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Archive for June, 2017

The reaction from many corners to President Trump’s decision to exit the Paris climate agreement was remarkably overstated and pessimistic. The Paris agreement is voluntary in implementation and miniscule in its impact; the temperature impact of the US commitment in the Paris accord is estimated to be only three hundredths of a degree. While climate alarmists see setbacks for carbon emissions limits as leading to imminent ruinous global warming, I have a different view:

The Paris agreement is a charade that solves nothing, while man-made global warming is on its way to being a solved issue no matter what the UN and diplomats agree to.

The truth is hard to find when hyperbole and groupthink abound. The truth is that you never get the truth via politicized agenda-driven ‘science’. Politically-appointed bodies are poor drivers and diviners of real science, which requires a marketplace of ideas rather than the blinders of political conformity. Climate skeptics have been shamed as treasonable dissenters rather than reasonable questioners; this too destroys rational debate. UN diplomatic agreements driven by self-interested parties is far from real problem-solving.

The measured impact of manmade carbon emissions has been mild so far. The temperature rise in the last 70 years has been inly 0.12C per decade. The temperature impact of atmospheric carbon dioxide is based on the logarithm of the increase in CO2 concentration in the atmosphere; that ratio is not accelerating. If the next 3 decades are like the past 7 decades, temperature rise will be no more than 0.36C additional by 2050.

Why is this important? Fear-mongering claims rest upon accelerating changes and ‘imminent’ threats that require action ‘now!’ Yet real temperature trends and other records (such as the 2-3 mm slow increase in sea level), show that changes thus far are mild, slow and long-term. The temperature rise in the last 20 years is less than half what models have predicted.

Technology is moving much faster than the climate. Consider: 20 years ago, the climate was only 0.15C cooler, barely different. But the internet was 50 times smaller, we didn’t have the smart phone, drones, social media or deep learning AI; wind turbines were 5x more expensive, solar 20x more expensive and LEDs 50x more expensive; we also had less efficient engines and fracking for oil and gas didn’t exist like it does now. Within another 30 years, frontiers will be opened we can only imagine now.

These improvements will happen with or without great concern over CO2 emissions, as non-emitting technologies improve and leapfrog fossil fuels. For example, solar power generation has been improving by 7% per year; if this rate continues, solar technologies will be among the cheapest forms of power generation. Gas and oil will still compete, but efficiency will make every gallon and MMBTU go farther, so a larger economy can prosper on lower carbon emissions. Next-generation nuclear technology could also deliver abundant economic power at zero emissions.

In the end, global warming is not a crisis, because technology will solve any challenge at a faster rate than it can become a serious problem.

The real crisis is failure in leadership and imagination. Imaginative leadership would let economically-driven market-based energy technology evolve us to a post-carbon future.

The failure of imagination to let market-based technology lead results in nanny-state non-solutions to non-problems. This path of making CO2 the enemy creates regulations, burdens, and job killing mandates. And to the extent treaty commitments are voluntary, they become empty promises, like new year’s resolutions that are quickly forgotten. The bottom line is that the Paris accord did virtually nothing to meaningful address climate change.

The shame of making CO2 the bugaboo is that more CO2 in the atmosphere has meant greener deserts, and a slightly warmer and wetter world with more CO2 is not bad for plant life, crop yields, or humankind. Predicted harms based on models have not come to pass because the models have overstated impacts and sensitivities. And suppressing the positive side of the CO2 story has distorted policy in a direction that’s not in anyone’s best interest.

Pretending to address real problems while not actually doing so often blocks real progress.  Thus, critics of President Trump’s decision to exit Paris accord may someday thank him for taking us out of the non-solution of nations making empty promises. Without regulation and phony promises from other nations as a crutch, those who view carbon emissions as a concern will see that the true path to a real solution is developing market-competitive non-emitting sources of energy and power. This will happen by 2050 at the latest, in time to avert long range concerns regarding CO2. Climate change solved!

-by Patrick McGuinness, CRI Advisory Council Member

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When we plan a home renovation or car repair, typically we call a few businesses who give us estimates either over the phone or in person. Sometimes these initial consultations are free, other times there is a charge, but at least we know what to expect. We understand that additional problems may be found and we expect to be consulted on any additional charges that may result. Why can’t we do this with a hip replacement? Or an ankle X-ray? Or any other non-emergency medical care?

The US General Accounting Office summarized the reasons listed by the healthcare industry.[1] Providers say they do not know the specifics of patients’ insurance plans, hence they cannot give estimates. Insurers say they do not know what services will be needed, hence they cannot give estimates.  Hospitals and surgery centers know their own charges (facility fees) but do not know what physicians (e.g. surgeons and anesthesiologists) charge, or what implants will cost, hence they cannot give estimates. So, although the construction and auto repair industries have surmounted these problems, the healthcare industry has not. What can the state do to promote changes in industry price practices?

Require providers to post self-pay (cash) prices for standard procedures. Require providers to give billing codes to insured patients for standard procedures.

Many visits are routine or predictable, e.g. strep tests, X-rays of sprains, etc. Providers may not know the specifics of each patient’s insurance coverage, deductibles, etc. but they do know the prices they charge uninsured and out-of-network patients. They also know the billing codes of standard procedures that are submitted to payers (insurers and Medicare).  With billing codes, patients can contact insurers directly to determine their out-of-pocket costs. In summary, patients need to know the self-pay (cash) prices, insurance plans that are accepted, and billing codes for the requested/likely procedures. Even if doctors are unsure what will ultimately be needed, at a minimum they should be able to quote a standard initial consultation cash price or billing code by phone or by website.

Require hospitals, surgery centers and/or doctors to give cost estimates for more complex, non-emergency procedures

 It may be argued that providing a price estimate for complicated procedures (such as surgeries) is impossible due to the intricacies of specific cases and the wide range of potential complications. There is also the problem of multiple providers (facilities, surgeon, anesthesiologist, etc.) However, there are institutions that manage to do just that. The Oklahoma City Surgery Center provides, on a website, prices for a variety of surgical procedures. These are for self-paying patients and explicitly exclude patients with insurance. The quotes are all inclusive for cases without complications (made very clear on the website). It would seem then that a local hospital/surgeon with the ability to consult directly with patients before surgery could, at the very least, provide a fairly accurate estimate. The existence and continued success of the Oklahoma Surgery Center proves that a health care provider can provide accurate cost estimates to their patients.

 What Other States Require

 Other states have taken steps to improve pricing practices in health care. Some states require hospitals/surgery centers/physician’s practices to post prices for common inpatient or outpatient procedures, sometimes with a breakdown between doctors’ and facilities’ fees (CA, IL, NH). A number of states (FL, MN, MA, CT) require hospitals and/or surgery centers to provide cost estimates upon request. Two states (TX, CT) require hospitals to provide cost estimates to patients who are uninsured or out-of-network, apparently regardless of request.[2] At least one (TX) requires that patients must be informed if services are from a provider that is out-of-network for that patient’s insurer.

Price/Cost Availability in Delaware

Currently no Delaware laws require health care providers to post prices, give cost estimates, or provide billing codes. Nor is there a requirement that providers list the plans that they accept. In an informal survey of the websites of major hospitals/hospital chains in Delaware, we discovered one that,  with sufficient persistence, yields a phone number to call for cost estimates. One website has a Consumer Guide but a login name and password are required. Two (with plenty of clicking around) reveal offers to make ‘arrangements’ but no dedicated phone number. One lists accepted insurance plans but no offer or phone number to make cost estimates. There is one standout: a southern Delaware facility posts both procedure prices and billing codes on its website.

In an admittedly unscientific survey of nine Delaware primary care, walk-in and urgent care clinic websites, none quote an initial consultation fee for self-payers. Only one offers to quote over the phone and also states that it is willing to provide cost estimates (only in person however). Several list accepted insurance plans.

Potential Problems

 In 2012 Massachusetts passed a law that required health care providers to give cost estimates within 2 business days upon request (effective 2014). However, a follow-up study reported that in a survey to obtain estimates for a routine CT scan, about half of the providers required multiple phone calls over multiple days (usually hospitals), and half provided estimates within a day (usually imaging or outpatient centers).[3] Moreover, the number of patient requests for cost estimates was typically low. However, given the persistence the researchers needed to get these estimates from so many providers, that is not surprising. With the spread of high-deductible insurance plans, health savings accounts and non-insurance, it is difficult to believe that patients do not need this information.

The solution to these problems is to model Delaware’s law, in part, after existing Delaware laws for other industries (e.g., Title 6 Ch 49A in particular 4908A). A hired contractor prior to service must provide an itemized list of costs to the customer before doing any work. The customer is entitled to this list by law, and the final price listed on this bill is the agreed upon price the customer will pay for the service provided. A similar approach to healthcare is a much more straightforward method for pricing when compared to informing the patient what the cost will be only after the procedure is done. Of course it may be unrealistic to suppose that a doctor can predict exactly what each patient will need before treatment, however it is not unreasonable to suppose that a fairly accurate estimate could be made. While, unlike the contractor, the healthcare provider should probably not be held to the quoted price, setting conditions requiring the final cost to be within some margin of error of that original estimate would alleviate much of the issue.[4] This policy, along with a posted initial consultation fee, would go a long way toward removing the fear many self-pay health care consumers have when going to the doctor, namely that they will end up being charged an amount massively greater than expected.

For insured patients, if providers find it too burdensome to find out what each individual patient’s insurance plan will cover, then as an alternative they should be required to provide billing codes for the initial consultation and any foreseeable procedures to patients who can then contact insurers directly.  Insurers should be required to provide a hotline or website so that patients can get quotes quickly. As in other states, patients should be informed whether any providers involved in their care are out-of-network. Finally, since insured patients are almost always are required to sign a statement accepting ultimate responsibility for bills not paid by insurance, a medical bill should be uncollectable unless this statement includes a specified price or maximum amount. Considering that the situation now is that patients can be surprised with prices quoted after the fact, this is a matter of simple justice.

 Conclusions

In a prior column we listed sources of market-wide health cost information, but this data is only useful for a very general estimate of what the final cost of care will be. Medical care providers typically disclose prices only after a procedure is completed, which can result in significant price discrepancies between what the patient may expect from market-wide price websites and the final bill. The practice of disclosing costs after the service is provided is almost unique to the medical community, and needs to be changed to allow consumers to accurately make decisions regarding their medical care.

Two problems have been identified here. One is the need to require providers and insurers to post their self-pay prices and/or the billing codes of standard procedures and consultations. The second is to make patients aware that they have a right to this information and to make it accessible to them. Unlike other states, Delaware should require providers give this information to patients or sign a statement that the patients waive their right to it. Other states require providers to give this information only upon request. Thus, patients remain unaware of it.

Consumer protection laws already exist in Delaware and other states for other industries. Given the evolution of the health care industry toward patient-directed care via high-deductibles, health savings accounts, self-payers and narrowing insurer networks, such laws are needed in health care. Other states have taken some steps toward this. Delaware should learn from their experience and act to fill this gap and promote health care price transparency.

-by Stacie Beck, Associate Professor of Economics, University of Delaware and member of CRI Advisory Board and John Libert, summer research intern for CRI.

[1] HEALTH CARE PRICE TRANSPARENCY: Meaningful Price Information Is Difficult for Consumers to Obtain Prior to Receiving Care, GAO-11-791: Published: Sep 23, 2011. Publicly Released: Oct 24, 2011.

[2] National Conference of State Legislatures www.ncsl.org accessed June 21, 2017.

[3] Barbara Anthony “Mass Hospitals Weak on Price Transparency” Pioneer Institute Policy Brief, June 2015.

[4] There is a printable model agreement on the Healthcare Bluebook website.

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Any district reduction study must first consider a BOLD systemic change to the way the current, bureaucratic education system operates with school boards and district hierarchies.  If operational decision-making authority is not shifted to the local buildings, we will end up with the same erroneous conclusions of the 2002 study conducted by the Delaware Secretary of Education in response to House Resolution 54.

Considering only Kent and Sussex counties, that study concluded that if those counties had only one school district each it would cost the state an additional $7.2 million dollars!  This result was caused by including teacher leveled-up pay scales but not reductions in district personnel expenses nor reductions in district office and facility operating expenses along with possible opportunities to rent or sell district buildings.  Why?  Because without changing the existing bloated, bureaucratic system and using regular state funding formulas, the new, larger districts simply rehired just about everyone (except for superintendents).  In some cases they actually added personnel.  Some current elected officials still cite that study to support their position of not reducing the number of school districts.

The concept of transferring operational decision-making authority from school boards and district bureaucracies to the individual school buildings is not new.  It originated and was piloted in Delaware in 1995 with the support of Governor Carper, the Department of Public Instruction (now the Department of Education), and the business community (led by the DuPont Company).  This education reform effort was done (listen up Governor Carney) to improve the state’s economy.  The Education Department’s draft of regulations stated, “Reliance on bureaucratic decisions would be a thing of the past.”  “Parents and teachers are less restricted by decisions made at a district or state level.”  “…try new approaches to learning without bureaucratic restrictions.”  “…empower local communities further with additional decision-making authority.”

The original Memorandum of Understanding offered to Delaware’s lowest performing schools also reflected the BOLD systemic change.  Under the MOU the Priority Schools would have authority over employment decisions, budget, curriculum, instructional practices, school calendar, scheduling, etc. and they would have autonomy from any district requirements not mandated by state or federal law.  If these local control changes were thought to improve the performance of the state’s lowest performing schools, why wouldn’t they be given to all public schools?  This should also provide comfort to parents who fear that they would have to deal with officials in a much larger, possibly impersonal district.  With district reductions and the shifting of authority to the local schools, parents would have better access to education decision makers.  In fact, they would be at their children’s schools every day.

The move to reduce the number of school districts is not a criticism of current district personnel.  It is, however, a condemnation of the existing, antiquated, bloated bureaucratic school system.   At one time transportation was heavily dependent on horses.  With the invention of the internal combustion engine, horses weren’t vilified but they were replaced by more efficient and productive means of transportation.  In education, some folks insist on providing more hay and oats and continue to deal with the inevitable muck that follows.  Einstein once commented on doing the same thing over and over again and expecting different results.  Well, it’s time to break out of the barn and move on to greener pastures.  Let’s shift the operational authority to the individual schools.  This will increase local control and since, “one size doesn’t fit all’, it will customize education and not standardize it.  Then we can talk about five or, maybe, three school districts for the state.

Ron Russo,

Senior Fellow, Caesar Rodney Institute

Founding President, Charter School of Wilmington

Former Principal, St. Mark’s High School

 

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Imagine shopping in a grocery store without prices on the shelves and a no-return policy. You gather cuts of meat and cans of vegetables, then the cashier tells you how much you pay. Or perhaps the prices are marked but then you find out that the cans are an extra charge and there is a service fee for cutting the meat. The prices at other grocery stores are likewise opaque. Without price data, living within a budget is nearly impossible.

A car is an expensive but infrequent purchase where quality is very important. You check quality with car reviews and Carfax reports, and get a sense of prices from cars.com. Then you are ready to negotiate with car dealers in the area. Without this information you are at a serious disadvantage in the marketplace.

We need to get routine health care, or to manage chronic conditions or to schedule non-emergency surgeries.  As high-deductible plans and health savings accounts proliferate and significant numbers of patients remain uninsured or find that they must purchase care out-of-network, price and quality data are urgently needed. However, due to a lack of transparency, shopping for health care has proved to be extraordinarily difficult. What private incentives are there to make price and quality information available? Can the state help make information more reliable and accessible to patients?

We describe sources of information currently available, and the state’s effort to improve price/quality transparency. The latter centers around the recent creation of an All Payer Claims Database. We will assess the likely impact on health care costs. In a follow-up column we will discuss additional actions that other states are taking to improve health care market’s efficiency.

What information resources are already available?

            Both price and quality information are needed. Otherwise consumers will rely on price as their indicator of quality despite plentiful evidence that they are not well correlated in health care. Consumers need prices on services bundled in an understandable way (e.g. an MRI price that includes both taking and reading an MRI) but with enough detail to understand what is not included. Price information from national averages is better than nothing, but given that healthcare is a local market, local/regional prices are better.

There are Internet tools available. At no charge, HealthcareBlueBook.com offers a suggested “fair price” with detailed breakdown for many medical procedures based upon a geographic area. With a subscription, price and quality information for a list of local providers is also available. These are quotes for cash-payers and are based on a proprietary database, according to parent company CareOperative LLC. In a helpfully provided price contract for consumer use, the company states that quotes are typically above insurer-negotiated rates but below most providers’ list price. Additional services are also available to employers. NewChoiceHealth.com gives a regional average and a list of providers and their price ranges for standard procedures. Consumers can also request quotes from individual providers. Saveonmedical.com quotes prices for standard radiology procedures from local providers and include a quality measure (docometer). Blood tests without doctor visits are available from Lifeextension.com, which co-ordinates with Labcorp or local hospitals and physicians in each state, to order tests and send results directly to consumers (except MD or PA).

These websites show that private entities are beginning to find ways to fill the information gap for uninsured, out-of-network, cash-paying consumers. Now there is also cost information for those who have the option of switching to HSA/catastrophic coverage plans. In addition to private sources, consumer information may eventually come from a state level initiative, the establishment of Delaware’s All Payer Claims Database (APCD) in July 2016 (Senate Bill 238). This database is still being constructed.

 What is an All Payer Claims Database (APCD)?

All Payer Claims Databases (APCDs) have been established in over fifteen states. An APCD is a statewide database of claims data collected (typically) from government-related programs.  In most cases they are established by legal mandate. The APCD compiles data from major insurance providers, Medicare, and Medicaid. Advocates envision APCDs as collaborative efforts by purchasers of health care, i.e. state government agencies, insurers, employers and consumers, to better understand and direct health care spending to providers. However, reporting requirements and the accessibility of the APCD varies between states.

Delaware’s APCD was established by legal mandate under Title 16 Chapter 103 of the Delaware Code. Subchapter I establishes a non-profit public/private administrative entity, the Delaware Health Information Network (DHIN) to administer the database. Subchapter II establishes the Delaware Health Care Claims (DHCC) database. Reporting requirements are imposed on ‘a mandatory reporting entity’ which includes any insurer in the state employee group health plan, the state Medicaid system, federal employee health benefit system, insurers participating in the ACA exchange, and Medicare.

The primary beneficiaries will be insurance companies, employers, and state agencies, who can then make better cost estimates, more successfully bargain with healthcare providers, and provide more effective service to Delawareans. The data will be available through an application process to the DHIN. This process involves the submission of a form to the DHIN detailing the request. Then each request will go to a board within the DHIN, which will either approve or deny the request. There is no provision for an appeals process regarding these decisions. Though this method will be effective for requests of large data sets and long-term analysis, it is not a viable consumer option.

 How can this information be provided to consumers?

At present it is unrealistic to expect a consumer to navigate Delaware’s DHCC database. However, a more consumer-friendly solution could be developed. Several states have created websites (State Health Price Information Disclosure Websites) which present data in APCDs in a readily accessible format. The best websites (New Hampshire’s nhhealthcost.nh.gov and Maine’s comparemaine.org) allow consumers to search via medical procedure, location, quality (Maine) and insurance carrier (Maine), and then display data on the number of cases treated, the average charge, and the range in price. Quality data on the health care providers in Delaware is already being gathered, in the form of the Common Provider Scorecard. This is a 26 point method for evaluating medical service providers in Delaware that is used at most locations. Though the Common Provider Scorecard is not currently public information, all or some of the information contained could be available to the public through this website. A website for Delaware, such as New Hampshire’s or Maine’s, provides an easy and effective means for consumers to access the data the state is already collecting on their behalf.

Conclusion

The establishment of the DHIN and the DHCC database are steps in the right direction, however more will need to be done to impact health care costs. In addition to (eventually) expanding the DHCC database to be consumer-friendly, it is necessary to get the word out about state-level and private websites described here. Use of price transparency websites by consumers has been slow to catch on. This might be partly because websites are still evolving and improving, and possibly because consumers are still transitioning to high-deductible plans. Moreover, most consumers still do not see price data in the office/facility of their providers. In our next column we will describe other states’ efforts to improve consumer protections and access to price information at the time of service. Researchers have also suggested that price/quality transparency is only half the battle, because competitive barriers keep providers from entering/expanding in an (overpriced) market. One such barrier is Delaware’s certificate-of-need (CON) law, described in a previous column. We will explore other possible barriers in a future column.

-by Stacie Beck, Associate Professor of Economics, University of Delaware and member of CRI Advisory Board and John Libert, summer research intern for CRI.

 

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