Category Archives: ACA

The CO-OP program, 5 years later

by Allan Joseph

Most PM readers can remember the heated debate over the public option that took place half a decade ago (!) during the ACA’s drafting — and are well aware that there is no public option in the law. What many don’t remember, however, is what was put into the law instead of the public option — the Consumer Operated and Oriented Plan program, or the CO-OPs.

I’ve been working with Dr. Eli Adashi, the former medical-school dean here at Brown, for some time now looking into the CO-OP program, which is a fascinating, under-studied provision of the law. We published a Viewpoint in JAMA that went online this week (ungated) that summarizes the CO-OP program and looks towards its future. Go take a look!


Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

How my PCP alerted me to the potential for abuse in telehealth

by Tom Liu

I recently called my primary care physician (PCP) for the first time in years to get my immunization records, and encountered a strange message saying he was not currently seeing patients. My mom had apparently encountered the same message weeks ago. “Maybe he retired,” she suggested.

I did a quick google search of my PCP’s name to find an alternate contact number, and instead found a shocking article from the local newspaper. Apparently my PCP has been indicted for falsifying tax returns and participating in an online pharmacy organization that provided prescription drugs without an in-person physician examination.

Remote Prescribing: Lucrative, Pervasive, and Very Illegal

I did a quick search online and confirmed that the practice of offering prescription drugs through a “cyber doctor” prescription, relying only on a questionnaire is indeed very illegal.

It is also very pervasive. The National Association of Boards of Pharmacy (NABP) reviewed 10,700 websites selling prescription drugs and found that 97% of them were “Not Recommended”. Of these, 88% do not require a valid prescription and 60% issue prescriptions per online consultation or questionnaire only.

What struck me was how this appeared to be a case where the market came together to produce a “triple win” for profit-seeking internet pharmacies, shady physicians (such as my own), and a subset of patients willing to pay a premium to access drugs (most commonly weight loss drugs, erectile dysfunction drugs, and commonly-abused antidepressants and painkillers).

According to one analysis, one such website offering prescriptions from its own doctors listed prices for fluoxetine (brand name Prozac) and alprazolam (brand name Xanax) that were roughly 400% to 1800% higher than prices from a more traditional Internet pharmacy not offering prescriptions. The fact that such “remote prescription” websites remain in business despite the huge price differential suggests that they are attracting patients willing to pay that premium to avoid seeing their regular doctor. And as for where that money is going—well, my doctor was alleged to have received roughly $2.5 million over six years.

Similar Incentives Could Exist for Telehealth Writ Large

Given the clear business case driving abuse in this model of “remote prescribing”, I wondered about the risks of overuse and abuse in the rapidly burgeoning field of telehealth more broadly. After all, one of the promises of telehealth is its ability to make the delivery of services more convenient for both patients and providers. A physician could vastly expand the number of patients he/she sees without leaving the office—which has been identified as a potent way to alleviate the physician shortage problem.

But that would only hold true if the proliferation of telehealth does not generate additional, potentially unnecessary demand. And substantial evidence points to the presence of physician-induced demand under a fee-for-service system. Currently, Medicare pays for a limited set of telehealth services under the same fee-for-service payment model used for in-person visits. Within Medicaid, while select states are experimenting with bundled or capitated payments that include telehealth, others are retaining their fee-for-service model.

In a testimony before the House Energy and Commerce Committee last month, Dr. Ateev Mehrotra, an expert on telehealth, noted, “To reduce health care costs, telehealth options must replace in-person visits.” I’m not convinced this is the case—especially when there is a clear financial incentive to provide more care.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel. Telehealth may be ‘too convenient.’” — Ateev Mehrotra

In some cases, fee-for-service payments for telehealth may result in outright fraud, as my physician may have done. In others, it may simply encourage providers to err on the side of providing more care given uncertainties in a practice environment. In fact, a study led by Dr. Mehrotra found that PCPs were more likely to prescribe antibiotics during e-visits than in-person visits.

As various constituencies continue to debate the best approach for paying for telehealth, it is imperative for us to better understand how the incentives and convenience of telehealth interact to affect overall utilization. Blindly carrying our existing fee-for-service system into the new world of telehealth options may produce some unintended consequences.


Tom is a healthcare researcher with experience in public health and blindness prevention. Follow him on Twitter at  @tliu14 or check out his blog.

Saving money in healthcare, PCMH edition

by Allan Joseph

I wanted to quickly follow up on Tom’s excellent post from yesterday on patient-centered medical homes (PCMHs), which nicely outlined some conflicting results from recent research on the model. (Edited to complete the sentence.)

It really shouldn’t surprise us that PCMHs only saved money in the 10% of patients with the highest risk. Why? Take a look at this chart from the NIHCM, which is one of my favorites in all of health policy:

Distribution of Healthcare Spending

Notice that the top 10% of spenders (not the same as the top 10% of risk scores, but pretty close) account for just about two-thirds of healthcare spending. The vast majority of patients account for very little spending — there’s no savings to be had there. Healthcare spending is highly concentrated at the top.

Now let’s look at spending from another angle. According to the Robert Wood Johnson Foundationtwo-thirds of healthcare spending is on patients with multiple chronic conditions. That means at minimum, roughly one-third of healthcare spending in America is spent on those patients in the top 10% with multiple chronic conditions. (To get even deeper, at least 16% of spending is on patients in the top 10% with three or more chronic conditions.) Of course, that’s only a lower bound — I’d be surprised if the number wasn’t much higher.

So what does this have to do with PCMHs? Well, the core idea behind a PCMH is greatly increased care coordination. That’s precisely the type of intervention that will help sick patients who have multiple chronic diseases — or the very group that accounts for a huge portion of our healthcare spending. No wonder the investment in PCMHs paid off for the sickest patients. They’re the ones where all the money to be saved is.

Given that the vast majority of patients who might use PCMH services account for little health spending, we should expect spending money to build a broad PCMH structure to save money on net. Nor should we be surprised that there’s money to be saved by better coordinating the care of the sickest patients. That’s the whole idea of the “hotspotting” movement. That’s also why Tom was spot-on to focus on the idea of “risk-adjusted population health,” such as focusing care managers on the sickest patients or designing separate clinics that focus exclusively on high-risk patients.

Sometimes it’s worth stepping back and taking stock of our intuitions about what might reduce healthcare costs. If an intervention isn’t aimed at the sickest patients, it’s probably not going to save a lot of money. Don’t be surprised when it doesn’t.


Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

PCMHs Don’t Work—Or Do They? Insights from Two Recent Studies (Of the Same Program)

by Tom Liu

A month ago, a JAMA study rocked the health wonk world by showing provocative evidence that Patient-Centered Medical Homes do not work. Evaluating 32 practices in the PA Chronic Care Initiative over a three-year period (2008-2011), the authors found that achieving NCQA PCMH recognition did not statistically reduce utilization or costs, and only improved one of 11 quality measures (nephropathy screening for diabetes). Aaron Carroll summarized the study and accompanying editorial over at The Incidental Economist. Mainstream media and health wonk blogs alike declared the death of the “touted medical homes model”.

That’s why I was surprised to read this headline last week:

Study: Medical homes cut costs for chronically ill members

The punch line: these two studies evaluated the same PA pilot project over the same time period (albeit with different practices and patient populations).


Medical Homes Work—But Only for High-Risk Patients

A close read of the studies reveals that their conclusions are not incongruous. Indeed, the more recent AJMC study found no significant decrease in utilization or costs across all patients, just as the JAMA study did. However, when the authors limited their analysis to the top 10% highest risk patients (defined by DxCG risk scores), they found significant decreases in inpatient utilization in all three program years, and significant decreases in costs in the first two.

We can’t discern if the JAMA study would’ve found the same significant effects if they did a sub-analysis of the highest risk patients. (Interestingly, they state in the Methods section, “we repeated our utilization and cost models among only patients with diabetes,” but the results of that analysis are nowhere to be found.)

These results underscore an insight that’s becoming increasingly clear: cost savings from care management are concentrated in the highest risk individuals.

But we can go one step further.


Cost Savings Came ONLY From High-Risk Patients

Among the 654 high-risk patients, the PCMH produced adjusted savings of $107 PMPM in the first year. That roughly comes out to an estimated $69,978 in overall savings. Almost all of this (and then some) came from an estimated 40 avoided hospitalizations (654 patients x 61 adjusted avoided hospitalizations / 1000 patients).

Among 6940 patients overall, the PCMH produced (statistically insignificant) adjusted savings of $10 PMPM in the first year—an estimated $69,400 in overall savings. Across this entire patient group there were an estimated 41-42 avoided hospitalizations.

In other words, this study didn’t just find that savings are concentrated among high-risk patients. Essentially all of the cost savings and avoided hospitalizations came from the top 10% high-risk patient cohort.

This doesn’t mean that other PCMH models couldn’t squeeze savings out of lower risk patients. It just means that this and many existing models haven’t found out how to.


How to Achieve “Risk-Targeted Population Health”?

That finding raises a broader question that these studies can’t answer: What prevented the hospitalizations among the high-risk patients, and more importantly, were those key interventions limited to only the high-risk patients?

For example, were the crucial interventions ones that were only used for high-risk patients, such as a dedicated care manager, targeted outreach messages, and special appointments for high-risk patients?

Or were they interventions that were indiscriminately used on all patients, such as standard patient education or practice-level infrastructure that all patients enjoyed (even if only high-risk patients “benefited” in terms of reduced hospitalizations)?

This question is important because all interventions (and the infrastructure to support them) have a cost. Developing patient registries, expanding EHR capabilities, maintaining after-hours access, and investing in new training all represent substantial financial investments. Less than $70,000 in savings among high-risk patients—while extremely meaningful and significant—would be wiped out by the $20,000 “practice support” and average $92,000 bonuses paid out to each PCP by the medical home program.

If all of the benefits and savings are coming from the high-risk patients, we need to devise ways to concentrate our costs as well. Implementing such “risk-targeted population health” may be the only way to make the financials work.

Some practices are trying to do this by using dedicated care managers for high-risk patients within their existing patient panels. Others are trying to create separate clinics entirely dedicated to high-risk patients—which would allow them to limit fixed costs to high-risk patients as well. In fact, the NHS in England announced this January they are piloting this latter approach, creating “complex care practices” of 400-500 high-risk patients drawn from surrounding practices.

Whichever approach proves most effective, one thing is clear from these two studies: we need to rethink our current PCMH model.


Tom is a health care researcher with experience in public health and blindness prevention. Follow him on Twitter at @tliu14 or check out his blog.

Risk corridors: What they are and what they do

by Galen Benshoof
Critics of the Affordable Care Act have a new bugbear: a program known as risk corridors, which is part of a trio of premium stabilization mechanisms collectively known as the 3Rs.

Back in November, Senator Marco Rubio introduced legislation aimed at doing away with risk corridors, branding the program a “bailout” of insurance companies. Over the past few weeks, multiple conservative media outlets have joined in the call for repeal.

Recent reporting on risk corridors has left plenty of questions unanswered. Here, I hope to provide a simple explanation of what the risk corridor program is and what it isn’t.

What it is
1. It’s certainty for insurers.Think of risk corridors as a hedge for insurers. Back in early 2013, they were facing a brand new market, with a huge amount of prospective consumers but little information on who among them would actually enroll. Thanks to the introduction of guaranteed issue and the departure of risk rating, they knew of the potential for adverse selection in the new market. For the first time, many sick people would now have access to insurance. Those consumers would seem likely to enroll, because they urgently need coverage and care. Less clear is the behavior of healthy people, who tend to pay less in premiums than they cost in claims. So if you’re an insurer facing this uncertainty, what do you do?

Maybe you don’t offer plans on the exchange at all. Or, if you’re set on participating, a conservative approach would be to set premiums high, so that you are less likely to pay out more in claims than you take in through premiums. But the higher you price your products, the fewer healthy people are interested in purchasing them. And the fewer healthy people you have, the greater your proportion of sick people, meaning you may have to raise premiums yet again. That is a pattern that the architects of the ACA were interested in avoiding.

Enter risk corridors. The program is a way for the federal government to give a little security to insurers in the new market by sharing in the gains and losses of all exchange carriers. Thanks to risk corridors, insurers know that any losses they experience will be limited, motivating them to enter the market in the first place and then to price rates competitively, which triggers competition among plans and choice among consumers.

2. It’s an affordability mechanism. Because risk corridors limit losses, insurers have reason to price their premiums competitively. That means lower premiums for consumers. Thus, the largest beneficiaries of risk corridors are consumers themselves! And some Republicans seek to take away that benefit. Depending on how enrollment looks in a couple of months, repeal of the risk corridor program could easily mean higher rates for consumers: insurers would no longer have a vital shock absorber, so they might feel compelled to raise their rates for 2015.

3. It’s only temporary. Risk corridors were intended to offer certainty during an uncertain period. They begin in 2014 and end with the third year of the ACA’s exchanges, in 2016. Once insurers have some experience with the new market, and once claims come in over the course of this year and next, they’ll have a better sense of what kind of risk pool they are facing and what their premium prices should be. Risk corridors help them get safely to that point, benefitting consumers in the process.

What it isn’t

1. It isn’t a bailout. Many talented writers have already covered this territory. For agreement that risk corridors do not constitute a bailout, I’ll point you to conservatives Yevgeniy Feyman and Scott Gottlieb and progressives Jonathan Cohn and Sy Mukherjee.

I’ll add one thing to their arguments: risk corridors are different from Wall Street bailouts because the moral hazard created by risk corridors ends up benefitting consumers. Risk-taking under risk corridors means low premiums for consumers and potentially some payment from the federal government. Risk-taking on Wall Street resulted in massive losses for investors and payouts from taxpayers. Put a different way, the most potent criticism of Wall Street bailouts was that they privatized gains and socialized losses. But the gains under risk corridors accrue broadly, to millions of consumers in every state across the country.

2. It isn’t new. As Cohn notes, risk corridors are not a feature unique to the ACA. In fact the program appears in Medicare Part D, legislation passed under President George W. Bush and a Republican-controlled Congress. Furthermore, while risk corridors in the ACA are only a temporary measure, the version in Medicare Part D is permanent. Republicans have been living comfortably with that program for almost a decade now.

3. It doesn’t guarantee federal spending. Yesterday, the WSJ posted a risk corridor explainer. Drawing a contrast with risk corridors, they write that risk adjustment, another one of the 3Rs, “is less controversial because it doesn’t call for any federal spending”—the implication being, of course, that the risk corridor program calls for federal spending. However, that’s a bit misleading. Although the reporters’ language implies that federal spending is a foregone conclusion, in reality it’s conceivable that net federal government outlays on risk corridors is zero. That’s largely because of two program characteristics:

First, some insurers will not pay or receive anything at all. I’m going to quote KFF’s excellent recent explainer: “If an insurer’s actual claims fall within plus or minus three percent of the target amount, it makes no payments into the risk corridor program and receives no payments from it.” Thus, insurers who priced their premiums close to the cost of their claims do nothing with regards to risk corridors, meaning no cost (or benefit) to the federal government.

Second, for the insurers above or below the three percent marker, some may receive payments and some may make payments. Plans with greater than expected gains make payments to the federal government, and plans with greater than expected losses receive federal payments. There could easily be plenty of instances of both. It’s possible, in other words, that the two sides actually cancel each other out. It’s even possible that the program ends up being a net money-maker for the federal government.

But the final result is up in the air. On one hand, last November’s like-it-keep-it fix could cause an increase in risk corridor spending in a handful of states (see Nicholas Bagley for more on that). On the other hand, the final risk pools may be healthier than expected: apparently most current enrollees were previously insured, meaning they were able to get insurance before the ACA, often impossible for sicker populations. But then again demographics could change between now and March: we could see increased enrollment among previously uninsured enrollees, who are likely to be higher-cost.

It’s hard to predict what will happen with the program, in the end. But it’s important to recognize that while federal spending on risk corridors is possible, it certainly isn’t assured.

Galen is a Master in Public Affairs candidate at Princeton University’s Woodrow Wilson School, where he focuses on health policy. Find him on Twitter: @benshoof.