Medicare Advantage plans, CMS, and providing high-quality care to -- and care for -- all people

Medicare Advantage plans, also known as Medicare HMOs, or officially as Medicare Part C, are an alternative to traditional Medicare. By enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient gets additional benefits that are characteristic of HMOs. This may include smaller (or no) copayments or deductibles, coverage for things not covered by traditional Medicare like dental care, eyeglasses, and hearing aids, and other “advantages”. There are disadvantages, also, of course, just as in other HMOs. Beyond cost, the main one is that there is a limited panel of providers – doctors and hospitals – that the person can use. This is particularly an issue for retired people who travel a lot, or may spend the winter in a warmer climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other providers employed by the HMO itself. There are fewer of these than there once were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”, where any doctor can be “approved” to be part of their provider group, but many doctors may choose not to be for reasons such as lower reimbursement or onerous regulation. Thus, it is at least theoretically possible that a Medicare Advantage enrollee could receive lower quality care from the doctors and hospitals that were part of the HMO’s network than from another doctor or hospital that might not be, but would be available to traditional Medicare patients. In addition, some Medicare Advantage plans are open to “dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying the additional premium. That such programs might provide worse care than others isnot an unreasonable concern based upon other services targeted Medicaid patients (e.g., nursing homes) and other programs targeted specifically to low income people.

Thus, Medicare has developed a rating system for Medicare Advantage plans, which assigns from 1 to 5 stars based, presumably, on carefully considered and assessed quality measures. If you want a good plan, it would behoove you to choose one with a “5 star” rating. Provided, of course, one is available in your area, and provided you can afford the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will pay for. Unsurprisingly, many plans that have enrolled Medicaid or other lower-income patients have had lower ratings, based on the outcomes of those patients. The plans argue that this is because these low-income patients are higher-risk, have more co-existing medical, mental health, and social conditions outside of the plan’s control. Others, including the Center for Medicare and Medicaid Services (CMS), which administers Medicare, have argued that considering these characteristics might “give a pass” to plans that provide lower-quality care to poor people. A similar rating system exists for hospitals, and similar arguments have been made. As I discussed in a blog from November 10, 2013, “Does quality of care vary by insurance status? Even Medicare? Is that OK?”, there are legitimate arguments to be made on both sides.

Now, however, according to a report in “Modern Healthcare” on October 21, 2015, CMS interim administrator Andy Slavitt and his deputy administrator who runs the Center for Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for Medicare Advantage plans based upon the pre-existing risk of the patients enrolled. This is important to the plans, since Medicare can drop them if they have several years of lower-than-3-star ratings. And they don’t want to be dropped, because these plans are moneymakers, in no small part because CMS treats them, financially, better than traditional Medicare plans (a result of purposeful federal policy to try experiments to “privatize” Medicare). While new criteria have not been officially announced, and would not take effect until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising because the CMS has previously downplayed the effects of socio-economic status on the ratings. The agency described the effect as ‘small in most cases and not consistently negative’ in a summary of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the (possible) change of heart is happening, it is difficult to not consider the financial and political clout of the insurance industry that sponsors these programs, and the political support that such “private” Medicare-replacement programs have.  It is worth noting that CMS has not indicated that it will consider revising the ratings for hospitals, despite the fact that hospitals that care a higher proportion of poor and socially disadvantaged people face the same issues. The financial penalty for hospitals is very direct, as Medicare is not paying for readmissions which occur within 30 days. If this seems, on its face, reasonable, consider that sometimes even when the care provided in the hospital is of high quality, people go back to their homes (or long-term care facilities) where it may not be. This is sometimes a result of lack of money, lack of social support, and other stressors, but the result is that they are more likely to be readmitted. Again, CMS has argued that it would not want to encourage hospitals providing lower-quality care for poor people (which certainly would be a bad thing). But if CMS penalizes hospitals for readmissions that are outside their control, it simply encourages hospitals to not care for low-income people, or, if they are sole providers in their community, possibly even close their doors, and that would be a very bad thing. Studies that have been done indeed show that readmissions are higher when hospitals care for lower income and Medicaid patients, and that this is not the result of poorer quality care provided when those people are inpatients. (See “Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program” from the Kaiser Family Foundation and “Socioeconomic status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to all Medicare recipients (indeed all people) by a hospital is not discriminatory or inequitable and that all patients have access to the care they need at the highest possible quality level. But unadjusted readmission rates are a very crude measure of quality, and it is unreasonable for CMS to expect that hospitals will be able to compensate for the impacts of poverty and lack of access to preventive care and early diagnosis and treatment. It is not unreasonable, however, for us, the American people, to expect that our government develop and help pay for programs that ensure that people’s basic needs for shelter, food, clothing, warmth and other social determinants of health, as well as post-hospital care (access to primary care, home health, and high-quality long-term care).

A single-payer health system is insufficient to address all of these needs. But it is a good start for some of them.

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.

The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.

That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!

Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.

We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.

What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)

In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.

To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.

The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.

We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

Who is left out of ACA, and how does this affect Health for All?

The Affordable Care Act (ACA, Obamacare) has been very successful, despite the pronouncements of doomsayers (mostly Republicans). More than 10 million people who were previously uninsured have received coverage, and this has dramatically increased their access to health care. However, many people remain without health insurance, and many more are barely able to afford their premiums or can afford only the most basic plans. These people fall largely into three groups: those who the law was never planned to make eligible (mainly those people who are living in this country without documents), those people who make less than 133% of the poverty level but were not previously eligible for Medicaid and live in states that have not opted for Medicaid expansion, and lower-income people above 133% of poverty who have either not bought insurance on the exchanges or bought it and have since dropped it.

The first group, those without papers, comprise over 11 million real human beings in this country, people who work and go to school and get sick and visit our emergency rooms. That they are not even considered in ACA or any other proposal considered politically viable is a head-in-the-sand approach that ignores both human suffering and the cost of providing care to them. This cost is often shifted to hospitals, doctors, and volunteer organizations, such as the student-run Jaydoc Free Clinic in Kansas City, KS. The work that volunteers do is admirable, like that of the people celebrated by the first President Bush as “1000 points of light”, but it is not the way a wealthy country should have to provide care to people.

The second group is composed of those that the ACA intended to be covered by Medicaid expansion, but who live in states that have opted not to expand Medicaid. Given that the federal government would have picked up 100% of the bill for the first 4 years and then 90% thereafter, it is financially a good deal for the states. The reason that states like Kansas have not done so is entirely political; these are all states with Republican governors and/or Republican-controlled legislatures (although it does not include all of those!) whose core political position is opposition to anything coming from President Obama. Their proposed health plan is -- well, nothing, but they are against Obamacare, and against expanding Medicaid, and if this seems not only mean but economically stupid, so be it. People who in other states can access care when they need it are going without care or showing up in extremis in ERs. Hospitals end up footing the costs for people who could have been insured..

In Kansas, the first hospital closure that might have been forestalled with Medicaid expansion has occurred. Closing of Kansas hospital adds to Medicaid expansion debate (Kansas City Star, October 18, 2015) describes the closure of Mercy Hospital in Independence, KS. Doctors from relatively nearby towns that still have a hospital report increases in ER visits from people from Independence.There are many reasons that contributed to this closing, including the fact that residents of rural areas such as Independence are older and sicker than the national or state average, but a large proportion of them would have been eligible for expanded Medicaid had the state implemented it. The article makes clear that “While Medicaid expansion may not have saved Mercy Hospital, there are some in Montgomery County who say it could save many individuals.”

The Kansas Hospital Association (KHA) has been lobbying hard for Medicaid expansion because their members are losing money caring for uninsured people who are covered in the states that have expanded Medicaid. These hospitals are absorbing the impact of cuts to MediCARE which were supposed to be offset by the decrease in the uninsured resulting from the expansion of MediCAID, which is of course not happening in states such as Kansas, and it sees Mercy as the first domino to fall. KHA has a lot of influence in the state capital, Topeka, and rarely loses battles that it engages as strongly as it has this one, but so far there has been no movement from the Governor or legislature. While some legislators are beginning to rethink the issue: “ ‘My sense is a lot of legislators are saying we need to have that discussion (about Medicaid expansion). We need to take a hard look at that issue,’ said Rep. Linda Gallagher, a Lenexa Republican. ‘I do support that myself’”, others are adamantly opposed: “’I know that’s on the table. I don’t think any decision has been made on that,’ said Rep. Tony Barton, a Leavenworth Republican. ‘I think it would be moving in the wrong direction. I’ll leave it at that.’” And well he might leave it at that, as there is really nothing he can say that makes economic or social sense. It is a quintessential statement of opposition, being against something because, well, he is against it.

The Star article makes clear that Independence, KS has had, like many small towns, difficulty in recruiting and retaining physicians, but even those towns with doctors have hospitals with major financial challenges that could be helped by Medicaid expansion. Dr. Doug Gruenbacher, board chair of the Kansas Academy of Family Physicians (KAFP), an organization representing the family doctors who are the mainstay of rural health care, practices in Quinter, KS. While Quinter has fewer than 1000 residents (compared to Independence’s 9300), its group of family doctors cares for people from perhaps a dozen surrounding counties. Dr. Gruenbacher wrote a letter to the Salina Journal (October 10, 2015) calling for Medicaid expansion. He says “I know that my hospital [Gove County Medical Center] and more importantly, my patients, would benefit from the expansion.”

This leaves the third group of people who have had little or no benefit from the ACA: those who have  either not been able to afford to purchase insurance on exchanges, despite subsidies, or have dropped it as a result of rate increases by insurance companies. In “Insurance Dropouts Present a Challenge for Health Law” (NY Times, October 11, 2015), Abby Goodnough focuses on people in Mississippi, another states that has not expanded Medicaid. She observes that many of those who are working and making more than 133% of poverty are eligible for subsidies on the exchanges – indeed, 95% of Mississippians receiving coverage this way have subsidies, the highest percentage in the nation – but increasingly are finding the premiums more than they can afford on their tight budgets. Sometimes people were dropped from their insurance companies simply because they did not provide some information that the law requires to prevent undocumented people from signing up. Sometimes they just couldn’t afford it.

The ACA prohibits insurers from denying coverage for those with pre-existing conditions, but does not prohibit them from charging more for that coverage. And they do. “Walter Whitlow, 56, a remodeling contractor in Volente, Tex., said he had never seen the emails the federal marketplace sent him asking for additional proof of income after he signed up for a Humana plan in January. Doctors diagnosed throat cancer in February, and in June he learned from his oncologist’s office that his monthly premium had gone to $439 from $103 and his deductible to $4,600 from $900.” Whoops. Glitch.

Or not. The ACA was an attempt to accommodate many political interests, and thus is a conglomeration of different programs. Its commitment to insurance companies, whose support seemed to be necessary to pass the bill, was to have the “individual mandate”, so that the insurers, now required to cover everyone, would have everyone, not just the sickest, in their risk pool. However, beyond this, the ability of insurers to increase premiums for the sick was projected to be a problem, but the advantages of passing the program outweighed it. ACA is not intended to ensure health for all, but coverage for most (except those noted above). In the aggregate, it has been of great benefit. But for individuals, like Mr. Whitlow, the impact has been disastrous.

It is important to remember that this impact is not because we passed a bill that tried to cover as many people as possible, as opponents of ACA maintain without any data. It is because that bill did not go far enough, did not cover everyone, did not provide sufficient protection for people from the predatory practices of insurance companies. These are not the reasons that most ACA opponents want to fix, although they should be fixed. Dismantling ACA will not help the people who are described above, suffering despite this program; it would only vastly increase their number.

But change is necessary. We do, in fact, need a comprehensive national health program that simply, like those of most countries, covers everyone. Like Medicare for all. This will not solve all problems. It will not necessarily bring doctors to rural Kansas. It will not insure quality. It will not, in itself, completely control costs. But it is a necessary, if not sufficient, step.

“Our mission as family physicians is to provide care to all Kansans, not just the insured,” Dr. Gruenbacher writes. The next step is to make sure that there are no Kansans, or Americans, left out.