Kids’ prescriptions often going unfilled

By Amy Norton

NEW YORK (Reuters Health) – A large share of medication prescriptions to children on Medicaid may go unfilled, a new study suggests.

Researchers found that of nearly 17,000 prescriptions made to kids at two urban clinics, 22 percent were never filled. That’s similar to what’s been seen in studies of adults – among whom anywhere from 16 percent to 24 percent of prescriptions go unfilled.

“There are lots of studies that show that if you’re not adherent to your medication, you’ll have worse health outcomes,” said lead researcher Dr. Rachael Zweigoron, of the Medical University of South Carolina in Charleston.

That goes for adults, but also for kids, according to Zweigoron. It’s not clear from the study why more than one-fifth of prescriptions went unfilled. But parents were more likely to pick up certain medications than others.

Antibiotics and other drugs for infections were filled 91 percent of the time, versus 65 percent of prescriptions for vitamins and minerals, for example.

“When your child has an ear infection and is in pain, you have much more of a sense of urgency,” Zweigoron said. But if a doctor recommends a vitamin D or iron supplement, she added, parents might not see the immediate need.

That raises the question of whether parents always know why a pediatrician has prescribed a medication or supplement. “Are we, as pediatricians, doing a good enough job of explaining the importance to parents?” Zweigoron said.

The findings, which appear in the journal Pediatrics, are based on 4,833 kids seen over two years at two clinics connected to Lurie Children’s Hospital of Chicago.

All of the children were on Medicaid, the government health insurance program for the poor. So it’s not clear if the findings would be the same for U.S. kids with private insurance.

But Zweigoron said that unfilled prescriptions are likely a problem, to some degree, among families on private insurance, too. Her team did find that electronic prescriptions were almost 50 percent more likely to be filled than old-fashioned paper ones.

The reason is unknown, but Zweigoron speculated that convenience is a big factor. The finding is also in line with other studies showing that adults are more likely to fill their own prescriptions when they’re sent to pharmacies electronically.

Zweigoron said more research is needed to weed out the reasons that parents often leave kids’ prescriptions unfilled. For now, she suggested that if parents have questions about a medication, including worries about side effects, they speak up.

“If you’re not sure why the doctor’s prescribing something, you should feel empowered to ask questions,” Zweigoron said.

“And if for some reason they’re having trouble getting the medication,” she added, “(parents) should bring that up, too.”

SOURCE: bit.ly/QvDRFS Pediatrics, online September 24, 2012.

IN 26-STATE DUAL-ELIGIBLE DEMO, HOSPITALS PUSH INSURERS TO PAY MEDICARE RATES

PROJECT AIMS TO IMPROVE CARE FOR THE NATION’S SICKEST, COSTLIEST PATIENTS

By: The Advisory Board Company’s Daily Briefing

September 20, 2012

A CMS demonstration program launching in 26 states will require hospitals and health systems tonegotiate rates for dual-eligible patients directly with insurers, rather than the federal government.

Under the major demonstration project, 26 states will shift up to two million patients that are dually eligible for Medicaid and Medicare into managed care or managed fee-for-service plans. The project hopes to improve care coordination for the nation’s sickest and costliest patients.

                      Which states have the most dual eligibles? Kaiser Family Foundation maps out the numbers

According to CQ HealthBeat, the government will set the managed-care plans’ per-beneficiary capitated payments that it gives the managed care plans selected for the program. Hospitals will have to convince the managed care plans to pay them at the higher Medicare reimbursement rates.

 Although CMS supports using the Medicare rate, it will follow a federal statute banning CMS from interfering in contract negotiations between plans and providers in Medicare Advantage’s managed care program. According to the law, which is included in an amendment of the Social Security Act, the ban is needed “in order to promote competition.”

However, CMS will conduct a readiness review to examine a range of issues and determine whether the health plans have built adequate providor networks for patients with complicated medical needs.

If many hospitals refuse to sign a contract with a health plan because of payment rates, then CMSmay not consider the plan ready.

States expect to receive Medicare rates

Massachusetts was the first state in the demonstration to receive approval for its plan, which is expected to launch on April 1. CMS soon will announce the health plan participants and their capitated payment rates.

State officials say they expect that hospitals will be offered Medicare rates. Nonetheless, hospitals have expressed concern over the uncertainty.

“Our strong support for the concept that underlies this initiative is equaled by our great concern that inadequate reimbursement may undermine its potential success,” says Massachusetts Hospital Association EVP Timothy Gens. He notes that the association continues to advocate for “a specific requirement for Medicare rates.”

Meanwhile, CMS officials are finalizing proposals that would allow states such as California, Ohio, and Wisconsin to move forward with their plans.

According to CQ HealthBeat,California’s proposal may be completed within one month. It would affect about 550,000 dual eligibles in eight counties. If adopted statewide, the plan would shift 1.1 million dual eligibles into managed care.

Echoing the statements of Massachusetts officials, Toby Douglas—director of the California Department of Health Care—last week said that “Medicare is going to be in many ways the floor” for payments to hospitals and health systems in the project (Adams, CQ HealthBeat, 9/12 [subscription required]; Adams, CQ HealthBeat, 9/14 [subscription required]).

Source: http://www.advisory.com/Daily-Briefing/2012/09/20/In-26-state-dual-eligible-demo-hospitals-push-insurers-to-pay-Medicare-rates

DARRELL GRIFFITH, PASSPORT TO SPONSOR ASTHMA AWARENESS EVENT

by chelsea on September 17, 2012 in News You Can Use

Darrell Griffith and Passport Health Plan to Offer the Healthy Hoops Kentucky Tip-Off for Children with Asthma

Basketball legend Darrell Griffith will join Passport Health Plan and other local sponsors to offer a free asthma awareness event for children ages 7 to 13 called theHealthy Hoops Kentucky Tip-Off. The Healthy Hoops Kentucky Tip-Off will be held on Saturday, September 22, 2012 from 10:30 a.m. to 4:30 p.m. at Moore Traditional High School in Louisville, KY. All asthmatic children ages 7 to 13 are welcome to attend free of charge and can register by visiting www.healthyhoopsky.com or by calling 1-800-578-0603, press 0, then press 8429. Children do not have to be Passport Health Plan members to participate.

Under the guidance of Griffith and other celebrity basketball coaches and medical experts, children and their families participate in a full day of health awareness, basketball drills, entertainment, asthma screenings and skills workshops. The program teaches the children and their families how to lead healthy, activelives. Participants receive a comprehensive clinical screening to evaluate their asthma and receive a free consultation with an asthma health professional. Each family leaves the screening with an asthma action plan and tools to keep asthma under control. Over the past three years, members who have attended the Tip-Off event have personally experienced fewer emergency roomvisits and hospital admissions, as well as having improved medication compliance.

In Jefferson County there are approximately 18,000 children with asthma, a disease that if left unmanaged can impact a child’s ability to go to school, participate in sports, and just have fun. By attending the event, children and their families will learn how to use medications appropriately, how to monitor exercise and recreation, and how to keep asthma under control. They will also receive nutrition counseling. “We hope to serve about 200 children on this special day. Asthma has a very real financial and emotional impact on families and we’re encouraging families to use the day to learn, have fun, and meet some of their favorite basketball celebrities.” said Stephen Houghland, MD, Chief Medical Officer for Passport Health Plan.

Healthy Hoops Kentucky is sponsored by Passport Health Plan, The Kroger Co., the University of Louisville, Astra Zeneca, KentuckyOne Health, The AmeriHealthMercy Family of Companies, Mainline Broadcasting and other local organizations. It is coordinated by a coalition of community leaders who represent the following organizations: Passport Health Plan, University of Louisville, University of Louisville Athletic Department, Metro Louisville Department of Public Health and Wellness, Kosair Children’s Hospital, Jefferson County Public Schools, Astra Zeneca, University of Louisville School of Public Health and Information Sciences, Metro Louisville Government, The Kroger Co., and the Commonwealth of Kentucky.

http://www.medicalnews4you.com/darrell-griffith-passport-to-sponsor-asthma-awareness-event/

ACO study reflects cost savings and reduced readmissions

September 17, 2012 | Erin McCann – Contributing Writer and Associate Editor for Healthcare IT News

 

Accountable care organizations (ACOs) can deliver cost savings and reduce readmission rates, according to a recent study from the Dartmouth Institute for Health Policy and Clinical Practice

The study, published in the Sept. 12 issue of The Journal of the American Medical Association, examined the cost savings associated with the Physician Group Practice Demonstration (PGPD), a Medicare program that ran from 2005 to 2010 and closely resembled current ACOs.

Study analysis pegged the overall annual savings from this value-based payment model at $114 per Medicare beneficiary, and the overall annual savings for duallyeligible populations  –  that is, patients who qualify for both Medicare and Medicaid  –  at $532 per beneficiary.

 

Report authors said the cost component findings are significant, as the nation’s 9million dual eligibles comprise 20 percent of the Medicare population but account for 31 percent of its spending, and comprise 15 percent of the Medicaid population but 39 percent of its spending.

Readmission rates were also affected in the demonstration, with 30-day medical readmission rates decreasing 0.67 percent overall for both populations, and 1.07 percent for dually eligible beneficiaries. Moreover, surgical readmissions for dually eligible populations decreased 2.21 percent overall. With 990,117 Medicare and/or Medicaid beneficiaries included in the experimental group, and 7,514,453 beneficiaries in the control group, report authors noted that these numbers are statistically significant.

“The study shows promise for the new healthcare delivery system reforms,” said Carrie H. Colla, lead author of the study and assistant professor at The Dartmouth Institute for Health Policy and Clinical Practice. “And these reforms should align incentives for payers, providers and patients.”

Colla pointed out that the study was done to examine the cost savings benefits of a value-based ACO program, and the PGPD was a near perfect match.  “I would say the two fundamental characteristics of the ACO-type contract are pay-for-performance and shared savings,” said Colla. The PGPD and the new Medicare ACO contracts include both these things, she added, and the quality metrics are very similar. 

Physician groups participating in the demonstration could receive up to 80 percent ofsavings they generated. In the new ACO programs, savings are generally lower, between 50 to 70 percent.

Out of 10 participating physician groups, the University of Michigan Faculty Group Practice saved the most money, averaging out to $866 per person, per year for both populations. When examining the dually eligible patients, the practice’s savings were more marked, pegged at $2,499 per person, per year.

The Middletown, Conn.-based Middlesex Health System saw the least savings all around, actually expending $749 per beneficiary for both populations and $598 for the dually eligible.?As far as non-dually eligible beneficiaries, PGPD savings were not as substantial, with some organizations seeing savings of only $59 per person, per year. However, some organizations, such as Wisconsin’s Marshfield Clinic and the University of Michigan Faculty Group Practice, observed savings of more than $500 per patient, per year for non-dually eligible beneficiaries.

Colla emphasized the significant cost and readmission improvements for the duallyeligible population. She said the study results are “a marker for populations that have higher rates of chronic disease,” and really show that “ACOs have the potential to improve healthcare and reduce spending for [the dually eligible] population.”

Overall, Colla said the study supports value-based healthcare for certain groups and can have a marked effect on complex patients in the system.

“The current fee-for-service payment system has contributed to the fragmented, poorly coordinated care that many patients, especially those who are sick, experience every day,” said Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project in a Dartmouth press release. “New payment models like ACOs are intended to encourage providers to coordinate care by offering them a share of any savings achieved when they improve care. These results indicate that when organizations really try to adapt to these new models, they can benefit their patients’ lives and theirbottom lines.”

 

Source:

http://www.physbiztech.com/news/aco-study-reflects-cost-savings-and-reduced-readmissions

Steve Beshear appoints members to health exchange board

Written by
The Courier Journal

FRANKFORT, KY. — Gov. Steve Beshear on Tuesday announced appointments to a 19-member advisory board that will provide recommendations for the new statewide health insurance exchange required under federal health reforms.

The exchange, scheduled to begin operation in 2014, will create an online marketplace for individuals and small businesses to shop for health insurance and compare coverage and costs among competing plans. It will also help individuals and employers enroll in plans and qualify for tax credits.

“We need the insight and experience of a variety of Kentuckians to ensure that the exchange not only meets the requirements of the law, but also meets the needs of Kentuckians who will be looking for affordable health insurance,” Beshear said in a statement.

States are required to establish health insurance exchanges under the Affordable Care Act and must demonstrate readiness to run them by the end of the year. Otherwise, the responsibility falls to the federal government.

According to Beshear’s office, the appointees have experience in health benefits, finance and policy, along with public health and the uninsured. The board will review program and policy issues, his office said.

http://www.courier-journal.com/article/20120918/NEWS01/309180100/Steve-Beshear-appoints-members-health-exchange-board

Dual-eligibles market creates opportunities for physician practices

The managed care market for the Medicare-Medicaid population could range from $86 billion to $183 billion in the next five years, Booz & Co. estimates.

By JENNIFER LUBELL, amednews staff. Posted Sept. 14, 2012. 

Washington- Physicians have new opportunities to partner with health plans to take advantage of the rapidly growing private market for beneficiaries who are eligible for both Medicare and Medicaid, according to a partner at a global management consulting firm.

“There’s been a tremendous interest and appetite around the so-called dual-eligibles population,” said Sanjay Saxena, MD, a partner in the North American health practice at Booz & Co. and co-author of a new Booz report (booz.com/media/uploads/BoozCo_Winning_ in_the_Medicaid_and_Duals_Markets.pdf).

Several years ago, discussions about changes in the private insurance market were all about health insurance exchanges, then about accountable care organizations, and “now it’s about the duals,” Dr. Saxena said.

The Booz report discusses ways in which managed care companies could leverage both the Medicaid and dual-eligibles markets by identifying states that present the best growth opportunities and then defining their operating models or “choosing a way to play” in these markets. Managed care organizations, for example, could enable care delivery by supporting or delegating care management activities to medical groups or hospitals, or going so far as to own or manage networks of hospitals or physician groups in an effort to integrate care management and create incentives to drive care coordination.

As managed care organizations engage in these models, physician groups also should think about how they want to participate in the growing Medicaid and dual-eligibles marketplaces, Dr. Saxena said. He said some medical groups may be proactive and well-positioned enough to reach out to health plans and say, “Look, we build medical homes, we have care coordinators, and have the kind of outreach and relationships with the community where wefeel we could share in the incentives and savings and benefits and high-quality care.”

As high utilizers of care, dual-eligibles have complex health needs and rack up roughly $300 billion in costs annually to Medicare and Medicaid. These challenges notwithstanding, many health plans have been viewing government-subsidized markets as very attractive opportunities, Dr. Saxena said. “For physicians, whether we like it or not, those are the markets that continue to grow in size.” In looking at future avenues for growth, analysts have seen that employer-sponsored insurance markets have been declining steadily, and while the individual market is expected to expand through theAffordable Care Act’s insurance exchanges, that’s going to be a difficult market to navigate as well, he said.

WellPoint’s recent acquisition of AmeriGroup and Aetna’s purchase of Coventry Health Care are two developments that illustrate a growing interest in Medicare and Medicaid managed care, Dr. Saxena said. InAetna’s case, “the major driver was greater exposure in the government market. For WellPoint and AmeriGroup, it’s a very similar story.” WellPoint and its competitors have shown recent interest in managing care for the dual-eligible population.

The health system reform law’s expansion of Medicaid, moves by states toward Medicaid managed care to get budgets under control, and a series of new federal demonstration projects that aim to find more efficient ways to manage the dual-eligible population “are three separate but related things that are creating this opportunity,” Dr. Saxena said. During the next five years, Booz & Co. estimates that the managed care market size for dual-eligibles alone could range from $86 billion to $183 billion.

http://www.ama-assn.org/amednews/2012/09/10/gvse0914.htm

Copyright 2012 American Medical Association. All rights reserved.

States Seek a Middle Ground on Medicaid

Some Governors Aim to Curtail Program’s Expansion, Steer More People Toward Federally Subsidized Private Insurance

 

By LOUISE RADNOFSKY and CHRISTOPHER WEAVER

A handful of states are considering only partially expanding their Medicaid programs under the federal health-care overhaul—a new twist on how states are interpreting the Supreme Court’s ruling on the law.

Indiana, New Mexico and Wisconsin are among the states asking the federal government to let them omit from the Medicaid expansion residents whose incomes put them just above the poverty level. The states hope to take advantage of provisions in the Affordable Care Act that offer a federal subsidy to help these residents buy private insurance, starting in 2014.

The strategy is the latest fallout fromthe Supreme Court’s June decision, which let states opt out of expanding Medicaid without losing federal funding for the program. A half-dozen governors have already said they would opt out, worried their states will be saddled with extra costs.

State Medicaid-eligibility levels currently vary. Under the law, all states were to open their Medicaid programs to Americans who earned up to 133% of the federal poverty level, which is currently set at $11,170 for a single person. The law also made those with incomes 100% to 133% of the poverty level eligible to buy federally subsidized, private insurance through exchanges.

Some states, however, are asking the Centers for Medicare and Medicaid Services if they can include people in Medicaid up to 100% of the poverty level, but keep people with incomes between 100% and 133% of the poverty level out of the program and instead funnel those people toward the exchanges.

Their main reason: States wouldn’t haveto contribute to the costs of the subsidies to purchase private insurance.

“It’s more expensive for the federal government, but it’s cheaper for the state,” said Seema Verma, a top adviser to Indiana Republican Gov. Mitch Daniels. “Obviously the costs are going to play into it, not just for Indiana, but for every state.”

Allowing partial Medicaid expansions could have broad implications for how the law covers uninsured Americans and add to the cost of the overhaul. The nonpartisan Congressional Budget Office has estimated the federal government would pay about $9,000 of subsidies for each person enrolled in the exchanges, compared with $6,000 for those enrolled in Medicaid.

Federal officials are under pressure tokeep states from opting out of the Medicaid expansion. Hospitals are warning it would leave them with a high number of nonpaying customers, at the same time they are having to absorb federal payment cuts, as a result of the law. Around half of the 30 million Americans expected to gain coverage from the health-care law as it was passed were to gain it through Medicaid.

A report for Indiana’s Family and Social Services Administration by actuaries Milliman, to be released Tuesday, found the state would pay nearly $1.1 billion between 2014 and 2020 to enroll alladults with incomes up to the federal poverty level in Medicaid, but that the full expansion would cost another $326.5 million.

The Department of Health and Human Services has yet to say whether it would let states deviate from the Medicaid expansion as it stated in the law. In other standoffs with the states over the health-care law, the department has tried a conciliatory approach, including offering them the option of jointly running new insurance exchanges.

Erin Shields Britt, a spokeswoman for the department, said it was “evaluating” the question. She pointed out the law covers states’ full Medicaid expansion costs for the first three years and at least 90% in subsequent years. That offers “significant new resources” to states that the administration was “hopeful” they would accept, she said.

Edmund Haislmaier, a fellow at HeritageFoundation, a conservative think tank, criticized Republican-led states forseeking to shift health costs onto taxpayers. “You have the tragedy-of-the-commons phenomenon, where everyone does something in their own interest, but in the aggregate, it’s harmful,” he said, adding that he is advising states not to expand Medicaid at all.

Wisconsin officials have run calculations to figure out the costs of a partial expansion, among other scenarios, saidDennis Smith, health secretary to Republican Gov. Scott Walker. He said thescenario could be attractive to health providers, who want to see the number of uninsured patients reduced but would prefer to be reimbursed by private insurers rather than the government, since private insurers typically pay more.

Officials in New Mexico, led by Republican Gov. Susana Martinez, are also considering a partial expansion, along with other options, said a spokesman for the state’s human services department, Matt Kennicott.

Write to Louise Radnofsky at louise.radnofsky@wsj.com and Christopher Weaver at christopher.weaver@wsj.com

A version of this article appeared September 18, 2012, on page A6 in the U.S. edition of The Wall Street Journal, with the headline: States Seek a Middle Ground on Medicaid.

 

http://online.wsj.com/article/SB10000872396390443720204578002583908495660.html

Doctors billing Medicare patients at higher rates, report finds

By NBC News staff

Thousands of doctors and other medical professionals have added $11 billion or more to fees for elderly Medicare patients over the last decade by choosing to use more expensive billing codes and ignoring cheaper ones, a new study says.

The report “Cracking the Codes” from the non-profit investigative journalism organization Center on Public Integrity analyzed Medicare claims for a year and found thousands of providers “upcoding,” which is “the practice of charging for more extensive and costly services than delivered, according to Medicare experts, analysis of the data and a review of government audits.”

Controlling rising Medicare costs has been a hot topic in the presidential campaign. The center’s report, which was released Saturday, suggested that reforms should start with a close look at the way hospitals and doctors submit bills for patient care. For example, the study found that 7,500 doctors charged the two most expensive paying codes for three out of four visits in 2008, up sharply from the number who did so at the beginning of the decade.  The CPIs’ report said medical groups argue that treating seniors has grown more complex and time-consuming because of new technology and because seniors are living longer.  But the report found little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.  Health care providers also said the rise in fees may be a reaction to years of under-charging, and that the higher costs reflect more accurate billing. The fees are based on a system of billing codes that is structured to make higher payments for treatments that take more time and effort.  Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks, according to the report.  “This is an urgent problem,” Dr. Mark McClellan, who directs the Engelberg Center for Health Care Reform at the Brookings Institution in Washington, told the CPI. McClellan, a former director of the Centers for Medicare and Medicaid Services, or CMS, said the agency must send a message that it “won’t stand by and do nothing … that they are paying attention to this.”

Most employers signal they will keep offering health insurance

Beginning in 2014, companies can move workers to health insurance exchanges, but a recent survey shows that few plan to do so.

By BOB COOK, amednews staff. Posted Sept. 10, 2012.

In the first few years after the Affordable Care Act is in full effect, physicians are unlikely to see many of their patients’ insurance status change as a result of employers dropping coverage in favor of employees buying individually through health insurance exchanges. Instead, those employed, insured patients will continue to be more responsible for the cost of their care.

Those conclusions came from a report issued by Towers Watson, a global human resources consulting firm. On behalf of the National Business Group on Health, Towers Watson surveyed 440 companies representing 6.6 million employees. The survey was conducted in July and released Aug. 27.

A month after the U.S. Supreme Court had affirmed the constitutionality of the Affordable Care Act, 88% of employers told Towers Watson they had no plans to terminate their health care plans for those working 30 hours or more a week — up from 71% in 2011. Also, 77% of companies said health care benefits were central to rewarding and retaining employees, and 72% said they were not confident — with only 4% saying they were very confident — that health insurance exchanges would provide a viable alternative to employer-sponsored benefits.

Under the ACA, companies that move their insured employees to exchanges, which are designed to provide people with a choice of individual coverage, in 2014 would pay up to a $2,000-per-employee penalty after the first 30 employees if at least one worker receives federal subsidies for the coverage. The exchanges are scheduled to begin in 2014, and the penalty would rise in future years. The Congressional Budget Office has predicted that about 7% of workers in 2014, the year exchanges go into effect, would lose employer-sponsored coverage and buy it from exchanges.

In theory, employers could stop offering coverage now with no penalty at all. Towers Watson, though, said companies don’t consider dropping coverage as a good human relations move. “Affordable health care remains a top priority for employers and a key component in the employee value proposition,” said Randall Abbott, senior health care consulting leader at Towers Watson.

Moving insured employees to exchanges will cost companies $2,000 per employee after the first 30 employees.

 

What companies are doing instead, according to the survey, is continuing to review the coverage they offer to see where they can save money, including by increasing employee contributions as part of a strategy that equates more spending on their part as an incentive to improve their health.

The percentage of employers offering consumer-directed health plans — a high-deductible plan eligible to be paired with a health savings account or health reimbursement arrangement — will increase to 61% in 2013 from 59% in 2012. But the big jump comes after the ACA is in place, with 80% of employers expecting to offer it by 2015. About 57% of employees will see an increase of one or more percentage points in their contribution in 2013, down from 66% in 2012, but still considered a reflection of companies’ desire to offload some costs onto their workers.

“Due to the increased costs of medical benefits and the additional burden of compliance, business leaders need to keep the pressure on to control costs, increase work force accountability and engage workers to lead a healthier lifestyle,” Abbott said.

Overall, health insurance spending per employee is expected to be $11,507 in 2013, of which employees will pay $2,596. The overall total is up 5.3% for 2013, a decline from 5.9% for 2012.

Other strategies companies are using to cut health insurance costs include discontinuing plans for retirees, with 28% saying it is very likely they would do so, up from 20% in 2011. Also, companies are looking at changing their plans to avoid paying a 40% excise tax beginning in 2018 for any plan with an aggregate value of more than $10,200 in individual coverage and $27,500 for family coverage.

Copyright 2012 American Medical Association. All rights reserved.

 

http://www.ama-assn.org/amednews/2012/09/10/bisc0910.htm 

 

Pediatricians call for uniformity on kids’ essential benefits

CHIP and Medicaid trump other state benchmark options for the minimum pediatricsbenefits that plans must cover under health reform, a report says.

By JENNIFER LUBELL, amednews staff. Posted Sept. 10, 2012.

 

Washington Citing inconsistencies between state plan options for upcoming minimum coverage standards, the American Academy of Pediatrics is urging the federal government to designate a public insurance program as the benchmark for children’s essential health benefits.

In 2011, the Dept. of Health and Human Services issued guidance that gave states the latitude to choose from one of several existing health plans to serve as the “benchmark” plan for their essential health benefits package under the Affordable Care Act. The healthsystem reform law mandates that these minimum coverage standards be offered by all plans on health insurance exchanges and by some additional plans outside of the exchanges. Starting in 2014, plans will be required to cover 10 broad categories of essential health benefits services.

The HHS guidance specified that a state could look at some of the largest health plans operating in its jurisdiction and then select a benchmark plan from one of four plan types: small-group, federal employee, state employee or commercial HMO. Public insurance options, however, were not included in the mix.

In an Aug. 28 report, the AAP found wide discrepancies among some of these plans in terms of what they offer to children — and that none of them met the expansive coverage options of either Medicaid’s standard benefits package for children or of packages offered by individualstate CHIP plans. The report focused on the largest federal employee, stateemployee and small-group plans in five states, then judged how well they covered the 10 categories of essential health benefits compared with each other and public insurance programs.

Public insurance programs covered more than 31% of all U.S. children in 2010, up from 26% in 2008.

 

CHIP and Medicaid trumped other plans on cost-sharing protections and breadth of coverage, the association concluded. Outside of public coverage, federal employee plans were found to have the most comprehensive pediatric benefits, whereas small-group plans offered the least expansive options. Coverage gaps in the small-group plans “were mostly found for rehabilitative/habilitative services and especially for pediatric, oral, vision and hearing services,” the report stated, although these plans provided more generous coverage in other areas, such as ambulatory and emergency services.

The AAP said its findings run counter to what HHS concluded in its guidance: that these benchmark options did not vary significantly in terms of the range of services they provided. “We can’t allow children to have different health benefits depending on where they live,” said Robert W. Block, MD, the AAP’s president.

Even with variations in public coverage among the states, establishing a public insurance option such as CHIP or Medicaid as the benchmark for children’s essential health benefits would provide a broader, more robust range of benefits than some of these other plans, Dr. Block said. Over the long run, this approach would save more money by keeping children healthier, he said.

The AAP and the American Medical Association previously had expressed concerns about the benchmark-setting process. In letters to HHS earlier in 2012, the organizations observed that a majority of the benchmark plans did not cover some benefits that were medically necessary for children. In reading the AAP’s latest findings, other pediatric organizations, such as the Children’s Hospital Assn. and Voices for America’s Children, recommended that states use the CHIP program in particular as thebenchmark for children’s benefits.

Applying just one insurance product uniformly across states as the minimum coverage benchmark does make sense, said Chantel Sheaks, a principal in government relations with Buck Consultants in Washington who specializes in health reform issues. It would level the playing field on benefits, she said, adding that many observers were surprised when HHS decided to defer to the states on choosing benchmark plans instead of just selecting one essential benefits plan for the country.

The situation may get more complex, however, if a program such as CHIP becomes the benchmark just for children while a range of other options applies to adults, Sheaks said. She said oneplan should set the bar on essential benefits for all age groups.

At this article’s deadline, HHS had not responded to calls seeking comment.

The AAP released its report shortly before the Robert Wood Johnson Foundation came out with its own results on the impact of public insurance on closing health care access gaps for children. The ranks of uninsured children are decreasing due to more CHIP and Medicaid coverage despite a recent rise in the number of those living in poverty, the study found. Public insurance programs covered more than 31% of all children in the U.S. in 2010, an increase of more than five percentage points from 2008. In most states, these increases more than offset a drop in the portion covered by private insurance, resulting in an overall decline in kids’ uninsurance rates.

These findings “are no surprise,” Dr. Block said. “As the economy tanks, you have more people who are at the lower end of middle class who are now dumped into poverty. So, where they weren’t eligible for Medicaid and CHIP before, they are now,” meaning the public safety net is doing exactly what it’s designed to do, he said.

 

 ADDITIONAL INFORMATION: 

CHIP, Medicaid lower ranks of uninsured

A study from the Robert Wood Johnson Foundation found that Medicaid and the Children’s Health Insurance Program helped to shrink the numbers of uninsured children in the U.S. As the numbers of publicly insured children have increased over the past few years, the numbers of those with private insurance have declined.

Year

Public

Private

Uninsured

2008

25.8%

64.5%

9.7%

2009

29.1%

61.9%

9.0%

2010

31.4%

60.1%

8.5%

Source: “Keeping Kids Covered: Number of Children with Health Coverage Increases During Economic Downturn,” Robert Wood Johnson Foundation, August (rwjf.org/coverage/product.jsp?id=74768)