Consumer Power Report #172

Inside Consumer Directed Care (ICDC) reports that enrollment in Aetna’s two consumer-driven plans for federal workers increased by 50 percent from 2008 to 2009. About three-quarters of these are in its HRA option with the remainder in the HSA option. The HRA has slightly higher premiums and enrollees are more likely to use all of their account balances during the course of a year. Only about half of HRA enrollees have a roll-over at the end of the year, while 96 percent of HSA enrollees do, averaging $1,398 for singles and $1,854 for families. The Postal Workers Union’s HRA plan also is growing, but not as fast. There has been a 15 percent gain in enrollment since last year.

The same publication reports that credit unions are warming up to HSAs, with account balances doubling in the past year to $139 million. There has been a surge of credit unions offering HSA programs since January of this year, according to the article.

SOURCE: Inside Consumer Directed Care, April 3, 2009 (not available on-line)

An article by Susan Tuz in the News Times of Danbury, Connecticut asks, “HSA plans: How effective are they?” Unfortunately, she seems to be poorly informed about them. She starts by saying, “Established by federal regulations in 2004, the plans have been slow to be picked up,” which is not true by any measure I can think of. And then she adds, “Like all managed care plans, HSAs require using health care providers on the plan’s baseline network.” Also not true. She goes on, “One of the problems seen with these plans is that people often want to keep the money in their HSA accounts and are very cautious about spending it.” That is not a “problem,” that is the very purpose of the plan.

Still, after all that she gets around to finding someone in the state who thinks they aren’t so horrible. “Jackie Mitler, actuarial [sic] and partner in Health Insurance Solutions of Stamford, thinks the plans are a good deal for employer and employee.”

Writing in The New York Times, Kevin Sack suggests Massachusetts may not be such a great model, after all. He says of the twin but contradictory goals of reducing cost and expanding access, President Barack Obama is tilting towards cost reduction. But in Massachusetts, “leaders decided from the outset to decouple access and cost, and to deal first with covering the uninsured.”

But, “rising costs now threaten the viability of the Massachusetts plan.” The state has raised about all the taxes it can, so it is left with the far more contentious issue of changing the way the state pays for services, “the gamble is that stakeholders are now so invested they cannot back away.”

In Washington addressing costs cannot wait, but “by addressing costs and access simultaneously, the White House and Congress risk alienating key interest groups from the get-go.” He quotes the executive vice president of BCBS of Massachusetts as saying, “When you start talking about cost, you create winners and losers and that leads to a political challenge.”

Sack writes, “Universal coverage should itself bring down costs over the long run by preventing chronic disease and reducing the amount of non-urgent care provided in emergency rooms.” But is there any reason to think that is true? We know it is the insured, not the uninsured, who go to the emergency room for non-urgent care, and there is absolutely no evidence that having insurance prevents chronic disease.

Sack says Jon Kingsdale, director of the Connector, recommends “that Congress pass legislation to expand access while delegating cost-control decisions to a commission.” Ah, yes. The old “create a commission” trick. Works every time.

Sack concludes, “If history is a guide, the success of health reform may depend on whether the White House and Congress can give interest groups enough to keep them on board. By tackling cost at the same time as access, they have made their political challenge more difficult.”

A recent article by Mary Ann Roser in the Austin American Statesman is causing consternation. The article is headlined, “Austin ER’s got 2,678 visits from 9 people over 6 years.” The article says, “All nine speak English; three are homeless; five are women whose average age is 40, and four are men whose average age is 50. Seven have a mental health diagnosis and eight have a drug abuse diagnosis.” The cost of these visits is estimated at $3 million. The article doesn’t say whether they have insurance coverage, but it does mention that Medicare and Medicaid helped pay the bill.

Actually, we know that the people “clogging” emergency departments are not the uninsured, but people on Medicare and Medicaid. Research shows the uninsured visit ERs at a rate lower than their presence in the population. One of the fallacies of the current obsession with “universal health insurance” is that there is a significant portion of the population who will never be able to cope with any kind of “insurance.” They may be illiterate, mentally ill, drug addicted, criminal underground, or otherwise dysfunctional. They cannot read or understand an insurance policy, cannot file a claim, cannot distinguish between par- and non-par providers. Many of these people are on Medicaid today and still just show up at the ER when they feel poorly. They don’t understand there are alternatives. These folks need health “care,” not health “insurance.”

Dr. Deborah Peel, president of Patient Privacy Rights, offered this perspective:

“What happens next to these 9 people who are not wanted at Central Texas hospitals? Will the public come to know who they are? Will this story lead to them getting the complex, long-term expert care they really need?

“Their privacy has been violated, even without the reporting of their names (so far), but will singling them out as costing the community $3 million/year cause the local health system to change and seek solutions to treat them effectively or will the public get outraged at them? As a cynic/realist, I fear the care these 9 get will worsen as a result of this story and the violation of their privacy will have not served their good or the public good. Violating someone’s privacy to uphold an important long-held key principle of medical ethics, such as saving a life, is clearly justified, but will a greater good or ethical principle be served by this report?

“As the former Chief of Psychiatry at Brackenridge Hospital in Austin for 11 years, I am well aware that Central Texas has extremely poor mental health and addiction services for people on Medicare and Medicaid (few private practitioners will treat people on Medicare or Medicaid because the pay is so low and the state MH system is massively inadequate).

“Hospitals do identify ‘frequent flyers,’ try to hustle them out, try to avoid treating them, or try to dump them ….and often end up blaming the patients for their problems. When a few patients have such high numbers of visits, they inevitably become very well-known to the staff. The problem is homeless people and people with mental illnesses or addictions also have a very high rate of serious medical illnesses too, which studies show are typically poorly treated or not diagnosed. Some ER staff come to feel so negatively about them that the quality of care is affected and they suffer and die from undertreated medical problems.

“20 percent of patients account for 80 percent of the costs in the healthcare system. But people with complex, hard to treat mental illnesses or addictions are not usually viewed as needing or deserving expert care. Patients with all other complex medical illnesses typically have access to highly trained specialists because reimbursement by Medicare, Medicaid, and private insurance comes much closer to the what treatment actually costs to provide. The new federal Parity law appears not to have helped much in Central Texas, nor can the strong negative attitudes toward mental illness, addiction and severe personality disorders be easily erased.”

Now that $20 billion has been appropriated to pay for health IT, there is a flurry of articles on the topic. One might think the time for all this information was before deciding to spend all that money, not afterwards. But so it goes in the New Utopia. Spend the money first, and then figure out what we’re doing.

An editorial in The New York Times informs us that we’re not talking about a mere $20 billion (chicken feed by today’s standards). That is only the two-year appropriation. It is actually $50 billion over five years. The article cites a recent study in the New England Journal of Medicine that found only 1.5 percent of American hospitals “had a comprehensive electronic-records system in all major clinical units that performed all 24 functions deemed important by a panel of experts. Such systems incorporated physicians’ and nurses’ notes, the ability to order laboratory and radiological tests, clinical guidelines on how to treat various conditions and alerts to avoid dangerous drug interactions, among other capabilities.”

Well, now. If “a panel of experts” decided they should have this stuff, they damn well better have it. Remember the reassurances that the money going in to “comparative effectiveness research” would not be used to tell doctors what to do? Yet the mandated health IT systems will include “clinical guidelines on how to treat various conditions.” I wonder if the computers will allow doctors to do anything other than what they are told by the machine.