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Health Care Reform Memo:
August 5, 2013

Deloitte Center for Health Solutions publication


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The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.
 

My take: a threat and an opportunity: shifting health care costs to consumers 

From Paul Keckley, Executive Director, Deloitte Center for Health Solutions

As Congress was wrapping up business before its August break, three government reports released recently frame an important reality for the health care industry as it looks to the implementation of the Affordable Care Act (ACA) in coming months:

  • The Department of Commerce released its assessment of the second quarter 2013 economic growth concluding the recovery continues to be slower than desirable. Gross Domestic Product (GDP) growth for the second quarter was 1.7% and averaged quarterly 1.4 percent growth for the past year. It reported that a reduction in federal spending (down 13.9 percent in the fourth quarter of last year) was a major contributor and that consumer spending helped—up 1.8 percent for the quarter. Since the U.S. economy’s growth is largely dependent on consumer spending, the analysis pointed to encouraging news in housing and auto purchasing, but an increasing number of households that live at/near poverty. (Source: Bureau of Economic Analysis, “Comprehensive Revision of the National Income and Product Accounts: 1929 Through First Quarter 2013,” July 31, 2013)
  • A report from the White House Office of Economic Advisors announced that “prices for personal consumption expenditures (PCE) on health care goods and services rose just 1.1 percent over the 12 months ending in May 2013, the slowest rate of increase in nearly 50 years.” It noted that the PCE drop was aided by decreases in spending in “hospitals and nursing home services (which comprise 42 percent of total health care expenditures) and outpatient services (which comprise 34 percent of total health care expenditures).” (Source: The White House Blog, “As ACA Implementation Continues, Consumer Health Care Cost Growth Has Slowed,” July 29, 2013)
  • And the Bureau of Labor Statistics’ (BLS) Employer Costs for Employee Compensation survey reported that, for private sector employers (56 percent of total employers that offer health insurance benefits), “the annualized growth rate (inflation-adjusted) costs for workers’ health insurance slowed from 2.2 percent a year from Q4 2006 to Q4 2009 to 1.8 percent a year from Q4 2009 to Q4 2012, with a particularly marked slowdown occurring at smaller establishments. For establishments with fewer than 50 employees, employers’ real costs for workers’ health insurance grew just 1.0 percent a year from Q4 2009 to Q4 2012, half the rate observed over the preceding three years.” (Sources: The White House Blog, “As ACA Implementation Continues, Consumer Health Care Cost Growth Has Slowed,” July 29, 2013; BLS, “Employer Costs for Employee Compensation,” June 12, 2013)

Reading the details in these reports was tedious: the bottom line is this:

Increasingly, the health care industry’s economics are tied to the consumer pocketbook. These reports point to a slowdown in consumer spending in health care for two reasons: the overall economy has slowed and for consumers, health care spending out of household budgets is problematic, especially for middle income Americans who can only afford an insurance plan that requires a high co-payment or defined contribution product.

The Deloitte Center for Health Solutions has studied consumer health care spending and opinions about the system since 2008. Notably, these data have affirmed that the majority of Americans do not feel the system of health care we are now seeking to reform operates well. Most think it wasteful and confusing:

(Source: Deloitte Health Care Consumer Surveys, Deloitte Center for Health Solutions, 2009-2013)

So while these government reports point to lower health care costs paid by the government or employers that provide coverage for health care, it does not paint the entire picture: much of the cost of health care has been shifted to consumers—employees, enrollees, retirees—and that poses both a threat and opportunity to the health system:

…a threat in that every dollar spent from discretionary household budgets will increasingly compete with dollars spent on housing, food, clothing, transportation, alternative health and even entertainment.

…and an opportunity for health care organizations to innovate around providing differentiated value to consumers, while operating under intensified scrutiny about prices, outcomes, executive compensation, business relationships and every aspect of how the business functions.

The value proposition for what’s spent in health care must be made to consumers. Dismissing consumers as “patients/members/subjects” is simply shortsighted. And they’ll pay attention, because it’s their money.

Paul Keckely
PS – Yesterday’s New York Times leading story is a case in point: For Medical Tourists, Simple Math: U.S. Estimate for a New Hip: $78,000. The Belgian Bill: $13,660,” Elizabeth Rosenthal.

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Implementation update 

Tavenner tells House Committee ACA implementation on track 

Appearing for three hours before the House Energy and Commerce Committee Thursday, Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner said, “CMS is ready for October 1,” referencing the day when the health insurance exchanges (HIXs) are scheduled to start enrolling those seeking coverage. Tavenner reported that HHS has been conducting live testing of the HIX system, from basic to more complex scenarios and should be complete by August. None of the contractors hired to develop the systems have asked for a delay in their timetables and applicants for federal subsidies in the federal exchanges will face “a 100 percent review” to ensure self-attestation about their income was accurate.

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HHS announces deal with eHealth to handle enrollment, subsidy verification in exchanges 

Wednesday, CMS announced an agreement with eHealthInsurance, the nation’s largest online health insurance broker, to support enrollment in the HIXs in 36 states with federally-facilitates exchanges (FFEs) or state-partnership exchanges (SPEs). eHealth will serve CMS as a “web-broker entity.” The agreement allows eHealth to access the federal electronic data hub to determine tax subsidy eligibility and the amount of a subsidy, while providing consumer privacy protection requirements and standards in addition to the U.S. Department of Health and Human Services (HHS) HIX regulations.

Next steps: another agreement regarding federal requirements for agents and brokers will still need to be signed by CMS and eHealth before the company is permitted to enroll individuals in FFEs.

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Insurers ask HHS for one-year delay to comply with technical interface requirements of HIXs 

In its comment letter last week, America’s Health Insurance Plans (AHIP) requested HHS grant issuers a one-year moratorium for the compliance period to allow time for plans to adequately comply with the technical requirements for the HIXs that open for enrollment October 1. At issue: the technical interfaces, data exchanges and program infrastructure per the proposed rule, “Program Integrity: Exchange, SHOP, Premium Stabilization Programs and Market Standards” (CMS-9957-P), released June 14. The trade group’s members do not feel they have been given adequate time to comply, having requested the proposed rule months earlier.

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Committee testimony: ACA employer impact most significant for mid-size companies 

Companies with between 51 and 249 employees face the greatest challenges under the ACA, Chairman of the Senate Small Business and Entrepreneurship Committee Senator Mary Landrieu (D-LA) testified last Wednesday. “The larger companies can take advantage of the lower rates for groups. The smaller companies will be able to pool their resources through the exchange,” Senator Landrieu said at a hearing, “Implementation of the Affordable Care Act: Understanding Small Business Concerns.” Notable data in the testimony:

  • 96 percent of all U.S. businesses (5.8 million companies employing 34 million workers) have fewer than 50 employees.
  • Small businesses that offer health insurance pay an average of between 18 percent and 25 percent more than rates charged to large employers.
  • The percentage of small firms offering coverage fell from 65 percent to 59 percent between 2001 and 2009.

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House passes bill to ban the IRS from enforcing the ACA, 40th bill passed in House to repeal ACA 

Friday, the U.S. House of Representatives passed “Keep the IRS Off Your Health Care Act” (H.R. 2009) with a 232-185 vote, with four Democrats voting with the Republican majority. The bill is proposing to prohibit the Treasury Department from enforcing any provisions of the ACA and is the 40th House vote that repeals all or part of the ACA. President Obama has promised to veto this legislation if it passes through the Senate.

Related: a letter from the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) on July 30 revealed that the budgetary impact of this bill is unclear. The CBO acknowledged the bill would significantly reduce both direct spending and revenues to the federal government between the ten-year budget window (2014-2023), although the net budgetary effects are unknown at this time.

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CRS: ACA funding not affected by a government shutdown 

The Congressional Research Service (CRS) issued a memo last Monday advising that a government shutdown will have no ill effects on ACA implementation. The report states that funding will continue for ACA implementation even if other government funding ceases because the law includes provisions requiring mandatory funding from multiple-year, non-year discretionary sources and is not solely reliant on annual discretionary appropriations, which expire at the end of each fiscal year.

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CBO estimates $12 billion increase in cost to Feds due to employer mandate delay 

On July 2, 2013, the Treasury Department announced that any penalties incurred by large employers for not providing health insurance to their employees would be delayed until 2015, in addition to corresponding reporting requirements. The CBO and the JCT assessed the effect of this delay, per request from Representative Paul Ryan (R-WI), Chairman of the House Budget Committee. The new CBO cost estimate for the federal government is $1,375 billion, $12 billion higher than estimations before the employer-based coverage mandate delay. A large portion of this increased cost estimate comes from the projected $10 billion penalty payments that would have been collected in 2015. In addition, exchange subsidies are estimated to increase by $3 billion due to the delayed employer mandate. The increased cost estimate is partially offset by $1 billion due to increases in taxable compensation from fewer people receiving employer-based coverage. CBO and JCT expect that most large employers will not change their plans to offer health insurance in 2014 (if they do not already offer health insurance), despite the one-year delay of penalties. Approximately 1 million people will be affected by the employer mandate delay—half will remain uninsured and half will obtain insurance via the HIXs, Medicaid, or state Children’s Health Insurance Program (CHIP).

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Poll finds voters less likely to support members of Congress who attempt to defund the ACA 

According to the Morning Consult National Healthcare Tracking Poll, published July 31, 47 percent of registered voters said they are less likely to cast their vote for members of Congress who make attempts to defund the ACA using other key government funding votes vs. 28 percent of voters who say they would be more likely to vote for members of Congress who have tried to defund ACA. Voters also vary on their views to repeal the ACA: 30 percent support repealing the ACA, 30 percent believe the ACA should be implemented as planned and 33 percent believe the ACA should be improved by Congress.

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HHS: ACA drug benefit saves Medicare beneficiaries $1,061 each 

Last Monday, HHS announced 6.6 million Medicare beneficiaries saved over $7 billion on prescription drugs as a result of the ACA, for an average saving of $1,061 per beneficiary. The savings are the sum of required discounts on branded drugs required in the ACA and the closing of the Medicare Part D donut hole.

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Legislative update 

House Energy and Commerce Committee passes SGR repeal legislation 

Last week, the House Energy and Commerce Committee unanimously (51-0) passed (H.R. 2810) to repeal the sustainable growth rate (SGR), approving a new amendment that proposes to improve the language of the bill and create a clearer timeline for implementation. The CBO has estimated the cost of repealing SGR will be $139.1 billion. CBO will make assessments regarding the new policy implementations within H.R. 2810 and report the findings during the August recess.

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FDA plans to increase enforcement of dietary supplement claims 

The director of the Food and Drug Administration (FDA) dietary supplements program Dan Fabricant announced on July 18 that the FDA intends to increase enforcement for non-compliant dietary supplement manufacturers.

Background: a report from the HHS Office of Inspector General (OIG) in 2012 urged the FDA to improve the system that tracks false supplement label claims and the regulations that hold manufacturers liable. The OIG report intended to galvanize the FDA to re-examine its requirements and penalties for structure/function unsubstantiated claims and now the FDA is actively researching the best methods to ensure scientific evidence exists to support what manufacturers claim the supplements do. The FDA does not have the same authority with supplements (as it does with prescription drugs) to subpoena evidence from manufacturers to substantiate claims, but may recommend legislation be proposed requiring supplement manufacturers submit substantial evidence supporting the information advertised to consumers.

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Democrats in Senate request cost-savings target for ACA 

Last Thursday, 19 Democratic Senators wrote a letter to White House Deputy Assistant for Health Policy Jeanne Lambrew requesting the Administration set a specific health care cost-savings target to help focus federal efforts and to give the general public a clearer sense of the savings potential.

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Republican Senators request information about federal agency involvement in ACA implementation 

Last week, Senate Finance Ranking Member Orrin Hatch (R-UT) and 38 Republican Senators sent a letter to White House General Counsel Kathryn Ruemmler requesting information on 21 federal agencies with no responsibilities under the ACA that are involved in implementation and promotion of the law.

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State update 

CAP identifies 200 counties with highest uninsured, least access 

Last week, the Center for American Progress (CAP) released a study identifying the 200 “worst” counties in the U.S. based on number of uninsured and health-related outcomes. The 30 worst counties were in Texas, New Mexico and Florida. Families earning less than $25,000 per year, people of color and individuals ages 18-39 are more likely to be uninsured, according to CAP. Based on U.S. Census data 2008-2010 for counties with populations over 25,000, the goal of the study was to show what states would benefit most from Medicaid expansion per the ACA.

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HIX update 

Sixteen states—12 led by Democratic governors, three led by Republicans and one Independent—and the Democratic mayor of DC have announced plans to operate state-based exchanges. Seven states—five led by Democratic governors and two led by Republicans—will participate in SPEs. The remaining 27 states will default to a FFE.*

State-based exchange State- partnership exchange Federally- facilitated exchange
CA, CO, CT, DC, HI, ID**, KY, MA, MD, MN, NM**, NV, NY, OR, RI, VT, WA AR, DE, IA, IL, NH, MI, WV AK, AL, AZ, FL, GA, IN, LA, KS, ME, MO, MS, MT, NC, ND, NE, NJ, OH, OK, PA, SC, SD, TN, TX, UT*, VA, WI, WY

Democratic Governor Republican Governor Independent Governor

*UT: individual market will be a FFE; small business health options program (SHOP) will be state-based.

**NM & ID: federal government will help run the individual market. States will continue to maintain plan management and consumer assistance functions; HHS will operate the IT system. SHOP will be state-based.

(Source: HHS)

  • Last Thursday, California named six insurers that will offer health plans on the state’s SHOP exchange and assured that each of the 19 regional markets throughout the state will include at least three options. The insurers offering plans are Blue Shield of California, Chinese Community Health Plan, Health Net, Kaiser Permanente, Sharp Health Plan and Western Health Advantage. The report noted that premiums will vary across the state but should be consistent with current rates for small businesses. California’s SHOP intends to reach roughly 500,000 small businesses (fewer than 51 employees) in the state.
  • Last Tuesday, Georgia’s insurance commissioner Ralph Hudgens requested an emergency 30-day delay of the deadline for states to approve proposed premiums in state HIXs. The deadline was Wednesday, July 31. Hudgens’ request stems from concerns about rate increases in the state, which he estimates to be as high as 198 percent premium increases for individuals, 100 percent increases for people under age 35 and the middle-aged and 40 percent increases for older residents. Georgia enlisted four independent actuaries to review the seven insurers that submitted proposals to participate in the state’s FFE.
  • Last Wednesday, Florida insurance regulators projected that the ACA will lead individual health plan premiums to rise by 30-40 percent and small group plans to rise by 15-20 percent. Florida’s estimates do not factor in federal subsidies, which reduce the out-of-pocket costs for lower income consumers purchasing insurance through the HIX. Additionally, these projections are based on health plans that do not currently exist in the state. Federal officials responded by citing a study of 11 states whose insurance plans have already been approved by HHS, where the average premiums were 18 percent lower than initial CBO projections. HHS has not yet approved any health plans for Florida’s HIX.
  • Last Tuesday, the North Carolina insurance department announced approval of health insurance plans from three insurers requesting to sell on the state’s FFE, which will now go through the federal government certification process. The three approved insurers include Blue Cross and Blue Shield of North Carolina, Coventry Health Care of the Carolinas and FirstCarolinaCare. All three are also expected to participate in the individual market outside of the HIX and Blue Cross and Blue Shield of North Carolina may also operate in the small group market.
  • Last Thursday, the Ohio Insurance Commissioner and Lieutenant Governor Mary Taylor (R) released estimates for health insurance costs in the state beginning in 2014. Costs for individual health insurance purchased through the FFE are projected to increase 41 percent on average and costs for small-business premiums for plans purchased through the SHOP exchange are projected to increase 18 percent. Additionally, the Department estimates that costs to insurance providers will grow by 83 percent. The analysis determined the average monthly cost for individuals was $236.29 at the end of 2012 versus $332.58 estimated for next year and $341.03 for small businesses versus $401.99 next year. The Insurance Department’s figures do not account for federal subsidies available for certain low-income individuals. The Ohio Insurance Department approved 12 insurers to sell 200 plans for the individual exchange and six insurers to sell 184 plans on the SHOP exchange; HHS will determine final approval for plans offered on the FFEs.
  • Bids from four of the nine insurers that applied to Washington State’s exchange were accepted, Insurance Commissioner Mike Kreidler announced last week. All new market entrants that applied were rejected, as were three Medicaid plans that wanted to sell on the exchange. Just one insurer will sell statewide. The finalized rates were 1.8 percent lower than what insurers had proposed. Kaiser Foundation Health Plan of the Northwest was the only insurer to apply to sell SHOP plans, but only in two counties. Kreidler is expected to finish reviewing those plans by August 6.

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Medicaid expansion update 

To date, 23 states and DC have said they will or are likely to expand their Medicaid programs; 24 states have indicated they will not expand their programs in 2014:

Expected to expand Medicaid Will not expand Maybe
AR, AZ, CA, CO, CT, DC, DE, HI, IA, IL, KY, MA, MD, MN, ND, NJ, NM, NY, NV, OR, RI, VT, WA, WV AL, AK, FL, GA, ID, IN, KS, LA, ME, MO, MS, MT, NC, NE, OK,SC, SD, TN, TX, UT, VA, WI, WY NH, OH, PA

Democratic Governor Republican Governor Independent Governor

(Sources: NASHP and Kaiser Family Foundation. Updated as of July 1, 2013)

  • During a news conference last Tuesday, Ohio State Senator Capri Cafaro (D) promoted Senate Bill 166, which includes provisions that cap Medicaid cost growth to 3.5 percent per year (the current annual growth of Medicaid in Ohio is 7.2 percent). Senator Cafaro argued that Ohio’s Medicaid spending will reach nearly $17.4 billion in 2025 if expansion does not occur, but Ohio could save up to $3.2 billion by 2025 under expansion. Senate subcommittee hearings on Medicaid are expected to continue August 13. Governor John Kasich’s (R) original budget included Medicaid expansion to nearly 275,000 additional uninsured Ohioans, but the final version passed by the Republican-controlled legislature left out expansion.
  • Last week, Medicaid officials from Michigan and Illinois announced they will share information systems. The states are calling the partnership an “unprecedented interstate alliance” that could save each state millions of dollars. “We anticipate a decrease in overall administrative costs for both states to make better use of program dollars which will help ensure better quality services for residents of both Michigan and Illinois,” said Nick Lyon, Chief Deputy Director of the Michigan Department of Community Health, in a statement announcing the deal. The ACA requires states to revamp their Medicaid claims systems. The partnership estimates it will save each state 20 percent of the costs for the required upgrades to their systems.

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State round-up 

  • A New York State appeals court ruled on July 30 that New York City Mayor Michael Bloomberg’s ban on the sale of 16-ounce sugary drinks is unconstitutional. The unanimous ruling by the Appellate Division of the state Supreme Court upholds the New York Supreme court’s decision from March that ruled the ban is beyond the city’s Board of Health regulatory power. In the ruling, Justice Dianne Renwick wrote: “Like the Supreme Court, we conclude that in promulgating this regulation the Board of Health failed to act within the bounds of its lawfully delegated authority.” Additionally, the court argued that the exemptions in the ban did not appear to support public health concerns. New York City may appeal to the highest appellate court in the state before the end of the year.

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Industry news 

Big deals announced last week 

  • Perrigo buys Elan: last Monday, Michigan drug manufacturer Perrigo announced it will buy Irish biotech firm Elan in an $8.6 billion deal. Perrigo, which makes over-the-counter medicines and vitamins, reported it would have annual savings of more than $150 million in taxes and operating costs by moving its headquarters to Ireland, where the corporate tax is 12.5 percent.
  • CHS to acquire HMA: last Tuesday, Community Health Systems (CHS) announced a definitive merger agreement with Health Management Associates (HMA). CHS will acquire HMA for approximately $7.6 billion, including the assumption of $3.7 billion of indebtedness. When completed, CHS will own or operate 206 hospitals in 29 states with a total bed count of more than 31,000.

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Wyeth fined for off-label use 

Last Tuesday, the Justice Department reached an agreement with Pfizer’s Wyeth to pay a $491 million fine for marketing the drug Rapamune for uses not approved by the FDA. The immunosuppressive drug was approved in 1999 for kidney transplants and the sales in question occurred prior to Pfizer’s acquisition of Wyeth.

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CT scans recommended for smokers 

Last Monday, The U.S. Preventive Services Task Force (USPSTF) recommended annual low dose computed tomography (CT) scans for the highest-risk smokers and former smokers, concluding 20 percent of the estimated 159,480 annual deaths from lung/bronchial cancer could be prevented.

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Meaningful use update: providers have received $15.5B in EHR incentive payments 

As of June 30, 2013:

  • 305,778 physicians and other eligible professionals have received $6.3 billion in meaningful use incentive payments for electronic health records (EHRs) from Medicare, Medicaid, or Medicare Advantage (MA).
  • 4,024 eligible hospitals have received nearly $9.2 billion in meaningful use incentive payments as of the end of June.
  • In total, 73 percent of eligible professionals and 80 percent of eligible hospitals have received incentive payments totaling $15.2 billion since the meaningful use program launched in 2011.
  • Around 24 percent of eligible professionals have not yet registered for the meaningful use program.

(Sources: Modern Healthcare, “Majority of Hospitals, Docs Have Received EHR Incentives,” July 2013; CMS, “June 2013 EHR Incentive Program”)

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Kaiser funds $1.8 million partnership to help safety net providers expand coverage under the ACA 

Kaiser Permanente’s Community Benefit arm announced it will provide $1.8 million to fund an alliance between America’s Essential Hospitals, the National Association of Community Health Centers and the George Washington University School of Public Health and Health Services to assist safety-net providers increase their capacity in light of the coverage expansion provisions contained in the ACA. The three-year project will help safety-net providers, such as clinics and hospitals, meet the needs of the newly insured population by encouraging providers to build medical homes and enhance collaboration across the board. The project will focus on five states or regions most in need of assistance and create a “stakeholder support network,” which will be used as a model for other states and regions.

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Research snapshots 

New industry and peer-reviewed studies of note to health system transformers…

Physician self-referral volume increase correlated to financial incentives: GAO analysis 

Background: the Government Accountability Office (GAO) examined Medicare self-referrals among radiation oncology services. “This report examines: (1) trends in the number of and expenditures for prostate cancer-related [intensity-modulated radiation therapy] IMRT services provided by self-referring and non-self-referring provider groups from 2006 through 2010 and (2) how the percentage of prostate cancer patients referred for IMRT may differ on the basis of whether providers self-refer. GAO analyzed Medicare Part B claims and developed a claims-based methodology to identify self-referring groups and providers. GAO also interviewed officials from CMS…and other stakeholders.”

Key findings: “The number of Medicare prostate cancer-related IMRT services performed by self-referring groups increased rapidly, while declining for non-self-referring groups from 2006 to 2010. Over this period, the number of prostate cancer-related IMRT services performed by self-referring groups increased from about 80,000 to 366,000. Consistent with that growth, expenditures associated with these services and the number of self-referring groups also increased. The growth in services performed by self-referring groups was due entirely to limited-specialty groups—groups comprised of urologists and a small number of other specialties—rather than multispecialty groups.”

“Providers substantially increased the percentage of their prostate cancer patients they referred for IMRT after they began to self-refer. Providers that began self-referring in 2008 or 2009—referred to as switchers—referred 54 percent of their patients who were diagnosed with prostate cancer in 2009 for IMRT, compared to 37 percent of their patients diagnosed in 2007. In contrast, providers who did not begin to self-refer—that is, non-self-referrers and providers who self-referred the entire period—experienced much smaller changes over the same period. Among all providers who referred a Medicare beneficiary diagnosed with prostate cancer in 2009, those that self-referred were 53 percent more likely to refer their patients for IMRT and less likely to refer them for other treatments, especially a radical prostatectomy or brachytherapy. Compared to IMRT, those treatments are less costly and often considered equally appropriate but have different risks and side effects. Factors such as age, geographic location and patient health did not explain the large differences between self-referring and non-self-referring providers. These analyses suggest that financial incentives for self-referring providers—specifically those in limited specialty groups—were likely a major factor driving the increase in the percentage of prostate cancer patients referred for IMRT. Medicare providers are generally not required to disclose that they self-refer IMRT services and HHS lacks the authority to establish such a requirement. Thus, beneficiaries may not be aware that their provider has a financial interest in recommending IMRT over alternative treatments that may be equally effective, have different risks and side effects and are less expensive for Medicare and beneficiaries.”

“Congress should consider directing the Secretary of [HHS], whose agency oversees CMS, to require providers to disclose their financial interests in IMRT to their patients.”

(Source: “Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny,” GAO-13-525, July 19, 2013)

My take: physician practice patterns and financial relationships associated with diagnostic testing, surgical volumes and relationships with drug and device manufacturers are increasingly in the spotlight. The bright light of health care transparency is likely to impact how physicians practice and how their business partners determine appropriate ways to work with them. This will be a big story in the new normal.

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Study: physician entry in EHRs accurate 

Background: the researchers at Brigham and Women's Hospital and Harvard Medical School compared emergency department (ED) data on the use of CT angiography for the evaluation of patients with suspected pulmonary embolus.

Key findings: data entered by physicians were correct for more than 90 percent of cases. In 4 percent of cases, data were entered incorrectly and alerts were halted. None of the errors resulted in critical tests not being performed.

(Source: Gupta, A, Raja, A.S., Khorasani, R., “Examining clinical decision support integrity: is clinician self-reported data entry accurate?,” Journal of the American Medical Informatics Association, July 25, 2013)

My take: sometimes a study offers reassurance that an intended result is actually being achieved. In this study, it’s reassuring to proponents of meaningful use that digital health is not prone to excess error originating from physician input.

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Quotable 

Missouri: “Looking for the new health insurance marketplace, set to open in this state in two months, is like searching for a unicorn.” Colorado: “Television commercials have already run suggesting that buying health insurance through the state’s new insurance market, Connect for Health Colorado, will feel like winning the World Series.”

—both from Robert Pear, Abby Goodnough, “Two States Reflect Divide on Obama’s Health Plan,” The New York Times, Page 1, August 3, 2013

“Markets work best when information is transparent for buyers and suppliers. But in most instances today, patients lack any comparative information and usually don’t find out the cost of their care until after the fact—if at all….By opening the [Medicare Physician] database up to the public, Medicare would serve as the anchor for the health care system. If costs go out of control, Medicare would provide the power needed to reel them back in.

This fundamental change might be uncomfortable for some people. While patients’ privacy would be fully protected by eliminating all identifying information, there have been some concerns about shedding light on individual practice patterns of doctors, hospitals and providers. Balancing the interests of individuals with the responsibilities to society as a whole is important and achieved by weighing these concerns against the overwhelming benefits of transparency.”

Senators Chuck Grassley (R-IA) and Ron Wyden (D-OR), Politico, Op Ed, July 29, 2013

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Fact file: special focus on “accountable care” 

  • GDP and National Health Expenditures: historically, national health spending has exceeded overall GDP growth by an average of 2.4 percent annually. (Source: CMS, “Expenditures National Health Expenditures by type of service and source of funds, CY 1960-2011, NHE Projections 2011-2021”)
  • Perceptions of system performance: the majority of U.S. adults give the U.S. system a grade of D/F (unfavorable); most critical are the uninsured and under-insured, but even those with employer-sponsored insurance (64 percent) are negative about its performance. (Source: Deloitte 2012 Survey of U.S. Health Care Consumers, Deloitte Center for Health Solutions, December 2012)
  • Cause of health costs increases: consumers blame health costs on hospitals, drugs, fraud and insurance company administrative costs, along with a myriad of other factors; by contrast, they are less inclined to consider “end of life care” and lack of competition in the private insurance market. (Source: Deloitte 2012 Survey of U.S. Health Care Consumers, Deloitte Center for Health Solutions, December 2012)
  • Spending by category: 2010: as consumers age, the disposition of spending for health care changes and increases: costs associated with facility-based services increase most dramatically. (Source: Deloitte Center for Health Solutions, The hidden costs of U.S. health care: Consumer discretionary health care spending, December 2012.)


  • Additional spending: spending for goods and services outside “normal medical care” are a major category of consumer spending, especially alternative health. (Source: Deloitte Center for Health Solutions, The hidden costs of U.S. health care: Consumer discretionary health care spending, December 2012.)
  • Uninsured: full ACA implementation will mean a 47.1 percent drop in the national uninsured rate and each state would see at least a 25 percent decrease in its uninsured population. (Source: Kaiser Family Foundation, July 2013 estimate)
  • Local public sector hiring: local public sector hiring will be up 90,000 in 2013 and 300,000 in 2014. Total local employment down 561,000 since 2009—local-government employment through June 2013 was 14.08 million, the highest level in more than a year and a half. (Source: Moody’s Analytics)
  • Hospital safety costs: total surcharge for hospital errors and the average amount spent on errors per patient admission each year: $7,780 in hidden surcharges (e.g., from errors, accidents and injuries) to purchasers (e.g., employers) when a patient is admitted to a hospital with a safety score of “C,” “D” or “F.” The calculator includes an example of an employer with employees that have 1,000 annual hospital admissions that would pay a $7.7 million surcharge for the year. (Source: Leapfrog, “The Hidden Surcharge Americans Pay for Hospital Errors,” July 25, 2013)
  • Health care employment: 20,000 new health care jobs in June 2013—10.26 percent of overall employment growth of 195,000 in all sectors. (Source: U.S. Department of Labor)
  • Online medication: 25 percent of Internet users in the U.S. have purchased medications online and one-third say they do not have confidence in the safety of the prescription drugs they purchased. (Source: FDA, “BeSafeRx Survey Highlights”)
  • Retail clinics: in 2012 28 percent of large U.S. employers hosted on-site medical clinics vs. 23 percent in 2011; 39 percent say they will have them by 2014. (Source: Towers Watson survey)
  • Pain medication overdose: annual fatal overdoses in U.S. men have risen 265 percent from 1999 to more than 10,000 in 2010; women increased nearly 400 percent from 1,399 to 6,600 in the same period. (Source: CDC Vital Signs, “Prescription Painkiller Overdoes,” July 2013)
  • Fitness: the number of Americans who exercise at least 30 minutes three times a week has fallen slightly in 2013—from 55.2 percent in the peak summer months in 2012, down to 53.8 percent in 2013 (based on monthly average). (Source: Gallup poll, July 2013)

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Subscribe to the health care reform memo 

Health care reform memo — The weekly health care reform memo is available for subscription. Please visit www.deloitte.com/us /healthmemos/subscibe.

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