And there goes the last one.
Cox (D) now beating Valadao (R) in #CA21 https://t.co/a4pRehc9CT
— G. Elliott Morris (@gelliottmorris) November 27, 2018
40 seats on net flipped Blue.
Open thread.
I am a student in the doctoral program at the Duke University Department of Population Health Sciences. I am working towards my my doctorate in Health Services Research with a policy focus. I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments. I'm currently RA-ing at the Duke Margolis Center for Health Policy.
I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.
Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy. I have received direct funding from the National Institute for Healthcare Management, and I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums. I serve as a consultant on a grant from the Commonwealth Fund and have acted as a consultant to several ACA insurers.
Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en
David Anderson has been a Balloon Juice writer since 2013.
by David Anderson| 61 Comments
This post is in: Don't Mourn, Organize, Election 2018
And there goes the last one.
Cox (D) now beating Valadao (R) in #CA21 https://t.co/a4pRehc9CT
— G. Elliott Morris (@gelliottmorris) November 27, 2018
40 seats on net flipped Blue.
Open thread.
by David Anderson| 45 Comments
This post is in: Open Threads, Science & Technology
Our @NASAInSight spacecraft stuck the #MarsLanding!
Its new home is Elysium Planitia, a still, flat region where it’s set to study seismic waves and heat deep below the surface of the Red Planet for a planned two-year mission. Learn more: https://t.co/fIPATUugFo pic.twitter.com/j0hXTjhV6I
— NASA (@NASA) November 26, 2018
Open thread for cool discoveries yet to happen!
This post is in: Anderson On Health Insurance, Election 2017, Election 2018, Fuck Yeah!
Here is a koan for Balloon Juice:
If you do not know you are insured, are you insured?
Maine is in the process of expanding Medicaid. The new Governor-Elect, Janet Mills (D), has promised to expand Medicaid on her first day in office. She wants to make the coverage retroactive to July 2, 2018.
A Maine judge has ordered the current Maine governor to expand Medicaid with claims payment retroactive to July 2, 2018.
In most states, Medicaid has an individualized retroactive eligibility processes. Someone who is uninsured will interact with the medical system. The medical service provider will ask several standardized questions to determine if the uninsured patient is highly likely to be eligible for Medicaid. If they determine that the patient is likely to be eligible, they can file a claim and an eligibility determination. If the beneficiary is deemed eligible, some state Medicaid programs will pay both the index claim that initiated the eligibility determination process and claims in the three previous months if the benefeciary would have been eligible for Medicaid if they had applied.
The trigger event is a claim which means the trigger is an encounter with the healthcare system. Most people who are eligible for Medicaid but not enrolled don’t interact with the healthcare system in any given month because most people don’t interact with the healthcare system in any given month.
Retrospective eligibility is a safety net for both the patient who will not be faced with crippling medical bills and healthcare providers who will get reasonably timely payment that is most likely more than the net present value of the minimal cash stream that uninsured and Medicaid eligible patients can and will pay.
Retrospective eligibility is highly likely to occur for either pregnancy or major medical events that require hospitalization. More common and lower cost events like a primary care physician visit are less likely to generate a claim and retrospective eligibility determination because that appointment will either not be made by the beneficiary or the appointment will be denied by the provider once they are sure that they won’t get paid.
Maine is going to be doing something very different. It will be declaring that all claims on or after July 2 will be eligible for retroactive payments if the beneficiary would have been Medicaid eligible (either for legacy or expansion).
Now this is where I have a question.
Will we see changes in provider and beneficiary behavior in anticipation of a Medicaid Expansion? Did they increase the number of determination assessments that they submitted that would fail for legacy Medicaid but pass for Medicaid Expansion in July, August and September? Are providers pre-emptively opening up appointment blocks for people who are uninsured but Medicaid Expansion eligible? Are people who are Medicaid Expansion eligible making appointments in anticipation of retroactive eligibility?
How do people behave when they are covered if they are not sure that they are covered?
I don’t know but I think that this is one hell of a question.
by David Anderson| 22 Comments
This post is in: Anderson On Health Insurance
The Portland Press Herald reports that a Maine judge has ordered Maine to expand Medicaid immediately.
Kennebec County Superior Court Justice Michaela Murphy issued the order Wednesday, detailing seven steps the Maine Department of Health and Human Services must take to comply with the expansion law, which extends health care coverage to as many as 80,000 low-income Mainers. The law was approved by 59 percent of the state’s voters in November 2017, but LePage repeatedly has blocked implementation by vetoing legislation to fund the expansion and refusing to take administrative steps….
Murphy’s order, retroactive to July 2, requires the DHHS to file an amendment to paperwork already submitted to the federal government. The amendment must state that there are no legal or constitutional grounds for delaying the expansion. In the initial paperwork filed by the DHHS, during a process known as a state plan amendment or SPA, the LePage administration urged the federal Centers for Medicaid and Medicare Services to reject the state’s application.
If this order is not stayed by the Maine appellate courts, then a straight forward expansion with no work requirements will begin almost immediately with retroactive claims being paid for services that happened during the summer.
For the people who make too much for legacy Medicaid and too little for subsidies, this is wonderful news in Maine.
by David Anderson| 12 Comments
This post is in: Anderson On Health Insurance
A recent paper** at AEA highlights the role of financial incentives in clinical decision making.
Medicare’s prospective payment system for long-term acute-care hospitals (LTCHs) provides modest reimbursements at the beginning of a patient’s stay before jumping discontinuously to a large lump-sum payment after a prespecified number of days. We show that LTCHs respond to the financial incentives of this system by disproportionately discharging patients after they cross the large-payment threshold. We find this occurs more often at for-profit facilities, facilities acquired by leading LTCH chains, and facilities colocated with other hospitals….
the average LTCH keeps patients about a week longer than they would if reimbursements were not tied to their lengths of stay.
To translate this out of academic economicese, Medicare pays long term acute care hospitals a little bit at the start of a course of treatment. After a while, there is a huge lump sum payment that is supposed to cover the entire bundle of services is triggered if a patient is still in the LTCH. A patient who is in the LTCH the day before the trigger date has only been a source of costs and low revenue for the LTCH. A patient who is in the LTCH the day after the lump sum trigger is a source of costs and big revenue for the LTCH. A patient who is in the LTCH for six months after the trigger date is a money losing patient.
LTCH hospitals want to push as many patients as they credibly can to the trigger date that releases a whole lot of revenue. Once revenue is triggered, the incentive is then to get the patients out the door as quickly as possible to minimize new costs.
If we were to assume that LTCH are run without profit motive and with pure altruism, we would expect to see a discharge pattern that does not spike immediately after the revenue release day. If we were to assume that economic incentives matter, we could expect at least some patient stays to be stretched to the trigger point.
This study sees the second story. LTCH hospitals respond to clear economic incentives.
Any payment structure that has controllable attributes that lead to a significant change in revenue or costs will see gaming. People, including doctors, respond to financial incentives. The response may vary between individuals and industries, but step functions create strong incentives where the decision to keep someone an extra day or two or to hurry up their discharge by the same day or two will occur.
As we move towards even more complex payment structures, we need to think through the incentives that the payment system creates. And then we need to look at the trade-offs and decide whether or not those trade-offs are good for the patient and society or if they are merely means of extracting rent.
**
Eliason, Paul J., Paul L. E. Grieco, Ryan C. McDevitt, and James W. Roberts. 2018. “Strategic Patient Discharge: The Case of Long-Term Care Hospitals.” American Economic Review, 108 (11): 3232-65. DOI: 10.1257/aer.20170092
by David Anderson| 192 Comments
This post is in: Election 2018, Open Threads, Politics
“Democratic Salt Lake County Mayor Ben McAdams declared victory Monday in his race against GOP Rep. Mia Love — after he gained a 739-vote lead in ballot updates from Utah and Salt Lake counties.” https://t.co/JqLh0ref9F #UT04 #Midterm2018
— Ericssen (@EricssenWen) November 20, 2018
Just a reminder, a Blue Dog Democrat in Utah is likely to vote with the majority of the Democratic caucus 60% or more of the time on decisive votes (who cares about votes to accept the minutes of the House etc). Any generic Republican from Utah is likely to vote with the majority of the Democratic caucus <5% of the time on a decisive vote.
We must always think about what the next best alternative when performing an evaluation.
Open thread!
by David Anderson| 44 Comments
This post is in: Anderson On Health Insurance
At the Health Affairs blog, I co-authored a piece with RAND’s Mark Friedberg and Jodi Liu asking a very simple question: When someone says Medicare for All, what do they mean?
For policy analysts, such high-level proposals quickly draw a question: “What do they really mean by Medicare?” Medicare has multiple components: traditional Medicare (Part A and Part B, also called original Medicare or fee-for-service Medicare), Medicare Advantage (Part C), and Medicare prescription drug plans (Part D). Each of these components requires a separate premium, and Parts C and D plans are offered by private insurers…..
There are serious holes in the insurance design features of Medicare in that there is no out of pocket maximum and low incentives for care coordination. Drugs and physical health services may or may not be seen as complements or substitutes as appropriate. These problems are often ameriolated if not resolved by beneficiaries buying Medigap plans or integrated Medicare Advantage plans.
As there is significant political movement towards a variety of Medicare for All proposals, we need to know what we are talking about. Is it Medicare as it is with new age qualifications? Is it a comprehensive no cost sharing cover everything proposal where the only thing that ties it to Medicare is branding and claims processing infrastructure? Is it something in between?
We must know what these answers are in order to actually figure out how things could work and how the transitions that need to be managed could be managed. The tough work of converting a slogan into policy requires honesty.