Insurance

News on the state's largest health insurers; the effects of health care reform on coverage; rising premium costs.

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U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

The extent of the government's role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17 in Charleston, S.C. (Mic Smith/AP)

The extent of the government’s role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17. (Mic Smith/AP)

By Richard Knox

Readers, a pop quiz:

The proportion of U.S. health care paid by tax funds is (a) less than 30 percent, (b) about half or (c) more than 60 percent.

If you picked “more than 60 percent,” you’re right — but you’re also pretty unusual.

“Many perceive that the U.S. health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France or the United Kingdom,” David Himmelstein and Steffie Woolhandler write in a new analysis of U.S. health spending in the American Journal of Public Health.

They find that 64.3 percent of U.S. health expenditures are government-financed. And they project the tax-supported proportion will rise to 67.1 percent over the coming decade as the baby boom generation ages and retires — nearly as high as Canada’s 70 percent.

“We are actually paying for a national health program, we’re just not getting it,” Woolhandler says.

tax dollars for U.S. health spending

Now, Himmelstein and Woolhandler have an agenda. For decades, they’ve been perhaps the leading researchers promoting the kind of single-payer health system that Socialist and Democratic presidential candidate Bernie Sanders has put on the debate agenda. One recent poll suggests more than half of Americans (and 30 percent of Republicans) support the idea.

But even if you disagree with the Himmelstein-Woolhandler ideology, their research is generally regarded as sound, and their method is straightforward.

They added up what federal and state governments spend on health through Medicare, Medicaid, the Veterans Health Administration, government employees’ health care premiums, tax subsidies and other programs. They argue that accounting by government agencies (the Center for Medicare and Medicaid) undercounts the real tax burden because it leaves out major pieces of the pie — such as government employees’ care ($156 billion a year) and tax subsidies for private, employer-sponsored coverage (nearly $300 billion).

And whatever you think about Medicare-for-all, it’s a good idea to see the present U.S. health care system for what it is — an increasingly government-funded financing scheme. Continue reading

Options Weighed To Address State’s Health Care Price Variations

Updated 6:50 p.m.

BOSTON — Variations in prices for the same service at different hospitals in Massachusetts do not reflect different qualities of care and have not evened out over time, according to a Health Policy Commission report released Wednesday.

The report found that higher prices “are not generally associated” with better care, and that prices vary across the different types of hospitals — academic medical centers, teaching hospitals, community hospitals — as well as within each individual group.

To highlight the difference in costs just at community hospitals during a Wednesday meeting, Health Policy Commission executive director David Seltz pointed to levels of spending on maternity care. Spending for a low-risk pregnancy ranged from $16,000 at North Shore Medical Center to $9,000 at Heywood Hospital.

“While some variation in prices is warranted to support activities, unwarranted variation in prices — combined with a large share of volume at those higher-priced institutions — leads to higher spending overall and inequities in our distribution of resources,” Seltz said.

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Health Insurers Step In To Help Stem Opioid Crisis In Mass.

For some health insurers, there are critical costs to helping members struggling with drug addiction succeed at staying healthy and off drugs. As a result, these insurers are trying new ways to offer support to those at risk. (Toby Talbot/AP)

For some health insurers, there are critical costs to helping members struggling with drug addiction succeed at staying healthy and off drugs. As a result, these insurers are trying new ways to offer support to those at risk. (Toby Talbot/AP)

For many people struggling with opioid use, a key to their success in recovery is having support. Some are getting that support from an unlikely place: their health insurer.

Amanda Jean (or “A.J.”) Andrade, 24, has been drug- and alcohol-free since October, the longest amount of time she’s been off substances in a decade. She gives a lot of the credit for that to her case manager, Will, who works for her insurance company. He’s helped her find the sober house where she moved after inpatient treatment, and he’s helping her figure out where she’ll go from there.

“Having Will is the best thing in the world for me. If I have the slightest issue with anything to do with my insurance, that included like prescriptions, even when I had a court issue, I know that I can call him,” Andrade said.

Her insurer, CeltiCare Health Plan, is one of several health insurance companies taking new steps to deal with the nation’s growing opioid epidemic. CeltiCare has about 50,000 members in Massachusetts and mostly manages care for low-income patients on Medicaid. Continue reading

Related:

Top CommonHealth Stories Of 2015: From Kale And Sex To Opioids And Suicide

This Jan. 1, 2014, file photo shows fireworks lighting up the sky over Boston Harbor to celebrate First Night in Boston, during New Year’s celebrations. (Elise Amendola/AP)

This Jan. 1, 2014, file photo shows fireworks lighting up the sky over Boston Harbor to celebrate First Night in Boston, during New Year’s celebrations. (Elise Amendola/AP)

In the Radio Boston segment above, Dr. Neel Shah looks back at the year in medicine and highlights several important trends, among them:

  • Obamacare is now here to stay, but health costs — particulaly out-of-pocket costs — continue to rise; Obamacare affected how health care is paid for, but curbing costs requires reform of how health care is delivered.
  • Health care is moving — slowly — toward more transparent consumer information about prices, and hospitals are taking more responsibility for the costs of care.
  • Tracking apps are transforming not just fitness but health care and disease management.

All important. Now, let’s also look back at 2015 through the CommonHealth lens. Of course, we must resist the siren song of easy metrics; if click counts were everything, we’d write about nothing but trendy vegetables and sexual organs. But just in case you missed them, these were our highest click counts of the last year:

Now to get serious, as serious as drug overdoses and suicide.

In this September photo, Joey, who had recently started using methadone to try and kick his heroin addiction, visits his parents grave at Woodlawn Cemetery in Everett. (Jesse Costa/WBUR)

In this September photo, Joey, who had recently started using methadone to try and kick his heroin addiction, visits his parents grave at Woodlawn Cemetery in Everett. (Jesse Costa/WBUR)

Opioids

There’s been a lot of (well-deserved) journalistic self-congratulation around Boston lately, so let’s limit ours to this: At a recent public forum, the dean of Harvard Medical School introduced WBUR’s Martha Bebinger as “a treasure,” and we concur with his diagnosis.

Along with her continuing coverage of health care, Martha has focused particularly this year on medical marijuana and, with WBUR’s Deborah Becker, on the opioid crisis. Three of her many memorable stories:

Suicide

WBUR’s Lynn Jolicoeur performed an important public service this year with her series, “Suicide: A Crisis In The Shadows,” and CommonHealth was honored to help bring the painful topic a bit further out of the shadows.

The opening segment — ‘The Biggest Barrier’ To Preventing Suicide: Not Talking About It — was shared about 30,000 times on Facebook within the first week or so. Lynn received messages from all over the country, from people who were glad to see the issue of suicide reported on, wanted to share their own stories of how suicide had affected them, or wanted to suggest angles to cover. Continue reading

1 In 6 Mass. Residents Put Off Health Care This Year To Avoid Costs, Survey Finds

A new survey of Massachusetts residents finds that about one in six did not get health care they said they needed in 2015 because of the cost.

The survey from the state’s Center for Health Information and Analysis (CHIA) highlights a trend showing more people have high-deductible plans in which insurance covers less care and patients pay more out of pocket. Continue reading

Related:

A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated

After receiving almost the exact same care at two different hospitals, a patient we're calling Nancy was stunned when she received both bills on the same day. (AP file photo)

After receiving almost the exact same care at two different hospitals, a patient we’re calling Nancy was stunned when she received both bills on the same day. (AP file photo)

The stomach cramp and nausea began one hot Friday evening in August, midway through a vacation on Martha’s Vineyard. The next morning, nearly doubled over in pain, a patient who we’ll call “Nancy” walked gingerly into the emergency room at Martha’s Vineyard Hospital.

Nancy is a 55-year-old former nurse who would prefer not to use her real name because she works with the hospitals in this story.

Even Nancy, who spends hours every day focused on health care costs, would gasp when she saw the bill for this visit.

In the ER, a doctor poked at Nancy’s tender belly and took blood for tests and a urine sample. The doctor ordered a CT scan of Nancy’s abdomen and pelvis, using contrast. It showed bulges, inflammation and thickening in Nancy’s colon. The diagnosis: uncomplicated diverticulitis. Nancy filled a prescription for an antibiotic, took some Advil, and felt better after a few days on a clear liquid diet.

Five weeks later, the diverticulitis monster invaded Nancy’s intestines again. This time she went to an urgent care center closer to home, run by Beth Israel Deaconess Medical Center (BIDMC). A doctor there ordered the same single CT scan of the abdomen and pelvis, again with contrast.

Nancy says the care she received at both places was great. But a month later, when she received the bills and her insurance company’s explanation of benefits for both visits on the same day, she was stunned.

The explanation of benefits show Blue Cross had paid Martha’s Vineyard Hospital almost seven times what it paid BIDMC’s urgent care center for the same CT scan — $3,888.76 vs. $574.97. Continue reading

Tufts Health Plan CEO Jim Roosevelt Stepping Down

Longtime Tufts Health Plan CEO Jim Roosevelt will step down January 1, the company announced Wednesday.

Roosevelt started at Tufts Health Plan as senior vice president and general counsel in 1999. He was appointed CEO in 2005, and since then has grown the insurer from about 600,000 members to more than one million in both private plans and Tufts-managed Medicare and Medicaid plans.

Roosevelt says he’s leaving Tufts in good financial health, but that there are still challenges to dealing with the cost of health care.

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Related:

First Step In Better Care For LGBT Patients? Find Out Who They Are

The U.S. Department of Health and Human Services said this week that electronic health records must include options for collecting information about gender identity and sexual orientation.

“This is enormously important for transgender patients,” says Dr. Joshua Safer, associate professor of medicine at Boston University. “Knowing how treatments affect men and women, and people of a certain age, is important information for physicians caring for patients. But right now we can’t know that for transgender patients because their medical records aren’t categorized by the correct gender.”

Fenway Health calls the new requirement “landmark.”

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As State Agency Fails To Keep Premiums Flat, What’s Ahead For Cost Control In Mass.

There’s a growing list of warning signs that Massachusetts, despite lots of effort, may be losing the battle to control health care costs.

Last month, the Division of Insurance approved a 6.3 percent increase in the base rate for small businesses.

Then, we heard that Massachusetts came in over the target cap for health care spending last year.

And now, an attempt to keep health care premiums flat for the largest employee group in the state has failed.

“It was ambitious, very ambitious,” said Dolores Mitchell, executive director of the state’s Group Insurance Commission (GIC), the agency that manages health insurance for 435,000 municipal, MBTA, state workers, their dependents and state retirees.

“Have we managed to slow cost increases, yes,” Mitchell said. “Have we got our arms around the cost monster, no.”

The GIC is in the middle of a five-year plan.

(Click to enlarge)

(Click to enlarge)

In the current fiscal year, which began July 1st, “it was supposed to be zero, but we didn’t make it,” Mitchell said. The increase this year is 5.7 percent.

The miss means millions of dollars in additional state spending as well as higher costs for the 435,000 people covered by the GIC.

So what happened?

“It has been tough year,” Mitchell said. “Pharmacy going through the roof. The Hep C drug is just a shocker: good for the patients, awful for the budget.”

New blockbuster drugs are just one factor. Mitchell said insurers tell her a big problem is patients who seek care outside of their network. So Mitchell agreed to let insurers require that most members name a primary care doctor and get a referral from that doctor for out of network care. It’s a change she says will save money and improve care.

“All over the country, everybody is saying, medical care is better if you have one doctor who is your major doctor,” she said. Continue reading

Health Connector Sees Rate Hikes For Some, Reductions For Others

Health insurance premiums for Massachusetts residents who purchase unsubsidized health insurance through the Health Connector Authority will see average increases next year of between 2.2 percent and 9.3 percent, according to rates approved by a state board Thursday.

Those who enroll in the state-subsidized private health insurance, known as Connector Care, and those enrolled in dental plans through the Connector can expect to see average premium decreases of 2.1 percent and 1.4 percent, respectively.

The Commonwealth Health Insurance Connector Authority Board on Thursday voted to give its final seal of approval to 15 health insurance companies offering a total of 83 plans for small group and non-group coverage.

Among the plans approved Thursday were the “bronze plans” offered through the Connector, which have low monthly premiums and some pre-deductible doctor visits but come with higher co-pays.

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