“David and Goliath (1599) oil painting by Caravaggio.
Herewith the story of Evergreen Health Cooperative, created under the federal Affordable Care Act to offer “patient-centered” care and cut healthcare-market costs. (We keep being slightly amused by term ”patient-centered” care. Isn’t that the population that healthcare was always suppose to be centered on? Well, maybe not….Follow the money?)
Evergreen has two parts: a nonprofit insurance company with a traditional network of doctors and a health system that directly employs providers.
“We’re the first new commercial insurer in 20 years in Maryland as far as we know,” Peter Beilenson, M.D., a former Baltimore health commissioner, told The Baltimore Sun. “It’s not easy to have a successful startup in a state that basically has a monopoly,” citing CareFirst BlueCross BlueShield, Maryland’s dominant insurer.
Evergreen is one of 24 such co-ops in America, officially called Consumer Operated and Oriented Plans, and, as The Sun noted, ”many of them face similar behemoths.”
And the ACA doesn’t let these co-ops do traditional marketing. Further, government rules make it hard to sign up large employers that could bring in many paying customers at once.
”That fierce competition {from big insurers} is the biggest hurdle to the co-ops’ success …. But there are a host of other potential stumbling blocks, including name recognition and funding, and the co-ops are responding by boosting their industry knowledge, aggressively marketing their services and cutting premium prices to lure customers, ” reports The Sun.
Evergreen looks to small businesses that it could attract on its own and enroll in groups. ”So far, about 1,000 small businesses employing {a total of} about 12,000 people have switched to the co-op.”
Research ”shows those insurers that follow the {co-op} model could save around 20 percent on hospitalizations alone, one of their biggest costs.”
We wonder how some of these co-ops might be integrated with Federally Qualified Health Centers.
“We figured out how to harness the power of the electronic medical record to embed evidence-based transfusion criteria into the computerized physician order entry process through the best practices alert functionality,” Nancy Dunbar, M.D., who led the project, said.
It reports:
And, it said: {F}inancial pressures on hospitals will {continue to} shift their recruitment focus to finding skilled nurses and primary-care physicians.”
Federal healthcare regulators said 5 percent of the hospital’s E.D. patients leave before medical professionals see them — compared with the national average of 2 percent. That might not seem like much of a difference, but given the huge population that runs through Presbyterian, it means a lot of untreated and/or irritated customers. Of course, given the location, a lot of these patients have no insurance and chronic illness. They’re heavy duty.
Among the suggested improvements: increased staffing, improved patient privacy, ”better access to urgent-care centers, and inclusive partnerships with community health providers and professionals,” reports WCBS. It should be noted that some politicians pushing these reforms see Presbyterian as an opportunity to create more local jobs, for which the politicians would take credit.
We at CMG have been in that E.D. (or E.R. as we instinctively first call it as pushback to certain commercials on TV) and so suspect that many, perhaps a majority, of patients there would do better going to urgent-care facilities, including Federally Qualified Health Centers, if there were enough of them. And most need patient-centered medical homes.
Mr. Shrinkman writes: “Few ordinary patients–the true bearers of change in healthcare policy–appear in this book, and virtually all of them came from the Time article {that Mr Brill wrote that was the basis of his book}. Mr. Shrinkman suggests that Mr. Brill is full of the hubris and social isolation of the “1 Percent” — as the gap between the very rich and everyone else widens.
Herewith a podcast discussion on cancer screenings. An increasing number of physicians and other experts see the physical danger of over-diagnosis and over-treatment; and, of course, many worry about the vast expense of American medicine’s testing mania. (Many of these tests can be very lucrative.)
But many patients (in particular) and physicians think that if wide screening by expensive tests saves just one life, it’s worth it.
(Clay Masters is a Iowa Public Radio journalist.)
It was a heck of a Christmas for David Fairchild and his wife, Clara Peterson. They found out they were about to lose their new health insurance.
“Clara was listening to the news on Iowa Public Radio and that’s how we found out,” Fairchild says. They went to their health plan’s Web site that night. “No information. We still haven’t gotten a letter about it from them.”
The two are the sole employees of a cleaning service and work nights. Fairchild has chronic leukemia but treats it with expensive medicine. Last year they saved hundreds of dollars switching from the insurer Wellmark to a plan run by CoOportunity Health. For the first time in a long time, Fairchild says, they felt like they had room to breathe.
“Basically it covered our office visits; covered exams,” he says. “It covered all but $40 of the medicine every four weeks. It was just marvelous. It probably was too good to be true.”
It was for them. CoOportunity Health has failed. The Affordable Care Act set aside funding for healthcare co-ops, to enable the organizations to compete in places where there aren’t many insurers. CoOportunity Health was the second largest co-op in the country in terms of membership, and one of the largest in terms of the federal funding it received.
But then CoOportunity hit a kind of perfect storm, says Peter Damiano, director of the University of Iowa’s public policy center. First, the co-op had to pay a lot more medical bills than those in charge expected.
“CoOportunity Health’s pool of people was larger than expected, was sicker than expected,” Damiano says. “So their risk became much greater than the funds that were available,”
The reason the co-op’s customers were sicker has a lot to do with what the insurance market looked like in Iowa before Obamacare. The largest insurer by far in the state was and still is Wellmark. But Wellmark decided not to offer any plans on Iowa’s health exchange, leaving just CoOportunity and one other insurer — Coventry — offering plans on the exchange throughout the state.
On top of that, when the Obama administration in late 2013 allowed people to keep the insurance plan they already had, many customers happy with Wellmark stayed put. Damiano says this meant many of the customers who flocked to CoOportunity tended to be like Fairchild — people with expensive health problems who’d had trouble paying for insurance before, in the market Wellmark dominated.
“It was always going to be a challenging market to try to reach,” says Damiano, “and on top of that, the whole idea of co-ops was relatively new and experimental. But it was to try to create competition, on that private sector approach,” says Damiano.
Not only were the patients sicker, but CoOportunity’s leaders initially thought they would enroll about 12,000 people in Iowa and Nebraska. They got about ten times that, according to Nick Gerhart, Iowa’s insurance commissioner.
Also, Gerhart says, the co-op thought it was going to get more federal money.
“On December 16 around 4 o’clock we were informed they weren’t going to get any further funding,” he says. “Nothing was pulled — it just wasn’t extended further.”
Gerhart is now essentially the CEO of the co-op because the state has taken it over. He likens the situation to a small business suddenly having its credit shut off by the bank. Even though CoOportunity is not officially dead yet, Gerhart is telling its customers to switch insurers.
He says it’s too early to make predictions about the fate for all co-ops.
“Ours was the second largest in the country, so you’ve got to look at it that way.” Gerhart says. “If the second largest can’t make it, how viable are the other ones? I don’t know. But at the end of the day they didn’t have enough capital to support 120,000 members.”
In a written statement, Dr. Martin Hickey, chairman of the board of the National Alliance of State Health Co-Ops, said, “The news about CoOportunity Health is not a statement on the health insurance co-op program or the co-op concept. It’s a reflection on the fact that all insurers — not just co-ops — are operating in unique markets with unique business plans and varying state regulations. The circumstances for CoOportunity Health in Iowa are not the same as those in the 23 other states in which co-ops are currently operating.”
But the co-op’s failure in Iowa has left David Fairchild and Clara Peterson scratching their heads.
“I mean the whole Affordable Care Act is [about] competition between insurance companies, and now we’re back down to what?” says Peterson.
For them, only one option: Coventry. They’ve already applied through healthcare.gov and now they’re now waiting for approval for a plan that will cover a lot less of Fairchild’s medicine expenses.
This story is part of a partnership between NPR and Kaiser Health News.
”The rules stipulate that nurse practitioners with more than 3,600 hours of clinical practice no longer need to work under a written collaborative agreement with a physician. The required clinical experience equates to about two years in clinical practice. Nurse practitioners with less than the required amount of experience will still be required to work under a physician….”
“The only requirement that remains that will tie experienced nurse practitioners to physicians or hospitals is that they must maintain an established relationship for referral or consultation.”
The rules also let NP’s diagnose illness, and perform therapeutic and corrective measures. Up until Jan. 1, 2015, nurse practitioners could only perform these functions within collaboration with a physician.
The effect of the new rules, besides making primary-healthcare more accessible just by sheer force of added staffing over time, will be to tend to pull down the income of physicians, especially internists and family practitioners. After all, you can train and put to work more NP’s more quickly than you can physicians and NP’s will usually be paid less.
The payers, be they private and public insurers and patients, will see the rise of NP’s as opportunity for more primary care at lower cost. A big question, of course, is how specialized NP’s might also erode the very high compensation of such specialists as cardiologists.
“Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool,” the authors wrote.
“If you discharge a patient from the hospital and the physician that is now going to be following them is not given a discharge summary that is accurate and complete, then [the doctor is] going to screw things up,” Steven Wolfson, M.D., a New Haven cardiologist uninvolved in either study told the New Haven Register. These transitions are particularly dangerous for patients, he said, because “[i]t’s like crossing an international boundary … largely because the information flow is critical and it’s often very poor.”