that all parties are to blame. By this I mean that we should not gang up on one sector, such as insurers or doctors. All parties are misbehaving, including hospitals, physicians, pharmaceutical companies, insurers and yes, consumers.

What follows is a series of recommendations, by category, for finally controlling costs:

Hospitals
Require full transparency on prices. Hospitals should publicly post “list” prices for common procedures or bundles of procedures. What is included in the bundle should also be posted. The requirement to post prices should not be clouded by the statement that “hospitals are actually reimbursed different amounts by different insurers”. While this is a true statement, it is a distraction and list prices should still be posted.

Crack down on sham Joint Ventures. These are the joint ventures where a hospital purchases a physician’s practice. They then designate the physician’s office to be an “outpatient satellite of the hospital”. They then receive increased reimbursements from insurers and the government because services are reimbursed more generously when provided in a hospital setting versus a physician’s office. Notice, nothing has changed except the sign on the door, that now says “part of the University Hospital Network” or something similar. Literally nothing has changed except the sign on the door and the reimbursement, which has increased dramatically. In some cases the increased prices are justified on the basis of “rolling the new practice into the Electronic Medical Record of the hospital”. EMRs were supposed to reduce costs. Weren’t they?

Limit “empire building”, where every hospital in a community feels they need to provide all things to all people- this results in “a cath lab on every corner”, low utilization for all, and increased prices to cover high fixed costs.

Physicians
Broaden the scope of practice for physician assistants, nurse practitioners and similar professionals, known as “physician extenders”. This means that these extenders are allowed to do more, which allows costs to decline. A concrete example would be for the Minute Clinics at CVS to be able to provide a broader range of services.

Implement a mandate for providers of all types to accept government plans. (Philosophically, this is where we need to understand that it is PROVIDING health care that is the privilege). Physicians, hospitals and other providers should not be able to pick and choose whom they see based on finances- a government plan should be sufficient. Providers who decline should not be eligible for government grants, tax subsidies, meaningful use payments or other government programs.

Create a national provider network. This will become important when insurance can be purchased across state lines. The challenge here is not the selling of insurance, but the delivery. If Blue Cross of Ohio sells a policy to someone who lives in Kentucky, but has no provider network in Kentucky, the person who bought the policy would need to go to Ohio for all of their care. A national provider network would address this. In practice, this is no more complicated than accepting Medicare, though I am not suggesting we combine the ACA with Medicare.

Pharmaceutical Companies
Implement price controls for very expensive drugs. In general, I am talking about “Specialty Pharmacy”, where we see drugs of $1000 per dose or $100,000 per year or more. Frequently the number of patients on a particular drug, or the patent protection held by the manufacturer, does not allow for a competitive market to exist. This is one of the rare cases where I support direct regulation.

Device Manufacturers and other suppliers
Similar to Pharma, above, some level of regulation is appropriate here to prevent price gouging, particularly for new devices and technologies that are protected.

Insurers
Allow the sale of policies across state lines (see comment on National Provider Network under Physicians above).

Maintain limitations on exclusions for pre-existing conditions.

Maintain MLR requirements (Medical Loss Ratio) for insurers. Currently, insurers are required to spend 85% to 90% of revenues on actual medical expenses, as opposed to marketing and administrative costs. If and when medical costs decline, as this ratio is preserved, the costs of the actual policy must decline too, instead of increasing profits.

Laboratories
Allow walk-in testing without a physician order.

Allow (require) a-la-carte pricing

Dialysis, Chemotherapy, Surgery and Imaging Centers
Require price transparency at the point of service.

Use government purchasing power to negotiate these prices downward.

Consumers
Require consumers to take more responsibility. Smokers should pay increased rates.

The Federal and State Governments
Allow government payors to negotiate with pharmaceutical companies.

Create a public option to provide insurance competition in all markets.

Plan Design
Reduce the breadth of services required for minimum plans.

-Offer catastrophic only coverage.

-Offer maternity and pediatric coverage as a rider, directed towards those planning families. This is generally, though not always a planned event. Today, it is treated as an “unforeseen illness”, which it is not. This might be one area where government subsidies are helpful, as the pool of people purchasing this coverage will be smaller than 100% of the population.

Access
Increase funding for expansion of Community Health Centers, funded through the Health Resources and Services Admistration (HRSA).

Expand the infrastructure for Remote Medicine. The vision here is diabetics testing themselves and corresponding with professionals remotely, e.g. email; or a patient with Congestive Heart Failure using a digital scale to remotely transmit their daily weight to professionals. This vision is less geared towards telemedicine, which envisions a specialist having a real-time discussion with a patient using expensive video technology and other devices.

These recommendations are designed to reduce the actual costs in the system, as well as to increase the cost effectiveness of the system (e.g. Community Health Centers).

Bending the so-called cost curve is simply not enough. Traditional cost shifting is not enough. We need to reduce actual costs significantly below the level of where they are today.

The time is now!

Announcing the Launch of The Health Tactics Social Network

Today our team is launching the Health Tactics Social Network.

The Affordable Care Act, popularly known as Obamacare, has been in place now for several years and it has withstood a number of challenges, including at the Supreme Court.

Even within this structure, however, prices have begun to rise, significantly for some. And we are beginning to see news reports about local exchanges failing financially and large insurers questioning their continued participation.

We at Health Tactics do not take a political stand. Instead, we believe that whichever path our health system takes, much will continue to fall on the individual and those who love and support them. Not just the measurable costs that appear on a bill, but things like rides, meals, errands, simple love and emotional support. And yes, items that cost money and are not covered. Sometimes lots of money.

This is where the Health Tactics Social Network comes in.

We are not here to complain, or to be an advocacy organization. We accept that “it is what it is”, even if we want more. What we are here for is to help people find each other, care for each other and deal with reality. And by doing this, we can help those in need put their lives back together.

Consider:

    Several people with the same condition have more collective knowledge about that condition than all but the most specialized physicians. Pool that knowledge.

    Much of what it takes to fully care for yourself or someone else actually falls outside of the structured medical system- everything from exercises to nutrition to a good nights sleep. And this is where people helping people will succeed in cases where the for-profit system has either failed us or abandoned us when the approved visits run out.

    And many times, there are those special, wonderful doctors and hospitals, and the rest of us need to know who and where they are. And not because we saw their advertisement, but because someone we trust who was in a similar situation told us about them. The true message gets lost in all of the marketing noise.

People helping people- that is what the Health Tactics Social Network is all about.

How does it work?
Almost everyone is in Facebook. And when you have professional networking needs, most people think of Linked-In. Beginning today and in the future, when you have personal health care needs, think of The Health Tactics Social Network.

A group in our network is designed solely to support the health care needs of the member. You can use a group differently, but this design is what makes us unique.

In the illustration below, 12 people join Mary’s Care Group. The sole purpose of the group is to care for Mary.

MarysGroup

Members of the group can upload documents or images for other group members to see. Mary, for example, might upload a list of her medications so others in the group have that information.

Mary could also create two groups, and have her private medical information available to one group, and other things like a food shopping list or a list of important phone numbers available to the other group. Her spouse might want to be in both groups.

The Health Tactics Social Network will also work well for athletes. Paul is a runner on his school team. In this illustration, 11 people join Paul’s Training Group. The sole purpose of the group is to support Paul’s training.

As before, members can upload documents, such as a schedule, or images, such as a map of a running trail.

PaulsGroup

How do you set it up?
This is a very easy, three step process:

First, as in any social network, everyone involved must join The Health Tactics Social Network.

Second, as in any social network, people who want to engage on any significant level must be “friends”.

Third and finally, you must create your group (easy!) and invite those friends that you want to join it.

That’s it! Group members can immediately begin providing support to their friend or loved one.

Some tips:
When creating your group, you will have some choices, as below:

GroupChoices

We strongly suggest that new users select “by invitation only” and “group creator only”.

Otherwise, friends will be able to join your group at will (and since this is your health, not all of your friends should see everything), and participants will be able to invite other people (same issue).

These choices are available because some people create groups that they want to grow large and without their effort, such as a general membership discussion group. Members are certainly free to do this, but there are other social networks that support general membership discussion groups if that is the true goal.

Important note on HIPAA regulations and patient privacy: The Health Tactics Social Network and the entire Health Tactics site are built and designed around the core principle of consumer (patient) control of their own situation, which includes their own information. When patients choose to disclose their own information, HIPAA concerns have been met. However, when patient information is stored or handled by people or institutions other than the owner (patient), HIPAA concerns can and do arise.

For this reason, our user agreement contains language not found in most social networks. Users are strongly encouraged to read this language and understand it, as it discusses your disclosure of your own health information. It includes a disclaimer that specifically states neither Health Tactics nor The Health Tactics Social Network will bear any responsibility for personal health information that is initially disclosed by you, regardless of what members of your group or others may subsequently do with that information.

And finally…

Expert Scenario:
Pam is a Discharge Planner at a community hospital. She joins the Health Tactics Social Network and begins to “friend” patients she is working with in her professional capacity at the hospital. As people leave the hospital and recover they “move out of her view”, and as more patients enter the hospital, they “enter her view”, so Pam is constantly “unfriending” those who have been discharged and who have recovered, and “friending” new patients who will soon require discharge.

Pam encourages these patients to create a care group, make friends with her- either party can initiate the friend request- and invite her to join. Patients are free to decline Pam’s recommendation. This is all up to the consumer (patient). And of course, Pam, as a professional, should obtain written consent from the patient.

If the member agrees, Pam and the hospital benefit from this wealth of individual care and home related information that is stored in one place- the individual patient groups, and which they have obtained consent to access.

The members of The Health Tactics Social Network- Pam’s patients- benefit from a smoother, higher quality hospital discharge and an improved transition to home care and recovery. The member’s family will better understand what is needed, and know where to find the key information they will need in caring for their loved one.

How to get going:
Visit www.healthtactics.com.

At the main site, select “Network” and you will be taken to The Health Tactics Social Network sign in page. Signing up is easy. After you have signed up, find friends and create your groups as described above.

The rest of the site:
The main Health Tactics site has eight sections, clearly visible on the navigation menu:

These eight sections are:

Home, where you can find the home page (pictured) and a description of the company;

HomePage

Network, which allows you to link directly to The Health Tactics Social Network;

NetworkPage

MediPilot, our own secure, private online personal health record.

MediPilotPage

Surveys, an embedded survey tool where we implement surveys and polls;

Blog, where we will post helpful tips about using the Network, posts from guest health care experts and other interesting content. You are at the Blog page now;

BlogPage

Forum; our online discussion forum where users can talk to each other;

Links, where we organize a wealth of health care related resources; and

Store, where we make available high quality health and lifestyle related products from 3d party vendors. This is what allows us to operate the rest of the site for free.

Everything at the site is absolutely free, except products purchased through the store. You will not see any ads or solicitations of any kind outside of the store. And we do not track, sell, monitor or mine your personal information in any way.

We hope that you enjoy and make valuable use of the site, and The Health Tactics Social Network!

Becoming More Health-System Independent

This blog has been quiet for a while, and for a reason. We will undergo a bit of a repurposing.

Our major focus in the recent past was the implementation of Obamacare, with commentary on the major developments as they occurred. Going forward, however we will become more focused on our core message: People should become more independent in managing their health.

We are not suggesting that people stop seeing their doctor. We are saying “be informed, take control, know you rights”.

In that vein, we have published an expanded set of useful health care links, built around a theme:

To increase your level of independence, become informed in these nine general areas:

1) Understand your personal situation
2) Understand who is treating you
3) Understand the finances- yours
4) Understand the finances- theirs
5) Understand your alternatives
6) Explore online tools to help yourself
7) Understand your rights
8) Plan for the future
9) Know where to get help

Within this framework, we share over 100 links to governmental organizations, insurers, foundations, associations, news articles, databases and additional high quality sources as we become aware of them.

And as additional functionality becomes available on our site (today you will find this blog, a discussion forum, health community resource sections and an online health record), we will share that information here. The new, expanded links can be found at Health Tactics Resource Links

We hope you find them to be useful.

The 7 Stages of Managing Our Health Information

Why did Google pull the plug on Google Health?  Why is consumer adoption generally low across the entire landscape? In my opinion, the consumer has still not embraced the change required for this to happen.  It will happen.  We’re just not there yet.  To explain this, I offer “The 7 Stages of Managing Our Health Information” (adapted from Elisabeth Kubler-Ross’ “The 7 Stages of Grief”).

Stage 1:  “Wait a minute, I have to pay for that now?”

Stage 2: “I can’t afford all of this! I don’t know what to do! I should have lost weight, quit smoking, taken better care of myself!”

Stage 3: “This is outrageous! Can’t we go back to the old way? It’s the government’s fault!  It’s the insurer’s fault!”

Stage 4: “Oh my God, I am so screwed!  Who is going to help me?”

Stage 5: “Maybe I need to do something about this.”

Stage 6: “I seem to remember something about Online Tools and Resources.”

Stage 7: “OK, I’m signed up now.  Let’s do this!”

Note: Progress through this framework is not smoothly linear.  Some jumping back and forth occurs.

In my opinion, consumers are generally in stages 1 through 3.  The light bulb will go on, and business models will become viable, when a large number of consumers get to stage 5.  As I stated, we as a country are not there yet.  But with the coming changes to Medicare and Medicaid, and the ongoing increases in deductibles, copayments and coinsurance, we soon will be.  Stay tuned.

For two very thoughtful, insightful discussions on why Google pulled the plug, see Missy Krasner’s post at “The Health Care Blog”, and Janice McCallum’s post at “Health Content Advisors”.

Finally, I am interested in what you think about consumer readiness.  Please take the following brief poll, using the “7 stages” framework above.  Select up to 3 answers.

In general, at which stage are most consumers when managing their health information? Select up to 3 answers.

View Results

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