Tag Archives: health insurance

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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Moving Beyond the Hospital

Recently, officials at Hoag Memorial Hospital Presbyterian, a regional health care system in Orange County, Calif., decided to rebrand their 60-year-old institution. The not-for-profit health care system is now known simply as Hoag. They weren’t just going for brevity. They specifically wanted to drop the word “hospital.”

Dr. Richard Afable, Hoag’s president and CEO, recently spoke to a small meeting of hospitalists in Las Vegas and explained that the name change reflects a shift toward providing more services outside of the hospital. Hoag’s hospitals do a great job treating the acutely ill, he said, but the leadership wanted to reach out to people in the community before they got sick enough to make it to the hospital.

Dr. Richard Afable. Photo by Mary Ellen Schneider/ Elsevier Global Medical News.

So officials at Hoag have been working to offer more services related to conditions that either slightly touch the hospital or don’t touch it at all, Dr. Afable said. For example, the system has beefed up its offerings around diabetes care and now provides counseling on how to manage the disease and prevent complications. In the old days, they would have waited for someone to have a heart attack or lose a limb before taking care of them, Dr. Afable said. They also are developing community-based programs for breast cancer, a condition that today is treated primarily outside of the hospital.

And Dr. Afable advised hospitalists to consider following Hoag’s lead and look how they can be involved in care outside of the hospital. He noted the example of CareMore, a medical group and health plan based in California, which is being acquired by the health insurer Wellpoint, Inc. Under CareMore’s model, hospitalists not only care for patients while they are in the hospital, but also after they leave. Once a patient is stable, they are sent back to receive the rest of their care from their primary care physician. Since CareMore uses a capitation payment model, there aren’t concerns about which physician gets the payment for the post-discharge care. The model is food for thought for hospitalists as care becomes increasingly less hospital centric, Dr. Afable said.

— Mary Ellen Schneider

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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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Big Mouth News: Watch for Oral Health

Have you brushed up on your understanding of good oral health lately? If not, you might consider doing so.

Image via Flickr user 176th Wing, Alaska Air National Guard

Improving Access to Oral Health Care for Vulnerable and Underserved Populations,” a report released by the Institute of Medicine and National Research Council this week, calls for expanding the role of physicians, nurses, and other non-dental professionals to recognize the risk for oral diseases, which can contribute to increased risk of respiratory disease, cardiovascular disease, and diabetes, as well as inappropriate use of hospital emergency departments for preventable dental diseases.

“The consequences of insufficient access to oral health care and resultant poor oral health—at both the individual and population levels—are far-reaching,” Dr. Frederick Rivara, chair of pediatrics at the University of Washington School of Medicine, Seattle, and chair of the committee that wrote the report said in a prepared statement. “As the nation struggles to address the larger systemic issues of access to health care, we need to ensure that oral health is recognized as a basic component of overall health.”

In 2008, according to the report, 4.6 million children did not obtain needed dental care because their families could not afford it. And in 2006, only 38% of retirees had dental coverage, which is not covered by Medicare.

One report recommendation calls for the Health Resources and Services Administration to convey key stakeholders to develop a set of core oral health competencies for nondental healthcare professionals—competencies that would be integrated into their requirement for accreditation and be a criterion for certification and maintenance of certification.

Once established, the minimum core competencies “will need to prepare graduates to recognize risk for oral disease through competent oral examinations, provide basic oral health information, integrate oral health information with diet and lifestyle counseling, and make and track referrals to dental professionals,” the report states.

The report was sponsored by the Health Resources and Services Administration and the California HealthCare Foundation. 

— Doug Brunk (on Twitter@dougbrunk)

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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.

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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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Video of the Week: AMA Backs Individual Mandate

The American Medical Association’s House of Delegates voted 326-125 to support the premise that all Americans should be required to buy health insurance if they can afford to do so.

Our reporter Alicia Ault was there to catch AMA President Cecil Wilson’s discussion of the organization’s position on health insurance.

You can read more about the American Medical Association’s House of Delegates activities at Internal Medicine News.

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Former Health IT Czar Starts New Chapter

Dr. David Blumenthal, the former National Coordinator for Health Information Technology, is taking on a new position at the Commonwealth Fund.

Photo courtesy HHS.gov

Dr. Blumenthal left his government post earlier this year after 2 years overseeing the federal government’s policy of expanding health IT use by physicians and hospitals. During his tenure, he presided over the implementation of the Health Information Technology Economic and Clinical Health (HITECH) Act, which offers incentive payments for physicians and hospitals to use health IT to improve quality of care; the program began this year. We conducted a Q&A interview with Dr. Blumenthal at the beginning of his time as national coordinator. Check it out here. And learn more about meaningful use incentives here and here.

Now that he is back in the private sector, he has signed on to chair the Commonwealth Fund’s Commission on a High Performance Health System. The commission has been in operation since 2005 and has produced a number of reports that lay out payment and system reforms aimed at improving the quality, safety, and efficiency of the health care system. Dr. Blumenthal takes over as chair from Dr. James J. Mongan, who died in May.

Dr. Blumenthal, who is a primary care physician, will have plenty of other doctors to keep him company on the commission. Among the commission’s 17 members are several physicians, including Dr. Christine K. Cassel of the American Board of Internal Medicine; Dr. Patricia A. Gabow, CEO and medical director of Denver Health, Dr. Neil R. Powe, vice-chair of medicine at the University of California, San Francisco; Dr. Martín-J. Sepúlveda, vice president of Integrated Health Services at IBM; Dr. David A. Share of Blue Cross Blue Shield of Michigan; and Dr. Glenn D. Steele Jr., CEO of the Geisinger Health System.

Stay tuned to see how Dr. Blumenthal puts his stamp on the commission.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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