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As I mentioned here, not all is bleak in the world of care delivery. Forbes recently ran two articles on how things are changing rapidly. The first, found here, is about how Aetna is  reformulating itself as a consequence of the Affordable Care Act and other pressures/ From the article:

Aetna recognizes the transition from the “do more, bill more” generation to the value/outcome-based generation is going to happen regardless of whether the Supreme Court overturns the health reform. The employers picking up the largest portion of the healthcare tab are fed up with the “get less for more” story they are told every year. In fact, IBM itself is a leader amongst large employers that pushed for facets of the health reform that included an emphasis on primary care.

From afar Aetna , it appears there are at least four key insights driving Aetna’s behavior:

  1. Traditional health insurance business profits have been capped so they are pursuing complementary businesses that are unregulated.
  2. Simply going through traditional channels of employers and providers won’t allow them to reach all of their target market. They have to create new pathways to the ultimate consumer. For a bunch of reasons, healthcare is becoming a more consumer-driven market so they must build or acquire that skillset.
  3. The devastating Medical Loss Ratio (MLR) requirements mentioned in the Health Insurance’s Bunker Buster article demand that 80-85% of premium dollars go to patient care (vs. administrative overhead). I believe the aggressive acquisition spree will be for services that can be classified as patient care and thus help them with their MLR requirements.
  4. An onslaught of new requirements are being placed on healthcare providers. Smaller providers are especially ill-equipped to handle these on their own. Thus, Aetna wants to provide backoffice services for these organizations.

The second item of interest, also in Forbes, is the use of the Direct Primary Care Medical Home (DPC) provision of the ACA by primary care docs. While the details are a little complicated (and found in the article) the results are not:

Because DPC models are a more pure form of primary care not having to worry about how to weave in cumbersome insurance-driven processes, they have shown an even more dramatic impact than the aforementioned PCMH. While garnering customer satisfaction scores higher than Google or Apple, achieving more 5 star ratings on CitySearch than any other business DPC practices such as Qliance, Iora Health and WhiteGlove Health have reduced expensive downstream costs (surgical, emergency department and specialist visits) by 40-80%. I predict some of the PCMH models being piloted will shift to DPC as payment reform continues.

In the words of Forbes, good primary care (mostly Family Medicine) is sexy:

Utilizing a collaborative care model, the patient becomes a valued member of the care team — more than just a vessel for billing codes. Patients win. Physicians Win. Employers Win. Even forward-thinking insurance companies win. In fact, most major health insurance companies have major efforts to make primary care the foundation of their plans and it’s not a moment too early.

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The Affordable Care Act is under assault in the House of Representatives and the administration is fighting back. The Department of Health and Human Services has issued a report that documents the effects of the repeal of the bill, found here. The investigators found that

Rescinding the new health insurance protections would, now and starting in 2014:

  • Reduce the health care and health insurance options of the 50 to 129 million Americans with pre-existing conditions;
  • Take away, for the 32 to 82 million people with both a pre-existing condition and job-based insurance, the ban on lifetime limits on benefits, restrictions on annual limits on benefits, new protections in the small group market from discrimination based on health status, and the security of knowing you can change jobs without losing your health coverage and care;
  • Lock older Americans into their current coverage if they have it, since up to 86 percent of people ages 55 to 64 have some type of pre-existing condition;
  • Limit insurance options for the parents of the up to 2 million uninsured children with pre-existing conditions, who today can no longer be blocked from purchasing individual market insurance due to their pre-existing condition.

Having cared for people who were denied insurance for preexisting conditions, I can attest to the tenacity of insurance companies in seeking out folks attempting to receive care for illnesses. The statement in our insurance is “known or unknown, manifest or unmanifest” meaning these are not people trying to scam the system, in my experience thaes are people who have a cancer growing inside of them that comes out up to 9 months after taking the job. Prior to the passage of the ACA and until 2014, it kinda sucks to be them.

In a separate article posted on Forbes, Rick Ungar writes on the Republican alternative. I had feared it was to let sick people suffer the consequences of their poor life choices, but it is apparent that the public likes not having the pre-existing condition clause. The Republicans claim to have developed an alternative. He writes

Their answer is to create government supported high-risk insurance pools, operated by the states and funded with federal financial assistance for those with pre-existing medical conditions.

To examine this properly (and you should as the proposal is not without merit), you’ll have to get past the irony that the party of small government wishes to expand government involvement in health care in order to solve the problem of too much government in health care. I know…it’s confusing. However, if you can put this bit of weirdness aside, read on.

He goes on to say that these pools exist today and are poorly funded and underutilized. This is because they have a rather long (12 month) waiting period and are often closed to enrollment for months to years at a time. Oh, yeah, and it’ll cost 10 billion dollars in new taxes to begin to set them up and it’ll perpetuate the current fee-for-service mess. Aside from that, a really good idea.

From a  statement I found in the comments

Careful examination of the facts show that those whom are truly unable to obtain healthcare coverage are not nearly the many millions quoted by the sycophant media. Many are either illegally in our country, young and not covered by choice, or temporarily/by choice not covered for a short amount of time. Medicaid covers the truly needy (as well as those taking advantage inappropriately of Medicaid due to the abysmal administration of Medicaid).

I know based on data that these are not true statements but are they are certainly “deeply held beliefs” in some circles.

There seems to be an attitude  that people who happen to be sick (and many are poor) are that way because of their own culpability or are trying to scam the system to avail themselves of free health care. It is important to people with this belief that undeserving sick folks are made to pay for their healthcare. If we want to prevent every “undeserving” person from obtaining any subsidized health care then I suppose fighting against providing care to people who have the misfortune of getting a job with insurance before their cancer came to the surface makes sense in some warped way. This is how our Senator sees it

[There is a] “big difference between those that have pre-existing conditions and those that are actually negatively affected by them.”

I invite him to follow me while I see some patients one day and see if he can tell who is deserving and who is not.

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