Thursday, March 27, 2014

Do you know your doctor's expiration date?

CMS is considering new rules to protect seniors if their Medicare Advantage Plan drops their physician.  I think that's a great idea, and wish everyone had such protection from network changes.  I was pretty sure I'd written something about that, but couldn't find it posted.  After digging through old files, here it is.

January, 2012

Imagine going to buy milk at the store, only to find that none of the cartons are marked with an expiration date.  You ask a clerk about it, only to be told that the dates exist, the store knows what they are, but that they are a trade secret and they can't disclose them to you.  All they will tell you is that the milk is not expired as of today.  "How," you ask, "will I know if it is safe to drink tomorrow?" 

"Check back tomorrow", is the answer.  "All we can ever tell you is whether your milk is expired as of the day you ask."

Such an arrangement would be absurd on its face, and if a store attempted to impose such conditions a regulatory or legislative remedy would surely not be far behind.  But in one industry such absurdity is the norm.  Do you know your doctor's expiration date?

Most private health insurance plans are circumscribed by networks.  Go outside the network and you face a steep increase in out of pocket expense through  copays or deductibles. In some plans the out of network coverage is so restricted that patients are functionally uninsured.  Most people know this and quickly learn to identify in-network providers.  But those networks change over time, depending on whether or not doctors and insurers continue agreeing to terms.  And included in those agreements are expiration dates.  If no renewal agreement is reached the contract expires and the provider drops out of network.

What notice do patients get when that happens?  Whatever their doctor feels like giving them.  Maybe they'll tell you when you make your next appointment, or maybe not.  As the paperwork repeats ad infinitum, patients are solely responsible for managing their insurance, and patients are solely responsible for payment.  Even if you've seen a doctor a hundred times and checked your insurer's web site to verify their network status yesterday, nothing guarantees that they are in network on the day of your appointment save checking with your insurer on that day.  Realistically, you probably won't find out until you get an Explanation of Benefits statement from your insurer stamped "Out of Network" followed by a hefty out of pocket medical bill.

What makes such circumstances frustrating is how unnecessary they are.  By simply disclosing the expiration date of the provider-insurer agreement, people would know when they needed to check to see if it renewed.  Not only could they avoid hundreds or even thousands of dollars in out of pocket expenses by being better able to avoid out-of-network physicians, they could improve the continuity of care.  Knowing at once if a provider had dropped out of network would allow more time for selecting and transferring records to a new provider, it could be done ahead of time rather than starting the process on the day you realize you need treatment and go to make an appointment.  All that, just from disclosing a date.

The only argument I've seen against such disclosure is that contracts between insurers and providers are trade secrets.  According to that logic, the contracts must remain secret to prevent collusion on prices.  I won't argue for or against that point, but I'd observe that the contract expiration date has no bearing on it.  What is the harm in disclosing an expiration date?  Is the market for milk screwed up because people know ahead of time when a particular carton will go bad? 

It's worth thinking about, because paying medical bills out of pocket because a physician's office didn't disclose they dropped your insurance  stinks worse than rotten milk.

Thursday, February 6, 2014

Why are we still talking about the CRC?

Generally speaking, you don't loan out money you're banking on getting paid back without collateral.  That's because people who don't put up collateral, who don't have any disincentive against walking away from their debt tend to walk away from their debt.

Applied to the CRC, if we think we need Washington support to build the CRC than we must have collateral to ensure their support.  That can come in the form of direct funding up front or it can be irrevocable collection rights against Washington citizens to the same effect, whatever.  What matters is that it's skin in the game, a reason for Washington to not walk away when the bridge is built but the bonds are only half paid off leaving Oregon holding the bag.

With that in mind it's hard to understand what Governor Kitzhaber is thinking.  How likely is Washington to put up collateral if they think Oregon can be suckered into going it alone?  Every step Oregon takes toward building the bridge without Washington support validates their inaction and makes their support on the next step less likely.  The path Kitzhaber is following  doesn't lead to a bridge supported on both ends.

If we really want Washington support we ought to give them a reason to give it.  The screamingly obvious one is to walk away from the CRC.  If the Feds are as loose with money as Kitzhaber's plan requires, a year isn't going to matter.  The only risk is that Washington might judge the benefit of a new bridge not worth its cost.  If that's the case aren't we better off finding that out now rather than 10 years and hundreds of millions of dollars in unsecured debt later?

Saturday, December 28, 2013

How We Do Harm

It's one thing to read a statistical assessment of overtreatment, and how some "cures" are either ineffective or worse.  It's quite another to read the personal stories of people who underwent such treatment. 

A woman suffered brutal side effects getting HDC-ABMT, only to discover that studies show the treatment doesn't prolong survival.  A few years later she finds the cancer has come back, and at almost the same time she loses her insurance for having blown the life time benefit max.

A 70 year old man gets free prostate cancer screening at the mall, finds an abnormality and gets "treated."  He spends his remaining years incontinent and with a colostomy bag before dying of a UTI.

Even as we spend vast sums on overtreatment we have people suffering from undertreatment, such as an uninsured woman who walked into an ER with a body part in a bag after suffering auto-mastectomy from advanced, untreated breast cancer.

Health care reform is going to have its ups and downs.  But if you ever need a reminder about why the pre-ACA system was unacceptable, why it was a gross moral failure, check out How We Do Harm by Otis Webb Brawley and Paul Goldberg.  In their words, incidents of failure weren't aberrations from the system, failure was the system. 

Saturday, December 7, 2013

Hollywood Micro Apartments- what exactly is the problem?

Micro-apartments continue to draw opposition, particularly the Hollywood location. Why?

Street-parking near the Hollywood location is already at capacity, it's extremely rare to see open spots.  And because of the configuration of the highway and Sandy Blvd there are no nearby neighborhoods that would absorb parking by new residents.  Given that, what difference could new residents make?  There's no such thing as negative parking spaces, street parking can't be more full than it is now.  I get the distinct impression neighborhood concerns are not about parking, but about other things.

A recent letter from the Hollywood Neighborhood Association Board printed in the Hollywood Star reinforces that impression, emphasis mine:

Imagine the effects on your neighborhood if small, single-family homes on standard 50-by-100-foot lots were replaced by 64-foot tall apartment buildings that housed 70 or more people stuffed into 56 dormitory-like units with no parking.  Imagine further that the buildings' tenants were temporary with no connection to each other despite its so-called "group living" designation.  Imagine no dorm proctor to keep things from getting out of hand.  It is easy to anticipate noise problems, even worse parking problems than we've already experienced from no-parking apartments…

Never mind the false insinuation that the block in question is for single family homes when in reality it is surrounded by commercial property and highway, and zoned CX intended for intense development.  And never mind the hand-wringing over the plight of people "stuffed" into dormitory like units since no one will be there except by choice, meaning without that choice they'll be somewhere worse. 

 Look instead at the concerns:  The residents will be noisy and temporary, they won't have a proctor.  Those concerns have nothing to do with parking, and everything to do with fears and preconceptions about potential new residents.

If residents of the new buildings create noise problems or "get out of hand," whatever that means, then it should be addressed via law enforcement just as it would be if they lived in a single family home.  And yeah, people in single family homes do get out of hand and we find a way to cope and the world goes on.  But do we prohibit construction of new single family homes because their residents might be criminals?  How is that any more rational with apartments?

People should be judged on what they do, not on where they live.  It is shameful when we do otherwise.

Saturday, November 30, 2013

Portland's problem with density

Portland has a problem with dense development.  The problem is that we are too willing to reject it, whether because we're enamored with what we have or afraid of what is new.  That mix of complacency and xenophobia will in my view doom efforts to build and sustain a livable city if it goes unchecked.

One problem is suburbs.  When we don't accommodate people living in the city, we force them into suburbs.  By their nature such areas are vastly more car-centric, and its citizens car-dependent.  Disproportionate population growth there will, through democracy, lead to a more car-centric public policy.  Highways instead of streetcars, more space devoted to parking instead of retail or other human use.  We can't force most of the metro population into an environment antithetical to livability without inviting blowback.

Another problem is economics.  What happens when you increase the desirability of something, but not its supply?  Prices go up.  And in Portland, housing prices go up a lot.  Despite the bubble, housing prices have increased more than 60% since 2000 as measured by the Case-Shiller index.  How many households have seen their income grow by 60% over this time?

Inflationary housing prices mean the city will be accessible only to an ever smaller, wealthier class.  That compounds the public policy problem (why should poorer suburbanites accept policy dictates that cater to urban elites?), and it reduces Portland's diversity.  Cities thrive on diversity and the interplay of different ideas that come from different backgrounds and experiences.  That dynamism creates jobs.  Restricting housing in the city will push out not only people, but creativity and job creation.  How livable is a city without those?

Here is a litmus test for Portlanders.  Take the number of years you've been living in your house and imagine someone born that many years after you.  Suppose this hypothetical person grew up in a similar environment as you and made similar choices about education, family, and career.  Would they now have the same ability to move into a city neighborhood, not necessarily the same neighborhood but one with comparable amenities, as you did years ago?  Extending the idea, I'd say a community which by design bars our children from doing and living as we do cannot be called sustainable. 

It isn't enough for livability to be a good idea, an affectation that we put on like a fancy hat.  To mean something in the real world it has to be able to grow.

Friday, November 29, 2013

Something to like about the Exchanges

There is a lot to dislike about exchanges and their rollout, but here is something to like.  Providers complaining about pay. 

The exchange is first and foremost a marketplace, it’s a means of communicating preferences between buyers and sellers of health care.  Buyers who choose low cost, limited networks are sending a message that the services of high cost providers are not worth the price.  What happens next?

One way providers could respond is to lower prices.  Another way is to make their case to the public justifying high prices and explaining why they are worth it.  Both of those are good things, as they'd force providers to think about costs and benefits.

Another way to respond is to lobby the government for preferential treatment as described by the WSJ.  To the extent providers are arguing for more money because that's what they're used to getting, the door should be slammed in their face.  But if a provider wants to argue that their service is so critical and so unique that a service area is being deprived of critical care if they're excluded from a network, than they've got a point. 

There are two kinds of facilities that might claim that:  those with high cost/low utilization services such as a burn unit, which serve only a tiny fraction of the population but are critical for them, or rural providers where they may be the only show in town.  Those cases are unique and may indeed warrant special treatment.  But that treatment can't be a simple mandate in their favor, it has to include obligations acknowledging that such providers are in effect monopolies. 

That's another conversation that has to happen, a recognition that there are areas of health care where because of monopolies, competition makes no sense.  In those areas the only answer is public oversight, as intensive and invasive as is applied to other utility providers.  And we should accept the possibility that for some services, the community really doesn't need a local provider and prefers the burden of having to travel further to receive such care.

All of these conversations about costs and benefits, monopolies and oversight are way overdue, ignoring them has turned health care into a runaway train.  Whatever the rollout problems, if the ACA makes those conversations happen I'd mark it a success.

Thursday, November 21, 2013

Messing up Cover Oregon is not an argument for single payer

Tim Nesbitt writing in the Oregonian suggests the state's problems with the exchange give reason to support single payer.  I don't think so.

Imagine going into a new restaurant in which you are a part owner and ordering  a meal.  Every few minutes the manager comes over and says it will be ready in another few minutes, but the meal doesn't come.  Finally, he apologizes and says that they hired a third party vendor to run their kitchen, and while they've tried their best to ensure that the vendor fulfilled the contract it just isn't getting done.  In order to be served the manager suggests you,
  1. Go to a food fair where there will be other chefs to prepare a meal
  2. Hire your own chef
  1. Do your own cooking and buy direct from grocers.

There are a lot of ways people might respond to that.  One might swear never to eat there again.  One might tolerate the problems in the short term, hoping for eventual improvement.  One might want to fire the manager, telling him and his cowboy boots to take a walk.  And one might try to shut down the whole restaurant, though that is a bad idea for reasons that don't fit into the analogy. 

But what I don't think people would do, what appears to me highly counter-intuitive, is to conclude that we should shut down every alternative kind of food distribution and trust this manager whose incompetence is proven to oversee delivery of all food to everyone for every meal. 

I'm glad the Medicaid rollout and CCO's are going strong, but lets be honest.  It's relatively easy to get buy-in from people whose only option is nothing.  More than three quarters of Oregonians not already on Medicaid and Medicare had insurance in 2011.  They have options, and the state's handling of Cover Oregon provides little reason to give them up.