Category Archives: Health care reform

What Is This “Health Care System” Of Which You Speak?

If there was an organizational chart outlining America’s process for supplying and paying for health care, it would look something like this. It’s not a “system” as much as a mare’s nest that grows more and more complicated — and less efficient and increasingly unjust — over time.

I’m guessing here, not a health care management expert or anything, but this mess has got to be costing us untold billions that might otherwise go to, I don’t know, making people healthier? There are inefficiencies, redundancies, and a massive amount of profit-skimming at every turn. That’s why other developed countries can provide much broader and more equitable coverage at a much lower cost. I have often thought that health care in America would be cheaper if we simply left big bags of cash everywhere.

Aside from the inadequacies and inequities of our “system,” there’s also the fact that it’s completely out of our control. Decisions made at high corporate levels trickle down like warm piss upon our heads, and damn but we’d better be grateful for the golden showers.

This line of thought was triggered by VTDigger’s story about likely reform efforts in the state Legislature. A story that could have been published, with alterations in the details, just about any time in the past. Yep, our health care “system” needs reform, and by God, our elected officials are gettin’ to work.

But the scope of that work will be limited indeed.

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The Dangerous Drift of Vermont’s Health Care System

When he was governor, Peter Shumlin made a big push on health care reform. It didn’t end well for reform or for Shumlin. Since then, the system has become less functional and more expensive but there’s been no appetite for another push.

With one major exception, and that’s OneCare Vermont. It has soldiered on in its effort to rein in health care costs by paying providers for outcomes rather than treatment. It has spent a tremendous amount of money, but so far there’s not much evidence of impact.

That’s troubling, and it’s more so when you read VTDigger’s piece about the latest Green Mountain Care Board meeting. Beyond that, there’s a broader critique of our health care system in a recent series of essays by journalist and health care policy analyst Hamilton Davis. Taken together, it looks like a huge sector of our economy (upon which our physical and financial well-being depends) is drifting along with a bunch of people who call themselves “Captain” staying as far away from the helm as they can.

The Digger article makes the leaders of OneCare look like The Gang That Couldn’t Shoot Straight. The GMCB, especially its new members, were asking questions that shouldn’t have been tough to answer. For instance, do you have any evidence that your system is working? Can you point to measurable results in terms of cost savings or improved outcomes?

OneCare leaders seemed to be taken aback by this line of questioning.

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Court Locks Black Box

Do high courts do Friday newsdumps? It would seem so. The Vermont Supreme Court issued a ruling on Friday, July 1 — heading into a three-day holiday weekend — with massive implications for independent oversight of OneCare Vermont, our favorite too-big-to-fail institution, and for the state auditor’s office.

The newsdump worked like a charm. VTDigger cranked out a quickie same-day story that hit the Internet at a time when lots of people had stopped paying attention to the news. By Tuesday, July 5, the decision had pretty much vanished from public attention. A strong statement from Auditor Doug Hoffer blasting the decision went largely unnoticed. But I sure hope responsible parties in the Legislature have taken note, because something needs to be done to fix this.

The unanimous decision denied Hoffer access to OneCare’s payroll information. He had sought access after OneCare’s payroll and benefits expenses jumped from $8.7 million in fiscal year 2019 to $11.8 million the following year. He understandably wanted to find out why. It’s an issue that should concern us all because OneCare is (a) kind of a rolling experiment that’s (b) playing with massive amounts of public money for which it is (c) not very accountable at all.

I’ll get back to OneCare, our most mysterious of public sector black boxes, but first I want to discuss the Auditor’s part of this. The court ruled that the Auditor has no authority in statute or in contract to access OneCare’s financial records. It asserted that financial oversight belongs solely to the Green Mountain Care Board, which is essentially OneCare’s captive partner in this grand experiment.

Well then, I ask, what in hell do we have an auditor for?

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The Curious Case of the Single Intolerable Word

Gather ’round, children, and you shall hear… how Vermont’s biggest health insurer has gotten its knickers in a twist about one single word in a Green Mountain Care Board decision. The word was so objectionable that Blue Cross Blue Shield of Vermont appealed the decision solely because of that word. It did not object to any other part of the ruling.

When the appeal was denied BCBSVT took the case to the Vermont Supreme Court, where it awaits action. Seems like a whole lot of time, trouble and billable hours for a single word, but what do I know.

Let’s go back to the beginning. On May 7, Blue Cross Blue Shield of Vermont filed a request for 2022 insurance rates with the Green Mountain Care Board. The Blues asked for a 7.9% increase on individual policies, and smaller increases for group plans.

The request meandered through a lengthy series of briefs, filings, hearings and testimony. (All can be downloaded from this webpage.) On August 5, the GMCB issued its decision, knocking down the rate hike on individual policies to 4.7%. In its decision, the GMCB characterized the 7.9% request as “excessive.”

There. That’s the fatally toxic word. ‘Excessive.”

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BCBS Makes Everyone’s Lives Miserable to Save a Little Coin

This won’t be news to any BlueCross BlueShield health insurance client, but the Blues did something this year that added fresh levels of annoyance to the lives of patients and providers throughout Vermont.

The Blues made a big change in its prescription drug coverage. It hired Optum RX as its pharmacy benefits manager. Which led to new, stricter requirements for a broad array of prescription medications. This will presumably save the Blues some money, but it will do so by offloading a lot of pain and extra work onto patients and prescribers.

(Before I go on, tip of the hat to fellow blogger Matt Sutkoski, who posted his own screed on this topic a few days ago. I’d been thinking about this for quite a while, but his essay crystallized my own thoughts.)

If you heard the ringing of a faint bell at the name “Optum,” that’s because it was a key player in then-governor Peter Shumlin’s Vermont Health Connect fiasco. Step with me into the Wayback Machine, which is set for October 31, 2014 — just a few days before the election Shumlin almost fumbled away to challenger Scott Milne.

On that day, we learned that the cost of VHC would be $20 million higher than expected. And that, my friends, was not the bad news. There were a number of horrible particulars, some of which involved Optum. Its employees were said to be poorly trained and making mistakes. A top VHC official observed that Optum had every motivation to let the work drag on and on, because the longer the project the more money it made.

So yeah, a corporation with some definite baggage in these parts.

What is Optum doing to, ahem, Optum-ize the Blues’ prescription drug coverage?

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The Assassination of OneCare Vermont by the Coward Douglas Hoffer

Not exactly convincing, I have to admit

The townsfolk are all horns and rattles, I never seen such a fuss. Must be that cold-blooded sidewinder Doug Hoffer’s back in town and up to no good.

This time, the ol’ gunslinger has taken aim at OneCare Vermont. Hoffer’released an audit on Monday finding that OneCare, which was supposed to glean savings from the healthcare system, has cost millions more than it’s saved.

The normal official response to a Hoffer audit is along the lines of “Well, he found some interesting information, but nothing we didn’t already know and weren’t already doing something about.” But the reaction to this audit is more direct, if not downright hostile. Mind you, they didn’t contest Hoffer’s findings, not at all. But they didn’t like his conclusions, not one little bit.

One might even detect a faint whiff of panic. Considering that free-lance health care expert Hamilton Davis just called OneCare “a dumpster fire,” I can see why Our Leaders would be unreceptive to a critical audit right now.

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Point of Personal Privilege, Insurance Scams Edition

There’s one thing they’re not telling you…

Seventeen years ago, my spouse and I bought long-term care insurance. We were just about AARP-qualified at the time, and we were trying to get ahead of the age-related increases outlined above. The earlier you buy a plan, the cheaper it is. (Spouse is five years younger than I, so his rate was substantially lower than mine.)

The premiums have remained constant ever since. Until now.

Sticker shock!

My carrier is seeking to raise my rate by 338.6%. Three hundred and thirty-eight point six percent! Kind of defeats the purpose of buying early, doesn’t it? If our carrier can jack rates through the roof when we get older, the only thing we accomplished by buying early is donating tens of thousands of dollars to the company’s shareholders.

The proposed increase is awaiting approval by the Vermont Department of Financial Regulation. I spoke to a very nice lady in the insurance division of DFR, who told me it’s one of the biggest rate hikes she has ever seen — on any kind of insurance.

Last week, my spouse got a rate hike notice.

Of a non-whopping 20%.

The only difference between us, as far as I can see, is that I’m 67 and my spouse is 62.

Looks a lot like age discrimination to me. Or like a carrier winnowing out its high-risk clients through targeted rate hikes.

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A case study in the pitfalls of free market health insurance

Seems like it was just the other night I was writing about a certain candidate who believes the cure for the health care crisis is to give insurance companies free rein. A Thousand Flowers Will Bloom, goes the fantasy. Problem is, when you let your garden grow, you get a thousand flowers and a million weeds.

A classic example of this was (briefly) in the news earlier this month, when the Vermont Department of Financial Regulation imposed its largest-ever fine against an insurance company.

The offender, Companion Life Insurance of South Carolina, was fined for selling cartoonishly bad health care policies to Vermont college students between 2014 and 2016 without ever seeking the requisite DFR approval. If the policies had been submitted to the state, they would have been found in violation of both state and federal law.

The policies did not cover most of the medical conditions that commonly befall college students: athletic injuries, mental health coverage, substance use treatment, immunizations, preventative screenings (including for STDs) and contraceptive management.

This is the kind of thing the Meg Hansens of the world see as the bright shiny free-market future of health care. Fortunately for us, we do regulate insurance.

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OneCare: “Please make us too big to fail”

As VTDigger reported a few days ago, Vermont’s public sector unions are feeling a little dubious about turning over their health care benefits to OneCare Vermont, the accountable care organization that’s beginning to develop a record of scoring own goals. For instance, OneCare seems to be (inadvertently, one would hope) doing its best to validate the unions’ concerns.

OneCare is in the process of seeking a dominant position in Vermont’s health care marketplace, by signing up as many groups and individuals as possible to its model of paying providers for outcomes instead of services performed. It’s the current hot idea in health care, and many smart people see great promise in it.

Of course, go back eight years and a lot of smart people saw great promise in then-governor Shumlin’s single-payer idea. And we know how well that went.

A little more than a month ago, OneCare went before the Green Mountain Care Board with a request for a $1.36 billion budget — a whopping 33 percent increase over last year’s. See, it’s been losing money and failing to produce the cost savings it promised.

OneCare’s explanation: It’s not big enough. Digger:

“We can’t measure success without scale,” [OneCare] CEO Vicki Loner told the Green Mountain Care Board at its budget hearing last month. The more people who participate, the more effective the system will be, she said.

Yeah, well, that may be true. But it’s also an invitation to pour more money down what might turn out to be a rathole. Loner is essentially saying that OneCare has to become too big to fail, merely in order to adequately test its health care model.

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I don’t know why Doug Hoffer puts up with our bullshit

State Auditor Doug Hoffer is at it again, pointing out the turds in the carefully curated punchbowls of state government. This time, it’s OneCareVermont, the massive, publicly-funded and poorly-understood initiative that seeks to reinvent the economics of health care by paying providers per patient instead of per treatment. The idea is that providers will be incentivized to encourage health instead of waiting to treat disease. (Not that there’s any evidence whatsoever that doctors and nurses can effectively change lifelong behavioral patterns that lead to chronic conditions like obesity and diabetes, lookin’ in the mirror there.)

Of course, the entity seeking to reinvent health care is owned by the two dominant providers in the current system, University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center. Kind of like the foxes guarding the henhouse, except they’re big ol’ grizzly bears.

Hoffer had the audacity to take a look at OneCare’s commitment to some creative community-based health programs, including efforts to encourage healthy food shopping and meal prep and providing palliative care. And he found — shocking, I know — that OneCare, having accepted millions in public dollars for those programs, had no evidence whatsoever that they had any effect. At all. (Link is to VTDigger’s story. You can read Hoffer’s memo here.)

In fact, the behemoth isn’t even pretending to try.

OneCare CEO Vicki Loner faulted Hoffer’s “expectation for documentation of every activity.” Instead, OneCare is evaluating the outcomes for the system as a whole.

Which, if true, is just fuckin’ dumb.

What kind of large-scale organization launches a series of initiatives with no intent to evaluate each one’s impact? If you’re evaluating the system as a whole, how do you figure out which parts of the system work and which are a waste of time and money? Do you think the good folks at Hannaford don’t bother to track sales and profit margins in each department (or in each individual store), as long as they’re getting good outcomes for their system as a whole?

Even worse, OneCare is taking public money for specific programs and refusing to be accountable for how effectively it’s being spent. Which is ironic, don’tcha think, for a so-called Accountable Care Organization?

But if you think Hoffer is getting a hero’s welcome for his work, then you haven’t been paying attention to his tenure as auditor. Because his reward never comes in the form of gratitude and promises to enact reforms. No, his work is greeted with deliberately misdirected criticism and claims that reforms are already in the works. And, as quickly as possible, his work is dumped in the circular file.

Like I said, I don’t know why he puts up with our bullshit.

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