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Health Care Hurdles

David P. Lind BenchmarkThe clock is ticking and finally, after waiting two years and with great anticipation, March 26-28 has come and gone. Now we must wait again, at least until late June. For what? For decisions that will determine the future of how we pay for health care coverage.

During March 26, 27, and 28, the U.S. Supreme Court has heard six total hours of arguments, the most time given to a case in decades. The arguments will determine whether the individual mandate, a cornerstone of the mammoth 2010 health reform law, will either remain in place (for implementation in 2014) or be ruled unconstitutional. Twenty six states (including Iowa) believe the federal government does not have constitutional authority to require most Americans to purchase health insurance.

The stakes are high, VERY high.

I will go out on a limb (not really!) and predict that each and every one of us will be greatly affected by the outcome of this decision…employers are definitely impacted for obvious reasons.

In my mind, there are at least four possible fundamental major outcomes from this historic decision (so choose your poison!):

1. The Justices decide that 2014 must come first so the mandate is in place BEFORE the Supreme Court can rule on the constitutionality of this case. This stems from a nineteenth century law that basically says you can’t have a lawsuit on taxes if no one has yet been harmed by the tax. By no means am I a legal expert…but we seem to be prolonging the inevitable if this happens. In fact, both supporters and detractors of the individual mandate agree that this should not happen. It’s nice to know that both sides can agree on at least one thing! Audio of oral arguments is found here.

2. The individual mandate is ruled constitutional and therefore most every provision within the law will survive and be implemented. Even if this happens, the controversy will not be over. We have elections in 2012 and 2014 that could greatly impact whether reform remains. Audio of oral arguments is found here.

3. The mandate is deemed unconstitutional, and this is where it becomes extremely interesting.  Health insurance companies would be thrown into chaos if there is no mandate in place, because the mandate assures coverage for most all people (those with good and bad health risks). Without the mandate, insurers would most likely assume much greater risk because people who are healthy are less likely to seek insurance coverage…but those with health problems are more likely to sign up for coverage – and insurers would have to accept them. Health insurance premiums would increase much faster as a result. Under this scenario, the Supreme Court will then need to decide whether the rest of the law will remain or be repealed in parts or in its entirety.

4. Regardless of the individual mandate decision, the expansion of Medicaid coverage could be struck down by the Court, resulting in low-income individuals having private coverage at a much higher cost. Audio of oral arguments for #3 and #4 is found here.

Complex stuff, isn’t it? There is so much at stake for all Americans it is mind boggling.  Regardless of the mixed bag of results, hopefully a decision by the Supreme Court will provide more certainty than we have today, which is an absolute necessity. One hurdle has been reached, yet many more are on the horizon – for years to come.


Wellness: Bending the Cost Curve

Wellness and Health Care Costs in IowaWill wellness programs stem the tide of rising health care costs?

That’s the million dollar question.

Health insurance rates in Iowa increased an average of 10.2% annually during the last five years, according to our Iowa Employer Benefits Study©. No wonder employers are looking for ways to bend the cost curve.

So are wellness programs going to provide the magic bullet? I have to say, “Possibly, however…”

There are at least two major forces—upstream and downstream—that adversely affect health care costs, and only one is affected by wellness programs.

  1. Upstream force: unhealthy lifestyle behaviors        
  2. Downstream force: a dysfunctional health care delivery system

Conventional wisdom suggests that if we identify and minimize or treat health risks upstream before they become major (and more expensive), we should eventually incur fewer costs downstream.

I admit there is truth to this. Decrease unhealthy behaviors that lead to the “lifestyle diseases” —heart disease, stroke, some cancers, type 2 diabetes, metabolic disorder and a few others—and you lower the need for expensive procedures.

But for most people, improving lifestyle behaviors leads to involvement with the health care delivery system – the downstream force – and this fragmented system is not geared to provide efficient, coordinated and recommended care. In fact, in 2003 the Rand Corporation released shocking results from the largest and most comprehensive analysis ever undertaken on health care quality in the U.S.

Adults in the U.S. fail to receive recommended health care nearly half the time!

Unbelievable, you say. We have the best health care system in the world, you say. Well, here are a few examples:

  • Less than a quarter of diabetics had their blood sugar levels checked regularly, putting them at risk for kidney failure, blindness and amputation.
  • Just 45% of heart attack patients received medications that would reduce risk of death by more than 20%.
  • Patients with high blood pressure received less than 65% of recommended care, putting them at increased risk for heart disease, stroke and death.

Just as staggering—according to the study, inappropriate care happens everywhere! While a study that came out in 2003 may seem dated, the reality on the ground has not improved. The Dartmouth Atlas of Health Care continues to support the Rand findings by documenting the variations of how health care is delivered in this country.

So by all means, implement a well-designed wellness program. But don’t expect miracles when it comes to bending the cost curve. Until we address our dysfunctional delivery system, your payoff may come in healthier and more productive employees.

A New Acronym in Iowa: ACOs

David P. Lind BenchmarkRecently, my interactions with the health care system have been up close and personal. I can tell you that my wife and I have experienced great frustration when seeking coordinated care for our daughter in recent months, both in and out of the hospital.

Having to reconstruct her medical history over and over and over for each new health care provider has been discouraging, annoying, and frankly, unnecessary. If you’ve been there, you know what I mean.

Lack of coordination between different health care providers for the same patient is a major concern in this country. Not only is it incredibly frustrating to the patient and family members, it’s potentially dangerous and very costly due to inefficiencies and duplication of services.

Your insurance premiums, by the way, are adversely affected by this current delivery of care.

What about ACOs

Accountable Care Organizations (ACOs) are the latest trendy model for delivering health care services by doctors and hospitals.

In a nutshell, an ACO is a network of doctors and hospitals who share responsibility for providing care to their patients.

Sounds good to me! However, I recently read that ACOs are being compared to the elusive unicorn: everyone seems to know what it looks like, but no one has actually seen one.

Imbedded in the massive new health law, ACOs were allotted only seven pages of provisions, but they’re causing a tremendous amount of interest with many stakeholders (patients being one!).

The intent of an ACO is to bring together the different aspects of care for the patient— primary care, specialists, hospitals, home care, etc.—and make providers jointly accountable for the health care of their patients.

Through the new health law, financial incentives will be given to providers to cooperate and save money by avoiding unnecessary tests and procedures. To do this, they must seamlessly share a patient’s medical information between themselves. So instead of the patient and family members having to educate each provider on the medical history, the ACO team would have all information at their fingertips.

Personally, I hope that ACOs (or something like them) become the “new normal” in our delivery system. It cannot come soon enough for this parent!

To learn more about the Final Regulations for ACOs, click here.