Friday, July 25, 2014


Chinese doctors bowing to a just-deceased 11 year old who had donated his organs before dying.

Wednesday, July 23, 2014

Halbig Decision Puts Obamacare Back on the Front Burner and Will Give Republicans a Huge Political Headache

Robert Laszewski

Posted 7/22/14 on Health Policy and Marketplace Review

Today's 2-1 decision by the DC Court of Appeals striking down federal premium subsidies, in at least the 27 states that opted for the feds to run their Obamacare insurance exchanges, has the potential to strike a devastating blow to the new health law. The law says that individuals can get subsidies to buy health insurance in the states that set up insurance exchanges. That appears to exclude the states that do not set up exchanges––at least the 27 states that completely opted out of Obamacare. Another nine states set up partnership exchanges with the feds and the impact on those states is not clear.

The response by supporters of the law, and the IRS regulation that has enabled subsidies to be paid in the states not setting up exchanges, hinges on the argument that the language is at worst ambiguous and the Congress never intended to withhold the subsidies in the federal exchange states.

But in the DC Court ruling one of the majority judges said, "The fact is that the legislative record provides little indication one way or the other of the Congressional intent, but the statutory text does. Section 36B plainly makes subsidies only available only on Exchanges established by states."

My own observation, having closely watched the original Obamacare Congressional debate, is that this issue never came up because about everybody believed about all of the states would establish their own exchange. I think it is fair to say about everyone also believed a few states would not establish their own exchanges. Smaller states, for example, might opt out because they just didn't have the scale needed to make the program work. I don't recall a single member of Congress, Republican or Democrat, who believed that if this happened those states would lose their subsidies.

At worst, this is clearly a drafting error that in the old days would have been quickly fixed in a technical corrections bill. But these aren't the old days.

This will now work its way through the courts. No one risks losing their subsidies until this issue is finally decided. That will not happen until well after the next open-enrollment on November 15th.

So, for now it is business as usual for Obamacare. But this will send a chill through about 4 million people in these states that are among the 87% who received a subsidy on the federally-run exchanges and are getting an average of 76% of their premium subsidized.

A few observations:

1. It is hard to see how a Roberts' Supreme Court would finally deal Obamacare so serious a blow given that the Court upheld one of the core elements of the law with the Chief Justice going through the legal contortions he did by calling the individual mandate penalty a tax. In fact, just after the DC ruling the 4th Circuit Court of Appeals in Richmond ruled in favor of the administration on this issue in a 3-0 decision.

2. If the DC Court of Appeals ruling is upheld it has the potential to be devastating for Obamacare. With so many people receiving so much in subsidy, the potential is there for the healthiest of these to drop their coverage while the sickest do whatever they need to do to keep their policies creating a major anti-selection problem for the insurers. Premiums on these federal exchanges would undoubtedly skyrocket.

3. This would put Republicans in the federal exchange states in a heck of a political bind. It seems to me these governors and legislators could opt to immediately contract with the feds to operate their exchanges in order to preserve the subsidies (If a state can contract with Accenture to build and run an exchange, why couldn't it contract with HHS to do the same?). If the states were to do this immediately, no one would have to lose their subsidies.

So what would these Republican governors and legislators do?

In effect, the political consequences for all of these people losing their subsidies and their coverage would immediately shift to the Republicans who control these state governments.

Proponents of Halbig argue that the fault for people losing their coverage would be on the Obama administration because they have operated Obamacare in an illegal manner by paying subsidies that are not allowed under the statute.

The courts could well end up supporting that argument.

And, millions of people would have their insurance yanked out from under them in what people will see as part of the ongoing partisan political wars being waged by people out of touch with life in the rest of the country.

The fundamental problem the Halbig proponents have here is that common sense, whatever a court rules, tells people that denying subsidies in half the states was never the intent of the Congress––that this is all about political point scoring and stopping a law Republicans hate.

Obamacare has lots of problems. But many would argue those problems should be solved in the Congress, not in the courts. If the proponents of Halbig want to effect real change they need to win some elections.

Poll after poll says a big majority of voters want Obamacare fixed not repealed.

Obamacare's most partisan and ideologically opposed enemies scored a big victory today.

On the surface, Republicans will be attributing this decision to the way the Democrats and the Obama administration wrote this flawed law and the way they have implemented it. But below the surface lots of sensible Republicans must be sweating bullets.

Tuesday, July 22, 2014

Obesity treatment guidelines’ expert panel report highlights thorough review process

Obesity management remains a top priority for employers, yet evidence to date has been limited on what works best. As more clinical research is done and reported on, employers can get another step closer to defining value-based strategies to address this growing epidemic in America’s workforce. An expert panel was commissioned to define clear treatment guidelines. Read more and access the report here.

Providers, insurers grapple with narrow-network backlash

A panel discussion about network adequacy on Monday in Washington sponsored by the Alliance for Health Reform revealed that nearly half of all insurance plans sold on the public exchanges in 2014 were narrow network plans, defined as those with less than 70% of area hospitals included, according to an analysis by the research firm McKinsey & Company. This panel also discussed the existing barrier of poor consumer education on coverage and options. Read the full story here.

UPMC-Highmark Accord Falls Far Short of What's Needed

Note from Brian: Here's a great piece pubished by Jessica Brooks, Executive Director of the Pittsburgh coalition, in Sunday's Pittsburgh Post-Gazette. She gives voice to the purchasers concerns in a murky deal between Highmark BCBS and the University of Pittsburgh Medical Center (UPMC). It is an articulate and thoughtful essay that effectively raises raises our collective profile.

Big Congrats to Jessica for getting this done, and for leading on this important topic.
Employers remain in the dark about how our health system is going to work

July 20, 2014 12:00 AM

The recent announcement by Gov. Tom Corbett claiming progress in the protracted Highmark vs. UPMC health-insurance battle missed the mark when it comes to putting patients first.

While the governor’s efforts are admirable, the consent decrees he hammered out did little to clear things up — in fact, they may be creating more confusion — about how employers are supposed to deal with the Highmark-UPMC divorce on behalf of their employees.

That’s why the Pittsburgh Business Group on Health recently launched its Priority Initiative to expedite discussion between Highmark and UPMC and ensure that the business community has a seat at the table. After all, commercial policyholders — the majority being employers — are the ones being most tussled over, yet they are the ones being least considered in this dispute.

Along with cost, patient access to health-care services is a top consideration for employers. Employers do not, however, want to be in the business of making physician choices for their employees.

As things stand, employers continue to lack the support they need to accurately communicate to their employees the impact that new regional health-care arrangements might have on their families, choices, costs, transparency of information or what kind of upheaval patients should anticipate during the transition.

A survey conducted this month among members of the Pittsburgh Business Group on Health, which represents more than 70 regionally headquartered employers, found that not a single employer highly agreed and only 20 percent agreed that the UPMC-Highmark consent decree brought “clarity and stability” to the local health-care market. Conversely, 32 percent disagreed and 16 percent highly disagreed. When asked what additional information they needed to choose a health-insurance carrier, local employers considered clarity of cost as most important.

All that said, there is a much bigger picture to consider, especially when it comes to keeping down costs for both employers and employees: We need competition among both insurers and health-care providers.

We are seeing more competition in health insurance with the influx of national carriers into the market. But at the provider level, there is continuing consolidation by two big systems — UPMC and the Allegheny Health Network — and the possibility of only one gaining a virtual monopoly. This threatens to result in even higher premiums, deductibles and out-of-network fees, and a lowering of average quality. Patients and employers would have even less influence.

The ideal system would give individuals maximum choice among insurers as providers compete on both cost and quality. This would require total transparency in patient outcomes, cost and prices.

Any willing insurer should have access to all providers at similar rates — rates that are publicly known. Instead of relying on secret deals with individual insurers to make money, providers should have to rely on innovation and their ability to raise the quality of their care while keeping costs in check.

In Pittsburgh, UPMC, Allegheny Health Network and community facilities would compete and accept reimbursement from all willing insurers — Highmark, Aetna, United Healthcare, UPMC Health Plan, etc. This is very different from what we face now: a region served by two dominant integrated financing and delivery systems, a potentially stifling competitive model.

The Pittsburgh Business Group on Health is committed to empowering employers to make value-based health-care purchasing decisions. PBGH is trying to help employers and their employees make decisions based on cost and quality. Fortunately, there remain numerous choices for high quality care in our region — within the UPMC and Allegheny Health Network systems but also among community hospitals, many of which produce better outcomes at lower costs.

Highmark says it is maintaining its grip on the insurance market, while UPMC says that by next year many customers — including employers and employees given a choice of plans — will switch to other carriers when the open-enrollment period begins this fall. If everything breaks the way UPMC hopes, 92 percent of the commercial market will, at the very least, have a non-Highmark option that includes full UPMC access.

In the meantime, the consent decrees meant to clarify the terms of divorce leave many questions unanswered. Among the concerns of PBGH employer members is the “safety net,” which is supposed to allow Highmark members to continue seeing UPMC physicians with in-network coverage through 2015 if they cannot find another doctor they like. Highmark and UPMC disagree about how many Highmark subscribers this would apply to.

Highmark and UPMC also disagree about conditions for Highmark subscribers to continue seeing UPMC oncologists for cancer care or how long they could pay in-network rates for emergency care. What happens to a Highmark subscriber on a list to receive a transplant at a UPMC hospital? How will referrals work between physicians affiliated with different health-care systems?

Administratively, how will Highmark and UPMC processing systems handle exceptions and medical-record management? UPMC has an integrated electronic medical-records system that does not share information with Allegheny Health Network. Errors and confusion could abound.

Despite all this, progress has been made and the sky is not falling. But significant work remains to be done and many answers must be addressed — now.

Employers’ decisions over the next couple of months will have great impact on our health-care delivery and financing systems, not just in 2015 but for years to come. Therefore, we need Highmark and UPMC to get on the same page as to who will be in-network, who will be out-of-network and who will pay how much so that employers can make informed decisions. Employers needed this information yesterday.

The best solution would be a comprehensive agreement that allows all willing insurers to cover all health care providers on an in-network basis. The next best would be a consent decree that makes clear how a Highmark-UPMC divorce would work.

The consent decrees recently announced were a step in the right direction, but they did not tell consumers and businesses across southwestern Pennsylvania what they need to know, leaving them hanging — again.

Jessica Brooks is executive director of the Pittsburgh Business Group on Health ( The group is hosting its annual Health Care & Benefits Symposium Sept. 4 at Pittsburgh Marriott City Center.

Read more here

Monday, July 21, 2014

NBCH Board Chair Testifies before Senate Finance Committee

Last week Cheryl DeMars, NBCH Board Chair and President & CEO of the Alliance, testified before the U.S. Senate Finance Committee. DeMars spoke at a hearing on "Chronic Illness: Addressing Patients' Unmet Needs." She represented the business community on a panel that also included a patient, caregiver and physician. Her testimony focused on employer innovations and how data is used to drive change in the health care marketplace. More specifically, she featured the QualityPath® program currently under development by The Alliance.

You can read Cheryl's testimony here or view the recorded testimony here.

Resource to Check Out: Compounded Drugs

Compounded drugs have significantly grown in usage and development in the past five years, raising significant question about efficacy, appropriateness, safety, and reimbursement. A report was recently released by CompPharma to address many of the questions and concerns surrounding these compounded drugs, especially within the workers compensation sphere. According to this report, compounds have not proven to be more effective than available FDA approved medications, are not often medically necessary, and can pose safety risks to patients. These expensive medications also raise challenges related to regulation, as this is handled state by state. The full report can be viewed here.

Friday, July 18, 2014

eValue8 Featured on Upcoming AIR Webinar

We would like to invite you to attend a webinar hosted by the American Institutes for Research (AIR) to share findings from a recently completed research project funded by the Agency for Research and Quality (AHRQ). The webinar will review the findings from May 2014 focus groups conducted by AIR to test eValue8 and other potential performance measures. The research looked into what measures consumers find useful when comparing and selecting health plans in the State-based Marketplaces (SBMs).

These focus groups were part of a larger project that AHRQ contracted AIR to complete. The webinar will be held on July 25, 2014 from 11am-12pm Eastern Time.You can register here.

Thursday, July 17, 2014

New Report from Catalyst for Payment Reform and National Academy of Social Insurance

Today, the National Academy of Social Insurance (NASI) and Catalyst for Payment Reform (CPR) released a comprehensive evaluation of state laws addressing the power of health care providers to negotiate higher prices. This report catalogs the laws and regulations state governments are using to maintain or increase competition in health care markets, which the recent wave of mergers among hospitals and other consolidation among providers has significantly reduced.

The report reveals a number of common strategies states are using, including laws and regulations pertaining to: antitrust; price and quality transparency; competition in health plan contracting; price regulation; the development of Accountable Care Organizations (ACOs); expanding the authority of state Departments of Insurance; and facilitating the entry of new providers into the marketplace

Wednesday, July 16, 2014

Grants Resources Round Up

Call for Applications – 2015 RWJF Culture of Health Prize: The RWJF Culture of Health Prize is awarded annually to communities that are working to build a Culture of Health. In 2015, up to 10 winning communities will each receive a $25,000 cash prize and have their accomplishments celebrated and shared broadly to inspire locally-driven change across the nation. RWJF wants to hear how your local leaders and community members are creating solutions that give everyone the opportunity for a healthy life. Access more details here. RWJF will be hosting an information webinar on Tuesday, July 22nd from 3-4:30 ET. Register here. Knowing that the business sector plays an important role in influencing the health of a community, NBCH encourages its coalition members to take a close look at this opportunity and highlight the great work of coalitions and employers  in transforming health in their communities.

EXTERNAL EVENT - Upcoming Webinar: Grant Writing Fundamentals -  Are you searching for ways to increase the success of your grant proposals? Do you need to win more funding for your organizations cause? Whether you’re new to grant writing or someone with years of experience, this webinar is designed to inspire you and to help you understand and refocus on the fundamental elements of developing a winning grant proposal.

The webinar is sponsored by Abila and hosted by The Chronicle of Philanthropy. Read more and register here.

Employers turn to online doctors to cut costs

Eighteen percent of large employers now offer telemedicine as part of their coverage, up from 15 percent in 2012, according to benefits firm Mercer.

One insurer, WellPoint, sees room for much more growth, which is why the insurer partnered with Boston health IT firm American Well to launch LiveHealth - an online service - this year for employer group plans.

"It often can replace an emergency room, urgent care or retail clinic visit, which purely from a price standpoint, are higher," said John Jesser, WellPoint vice president and general manager of LiveHealth Online.

The insurer plans to make an even bigger bet on the technology with a LiveHealth virtual worksite clinic—a private booth with tools to measure pulse and blood pressure, and even a camera that allows a doctor to look at a patient's skin problem in real time—all at a fraction of the cost of having a doctor or nurse physically on site.

 Read the full story from CNBC here.

Monday, July 14, 2014

NBCH Board Chair to Testify at U.S. Senate Finance Committee Hearing on 7/15

Cheryl DeMars, President & CEO of The Alliance and newly elected NBCH Board Chair, has been invited to testify before the U.S. Senate Finance Committee in Washington D.C. Tuesday, July 15 at 10:00 a.m. Eastern.

The hearing will focus on "Chronic Illness: Addressing Patients' Unmet Needs." DeMars will provide the employers' perspective, focusing on how employers with self-funded health plans use data to drive change in the health care marketplace. Her testimony will feature the QualityPath® program under development by The Alliance. The event will be available via webcast.

Click here to read the full announcement from The Alliance.

National Business Coalition on Health Elects New Board Officers

The Alliance's Cheryl DeMars named Chair

WASHINGTON – July 14, 2014 –The National Business Coalition on Health (NBCH), a non-profit organization of employer-based health coalitions, representing over 4,000 employers and approximately 35 million employees and dependents across the United States, selected its slate of new officers for the Board of Governors. Cheryl DeMars, president and CEO of The Alliance will serve as Chair. Officers are elected by their board peers based on proven leadership and commitment to NBCH, as well as their efforts to advance and strengthen the tenets of value-based purchasing.

“We’re at a decisive point in the health benefits community and NBCH has a renewed focus on helping employers control costs, improve quality and engage individuals in their health,” said Brian Klepper, PhD, NBCH CEO. “Fixing America’s health care cost and quality problems requires knowledgeable and highly-regarded leaders to mobilize the business community to bring health care back into balance so that we can remain competitive in a global economy.”

Other newly elected are Karen van Caulil, president/CEO, Florida Health Care Coalition, Vice Chair and Anne Ladd, CEO, Wyoming Business Coalition on Health, At Large Representative. Don Creveling, executive director, Montana Association of Health Care Purchasers, was reappointed as Secretary/Treasurer, and Beverly Rossmiller, executive director, Tri-State Health Care Coalition, as At Large Representative to the Executive Committee. Other elected At Large board members include Larry Boress, president and CEO, Midwest Business Group on Health; Gaye Fortner president and CEO, HealthCare 21 Business Coalition; and Cristie Travis, CEO, Memphis Business Group on Health.

Continuing board members include: Marianne Fazen, executive director, Dallas-Fort Worth Business Group on Health; John Miller, executive director, MidAtlantic Business Group on Health; Laurel Pickering, president and CEO, Northeast Business Group on Health; and Cheryl Tolbert, executive director, Louisiana Business Group on Health.

“Driving better health outcomes at lower costs requires a forward-thinking collaborative approach,” said Chery DeMars. “It’s an honor to serve as the board chair of NBCH, particularly at this moment in time. The work of regional coalitions to transform health care, community by community, is as important as ever. Working together, we can make a real difference.”

Sunday, July 13, 2014

PwC: Health Care Behind the Numbers, 2015

Note from Brian

PricewaterhouseCoopers has a long track record of providing dispassionate health care insight. I often refer to their 2008 study, The Price of Excess, that estimated that 54.5% of all US health care spending provides no value. In today's dollars, that would blow about $1.6 trillion per year.

Here's a new report, Behind the Numbers 2015, projecting that the economy's rise will finally produce a not surprising uptick in health care cost trends. Their comment, though, acknowledges the rising importance of value and the power of purchasers.

"the fact that health spending continues to outpace GDP underscores the need for a renewed focus on productivity, efficiency, and, ultimately, delivering better value for purchasers.

As employers continue to shift financial responsibilities to their employees, the cost-conscious consumer will exert greater influence in the new health economy. Savings that come from standardization can help position health businesses for the value-driven future. But real success and profitability will go to the insurers, drug makers, and healthcare providers that deliver highly personalized customer experiences at a competitive price."

For those of you who track this kind of economic detail, a worthwhile quick read.

Friday, July 11, 2014

Resource to Check Out: Supporting Consumer Access to Specialty Medications Through Value-based Insurance Design

A new report published by the University of Michigan Center for VBID and the National Pharmaceutical Council explores how value-based insurance design may be utilized to address specialty medication access concerns. The report outlines that high spending on specialty medications is often money well spent for many patients and clinical indications given that high cost sharing for specialty medications can be harmful to patients and employers. The report describes a number of specific value-based benefit design techniques that payers and purchasers can apply to specialty medications to encourage better access and adherence to the most clinically effective treatments. Such techniques include:

- Imposing no more than modest cost sharing on high value medications;
- Reducing cost sharing based on patient or disease specific qualifications;
- Selectively reducing cost sharing for patients who fail to respond as desired to another medication based on current access restrictions used by insurance companies; or
- Using cost sharing to encourage patient selection of high performing providers.

Click here to learn more and to access the full report.