Tag Archives: health care reform

ACA: Helping or Hurting Solo Practice?

It won’t surprise many to learn that the age of the solo practitioner has, for the most part, come to an end. Over the past several years, small and solo practices have closed, been sold to hospitals, or merged with larger groups. The reasons are fairly obvious. Declining payments, rising malpractice costs, increasing regulatory burdens, costly new health information technology requirements, and crushing medical school debt have made it difficult for physicians to operate the small practices that once were commonplace around the country.

Now add the Affordable Care Act (ACA) to the mix. At a July 19 hearing of the House Small Business Subcommittee on Investigations, Oversight and Regulations, lawmakers questioned whether the health reform law would help or hurt physicians looking to keep their practices small and independent. The answers from the expert panel were mixed.

Gone are the days of Marcus Welby. Courtesy Wikimedia Commons/Public Domain License

The emergence of accountable care organizations (ACOs) will drive more hospitals to buy up small physician practices, Mark Smith, president of the physician recruiting firm Merritt Hawkins, predicted. The health reform law heavily promotes the formation of ACOs, which call for physicians and hospitals to work more closely and to share in bundled payments for episodes of care. Mr. Smith said small practices aren’t well-positioned to enter the ACO world if they aren’t integrated with a hospital because the ACO model calls on practices to assume financial risk.

But Joseph M. Yasso, Jr., DO, a family physician in Independence, Mo., who sold his practice to a hospital group 20 years ago, said the ACA’s promotion of patient-centered medical homes could be a lifeline for small practices. Physicians are adapting to the new environment by becoming medical homes and participating in government pilots where they can share in the savings they generate by providing more efficient care, he said.

One thing everyone on the panel did agree on was the need to fix the Sustainable Growth Rate (SGR) formula used in setting physician payments under Medicare. No surprises there either.

— Mary Ellen Schneider

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A Hospitalist’s Call to Action

Dr. Patrick Conway is the Chief Medical Officer at the Centers for Medicare and Medicaid Services, but he also happens to be a practicing pediatric hospitalist. So when he showed up at the Society of Hospital Medicine’s annual meeting earlier this week to deliver one of the keynote addresses, he got a warm welcome from fellow hospitalists happy to see one of their own in a real position to make decisions about Medicare’s policies.

Dr. Conway gave the standard speech about what CMS officials are doing to transform the health care system. Then he turned to his hospitalist colleagues and gave them some things to do, too. Hospitalists need to partner with the hospital administration and their quality improvement teams. They need to understand their hospital’s performance data. And they need to take charge, he said, by leading multidisciplinary teams.

“We’re at a unique time in health care where we can drive change,” Dr. Conway said. “My challenge to you would be, please don’t sit on the sidelines.”

Dr. Patrick Conway

He urged the audience – hospitalists gathered in San Diego for continuing education and networking – to make an effort to lead some type of system improvement in their hospital. “I don’t actually care what it is, but work on some broader system changes in your local setting,” Dr. Conway said.

If hospitalists are looking for a reason to get out in front when it comes to system change, there are plenty of financial carrots and sticks coming very soon from the Medicare program. Dr. Conway outlined many of them, from Accountable Care Organizations to the readmission reduction program to the hospital value-based purchasing program. But the best reason to be active in changing the way the health system works is for the benefit of patients, he said. That’s the reason that Dr. Conway still works as a hospitalist nearly every weekend for free. “It’s about those families that you take care of,” he said.

– Mary Ellen Schneider

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What if the Supreme Court Tosses Out the ACA?

Opponents of the Affordable Care Act are hoping that the Supreme Court will soon invalidate the law and put a permanent end to the federal government’s expanded role in health care. But one Capitol Hill watcher says the defeat of the ACA by the high court could lead to something conservatives would like even less – single-payer health care. Well, not anytime soon. But tossing out the law could help nudge things in that direction over time.

Norman J. Ornstein, Ph.D., an author and resident scholar at the American Enterprise Institute, said he could imagine a scenario where if the ACA were defeated, over time, Democrats would move to expand Medicare beyond the 65 and older crowd. Mr. Ornstein, who has a new book coming soon on the growing dysfunction in Washington, offered his two cents while speaking to a group of physicians at the Society of Hospital Medicine’s annual meeting in San Diego this week.

Protesters outside the Supreme Court in March. Photo by FRANCES CORREA/ IMNG Medical Media.

Another way that single-payer health care could become a reality is at the state level. Individual states might experiment with single payer-type programs along the lines of the Green Mountain Care program in Vermont, Mr. Ornstein said. Lawmakers in that state have enacted legislation allowing them to phase in a single-payer health care system over the next several years. But they have yet to hammer out details on how to pay for the program and it’s unclear how long it will take to move from the current framework of public and private insurance to a single-payer system.

– Mary Ellen Schneider

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Getting Ready for the Insurance Exchanges

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy.

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

— Mary Ellen Schneider

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Innovation Center Seeks to Renovate Medicare

Government officials have stood before doctors many times and talked about the need to change the perverse incentives that pay them more for caring for sick patients than for keeping people healthy to start. Dr. Richard Gilfillan, who runs the new Center for Medicare and Medicaid Innovation, had a similar pitch when he talked to more than 1,000 people who recently convened at a Washington, D.C. hotel for a day-long summit on health care innovation. The difference is, Dr. Gilfillan has some leverage.

Under the Affordable Care Act, his new center is charged with rapidly testing alternative payment and health care delivery models. If those pilot projects are proven to both improve the quality of care and bring down health care costs, the Secretary of Health and Human Services can roll out the program nationally. There’s a little more paperwork involved, but that’s the general idea.

Dr. Richard Gilfillan (R), with HHS Secretary Kathleen Sebelius and former head of the Centers for Medicare and Medicaid Services, Dr. Don Berwick, in November. HHS Photo by Chris Smith.

What that means is that in a relatively short amount of time, Medicare could fundamentally change the way it pays doctors. That is, if the pilot projects sponsored by the Innovation Center are successful.

Dr. Gilfillan offered an example: Let’s say the Innovation Center launches a project where it pays primary care physicians an extra $10 per patient per month to coordinate care. If officials at the Innovation Center can prove that the project improves outcomes and reduces costs, HHS can publish regulations to roll it out to primary care physicians around the country. “As you can see, this is a powerful tool for changing the way we deliver care,” Dr. Gilfillan said at the summit.

The Innovation Center has been around for about a year and officials there have been busy putting together a set of pilot projects that look at new ways to deliver primary care and home-based care. They are also testing other concepts like bundled payments and accountable care organizations. Check out the Innovation Center’s report on its first year for descriptions of all the projects.

One thing they are trying to do in each of the projects, Dr. Gilfillan said, is to work closely with private payers. The goal, he said, is to make life a little simpler for doctors by ensuring that when they find new payment mechanisms that work, all the payers, both public and private, will adopt it in the same way.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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HHS Cries Foul on Insurance Hikes

Nowhere in the thousands of pages of the Affordable Care Act does it give the federal government the power to stop insurance companies from charging excessive premiums. But the controversial health reform law does grant the Department of the Health and Human Services the right review some large rate increases and to tell consumers when they think health plans are charging too much.

HHS did just that today when it held a press conference to protest what it said were “unreasonable” rate hikes by Trustmark Life Insurance Company in five states. The company recently proposed premiums hikes of 13% or more for its plan members inAlabama, Arizona, Pennsylvania, Virginia, and Wyoming.

Courtesy Wikimedia Commons/FBI Buffalo Field Office/Public Domain

Gary Cohen, the Acting Director of Oversight at the HHS Center for Consumer Information and Insurance Oversight, said it wasn’t just that the increases were so high. HHS officials, after consulting with a team of outside analysts, concluded the rates were unreasonably high because the health insurance company was spending only a small percentage of its premium dollars on medical care and quality improvements. Trustmark also based its increases on “unreasonable assumptions,” HHS said. You can read more about HHS rate review authority here.

In its challenge to Trustmark, HHS called on the company to immediately rescind the rates, issue refunds to consumers, or publicly explain why they are standing by such a large rate hike.

It looks like Trustmark is going to stand by its rate increase. Following the HHS press conference, Trustmark issued its own statement saying that they disagreed with the federal government’s assumptions and conclusions. “Our premiums are driven by the rising cost and increased utilization of medical services,” the company wrote. “As a smaller carrier, our loss ratios can vary significantly from year to year, and we take that volatility into consideration.” As for spending too little of its premium dollars on medical care, the company said it has been in compliance with the federal Medical Loss Ratio requirements in that area. However, if they should fail to meet the federal standards, they will offer rebates to consumers.

So is this an effective strategy for bringing down health insurance rates? Share your thoughts on whether rate review by HHS and public disclosure will be powerful enough to force companies to keep premiums low or if you think insurers will be willing to ride out some bad press.

— Mary Ellen Schneider

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Here Comes the Super Committee

The Joint Select Committee on Deficit Reduction was created as a part of Congress’ debt deal in July. The 12-member bipartisan committee is charged with cutting $1.5 trillion in federal spending by Thanksgiving. Medicare and Medicaid benefits, doctor’s pay, and the Children’s Health Insurance Plan could be on the chopping block. As physicians advocate for a permanent fix to the Sustainable Growth Rate Formula and medical liability reform(among other things), here’s a look at what you can expect from committee members concerning the issues that matter to you.

Co-Chair: Senator Patty Murray (D-Wash.)

Courtesy Sen. Murray

As a supporter of the Affordable Care Act (ACA), Sen. Murray (@SenMurrayPress) advocates for expanding access to health care, including increasing mental health coverage and the use of health technology. She also supports decreasing long-term health costs through preventive care.

She has experience in handling budget and spending issues after serving on the Senate Budget Committee and the Appropriations Committee. She is currently the chair of the Appropriations Subcommittee on Transportation. Click here to learn more.

Health-related legislation: Sen. Murray has sponsored several health-related bills including legislation to increase awareness of emergency contraception, and a bill to improve mental health services for the military.

Co-chair: Rep. Jeb Hensarling (R-Tex.)

Courtesy Rep. Hensarling

Rep. Hensarling (@RepHensarling)  has a background in economics and previously served on the Congressional Oversight Panel for the Troubled Asset Relief Program (TARP) and on the President’s Debt Commission.

Rep. Hensarling has maintained a conservative voting record and opposed the ACA, calling it a “travesty.” He advocates for limited government, including arguing against the expansion of Medicare, Medicaid, and Social Security. He currently serves as the chairman of the House Republican Conference and as vice-chairman of the House Financial Services Committee. Click here to learn more.

Health-related legislation: Sen. Harling has cosponsored legislation to repeal the ACA (H.R. 4903, H.R.4919,  and H.R.4972). He has also cosponsored H.R. 3217, to allow Americans to purchase health insurance across state lines, and H.R. 1086 to enact medical liability reform.

Other members of the Joint Select Committee on Deficit Reduction include:

Sen. Max Baucus (D-Mont.)

Courtesy Sen. Baucus

A long-time supporter of the ACA, Sen. Baucus (@MaxedBaucus) supports expanding Medicaid and Medicare benefits, increasing preventive services, and closing the prescription drug coverage gap under Medicare Part D. He also supports programs to provide access to health care for displaced workers, farmers, and ranchers. He has advocated to increase funding for the Children’s Health Insurance Program (CHIP) and is the chairman of the Senate Finance Committee. Click here to learn more.

Sen. John Kerry (D-Mass.)

Courtesy Sen. Kerry

Sen. Kerry (@JohnKerry) has been a steady advocate for expanding health coverage for children. He has also been behind legislation to improve funding for hospitals as well as consumer protection in the Medigap marketplace. A supporter of the ACA, Sen. Kerry also has worked to improve and expand access to health care in his own state, which functions under a single-payer system. In 2010, Sen. Kerry worked to provide incentives for small businesses to offer health insurance for their workers. He is chairman of the Senate Foreign Relations Committee. Click here to learn more.

Sen. Jon Kyl (R-Ariz.)

Courtesy Sen. Kyl

Sen. Kyl (@SenJonKyl) supports repealing the ACA, maintaining the belief that the law takes decision-making away from physicians and patients and puts it in the hands of the government. He also advocates for medical liability reform, the purchase of health insurance across state lines, and expanding coverage through improving the system of health spending and flexible spending accounts. He currently serves on the Senate Finance Committee. Click here for more on his preferred approach to health care reform.

Sen. Pat Toomey (R-Pa.)

Courtesy Sen. Toomey

Sen. Toomey (@SenToomey) cosponsored the bill the repeal the ACA. In an op-ed piece, Sen. Toomey voiced support for individuals purchasing health insurance, as opposed to an employer-based system, as well as purchasing coverage across state lines. He also supports the need for medial liability reform and federal regulations to allow small businesses and organizations to purchase health insurance on behalf of their members. He sees this as a path to decreasing costs and increasing competition. Click here to learn more.

Sen. Rob Portman (R-Ohio)

Courtesy of Sen. Portman

Sen. Portman (@robportman) does not support the ACA. He argues that the health care law increases costs for employers, making it more difficult for them to hire workers. Sen. Portman has voiced his support for expanding health savings accounts, purchasing health insurance across state lines, implementing tort reform, and encouraging medical innovation. Click here to learn more.

Rep. Xavier Becerra (D-Calif.)

Courtesy Rep. Becerra

Rep. Becerra (@RepBecerra) has spoken out in ardent support of the ACA, calling it “transformative.” He has advocated for the expansion of Medicare, Medicaid, and CHIP. In 2010, Rep. Becerra was recognized by the California Hospital Association as  a “health care champion” for his work to preserve $3 billion in Medicare funds  for hospitals in California.  Click here to learn more.

Rep. Dave Camp (R-Mich.)

Courtesy Rep. Camp

Rep. Camp (@RepDaveCamp) is the chairman of the House Ways and Means Committee. He was the first to introduce a bill to repeal the ACA, although he has supported certain aspects of the law including providing affordable coverage for individuals with pre-existing conditions.   Rep. Camp submitted his own alternative to the health care law, which he says will lower to cost of care without raising taxes or cutting Medicare. Click here to learn more.

Rep. Jim Clyburn (D-S.C.)

Courtesy Rep. Clyburn

Rep. Clyburn (@Clyburn) was one of the main advocates for the passage of the ACA. He previously voted against capping damages in medical liability suits. Rep. Clyburn  also supports the expansion of Medicare, Medicaid, and CHIP, as well as negotiating prices for prescription drugs covered under Medicare Part D. Click here to learn more.

Rep. Fred Upton (R-Mich.)

Courtesy Rep. Upton

Rep. Upton (@RepFredUpton) advocates for repealing the ACA, expanding health savings accounts, allowing the purchase of coverage across state lines, and implementing medical liability reform. He has also spoken out against the Independent Payment Advisory Board (IPAB), an 15-person appointed board that will be tasked with reducing costs to Medicare, without affecting quality or coverage. IPAB opponents say it could take aim at reimbursements to health professionals, who already face a 30% pay cut in January. Rep. Upton serves as chairman of the House Committee on Energy and Commerce.

Rep. Chris Van Hollen (D-Md.)

Courtesy Rep. Van Hollen

Rep. Van Hollen (@ChrisVanHollen)  supports the IPAB, saying it is a tool that ensures the solvency of Medicare. He has also argued against raising the age Medicare eligibility. In a recent interview with National Public Radio, Rep. Van Hollen said the government should improve incentives for doctors and hospitals to provide quality care. Rep. Van Hollen serves as ranking member of the House Budget Committee. Click here to learn more.

–Frances Correa (@FMCReporting on Twitter)

Research for this article was gathered from the following sources: govtrack.com, PRNewswire, Senate websites, House websites, politifact.com, ohiogop.com, ontheissues.org, politico.com, and npr.org

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Examining the IPAB: The Policy & Practice Podcast

The Independent Payment Advisory Board, the new panel that will be charged with reducing the growth in Medicare spending, was the focus of intense debate on Capitol Hill last week. In the July 18 edition of the Policy & Practice podcast, we have all the details on the two House hearings held on the panel and why physicians are worried about its impact.

The Independent Payment Advisory Board (IPAB) was created under the Affordable Care Act to help keep Medicare spending under control. But most physician groups are calling on Congress to scrap the board or substantially change how it operates. Opponents, who include the American Medical Association, say that if the IPAB goes forward, physicians would be subject to two levels of cuts: one from the IPAB and one from Medicare’s Sustainable Growth Rate (SGR) formula. Physicians are already facing a nearly 30% Medicare fee cut next year from the SGR unless Congress steps in.

HHS Secretary Kathleen Sebelius tours Frager’s Hardware Store in Washington, D.C., before an event to announce new rules on health insurance exchanges. HHS photo by Chris Smith.

This week’s Policy & Practice podcast also has news on the new federal regulations for how states can set up health insurance exchanges. Those exchanges, which aim to make it easier for Americans to buy insurance, are slated to be up and running by 2014. And check out the podcast for the latest on the debt ceiling negotiations and how Medicare could be affected.

Take a listen and share your thoughts:

Check back with us next week for more on the debt ceiling legislation and the Institute of Medicine’s recommendations on what preventive services health plans should cover for women.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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A Chance at an SGR Fix?: The Policy & Practice Podcast

There’s a lot at stake in the negotiations over raising the nation’s debt limit, from the impact on the global economy to the potential elimination of Medicare’s Sustainable Growth Rate (SGR) formula. That’s right, the much-despised SGR, which is used in determining physician payments under Medicare, has even made its way into the talks about increasing the debt ceiling.

House Speaker John Boehner (left) and Senate Majority Leader Harry Reid (right) met with the President on July 10 to discuss the debt limit. Official White House Photo by Samantha Appleton.

As the president and congressional leaders go into overdrive, holding daily meetings on ways to trim the deficit, the medical establishment is pushing hard for lawmakers to stop the cycle of threatened physician pay cuts followed by last-minute legislative Band-Aids. The American Medical Association, along with more than 100 state and medical specialty societies, recently sent a letter to lawmakers warning that the cost of an SGR fix will only go up. Right now, they estimate the 10-year cost of replacing the SGR is nearly $300 billion, but that figure could rise to more than $500 billion in just a few years, they wrote. The debt ceiling legislation provides “the best—and perhaps only—opportunity to ensure stability in Medicare payments, ensure continued beneficiary access to care, and address the SGR deficit in a fiscally responsible manner,” the organizations wrote in their letter.

Get the full scoop on the SGR in this week’s Policy and Practice Podcast.

Take a listen and share your thoughts:

And stayed tuned next week for all the details on new regulations on state-based health insurance exchanges.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Rolling Out Health Reform: The Policy & Practice Podcast

Many of the hallmarks of the Affordable Care Act, such as state-based health exchanges to purchase insurance, won’t go into effect until 2014. But, in the meantime, officials at the Department of Health and Human Services are plenty busy rolling out other provisions of the law, making adjustments to some of the law’s programs, and just promoting what they’ve done so far.

Recently, HHS officials announced that they would stop granting exemptions that allow limited-benefit health plans to keep in place low annual coverage limits that are at odds with the Affordable Care Act. HHS has been granting waivers to these so-called “mini-med” plans in an effort to keep the products affordable for consumers. But no more. Starting on Sept. 23, HHS will no longer accept waiver applications or extension requests from these plans. And, in 2014, all health plans will be barred from placing annual limits on coverage under the health reform law.

HHS has also been busy promoting the availability of free preventive services for Medicare beneficiaries. Starting at the beginning of this year, Medicare beneficiaries were eligible to receive recommended preventives services ranging from mammograms to smoking cessation counseling with no copays or deductibles under Medicare Part B.

Photo courtesy National Cancer Institute.

But seniors haven’t flocked to take advantage of the services. Only about one in six Medicare beneficiaries has accessed the free services, according to a government report. So HHS is launching a public outreach campaign that includes radio and TV ads. The government is also reaching out to physicians, asking them to discuss the preventive services with patients.

For more on the implementation of the Affordable Care Act, plus a recap of the American Medical Association’s House of Delegates meeting, check out this week’s edition of the Policy & Practice podcast.

Take a listen and share your thoughts:

The Policy & Practice podcast is taking a break next week, but check back on July 11for all the latest developments in health reform.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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