Affordable Care Act at 3: Holding Insurance Companies Accountable

By: Secretary Kathleen Sebelius | The White House Blog

March 19, 2013
04:15 PM EDT

 

Ed. note: This post was first published on the official blog of healthcare.gov. You can see the original post here.

Enacted three years ago, the health care law is making the insurance market work better for you by prohibiting some of the worst insurance industry practices that have kept affordable health coverage out of reach for millions of Americans.

As a former state insurance commissioner, I know that for too long, too many hard-working Americans paid the price for policies that handed free rein to health insurance companies. For more than a decade before the Affordable Care Act, premiums rose rapidly, straining the budgets of American families and businesses. And insurers often raised premiums without any explanation.

It wasn’t fair and it was costing you your hard-earned dollars, security, and peace of mind.

The Affordable Care Act is working to bring affordability and fairness to the marketplace by barring insurers from dropping your coverage when you get sick or placing a lifetime dollar limit on coverage. In 2014, it will prohibit discriminating against you or anyone with a pre-existing condition, such as high blood pressure, asthma, or cancer.

In an effort to slow health care spending and give all Americans more value for their health care dollars, the Affordable Care Act has brought an unprecedented level of scrutiny and transparency to health insurance rate increases by requiring an insurance company to justify a rate increase before it shows up on your bill, thereby preventing arbitrary or unnecessary costs. Insurers must provide clear information so you can understand their reasons for significant rate increases.

We know this is making a difference, and that the law is driving down health insurance premium costs in the private market by holding insurers accountable.

A report last month shows that since the rule on rate increases was implemented, the number of requests for insurance premium increases of 10% or more plummeted from 75% to an estimated 14% since the passage of the health care law. The average premium increase for all rates in 2012 was 30% below what it was in 2010. And available data suggests that this slowdown in rate increases is continuing into 2013.

Even when an insurer decides to increase rates, consumers are seeing lower rate increases than what the insurers initially requested. More than half of the rate requests for 10% or more ultimately resulted in customers receiving either a lower rate increase than requested or no hike at all.

In 2014, insurers will be required to report all proposed rate increases, not just those 10% or more, in the individual and small-group markets.

Furthermore, the rate review program works in conjunction with the 80/20 rule, which requires insurance companies to spend at least 80% (85% in the large group market) of premiums on health care, rather than administrative costs (such as executive salaries and marketing) and profits, or provide rebates to their customers. Insurers that did not meet the 80/20 rule have provided $1.1 billion in rebates that benefited about 13 million Americans, at an average of $151 per family.

Insurance benefits and costs also will become clearer to millions of Americans and small businesses starting on October 1, 2013, when they will have the opportunity to shop in a Health Insurance Marketplace in their state. You will be able to find information to make apples-to-apples comparisons of health plans by quality and price and buy the one that best fits your needs and budget.

Delivering smarter health care includes holding insurers accountable, and that is helping to hold down costs. In the past three years, we’ve seen the slowest growth in overall health care spending since the government started keeping records more than 50 years ago.

We still have challenges to face. But for the first time in recent history, we’re making real progress in driving down the rate of growth and driving up the quality of care.

Find out more about the Effective Rate Review Program:

•        Health Insurance Rate Review: Lowering Costs for American Consumers and Business
•        The 80/20 Rule: How Insurers Spend Your Health Insurance Premiums
•          Key Features of the Affordable Care Act

 

Follow Secretary Sebelius on Twitter at @Sebelius.

Article Link: http://www.whitehouse.gov/blog/2013/03/19/affordable-care-act-3-holding-insurance-companies-accountable

Health Care Prices Remain A Mystery In Most States

Bruce Japsen, Contributor | Forbes.com

As public scrutiny intensifies over price transparency in health care, a new report shows 72 percent of the nation, or 36 states, failing to improve information to consumers on what medical treatments and procedures actually cost.

The report from two business coalitions representing some of the nation’s largest employers is the latest troubling sign that most prices in health care remain a mystery to consumers, employers and patients picking up the tab for health care services. They cite national studies showing prices for identical procedures can vary more than 700 percent in some cases.

“It should be concerning to every lawmaker in the country that 18 percent of the U.S. economy is shrouded in mystery,” said Francois de Brantes, executive director of Health Care Incentives Improvement Institute and report card co-sponsor, the Catalyst for Payment Reform.

“More Americans than ever before are paying a significant percentage of health care costs and they can’t comparison shop without price information,” de Brantes said. “We’ve been all focusing so much on utilization, that we’ve ignored price almost completely. We’re now seeing a convergence of issues highlighting the criticality of price transparency, and state and federal legislators are asleep at the switch.  It’s time for a wakeup call and we hope this is it. ”

The report shows only 14 states are achieving a grade of “C” or better when it comes to price transparency, while 72 percent are scoring a “D” or an “F.” The majority of states are providing information about “charges” yet those figures do not reflect what patients, consumers, employers and health plans end up paying for tests, procedures and other medical care services. And when consumers seek pricing information, it is generally only “available on request,” the study said.

“It is only fair and logical to ensure that consumers have the information they need about quality and cost to make informed decisions about where to seek care,” said Suzanne Delbanco, executive director of Catalyst for Payment Reform, a non-profit group that represents large purchasers of health care like AT&T (T), Boeing (BA), E-Bay (EBAY) and Wal-Mart Stores Inc. (WMT).

Just two states — Massachusetts and New Hampshire — received an “A” for sharing an array of price information. Both states, for example, share information about the price of services for both “inpatient and outpatient services” as well as “information for both doctors and hospitals.” In addition, they share data through a public web site or in public reports, allowing consumers to request such information before patients are admitted to a hospital.

“We know from studies that the price for an identical health care procedure performed in the same city can vary by as much as 700 percent, with no difference in quality,” de Brantes said. “When consumers shop for value, they can help rein in health care costs. But to do this, they first need timely and actionable price information.”

The employers and other businesses that are part of the institute and the Catalyst for Payment Reform are advocating for “laws and forthcoming legislation” to “provide powerful motivation to be more transparent,” Delbanco said. “We hope this report card spurs states to act to help consumers further.”

Article Link: http://www.forbes.com/sites/brucejapsen/2013/03/18/health-care-prices-remain-a-mystery-in-most-states/

 

Washington could wind up running more health exchanges: official

Reuters – 17 hrs ago

 

WASHINGTON (Reuters) – The U.S. government could have to run more state health insurance exchanges than expected under President Barack Obama’s healthcare law, if U.S. states pursuing their own marketplaces cannot complete them on time, a senior official said on Thursday.

The Obama administration has given 17 of the 50 states conditional approval to set up online exchanges where working families would purchase private plans at subsidized rates. The remaining 33 states will all have federally run markets, at least in the early years of the coming reform era.

But Gary Cohen, who spearheads exchange implementation for the U.S. Department of Health and Human Services, said some of the approved states face hurdles that could require Washington to step in with federal exchanges before open enrollment starts on October 1.

“I’m absolutely confident that every state will have an exchange that will be functioning and ready,” said Cohen, who declined to elaborate on the number or identity of states that could be in for difficulties.

“The type of exchange may be different,” he told reporters. “(But) there will be an exchange of one kind or another in every state.”

Obama’s Patient Protection and Affordable Care Act requires Washington to provide an exchange in any state that cannot or will not set up their own.

The exchange initiative is expected to insure 26 million Americans, many of whom currently have no coverage, according to the nonpartisan Congressional Budget Office. A planned expansion of the Medicaid program for the poor is likely to cover another 12 million people.

Both the exchanges and the Medicaid expansion are due to begin providing coverage on January 1, 2014.

Republicans and other healthcare reform critics have warned of potential problems for states, saying the administration has been slow to release rules governing implementation.

Many states also held off on implementation in 2012 until after the law survived a U.S. Supreme Court ruling in June and last November’s Republican presidential election challenge to Obama’s re-election.

Cohen said the main hurdles for states are development of information technology systems for applicant enrollment eligibility and continued legal and political challenges from reform opponents.

“The biggest challenges are for states that started later. Obviously, they have less time,” he said.

New Mexico and Idaho, two of the few Republican-led states to move toward establishing their own marketplace, are still awaiting final approval from their respective legislatures.

But even in Connecticut, one of the first states to embrace the healthcare exchange model, media reports have described implementation problems linked to vague or changing federal guidance.

(Reporting by David Morgan; editing by Matthew Lewis)

 

Article Link: http://news.yahoo.com/washington-could-wind-running-more-health-exchanges-official-220411060–finance.html

 

Can you afford the Affordable Care Act? Find out at events

Major provisions of the Affordable Care Act are scheduled to take effect starting next year.

 David A. Mann

Reporter- Business First of Louisville

 

The Kentucky Chamber of Commerce is putting together two, half-day-long seminars that aim to take a closer look at the impact of the federal Patient Protection and Affordable Care Act.

The first seminar starts at 12:30 p.m. May 8 at the Griffin Gate Marriott Resort & Spa in Lexington. Those interested in the Lexington event can register here. A second seminar starts at 8 a.m. May 9 at the Louisville Marriott Downtown. Those interested in the Louisville event can register here.

Registration is $229 for the public or $179 for chamber members.

An agenda or speakers list still is forthcoming, according to information from the chamber. Topics that will be covered include insurance premium increases, health benefit exchanges, growth in the individual insurance market, deadlines, taxes and accountable care organizations.

Major provisions of the Affordable Care Act are scheduled to take effect next year. With that in mind, experts are advising businesses to learn what their responsibilities will be under the new regulations.

David A. Mann covers these beats: Health care, health insurance, distribution/logistics (UPS), manufacturing (GE, Ford), environment, travel, minority/women’s affairs and Southern Indiana.

Article Link: http://www.bizjournals.com/louisville/news/2013/03/12/can-you-afford-the-affordable-care.html

 

Study shows consumer interest in state health insurance exchanges

Dennis Domrzalski

Reporter- Albuquerque Business First

Mar 11, 2013, 1:57pm MDT

 

Nearly half of all Americans who have health insurance say they are interested in using a state health insurance exchange to buy insurance, according to a new report by J.D. Power and Associates.

Forty-eight percent of health plan members say they are interested on shopping on the exchanges – online marketplaces – that are supposed to be operational in October. Of those whose employer offers only one health plan, 50 percent say they might shop on the exchanges. Among those whose employer offers a choice of health plans, 36 percent said they might use the exchanges.

And, people whose health plans have high deductibles (59 percent) said they will look at the exchanges.

The health insurance exchanges are mandated for the federal Affordable Care Act. They are intended to be online marketplaces where individuals and small businesses can shop for insurance. In theory, they will bring about more competition in the health insurance industry and reduce prices.

New Mexico has committed to building its own insurance exchange. However, the process has stalled as state legislators and Gov. Susana Martinez battle over the shape and form of the state’s exchange – especially the composition of its board of directors.

J.D. Powers’ 2013 Member Health Plan Study was based on responses from more than 33,000 members of 136 commercial health plans in 17 regions in the United States.

Article Link: http://www.bizjournals.com/albuquerque/news/2013/03/11/study-shows-consumer-interest-in-state.html

States Push Back Against Health Insurers’ Fee in the Affordable Care Act

CaliforniaHealthline.org

Monday, March 11, 2013

 

Officials in several states are expressing concern about a health insurance providers fee under the Affordable Care Act, arguing that it amounts to a tax that could disrupt Medicaid programs and other state services, The Hill‘s “RegWatch” reports (Goad, “RegWatch,” The Hill, 3/8).

About the Fee

Earlier this month, the Internal Revenue Service issued proposed rules implementing an insurer fee that would collect $8 billion in 2014 and $14.3 billion by 2018. The fee — which would be due on Sept. 30 each year — would vary in size based on insurers’ net premiums. The fee also would carry penalties of $10,000 if deadlines are missed, plus $1,000 for every unmet day.

America’s Health Insurance Plans has described the fee as an annual tax that would exceed $100 billion in the next decade, affecting most families that still are struggling to recover from the recession. The group estimated that the average cost of a family plan would rise by more than $300 next year and surpass $500 in subsequent years as a result of the proposed rules (California Healthline, 3/4).

A study commissioned by Medicaid Health Plans of America estimates that states that provide Medicaid managed care plans would have to pay as much as $15 billion over the next decade because of the fee. Joe Moser, executive director of the organization, said the fee would raise overall Medicaid costs.

In Louisiana, Department of Health and Hospitals Secretary Bruce Greenstein said the proposed levy discriminates against some plans, noting that those offered by not-for-profit insurers are exempt from the fee.

In Wisconsin, the private insurance market would face as much as $3 billion in additional costs over the next 10 years as a result of the fee, according to J.P. Wieske, legislative liaison and public information officer for the state’s Commissioner of Insurance. Wieske said some smaller private insurers have signaled that they might modify their business model to not-for-profit status because of the extra costs (“RegWatch,” The Hill, 3/8).

House Ways and Means Oversight Subcommittee Chair Charles Boustany (R-La.) has reintroduced a bill (HR 763) that would repeal the insurance fee (California Healthline, 3/4). However, the bill could face challenges in the Senate if it is approved by the House and a likely presidential veto if it reaches the White House, according to “RegWatch.” The Obama administration has not yet responded to states’ concerns about the fee.

The regulations are open for public comment for three months (“RegWatch,” The Hill, 3/8).

 

State Roles Similar in Partnership, Federal Exchange Models

In other ACA news, some states that opted for a federally run health insurance exchange — such as Ohio and Virginia — might maintain more oversight of their insurance market than initially believed, Politico reports.

Observers say states with a federally run exchange could have approximately as much oversight as states that opted for a federal partnership exchange (Millman, Politico, 3/10).

Under the ACA, states must create exchanges to provide more affordable coverage options to individuals and small businesses. States can operate their own exchange, ask the government to run an exchange for them or partner with the government to operate an exchange.

Open enrollment in the exchanges is slated to begin in October, with the marketplaces launching in January 2014. Last month, all 50 states and the District of Columbia informed HHS about their exchange decisions. The government will run exchanges in 26 states, seven states will partner with the federal government and 17 states and D.C. will run their own marketplaces (California Healthline, 2/19).

According to Politico, HHS is in fact hoping that local insurance regulators will manage oversight of the federally run exchanges.

Joel Ario — former director of the CMS Office of Health Insurance Exchanges and current managing director at Manatt Health Solutions — said there are many similarities in states’ roles in federally run and partnership exchanges. However, the “big difference … is that the partnership is about collaboration and has a political connotation that states are uncomfortable with.”

Caroline Pearson — a vice president of Avalere Health who has been tracking the development of the exchanges — said, “I can’t discern any meaningful difference between a partnership where a state controls plan management and this (federal-run exchange) plan management option.”

Meanwhile, states that opted to run their own exchanges would have to enforce new insurance requirements under the ACA or they could be forced to give up full regulatory control of their insurance markets to the government, Politico reports.

Ario said, “The idea that a state can get away from doing anything at the state level that has anything to do with interpreting and applying the [ACA] — they can’t,” adding that the law “now permeates the regulatory arena” (Politico, 3/10).
Read more: http://www.californiahealthline.org/articles/2013/3/11/states-push-back-against-health-insurers-fee-in-the-affordable-care-act.aspx#ixzz2NKZjTd9S

Feds Take Lead on Health Insurance Exchanges

State marketplaces may offer more refined choices, but either vehicle should work, experts say
WebMD News from HealthDay

By Karen Pallarito

HealthDay Reporter

FRIDAY, March 8 (HealthDay News) — More than half the states in the nation have decided to let the federal government take on the task of creating one of the most complex yet vital parts of the massive 2010 health reform law, which was championed by President Barack Obama.

In 26 states, the federal government will set up so-called health insurance exchanges, where many Americans can shop for coverage beginning with open enrollment this October. Most of the states handing off exchange duties to Washington are led by Republican governors, including heavily populated states like Florida and Texas.

Only 17 states and the District of Columbia plan to create and run their own exchanges, and the remaining seven states will do it in partnership with the federal government, according to the Henry J. Kaiser Family Foundation’s latest count.

Colorado, one of the first states to enact health exchange legislation, expects to cover 300,000 uninsured residents through its state-run exchange, Connect for Health Colorado.

“I think we feel strongly that we have certain opportunities and challenges that we understand best, and so it does make sense for us to create a system that really is going to work for the stakeholders in Colorado,” said Dede de Percin, executive director of the Colorado Consumer Health Initiative in Denver.

Some states had placed exchange-building on the back burner as they awaited last June’s U.S. Supreme Court decision on the constitutionality of the health reform law, as well as the outcome of the November presidential election.

Republican Gov. Paul LePage of Maine was among those who, in the wake of President Obama’s reelection, decided not to implement a state exchange.

Maine has an estimated 133,000 uninsured people, a number that may swell by as many as 44,000, according to Joseph Ditre, executive director of Consumers for Affordable Health Care in Augusta.

“We are hopeful that the [federally facilitated exchange] will enable a vigorous outreach and enrollment campaign,” Ditre said. Still, he added that Maine’s decision to forgo a state-run exchange means the state won’t play an active role in negotiating with health plans to keep rates down and improve quality — at least not immediately.

White House says exchanges will be ready by Oct. 1

State-based health insurance exchanges are one of the mainstays of the Affordable Care Act, also known as “Obamacare,” for expanding access to health insurance coverage. An estimated 25 million people are expected to gain health coverage through the exchanges by 2022, substantially slashing the ranks of the nation’s 48.8 million uninsured.

The exchanges are intended to serve as a virtual “marketplace,” where consumers and small businesses can access online health plan descriptions and data on quality and consumer satisfaction. All exchanges must have a toll-free hotline that people can call to get their coverage questions answered, and trained “navigators” to assist with the enrollment process.

About 18 million people with incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four) may qualify for premium assistance through the exchanges, according to the Families USA website.

To encourage greater state involvement in the exchanges, the federal government had proposed partnering with states to get the job done, but that option lacked broad appeal. Only four additional states — Iowa, Michigan, New Hampshire and West Virginia — applied for a partnership by the Feb. 15 deadline.

On March 7, the U.S. Department of Health and Human Services (HHS) conditionally approved those four partnerships. Earlier, HHS had conditionally approved partnerships with three states: Arkansas, Delaware and Illinois.

New Jersey is one state that nixed a state-federal partnership, opting instead for a federally run exchange. In a letter to HHS Secretary Kathleen Sebelius, Republican Gov. Chris Christie said his state was committed to complying with the Affordable Care Act, “but only in a manner that is the most efficient and effective for the residents of New Jersey and the businesses that will carry the costs of this new program.” He concluded that “federal operation of the exchange is the most responsible choice” for the state.

Despite the task ahead, the Obama administration insists that it will get the exchanges up and running by Oct. 1.

“No matter where a qualified consumer lives, he or she will have access to coverage through a marketplace,” Sebelius said in a recent blog post.

State vs. federal exchange

Consumers looking to buy coverage through that marketplace may not be able to tell whether it’s a state or federal effort.

“I think it will look like a state exchange to anyone. They won’t necessarily know,” said Sonya Schwartz, project director of State Refor(u)m, an online network for health reform implementation developed by the National Academy for State Health Policy in Washington, D.C.

There will be clear distinctions, though. Some state exchanges have adopted an “active purchaser” model, meaning they will limit consumer choices to health plans offering the best value. The federally facilitated exchanges, by contrast, will include all qualified health plans in a state.

“The other thing is, I think that consumers do probably have a better chance of getting their complaints or problems addressed in state-exchange states,” Schwartz said. In states with federally facilitated exchanges, she explained, “people will still go to their state officials, and officials won’t really know how they can help, necessarily.”

State-run exchanges may also have a leg up when it comes to spreading the word to people who need health insurance. “Everybody’s going to have to be engaged in reaching those people and educating them,” de Percin said.

Article Link: http://www.webmd.com/health-insurance/news/20130308/feds-take-lead-on-health-insurance-exchanges?page=2

 

Medicaid insurers gear up for profit

Phil Galewitz, Kaiser Health News11:14a.m. EST March 8, 2013

Story Highlights

• The Affordable Care Act could mean a boom in Medicaid patients in 2014
• Many health care companies are hiring doctors and other staff
• An influx of older patients could make clinics less profitable

WEST PALM BEACH, FLA. — After his back injury kept him out of work last year, Sergio Mera enrolled his family in Medicaid, the state-federal health insurance program for the poor.

These days when they need a doctor, the Meras travel less than a mile from their home to a new clinic. “They take good care of you,” says Mera, 37, as he sits in an exam room with his wife and two kids.

The clinic, affiliated with Molina Healthcare, one of the nation’s largest Medicaid managed-care plans, is one of about a dozen facilities the company is opening across the country to handle a wave of new customers in 2014. That’s when about 10 million more people are expected to sign up for Medicaid managed care under the Affordable Care Act, and as states shift enrollees into private plans, according to trade group Medicaid Health Plans of America.

For industry titans such as UnitedHealthcare and WellPoint, as well as smaller, Medicaid-focused plans such as Molina, the Medicaid expansion is expected to bring significant enrollment and revenue growth. “This is several hundreds of billions of dollars of new market opportunity for these plans over the next couple of years,” says Jason Gurda, managing director of health care at investment bank Leerink Swann in New York.

The plans already cover about half of all Medicaid recipients, or almost 30 million people. The Congressional Budget Office projects that 8 million more will enroll in the program next year, with the number growing to 12 million by 2020, as a result of the health law.

To better position themselves for the surge — and to avoid the overwhelmed doctors’ offices that were common in Massachusetts after that state expanded coverage in 2006 — many plans are adding doctors and other staff now. “We know demand for care is only going to increase, and we are trying to build capacity to get ahead of the curve,” says J. Mario Molina, CEO of the health plan his father started in 1980 with one clinic in Long Beach, Calif.

Preparations for a Medicaid managed-care boom include:

Molina, with nearly 2 million members, is building clinics in Florida, California, Michigan, New Mexico, Utah and Washington to supple-ment its network of independent doctors.

Health Plan of San Joaquin in California is using telemedicine so patients can “see” dermatologists while at a primary care physician’s office, due to a shortage of dermatologists willing to treat Medicaid patients, says CEO John Hackworth.

Meridian Health Plan, a Detroit-based physician-owned health plan, lets members choose a nurse practitioner as their primary care provider. It’s hiring community health workers to keep them well between appointments. “We have the same concerns as everyone else: making sure patients have enough access to providers,” says President Michael Cotton.

UnitedHealthcare, the nation’s largest Medicaid insurer, with nearly 4 million members, is opening health benefit stores around the country to assist Medicaid enrollees and offer free public health education.

Something of a gamble

The growth is not without risks for the insurers, Gurda says.

Until now, most Medicaid managed-care enrollees have been children, pregnant women and young parents. But many of the newly eligible will be older, and some may come with health needs that haven’t been addressed. “You certainly run the risks that medical costs can be higher than expected,” Gurda says.

States pay Medicaid health plans a monthly rate per member. The plans profit if they keep costs below that. Plans have an incentive to keep members out of the hospital.

When plans determine states are paying them too little, they pull out. For example, Centene announced in October that it would quit Kentucky’s Medicaid program, citing financial issues. WellPoint previously pulled out of state Medicaid programs in Connecticut, Nevada and Ohio after deciding the payment rates were inadequate to cover medical costs.

To keep members well, Centene, a Medicaid health plan with 2.5 million members in 18 states, recently started paying enrollees a few dollars each time they seek preventive services, such as $10 for a flu shot or $20 for an annual breast cancer screening. The money goes into an account that recipients can use to pay for utilities, transportation, baby supplies, child care or various health services.

More than 400,000 people have enrolled in Centene’s CentAccount program, which paid out $7.8 million last year. The idea is to avoid expensive emergency room visits and catch problems before complications set in, thus cutting costs. “It’s a way to help our members get the care they need and save money,” says Jonathan Dinesman, a Centene vice president.

Finding physicians

Another big challenge health plans face is recruiting doctors, since Medicaid pays them less than Medicare or commercial insurance carriers. To entice doctors to participate, the federal health law this year temporarily increased pay for those providing primary care services to the same level as Medicare rates — an average 70% pay raise. The pay raise only lasts through 2014, which has limited its effectiveness, Molina says.

Some insurers, such as Philadelphia-based AmeriHealth Mercy Family of Companies, with about 1 million members, have begun paying doctors and hospitals bonuses to meet quality targets, such as making sure their patients take prescribed medications. “The incentives give us added leverage with providers,” says Marilyn Eckley, senior vice president of operations at AmeriHealth Mercy.

Health plan officials say they’re also trying to broaden the pool of doctors by easing administrative hassles, by making it easier to get prior authorizations for tests and by providing real-time data showing which preventive exams a member needs.

Molina is building clinics with doctors on staff in areas that lack Medicaid doctors or federally funded community health centers. It decided on the West Palm Beach location after records showed many members were using ERs for routine care.

The clinic takes patients by appointment and walk-ins. Jose Hernandez, the family physician who works at the clinic, says he enjoys caring for the poor and wanted a job closer to his home near West Palm Beach. While the clinic is still building business, Hernandez says he expects that will soon change. “This is the calm before the storm,” he says.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.

AHIP REPORT TOUTS MEDICAID MANAGED CARE AS COST-CUTTING OPTION

Inside CMS

March 8, 2013

America’s Health Insurance Plans’ (AHIP) unveiled Tuesday (March 5) a 40-page report detailing wide-ranging efforts by Medicaid managed care plans to implement innovative programs that aim to improve care and reduce health care spending. The report, which industry notes comes at a time when lawmakers are looking at ways to improve care and save money, highlights plan efforts and achievements in three categories: working with community partners, addressing obesity, and caring for people with complex needs.

AHIP President and CEO Karen Ignagni says the report, Innovations in Medicaid Managed Care, could demonstrate to members of Congress that Medicaid health plans offer a compelling solution for states and federal governments who are looking at ways to reduce spending, and improve health outcomes. The report says it is industry’s hope that a review of best practices will be “especially productive” during this transition period for Medicaid, which could result in as many as 7 million more people enrolled in the program, even taking into account the Supreme Court decision that made the expansion optional.

She says the report shows that Medicaid plans have been providing “game changing” services and supports to vulnerable populations. It also shows that plans are already accomplishing the number one goal that the policy community has been talking about for low-income, disabled beneficiaries: Providing the supports and services to beneficiaries who want to be at a home, rather than in an institutional setting.

The amount of activity in that areas is “striking,” she says.

Care coordination, which the Medicaid plans pioneered, Ignagni says, is the best way of providing health care for vulnerable populations. “The consequences of not doing this are simply far too high to not have everyone in a health plan,” she says.

AHIP notes that more and more states have been relying on Medicaid managed care plans and as of 2011 about 50 percent of beneficiaries were in such plans. From 2010 to 2011, enrollment in Medicaid plans was nearly double traditional Medicaid enrollment ( 9 percent compared to 4.6 percent), according to the report.

The report also arrives as AHIP and other groups — including Medicaid Health Plans of America (MHPA) — are working to repeal the health law’s premium tax, which a Milliman report suggests could result in $38.4 billion more in federal and state health spending. Many states are looking to Medicaid managed care as they seek to align payments for beneficiaries eligible for both Medicare and Medicaid services, either via the demonstration or in other ways.

One plan, Medica, has been working with nurses and social workers who serve as care coordinators to help seniors enrolled in Minnesota’s Senior Health Options program for dual eligibles live independently at home, according to the report. The coordinators help seniors with a range of activities, including transportation, meals, adult day care, and “even services to mow the lawn and shovel the driveway.”

The coordinators sometime join members on doctors and other medical visits to help explain any medication instructions and ensure that all questions are answered.

Results show that from 2006 to 2012 the portion of members who lived in their own community grew from 39.4 percent to 71 percent. Other plans included in the “caring for people with complex needs” category focus on transitioning patients from care settings — including an Affinity Health Plan — that helps move people from in-patient psychiatric hospitals to home settings, and provides patients with more care choices, including a plan in Tennessee that allows patients or other representatives to hire personal care aides.

Passport Health Plan in Kentucky partnered with Louisville’s EMS services in a public-private partnership that came to being after EMS realized that many people called 911 services for non-emergency situations, which overwhelmed the system and threatened its ability to respond to true life-threatening needs. EMS applied for, and received, a grant from Passport to create a new Priority Solutions Integrated Access Management (PSIAM) intuitive that helps triage callers. People that do not have immediate need for an ambulance or fire services are transferred to a PSIAM nurse who asks questions based on “nationally recognized clinical standards” that determine the best way to respond.

“Our triage nurses are not only medical professionals but they’re care navigators, patient advocates, negotiators, transportation coordinators, salespeople — it’s a unique combination of skills,” Kristen Miller, chief of staff of Louisville EMS, says in the report. “With a little guidance and confidence on our end of the line, most patients realize that it’s a tool that’s there to help them, not simply remove them from the 911 system.”

The report says that since 2011 the program has served more than 1,200 callers with non-emergency conditions, and saved patients an estimated 30 percent in transportation costs from 21010 to 2011. The city made the program permanent, and this year Louisville was one of five cities to get funding from Bloomberg Foundation to help improve customer services. The city plans to expand the program by adding weekend hours, hiring another nurse, adding a direct phone line and offering case management services for chronic care patients who frequently call EMS.

Health Partners in Philadelphia is one of the plans highlighted for its work to address obesity for it’s “Biggest Winner” nutrition program launched in 2009.

For the program, the health plan offers a 13-week session during which beneficiaries are counseled on ways to improve nutrition and pay attention to calories. The program is small — 46 people completed the sessions in 2011- but the report notes that most of the people who finished it lost weight or reduced triglyceride or blood sugar levels. Other programs touted in the report offer community and family fitness classes, nutrition educations and other tools that have helped people to lose weight and control diabetes and other medical issues.

Ignagni says that AHIP decided to put the report together last summer as part of an innovation series, which has previously focused on plan innovations in health information technology, Medicare Advantage and other subjects but had not probed Medicaid plans for a while. She says she was not surprised by the number of innovative programs offered by the plans, but that reading the report with all of them put together tells an important story. — Amy Lotven

Copyright © 2013 Inside Washington Publishers. All Rights Reserved.

Charity Spotlight: Passport Health Plan CEO, Mark Carter

Charity Spotlight: Passport Health Plan CEO, Mark Carter

NFOCUS Magazine | NFOCUSMAGAZINE.COM
Debra Childers
pg. 45, March 2013

Mark Carter came to Passport Health Plan as interim CEO in the wake of a critical state audit revealing the plan was in jeopardy. He put in place internal controls and made some fixes he terms “easy.” The reason he stayed, however, was the story of one person’s need and one employee’s generous response. The Courier-Journal ran a story of a woman with unmet health-care needs. She was one of the many vulnerable members of our society who lacks access to healthcare and whose needs are most often neither seen nor heard by the more fortunate.

But not this time. A Passport employee read the story and tracked down the woman in need. Although she was not eligible for Medicaid and Passport, her guardian angel was able to connect her to other social services agencies. Carter discovered that this “above-and-beyond” effort was the essence of the Passport culture. That began his “attraction to Passport,” and four months later, despite the comple-tion of his goals during an interim role at Passport, he decided to stay.

“I feel a compelling personal desire to do something meaningful in our com-munity. My best opportunity to serve is right here, right now.” Though many are aware of Passport in our community, few understand the one-of-a-kind health care network that serves over 100,000 children, and Medicaid-dependent adults in Kentucky.

Carter’s confidence in the vision and mission of Passport is supported by a unique business model. Sponsored by a group of compassionate physicians that assumes 51% of the financial risk, Passport has provided a consistent, provider-sponsored, community-based Medicaid health plan for more than 15 years. The plan employs over 230 individuals and offers a large provider network, including approximately 914 primary care physicians, 3,977 special-ist physicians, and all hospitals in the 16-county region it serves—all of whom are dedicated to improving the health and quality of life of Passport members. In addition to working closely with local providers, Passport also works with area health departments and social service agencies to promote events that support healthy living such as Healthy Hoops Kentucky, a program for children living with asthma, and the 2013 March of Dimes’ Walk for Babies. 

Carter’s work day begins at 5:00 with a vigorous encounter on his treadmill, and with the demands of Passport and his many philanthropic commitments, it doesn’t conclude until around 8 pm. Yet he says that his enduring marriage to wife Kellie keeps him centered and balanced. Mental and emotional renewal come from his family retreat on Lake Cumberland, enjoying his three children and four grandchildren, piloting his sin-gle-engine Beach Bonanza, and listening to old style country music.

Volunteering his time on behalf of the American Heart Association, Carter served as President of the 2013 Heart Ball Gala, which raised over $515,000! His philanthropic energies line up with his professional choices. The Heart Association has a “Big Goal of reduc-ing heart disease by 20% in 2020,” and Carter says that “gets his motor running.”

“When I leave here, ten years from now, I want to point to real improvements in the health status of Kentuckians. Obesity and diabetes threaten our population. Many of them are children, whose lives are just start-ing out. The implications are daunting. If we want a vibrant economy, we must have a very productive workforce. The choices we make now affect our health status as these young people grow up to live and work in their 40s and 50s. We are small and nimble with close con-nections to our providers. Together we make a difference.”  

—Debra Childers

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