RCT of Palliative Care in Heart Failure

A big team from Duke lead by Joseph Rogers has a new Paper (PAL HF) reporting the results of a RCT of palliative care in late stage Congestive Heart Failure, published today in the Journal of the American College of Cardiology. Patients who got palliative care had better quality of life, higher function and reduced anxiety and depression (with no survival difference, as hypothesized). Costs were not a primary endpoint, but will be analyzed in later work.

CHF_7-11-2017 8-56-05 AM.

After the publication of a RCT of early palliative care in stage 4 lung cancer in the NEJM in August 2010 showed improved quality of life, lower costs and longer survival, there was a move to see if such findings could be replicated in other diseases. This NHLBI funded study is part of that effort.

Real world evidence is provided imperfectly, especially with respect to policy. One example from this paper. This studies’ exclusion criteria ruled out patients with anticipated heart transplant or LVAD implantation within 6 months. Arguably, these patients aren’t ready for palliative care because they are seeking such aggressive treatments, but from a policy perspective, it is arguable that they definitely need the goals of care type of discussions that are a key part of palliative care. The successful conclusion of a trial of CHF without patients on the way to heart transplant or LVAD implantation leaves an evidence hole, even as we add to the evidence base.

Should patients thinking about an LVAD or a heart transplant get palliative care? I think the answer is yes, but this trial provides no direct evidence to inform this question. So, there remains an evidence gap (as always–good studies suggest more questions than they answer). However, the health care system often doesn’t and can’t wait for such answers, and in the case of palliative care there has been a tremendous increase in its provision at Duke, and across the nation since this study was began. The process and timing of research is slow, and the answers are often muddled, while the pace of change in addressing the needs of seriously ill patients is much more rapid. When one’s interest is policy applications, even an RCT–the gold standard of research–cannot answer all of the most pressing questions.

The Senate bill confuses already confused consumers

The Senate’s Better Care Reconciliation Act (BCRA)[1] is a significant modification to the current Patient Protection and Affordable Care Act (PPACA)[2] exchange structure in a variety of ways.  One major change is the designation of the benchmark plan which determines the level of subsidy that the federal government provides to individual buyers on a health insurance marketplace.  There are two elements of note.  The first is that the benchmark plan is now a plan with a calculated actuarial value of 58%.  This is a significant change from the current benchmark plan with a calculated actuarial value target of 70%.  More importantly for this post is the benchmark plan in the BCRA is the median qualified plan.

Research has shown that consumers can be overwhelmed by too much choice[3].  Dominated choices can and often will be selected.[4]  Buyers have frequently confused the value proposition of Gold and Bronze plans based on prioritizing either more out of pocket maximum protections or lower monthly premiums. [5] Buying and using insurance is a complex task with significant uncertainty and cognitive demands.  The BCRA subsidy attachment system creates incentives for insurers to further increase complexity.

Within PPACA the incentive for insurers to clone plans with minimal meaningful differences between them only applies to the insurer which controls the least expensive Silver plan in a county.  This single, low cost, insurer faces a decision as to whether or not to design a second plan with the same actuarial value in a slightly different cost sharing structure in order to guarantee that this single carrier controls both the least expensive and the benchmark Silver point.  All other insurers plan offering decisions are made independent of subsidy attachment point manipulation purposes.

The BCRA creates a broader and more complex strategic design problem for carriers.  Every entry in the benchmark category influences the benchmark price.  Once an insurer has built a network and performed the basic actuarial calculations, modifying a basic plan design by altering co-insurance slightly or decreasing deductibles while increasing co-pays to achieve a constant actuarial value is a fairly low cost action.  A high cost carrier can introduce an isomorphic plan design to increase the benchmark and asymmetrically decrease the relative post subsidy price of its preferred offerings.  Low cost carriers have an incentive to offer one more plan to lower the benchmark and make its offerings more attractive compared to higher cost peers.

Counties with multiple insurers will face an unstable equilibrium.  Every insurer will have an incentive to add a marginal, incremental plan to be offered on the BCRA exchanges in order to move the subsidy attachment point closer to their preferred position.  Once this arms race begins, consumers will be asked to differentiate miniscule differences between dozens of plans offered by two or more insurers.  Common heuristics such as evaluating a plan first on the inclusion of a specific doctor or hospital in network and then examining a subset of plans based on maximally acceptable premium with the final decision step based on minimizing deductible will be corrupted.  Plans can be offered with low deductibles but higher maximum out of pocket exposure with a cost structure that significantly advantages or disadvantages certain types of consumers.  Insurance buyers will face decision fatigue and be overwhelmed with almost meaningless choice.

There are two possible solutions.  The first is for the Department of Health and Human Services to update stringent meaningful difference regulation.  Current regulation[6] allows carriers to offer multiple plans built on the same network ID and same plan type (HMO, POS, EPO, PPO) with fairly minor differences in cost sharing.  Stronger meaningful difference regulation would restrict carriers to offer only a single cost sharing design per network ID and plan type dyad.  The second is for the Senate to modify the benchmark.  Every participating carrier would place their lowest cost plan in the benchmark set and the median plan from the benchmark set would be the benchmark plan for the county.

These design modifications lower consumer confusion and will minimize strategic manipulations of the subsidy formula which will lead to more effective and efficient markets.

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Does Health Insurance Improve Health?

An old question has gotten some new evidence. Does health insurance coverage improve health? This is a simple (and important) question that is complicated to answer definitively due to methodological reasons, but the evidence base has grown by two important papers in peer review journals in the past few weeks:

  • Ben Sommers has a recently accepted paper in the American Journal of Health Economics that is available online as an eprint. He finds that Medicaid expansions in the early 2000s in 3 states saved lives, and he documents the costs of doing so. The point of the paper is better methods of determining if Medicaid expansions did in fact save lives and looking at the cost of coverage. His top level findings:
    • 1 life saved for every 239-316 persons newly covered by Medicaid (the range represents the uncertainty in the estimate–could be as high as 316 lives saved, or as low as 239, for each newly covered person).
    • The cost per life saved was $327,000-$867,000
    • He discusses the other things that could be done with this amount of money and notes these amounts are less than often paid per life saved for many interventions
  • Ben Sommers, Atul Gawande and Kate Baicker have a paper in the most recent NEJM that looks more comprehensively (not only mortality as an outcome, and at different types of insurance, public and private) and reviews the recent peer reviewed work on the broad topic of does health insurance improve health. This is a nuanced paper that focuses on the current health reform discussions that our nation is having and goes directly to how important losses in recent coverage expansions could be to public health. On the most basic question at hand they conclude

    There remain many unanswered questions
    about U.S. health insurance policy, including
    how to best structure coverage to maximize
    health and value and how much public spending
    we want to devote to subsidizing coverage for
    people who cannot afford it. But whether enrollees
    benefit from that coverage is not one of the
    unanswered questions. Insurance coverage increases
    access to care and improves a wide range
    of health outcomes. Arguing that health insurance
    coverage doesn’t improve health is simply
    inconsistent with the evidence.

The evidence base changes weekly. These two important papers need to make their way into the ongoing policy debates.

A cheat sheet to read the Senate version of AHCA

The Senate healthcare and tax cut bill is expected to drop soon. Here is a cheat sheet on how to read it.

1) Reconciliation places severe constraints on the bill

a) The Parliamentarian is most likely going to be stripping out significant, non-germane to the budget, items that were in the House bill.
b) $1 billion in savings must come from each of two committees (HELP and Finance).
c) Anything the Senate passes must meet or beat the $119 billion in budget window deficit reduction that the House AHCA was scored at.

2) Three major pots of money

a) Tax cuts
b) Individual market changes
c) Medicaid cuts to pay for tax cuts

3) Follow the money
Any extra dollar used to pay for a slower Medicaid termination has to come from either Medicaid on the back-end, fewer tax cuts or lower individual market changes. Anything used to up subsidies on the individual market has to come from itself, faster/steeper Medicaid cuts or fewer tax cuts. Anything that ups the tax cuts must come from the individual market or Medicaid…etc.

4) Index rates matter
Slower terminations but lower index rates on per capita caps is a budget gimmick. It gives a little bit of money in the 10 year budget window but leads to massive cuts in the out years against the current counterfactual.

5) Market design and incentives matter

a) Look at where the work disincentives apply

a1) Medicaid expansion where the FMAP disappears once a person churns out once
a2) Medicaid expansion to individual market transition without CSR as people move from high AV low premium insurance to low AV high premium insurance if they earn a dollar too much
a3) 350% FPL instead of 400% FPL

b) How does the individual market function without a mandate and without the patient and state stability funds?

Where to expect higher deductibles this fall on Healthcare.gov

The Silver plans are supposed to be 70% Actuarial Value (AV). AV is the percentage of costs for the pool that the insurer covers. 70% AV means the insurer pays roughly 70% of the costs, and the people in the pool pay roughly 30% in cost sharing. There are lots of different ways to arrange the cost sharing but that is a detail.

Under the Obama administration, there was a de minimas variation rule where a plan could be called Silver if it was between 68% and 72% AV. The Trump administration released a new rule that changed the allowed variation for a Silver plan to range from 66% to 72% AV.

The out of pocket maximums are likely to increase significantly in the highlighted Healthcare.gov counties below:

The highlighted counties have a Silver plan with a 2017 AV between 68% and 68.05%. I figure that companies are more likely to do what they were doing, reaching for the lowest possible AV if the rules are relaxed. Counties where the lowest AV was above 70% are, in my opinion, less likely to see their incumbent carriers race to the bottom as they already had not shown that proclivity. This is most of Oregon and significant chunks of Pennsylvania and Illinois with a few random counties elsewhere.

The distributional consequences are complex. Lower AV values, all else being equal, means lower premiums. The insurers pay less in claims. It is a good deal for the federal government as the premium of the benchmark Silver will either be constant or decrease so advanced premium tax credits will decline. It is a win for healthy people who are not subsidized as they weren’t going to hit the previous, lower out of pocket maximum anyways so they save 3% in premiums. It is a wash for people with Cost Sharing Reduction (CSR) subsidies as the CSR holds constant. It is a wash for subsidized buyers who don’t get CSR but who are healthy and were going to buy Silver anyways. It gets complex for those buyers who wanted to buy another metal band as county specific pricing variations will be altered. Bronze plans will be slightly more expensive and Gold/Platinum plans will be up in the air as to their relative price.

The worst off are the Silver buyers who are not receiving CSR assistance and who are likely to be sick. They are picking up more out of pocket. Non-subsidized buyers will get a slight improvement in lower premiums but all that plus more will go back out the door via higher cost sharing. Subsidized buyers won’t see the slight improvement in premiums. They will only see higher cost sharing.

Finally, the Tableau that I was using to play with this idea is below.

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Time & Motion Study of Community Based Palliative Care

We have a new paper (open access) in the Journal of Palliative Medicine, providing a Time and Motion study overview of the care delivery model at the heart of our CMMI HCIA-2 innovation award with Four Seasons Hospice in Western, North Carolina (Janet Bull, who is also President of the American Academy of Hospice and Palliative Medicine and I are the co-PIs of the project).

This figure provides an overview of the palliative care model that we are providing across setting (~5,000 patients will enrolled by the end of Summer, 2017, and we just received Medicare claims records for the first 2+ years of the project, so should have preliminary cost findings in the Fall).

TimeandMotion.6.6.17jpm.2016

 

Hidden good news in the BCBS-NC filing

Blue Cross and Blue Shield of North Carolina just filed their initial rates for the ACA individual market for 2018. The headline will be that they are asking for a 22.9% average rate increase. The second headline is that they assume that Cost Sharing Reduction subsidies will not be paid. That assumption drives 61% of the rate increase. The SERFF filing is here.

There is subtle good news in the rate filing. Another 13% of the rate increase is driven by the reinstitution of the 3% Health Insurance Premium tax. That is a one time hit that is to be baked into the cake of future rates. This means only 26% of the entire rate increase or roughly five percentage points is due to increased medical costs or service utilization. Trend and morbidity is under control. Below are segments of the consumer justification.

5% trend is a healthy trend. That is a the trend of a market that is fairly stable and reasonably priced.

There are a few other North Carolina notes for the individual market. Aetna is withdrawing. This should allow Blue Cross and Blue Shield to play aggressive subsidy attachment pricing strategies. Subsidized buyers have the chance of seeing excellent deals on the Exchanges if BCBS-NC prices in the same manner as BCBS-Tennessee prices in their single carrier counties.