Tag Archives: ACA

Why Do We Let People Pick The Wrong Health Plan?

I was reading some of the research by McKinsey this morning on the individual market enrollment and the overall exchange product benefit design.  It got me thinking about the issue where consumers choose the wrong plan design based on their personal utilization of healthcare.  Why do we let that happen?

I know some of you are thinking “let that happen”…we don’t do that.  Others who work in the industry may be thinking that consumers can make good decisions. 

But, we know that consumers don’t spend enough time evaluating their options.  We know that consumers are overwhelmed by all the information they get about healthcare.  We know that consumers don’t have access to all their data.  And, we know that consumers can’t understand all the healthcare mumbo-jumbo that we use to explain what we do. 

“The ACA deals with the problem of consumer misunderstanding by requiring insurance companies to publish standardized and simplified information about insurance plans, including what consumers would pay for four basic services,” noted lead author Loewenstein. “However, presenting simplified information about something that is inherently complex introduces a risk of ‘smoothing over’ real complexities. A better approach, in my view, would be to require insurance companies to offer truly simplified insurance products that consumers are capable of understanding.” (source of this study)

This study from a few months ago predicted that over half of consumers would choose the wrong plan thereby causing them to spend more money out-of-pocket annually for their healthcare.  Companies understand this.  There is an initiative called Putting Patients First which created a cost estimation tool – http://www.puttingpatientsfirst.net/.  This conceptually helps.

But, the reason I say “let” is because the healthcare companies all have our data.  They know our medical claims.  They know our pharmacy claims.  They have our lab values.  Everyone has predictive risk models now.  If that data could be downloaded to a Personal Health Record (PHR) and then used to model our costs under each of the benefit plan options, we could make an informed decision. 

And, no…this isn’t just a healthcare.gov issue.  Most employees have had access to multiple plan options at their employer for years.  Sometimes all under the same health plan and sometimes with multiple health plans.  I’ve talked about this for a long time.  This would be relatively simple for an IT team to build and deploy.  It could also be a huge catalyst for the PHR movement to get data into the hands of the consumers and give them a reason to do this.  If I knew I could save $500+ per year by tracking and using my data, that should be a great reason to take action. 

If E-Prescribing Doesn’t Have All The Data…Is It Helpful?

This is an interesting dilemma.  At this point, I think everyone is pro e-prescribing even if it’s simply for the benefit of reducing errors.  But, I think the original intent of the solutions were to do a lot more than reduce errors.

The hope was to improve adherence (which I think may have been too lofty).  The idea was that e-prescribing would reduce the abandonment rate at the pharmacy.  I’m not sure picking up a prescription is the same as taking a prescription.  And, taking a prescription once isn’t the same as staying adherent over time.

Another hope was that the use of e-prescribing would drive formulary compliance and increase generic utilization.  The idea was that putting this information in the hands of the prescriber would allow them to make more real-time decisions that were aligned with the consumer’s interests (i.e., lower out-of-pocket spend).  The latest report doesn’t seem to support this at all.  It also echos my prior posts about whether e-prescribing was aligned with pharma at all.

Fewer than half (47.5%) of the 200 PCPs polled said they have access to formulary information when e-prescribing, and fewer than a third said they have access to prior authorization (31.0%) or co-pay (29.5%) information. Among physicians with formulary information access, that information was available 61.1% of the time and was said to be accurate 68.6% of the time.

Physicians with an EMR (54.1%) were more likely to have access to formulary information than physicians without an EMR (29.6%). And differences were seen depending on the EHR vendor: Allscripts physicians (32.2%) were less likely to have access to this information than “All Other” software suppliers (60.5%), Epic physicians (62.5%) and eClinicalWorks (68.8%). 

Another big effort that e-prescribing and integration with EMR was going to have was to push utilization management (UM) to the POP (point of prescribing) rather than having the pharmacy and the PBM dealing with it.  I never really thought this would work.  If the information isn’t there or they don’t trust the information, the prescriber isn’t going to want to deal with this.  It’s already work that they let their staff handle and isn’t something they want to deal with during the patient encounter.

While e-prescribing is definitely here to stay and becoming the norm, the question is whether it’s creating simply a typed “clean” Rx to transmit electronically or whether it’s actually an intelligent process which will enable better care.

Given multiple studies and surveys recently about transparency in healthcare billing and the general push with Health Reform to drive to outcomes, I’m not sure the “dumb” system process can be a sustainable value proposition.

A New Approach To Care: Health Incentives In The Affordable Care Act (Guest Post)

Preventative Care is a key aspect of the Affordable Care Act that stands to benefit millions of Americans, in ways that you might not expect.

The term describes an array of services, programs, and incentives that are funded by the government in order to make people healthier. Contrary to what you might think, however, the funds are not limited to impacting care on the individual level.

Rather, the reforms will include everything from building public health centers to creating bike lanes and walking paths. Not to mention, free immunizations for individuals and families.

It’s important for consumers to understand what these changes could mean for them, in every respect. With this thought in mind, let’s explore the ways in which individuals, families, and communities will be impacted by these new reforms.

Individual and Family Health

Individuals and families will benefit tremendously from a host of preventative services that will be offered free of charge by insurance providers, regardless of pre-existing conditions.

Offered services will include: Breast cancer screenings, wellness checkups, domestic violence screenings, contraception, and breast-feeding supplies. Immunizations, counseling services, and depression screenings will also be made available as a result of the new legislation.

For many Americas, this change will mean first time access to potentially life-saving services that work in turn to promote further wellness among individuals, families, local and regional communities.

Public Health and Prevention

Without funding, reforms are simply laws on the books that don’t have any real-world import.

In 2010, The Prevention and Public Health Fund was created in order to ensure that care actually gets to the people who need it, through the development of programs that mobilize entire communities toward the goal of better health.

The fund’s initial budget has been compromised since 2010, but local governments have already received an estimated $290 million to put towards the development of healthy eating programs that are aimed at some of our nation’s deadliest health issues, such as child obesity and diabetes. Funding has also been put to work through infrastructure development to create sidewalks and bike paths, in an effort to encourage daily exercise.

Although the Prevention and Public Health Fund has met some opposition from congressional republicans, the potential for positive impact is clear.

Smoker’s Penalty: Two Sides Of The Same Coin

The Affordable Care Act takes a bold stance on smoking.

The Smoker’s Penalty, as it’s come to be known, has to do specifically with plans offered in the state health insurance marketplaces, which will open for business this October.

Under the ACA, insurance providers are allowed to charge smokers up to 50% more for their coverage than non-smokers, due to the associated health risks.

However a recent, highly publicized computer error has delayed this possibility. This is due to the fact that the computational system in place cannot differentiate between price inputs for smokers of differing ages. The glitch may take up to a year to fix.

Although this may seem like good news to smokers, no one knows how insurance companies will respond to the penalty issue come October.

Some view the smoker’s penalty as discriminatory, while others see the benefit in a hard-nosed incentive to get people to quit.

The good news is that the ACA will provide access to quitting services and products at no charge to consumers, and you can’t be denied coverage for having been a smoker.

All of these incentives, controversial or otherwise, are clear indicators of a much needed change in government thinking. Healthcare reform is doing more to help Americans avoid potential problems altogether. Let’s hope this is just the beginning.

Michael Cahill is the Editor of the Vista Health Solutions Blog. He writes about the health care system, health insurance industry and the Affordable Care Act. Follow him on Twitter @VistaHealth and @VistaHealthMike 


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