Monthly Archives: September 2013

What the Affordable Care Act means to you

My patients, colleagues, and friends still have many questions about the Affordable Care Act.  Multiple surveys show most Americans still do not understand many key details of the new law.  Since the Health Insurance Exchanges open tomorrow (October 1st), I am posting this summary from a colleague to shed some light on the subject.


Why bother?  Isn’t the government going to shut down and stop this?  Won’t Congress delay Obamacare anyway?

Even with a government shutdown, the exchanges will open as scheduled on Oct. 1. The money the federal government is using to run them doesn’t rely on appropriations from Congress. The Republican-controlled House of Representatives has deliberately linked the Affordable Care Act to the continuing resolution — the law that keeps the federal government funded. They want Democrats in Congress and President Obama to agree to delay or even repeal the law in return for keeping the government running. Not going to happen, say the Democrats and Obama. It’s far more likely that the government will shut down for a few days and then both sides will agree to keep cash flowing without bringing the health-reform law into it.

And it’s very unlikely the Republicans in Congress, who have vowed to repeal the health-reform law, can succeed; because all laws have to pass the Senate and Democrats who support the law control the Senate. And President Barack Obama would veto any such repeal, of course. Even some Republicans point out that the Supreme Court has ruled Obamacare constitutional and it is now the law of the land.

Got insurance already? You don’t need to worry

Most of us — 58 percent of non-elderly Americans — get health insurance through an employer, and 32% get government-sponsored insurance such as Medicare or Medicaid. The U.S. Census Department says about 15 percent of Americans don’t have health insurance and these are the people who should be either buying health insurance on the new exchanges, or getting it through Medicaid in the states that are offering it to more people.

The opening of the exchanges doesn’t affect anyone who already has insurance. The law does change some of the rules regarding health insurance, but the only thing happening Tuesday is the opening of the exchanges. Other changes go into effect Jan. 1.

Some news reports have highlighted the cases of employers who have decided their workers will be better off buying insurance on the exchanges. This may be because the federal subsidies would actually lower costs for them. If you have workplace-sponsored insurance, your employer must give you a letter detailing what your options are.

What are these exchanges?

The exchanges are a new way to buy health insurance<> that let people compare the plans available to them and to also see, within minutes, whether the federal government will pay for part of the premiums. They’ve been compared to online sites such as Travelocity or Expedia, where people can compare the prices of airline flights across different carriers. At the same time, the sites check to make sure people are telling the truth about their income and employment.

How much will it cost?

The prices vary<> based on the different plans — a lot like employer-provided insurance works now. There are four tiers of coverage: bronze, silver, gold and platinum. The bronze plans usually charge lower premiums, but then you’ll be charged a higher co-pay, which means you pay each time you see a doctor or other provider, each time you fill a prescription, or each time you have a procedure. The platinum plans charge the highest premiums but provide much more care before the patient has to pay a share. In some places, young adults can also buy bare-bones catastrophic insurance for people who really think they’ll only need health care if they have an accident.

A lot depends on where you live. In some counties, a family of four with an income of $50,000 may pay $11 a month for a low-level silver plan. In other places a similar family might pay $280 a month for the same plan. This is because care costs more in different places. You can give the federal government site a run now at<> although you cannot actually enroll until Tuesday.

Will the plans be expensive — more than plans cost now?

Some of the bare-bones plans are likely to cost more than the minimal-coverage plans on the market now, but that’s because you get much more coverage. Many of the plans available now don’t provide much coverage, and can stop paying for services once patients start running up bills. The Affordable Care Act requires insurers to provide a basic level of care, which includes free preventive services such as vaccines, mammograms and wellness checkups. They cannot cap your coverage and they can’t charge you more just because you are a woman, for instance.

Can people get help paying for the insurance?

Many people can get a federal government subsidy. It depends on how much you make<> and your family size, but the subsidies can be very generous. It’s a complicated formula but families with incomes of up to $94,000 might get a subsidy. There’s a calculator here<> that you can use to estimate what it might cost.

There’s a big exception <> for people who make very little money. The law assumed that states would expand Medicaid to cover people who earn less than 138 percent of the federal poverty level, which works out to $16,000 for an individual or $32,500 for a family of four. But the Supreme Court ruled that states don’t have to, and many states won’t. These people also don’t qualify for subsidies if they make less than the federal poverty level, and right now they are stuck. They’ll either have to pay full price on the exchanges, or go without insurance.

If your employer offers adequate insurance but you decide to go to the exchanges to buy some anyway, you can’t get a subsidy. But you may qualify for one if the insurance you have now isn’t adequate.

What if I don’t want to pay?

Technically, you’ll have to pay a fine<>, which varies depending on your income. The argument is that people without health insurance cost everyone money because they do get sick or hurt and they do go to emergency rooms and someone has to pay in the end. The Supreme Court says it’s a tax. The IRS can take the money out of any refund you have coming. In reality, it’s not clear how hard the federal government will go after holdouts.

What if I’m already sick?

That’s called a pre-existing condition. Right now, insurance companies can refuse to cover you if you’re sick, or they can refuse to pay for care for some condition, such as diabetes, if you had it before you bought insurance. Not any more. Now insurers have to cover everyone, regardless of their health or previous illnesses.

What about if people are too busy to sign up Oct. 1?

Tuesday’s just the first day that the exchanges are open for business. People have six months to sign up for health insurance during what’s called open enrollment. If you get signed up by Dec. 15, you can start using your insurance on Jan. 1, 2014.

So where do I go to get started?

Anyone can go online and sign up at You can find a person or place to help you by entering your zip code here<>. States that are offering health insurance have their own sites, too, like Delaware<> and California<>. Various privately funded groups like Enroll America <>  also have websites to help people sign up.

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Doctor bonuses lead to more blood pressure lowering than team bonuses

A recent randomized, controlled trial of the impact of incentive payments based on quality outcomes showed some expected – and unexpected results:

  • Individual physician bonuses increased % patients with controlled BP by 8.4%,
  • Practice-level bonuses increased % patients with controlled BP by 3.2%
  • Combined bonuses increased % patients with controlled BP by 5.5%

This study seems to contradict the hypothesis that team based care improves quality outcomes.  The newspaper article below discusses some reasons the team bonuses may have been less effective.  I think we can conclude that when physicians stand to gain directly from improved control of chronic disease measures, they will do more to meet those goals.


Petersen, Laura, et al “Effects of individual physician-level and practice level financial incentives on hypertensive care” JAMA 2013;310(10):1042-50.


Houston study finds doctor bonuses produce better care

By Todd Ackerman

September 17, 2013

Patients fare better when their doctor receives a bonus for positive results, but they regress after the payment ends, according to a new study of the emerging movement to reward quality rather than quantity.

The study, conducted by Baylor College of Medicine researchers, found significant but not sustained improvement in the blood pressure of patients whose doctor got a modest financial incentive to produce better outcomes. Such incentives are an example of what’s known as “pay for performance,” a key component of health-care reform.

“Pay for performance isn’t a panacea for all that ails health care, but this study shows even modest incentives can be effective in improving care,” said Dr. Laura Petersen, a Baylor professor of medicine and the study’s principal investigator.”It isn’t the only answer, it’s not the sole intervention needed, but this study suggests incentives should be part of the package of reforms that can improve health care.”

Petersen said she was surprised study participants’ blood pressure backslid after the study ended, but didn’t draw the conclusion incentives need to be provided in perpetuity to work. She acknowledged, however, she had expected patients would have developed better habits and sustained improvement.

Also to Petersen’s surprise, the study found that patients did not fare better when the patient’s whole health-care team received incentives.

Petersen said she undertook the research, published in last week’s edition of the Journal of the American Medical Association, because health policy often is adopted because it sounds like a good idea, not because of rigorous scientific evidence in support of it.

Pay-for-performance emerged as one recommended solution to America’s overpriced, under-performing health-care system in the middle half of the previous decade. Health-care economists argued that a system that rewards outcomes would be less wasteful than the current fee-for-service system, whose reimbursement is based on the number of tests ordered or procedures performed.

Petersen, also associate chief of staff for research at Houston’s Michael E. DeBakey Veterans Affairs Medical Center, conducted the study at 12 VA hospital outpatient clinics in five different regions over a 15-month period in 2007 and 2008.

Four groups studied

Eighty-two doctors and 43 support staff members were split into four groups: one in which only the doctor received an incentive; one in which an incentive was split equally among a health-care team; one in which all members of the team received an incentive but the doctor’s was significantly more; and a control group in which there was no incentive.

The study found the incentive to doctors alone resulted in an 8.36 percent increase in patients whose blood pressure was reduced to desired levels or who received appropriate medical intervention when it became clear their high blood pressure couldn’t be lowered sufficiently without drugs. Petersen said the improvement was particularly impressive because blood pressure levels of VA patients nationally already are considered good.

There was not a statistically significant benefit to either of the teams that shared incentives.

The incentives averaged $1,648 when the teams shared equal amounts; $4,270 to the doctors and $1,181 to members of the team in the groups in which the money was unequally allocated; and $2,672 to doctors who alone got the bonus.

Petersen said the disappointing results from the incentivized teams may have been because the VA only made a priority of organizing home-care teams after the study. But Jim Rebitzer, a Boston University professor of management, said it is not uncommon for there to be problems with team incentives.

“The more people in a team, the more the incentive gets diluted, the greater the chances of someone free-riding,” said Rebitzer, who’s written extensively about incentive programs in and out of health care. “It’s not that they can’t work, but as we know from families, groups don’t automatically function at a high level.They take a lot of management.”

Limits to incentives

Rebitzer added that the regressions found after the study ended show the limits of pay-for-performance. He acknowledged that incentives can work well for discrete, specific targets.

He said that would mean spending more time on them and less on something else, something doctors find hard to manage, particularly given the number of conditions that require constant attention for sustained results.

The study was applauded as an important contribution to the field by Rebitzer, Rice University health economist Vivian Ho and Pauline Rosenau, a professor of management, policy and community health at the University of Texas School of Public Health in Houston.

But Rosenau added that “it is sad that health-care providers must be offered a relatively trivial financial incentive to do the job that they should be doing anyway.”

Rosenau added that “pay for performance is here to stay – and patients should know about it. They should ask their doctor if he or she is receiving a bonus and how it might affect their care.”

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Thoughts for the Jewish New Year from “Not Running a Hospital” by Paul Levy


Posted by Paul Levy in his blog “Not Running A Hospital”

Wise words from my friend Boaz Tamir

On this eve of the New Jewish Year, the fog grows thicker and the horizon seems to be moving ever-further away: We face uncertainty, confusion and daily challenges to our assessments of what the morrow may bring. Once our slogan was, “Every plan serves as a basis for change;” but the in the current pace of change, we must adopt a slogan of, “Changes are the basis for never-ending planning.”

The changes are multi-dimensional: technological innovations; global climate change, civil uprising and political unrest, drastic adjustments in public consciousness, consumer awareness and the political arena and the rearrangement of global and local systems are bringing about epic transformations. These are leading to a destabilization of the validity of established economic, political and managerial paradigms and their usefulness as a base for the development of economic-political polices and sustainable business strategies.

What should we wish for others and for ourselves as this New Year begins?

  1. That we learn to adjust to reality, even if we have no theory to explain it.
  2. That we learn to view chaos as a lever for creativity, disruption as an advantage and crisis as an opportunity.
  3. That we are wise enough to create systems that blur hierarchical boundaries, whose stability stems from constant movement in fluid surroundings.
  4. That we replace the paralyzing anxiety brought about by uncertainty with the ability to grow in a storm.
  5. That we exchange pride with modesty, answers with questions and certainty with investigation.
  6. That we succeed in integrating internal and external strengths as we enlist workers and managers to cope with an environment full of contradictions and disharmony.
  7. And to those who have lost their way in the fog: We hope that they will be able to return to their foundations – to interpersonal relations, the foundations of culture, and to be willing to learn from organizational frameworks and cultures that have survived for thousands of years.

Happy New Jewish Year,
Boaz Tamir, Zicheron Yaakov, September 5th, 2013

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