The court struck down part of the Medicaid expansion.

BREAKING: Supreme Court upholds healthcare reform law

By Joe Carlson

Posted: June 28, 2012 – 10:15 am ET

 

The U.S. Supreme Court ruled that the insurance provisions of the Patient Protection and Affordable Care Act are constitutional, handing President Barack Obama a major election-year victory and shunning 26 states that had sought to overturn the reform law.

The court ruled that Congress has the power to compel individuals to purchase insurance as a tax on people who do not have health insurance.

“The individual mandate cannot be upheld as an exercise of Congress power under the Commerce Clause,” Chief Justice John Roberts wrote in the majority opinion (PDF). “In this case however, it is reasonable to construe what Congress has done is increasing taxes on those who have a certain amount of income but choose to go without health insurance. Such legislation is within Congress’ power to tax.”

The landmark decisions end two years of legal uncertainty and clear the way for full implementation of the 906-page law. That includes establishing insurance exchanges in each state, prohibiting insurance companies from discriminating against the sick, and requiring nearly all Americans to prove on their income taxes that they carry health insurance starting in 2014.

Read more: BREAKING: Supreme Court upholds healthcare reform law – Healthcare business news and research | Modern Healthcare http://www.modernhealthcare.com/article/20120628/NEWS/306259982#ixzz1z6KyDQIq
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Primary care physician shortage looms in Louisville

Written by
Patrick Howington
The Courier-Journal
2:42 AM, Mar. 28, 2012

They are the quarterbacks of the health care system — generalists who monitor the entire body, give preventive care, spot problems early and send patients to specialists if needed.

Despite their key role, primary care physicians are in increasingly short supply, and a new study says the shortage is expected to become critical soon in Louisville — as it has been in many rural areas of Kentucky for years.

The impending Louisville shortage is due to a perfect storm of factors — an aging population that will need more care, a large number of doctors approaching retirement, and medical students shunning primary care practices for specialties with higher pay and better hours.

By 2020, Jefferson County will need 455 new primary care doctors — almost as many as the number that work in local medical practices now. The new doctors will be needed to replace current doctors who are expected to retire and to meet federal guidelines for serving the projected 2020 population, according to the study the Louisville Primary Care Association commissioned.

And that doesn’t take into account the extra demand for more doctors when health reform could cause millions more Americans to have health insurance in 2014 if upheld by the Supreme Court.

“We see a real workforce crisis in the future — in the immediate future,” said Bill Wagner, executive director of Family Health Centers, a group of community clinics serving low-income residents. “It is a perfect storm.”

Family Health Centers is a member of the primary care association. Others are the Park DuValle Community Health Centers, the Louisville Metro Department of Public Health & Wellness, and the University of Louisville’s dental school and primary care centers.

The study, conducted by REACH Inc. and based on a survey of local physicians, found that about one-third of all the primary care doctors — general internists, family practitioners and pediatricians — are 56 or older and plan to retire within 10 years.

The combination of impending retirements, expected population growth and the trend toward doctors working strictly inside hospitals or urgent-care centers rather than holding office hours means that:

• Jefferson County will need to attract 220 new family practitioners by 2020, or more than the current supply of 167 who don’t work solely at institutions such as the VA Medical Center or hospices.

• An additional 192 general internists and 43 pediatricians will be needed.

• While Louisville has 697 primary care doctors overall, only 517 of them are in typical office settings where they can have an ongoing relationship with patients — and 178 of those are expected to retire by 2020.

To replace those retirees and add other new doctors to meet federal guidelines calling for 100 primary care physicians per 100,000 people, the study projected that 455 new primary care doctors will be needed by 2020.

And not enough younger doctors are in line to fill that gap.

Shift to higher pay

Saddled with $100,000 or more in medical school loans, graduates in recent years haven’t chosen lower-paying primary care as often as older generations did, statistics show.

In the past 15 years, the number of U.S. medical school seniors who entered residencies in family medicine has fallen from 17 percent in 1997 to 8 percent last year, according to the Association of American Medical Colleges. However, the number has rebounded slightly since 2009.

The picture is similar at the U of L School of Medicine. The number of entering medical students the school believed would go into primary care upon graduation, based on statements at the time of admission, has declined 50 percent in the past 11 or 12 years, said Dr. Steve Wheeler, associate dean for admissions.

“The debt load in medical school has increased, the ability to repay debt is influenced by salary once you get out, and primary care is at the low end of that spectrum,” said Wheeler, who is also associate professor of family and geriatric medicine.

On average, primary care doctors are paid as little as half as much as specialists, such as radiologists and invasive cardiologists, according to a national compensation survey.

Yet they typically see many more patients a day and must complete exhaustive paperwork to oversee patients’ overall care.

The time demands and administrative burden are perhaps as important as the pay gap in students’ decisions to shun primary care in recent years, experts said.

“I think it has become a much more difficult environment to enjoy working with your patients in,” Wheeler said.

“It’s more difficult, more stressful, and less rewarding” than it used to be, Dr. Greg Ciliberti, a Louisville internist for 26 years. “And then you’ve got the other stress of, you’re trying to run a business and you never get a raise.”

Not just rural

In Kentucky, physician supply has typically been seen as a rural problem, given that some counties are served by a handful of doctors — while Louisville is home to large hospital companies and a university medical school.

But both in Louisville and nationwide, “I don’t think there’s any question that it’s not just a rural issue,” said Dr. Dan Varga, chair of the Kentucky Medical Association’s physician workforce committee.

“No matter where you’re talking about, we clearly have an aging primary care workforce,” because primary care has been “so unpopular” a career choice in recent years, said Varga, chief medical officer of Kentucky’s St. Joseph hospitals and a former Louisville internist.

“There just aren’t as many students who see that as their call,” Wheeler said.

Given that trend, Wagner said he doubts that medical schools will train enough primary care doctors to fill the gap.

Wagner said his clinics already have a difficult time recruiting primary care doctors in the face of competition from higher-paying hospital operations that increasingly are hiring doctors as full-time employees.

That can leave doctors at Family Health Centers and similar clinics stretched even further to handle their patient load.

“There’s not enough of us,” said Dr. Sarah Fortuna, a staff doctor at FHC’s Iroquois clinic on Taylor Boulevard, during a brief break between seeing patients, updating charts and conferring with a medical technician. “We’re getting more and more patients, but we’re not getting any more staff.”

Fortuna said she probably doesn’t get enough time with her patients.

“I try,” she said. “But is the clock ticking in the back of my head? Yes. I know I have to get to day care at the end of the day, and my techs have other things they have to get to as well.

“I try to stop long enough to give them the time, but there’s days when I go home and go, ‘I know I’ve made (patients) come back in three weeks because I want to talk to them more.’ ”

Fortuna, 39, a single mother and former Air Force doctor, said she doesn’t regret her decision to go into primary care. She likes treating a wide variety of conditions and is “a people person, so I wanted to have long-term relationships with my patients.”

Making the switch

Fortuna said it would be nice to make more money, but that’s not enough to make her switch to a specialty.

But many primary care doctors have done just that.

Fortuna said she trained in a group of eight primary care residents at Eglin Air Force Base in Florida, ending in 2003 — and four of them have since entered specialties.

“They were faced with longer and longer hours in private practice, and most of them didn’t want to do that,” she said. “They wanted to have a life. So they opted out.”

Dr. Dan Garcia, a Louisville allergist, was a pediatrician for 17 years before becoming an allergist in the early 1990s — a move he said he made for his health and to see his family.

With long hours at the office combined with hospital rounds, “I wasn’t getting to see my children” because of caring for other people’s children, said Garcia, 64.

“We had our fifth child, and I came down one morning … Patrick was about 4 months old, and he looked at me like I was a complete stranger, because I hadn’t seen him for over a week,” Garcia said.

A heart bypass operation convinced Garcia he needed a slower pace, and he underwent two years of training to become an allergist. Instead of working 12 hours or more a day, he now works 8 to 10.

“It’s been well worth it,” he said. “The tail doesn’t wag the dog any more.”

Cost of solutions

Though there is a consensus that more primary care doctors are needed, the solutions aren’t easy — and often call for money that isn’t there.

Medical associations have advocated repaying emerging doctors’ medical-school debt as an incentive for them to enter primary care. The National Health Service Corps has such a repayment program, but only for doctors who agree to practice in underserved areas.

And national proposals to increase medical schools’ federal funding for training primary care physicians have lost out to deficit-cutting measures in recent years, said Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. She said the organization’s top priority is to avoid cuts to existing funding, though it believes federal training money should actually be increased.

With pay levels persuading many doctors to leave primary care or not enter it, some private health insurers and the federal Medicare program are moving to boost reimbursements for primary care physicians compared with specialists.

Last year, the Obama administration established a Medicare pilot program, called for under the 2010 health reform law, to pay primary care doctors to supervise teams of “physician extenders,” such as nurse practitioners, to treat target populations. The so-called “patient-centered medical home” program would directly reward primary care doctors for their time-consuming role in coordinating patients’ care.

Health insurer Aetna announced a pilot program in January to give extra monthly pay to physicians whose practices qualify as patient-centered medical homes, while last July Louisville-based Humana announced a program to award nearly $10 million to primary care practices that show quality improvements.

WellPoint, the parent company of Anthem health plans, also announced a national program in January to pay more to some primary care doctors who keep patients healthy.

But Anthem’s Kentucky organization took a broader and earlier approach in 2008 by boosting all primary care office-visit reimbursements to a level higher than specialists get, said Mike Lorch, an Anthem vice president.

“What we’re counting on, and what we firmly believe, is that … as you improve reimbursement so they can take better care of the patient, you’re going to see a payback in cost of care,” Lorch said.

Without regular access to a primary care doctor, he said, “a lot of times you’re going to end up in the (emergency room), and that’s the most expensive setting.”

SOURCE:

http://www.courier-journal.com/article/20120327/NEWS01/303280053/Louisville-primary-care-physicians-shortage?odyssey=tab|topnews|text|News

Region’s hospitals, insurers keep close eye on impact of federal decision

9:21 PM, Mar. 26, 2012  |  

Written by

Laura Ungar for the Louisville Courier-Journal

It’s been cited as a driving force behind the proposed but thwarted merger involving University Hospital and a Catholic health care system.

It’s inspired new partnerships called “accountable care organizations,” including one being piloted by Norton Healthcare and Humana.

And it’s been hailed as providing extended coverage for more than 35,000 young adults in Kentucky.

The federal health reform law has already started making an impact locally — so area health advocates and officials are tuned in to this week’s Supreme Court proceedings.

“I think the entire health care sector and insurance sector are watching this closely because it has significant implications on both industries,” said Stephen Williams, chief executive officer of Norton. “This is very far-reaching.”

Jodi Mitchell, executive director of Kentucky Voices for Health, a coalition of health advocacy groups, said her organization takes no position on the arguments before the Supreme Court, instead concentrating on educating the public about health reform. But she added: “We expect the law will be upheld.”

One of the most well-known provisions of the Affordable Care Act, as the reform law is called, requires insurers that offer coverage to children on their parents’ plans to make that coverage available until the child is 26.

That portion of the law took effect in September 2010. According to the U.S. Department of Health & Human Services, 35,610 young Kentuckians already have gained coverage through that provision. In Indiana, 38,480 young adults gained coverage.

“This is helpful for college students going to school who can’t afford coverage,” Mitchell said. “And because they’re generally healthy, they’re advantageous on plans where you’re trying to spread out the risk.”

This week’s arguments before the Supreme Court won’t involve that provision, nor several others of the broad-ranging law, but instead will focus on a key and controversial provision — requiring nearly all Americans to have health insurance by 2014.

According to the U.S. Census Bureau, an average of 15.5 percent of Kentuckians — or 663,000 people — lacked health insurance from 2008-2010, as did 12.8 percent of Hoosiers, or 813,000 people. Nationally, 15.8 percent of Americans lacked health insurance during that period.

Health care experts say the reform law eventually would bring the rate of uninsured Americans down by about 60 percent.

Louisville-based Humana Inc., one of the nation’s largest health insurers, said it has long supported universal health coverage for all Americans.

And the company said that other parts of the reform law, such as requiring insurers to cover all applicants regardless of their health condition, cannot work without the “individual mandate” provision. Otherwise, healthy people could pass up insurance while sicker people would get it, raising premiums for all.

Officials at local hospital systems, which provide charity care for many uninsured patients and have unpaid bills from others, have said projections of how many people would gain coverage under the reform law are encouraging.

But they add a caveat — saying it’s unclear if projected gains in patients who would get insurance under health reform would be offset by funding reductions in a state and federal program for hospitals that treat large numbers of low-income people.

Officials at University Hospital, which cares for large numbers of uninsured patients, talked about this uncertainty during the debate involving the proposed merger with Jewish Hospital & St. Mary’s HealthCare and Lexington-based St. Joseph Health System, which is part of Catholic Health Initiatives of Denver. Gov. Steve Beshear ultimately rejected the proposed three-way merger, and Jewish and St. Joseph merged without University to create KentuckyOne Health.

Officials at those health care organizations — as well as others such as Norton and Baptist Hospital East — have said the reform law encourages them to partner with others to become more efficient, improve care and reduce costs.

Norton and UK leaders said the law is one of the main reasons behind their partnership, announced in June. That partnership includes a statewide stroke collaboration and a cancer program that would share resources.

Norton and Humana are also piloting an “accountable care organization” for commercially insured patients, a program that establishes financial incentives for health care providers to improve quality, eliminate waste and control costs. Louisville is one of four national sites in the ACO Pilot Project of The Engelberg Center for Health Care Reform at the Brookings Institution and The Dartmouth Institute for Health Policy and Clinical Practice. Officials said the program brings a emphasis on wellness and preventive care for patients.

Last October, the U.S. Centers for Medicare & Medicaid Services finalized new rules under the health reform law to help doctors and hospitals better coordinate care for Medicare patients through ACOs. The Medicare program is designed to reward ACOs that lower the growth of health care costs while still providing quality care.

Williams said Norton will still go forward with the ACO and partnerships no matter what happens with the health reform law.

“Even if major parts of it get repealed, I believe what we are doing and what other providers are doing we will continue to do,” he said. With health care expenditures making up 18 percent of the Gross Domestic Product in the United States, “we have to bend the cost curve or we are going to cripple the economy.”

SOURCE:

http://www.courier-journal.com/article/20120326/NEWS01/303260073/Region-s-hospitals-insurers-keep-close-eye-impact-federal-decision-

Some Insurers Paying Patients Who Agree To Get Cheaper Care

By Michelle Andrews

Mar 26, 2012

In recent years, insurers have tried to cajole consumers into using less-expensive health-care providers by promising lower co-payments and other cost-sharing breaks for members who select those doctors and hospitals.

Lately, they’re trying an even more direct approach: cash rewards.

Some Anthem Blue Cross and Blue Shield members in New Hampshire, Connecticut and Indiana can receive $50 to $200 if they get a diagnostic test or elective procedure at a less expensive facility than the one their doctor recommended. The offer covers nearly 40 services, from standard radiology tests such as mammograms and MRIs to such surgical procedures as hip and knee replacements, hernia repair, bariatric surgery and tonsillectomies.

“We identified a subset of highly utilized services with cost variances that we thought would have a big impact,” says Denise McDonough, regional vice president of sales for Anthem BCBS of New Hampshire. “We want to provide information to members to drive health-care costs down.”

It seems to be working. The city of Manchester, N.H., the first employer to pilot Anthem’s Compass SmartShopper program in January 2010, has saved more than $250,000 in health-care costs in two years, even after factoring in the cash rewards paid to the 476 members who have participated.

The differences in costs can be eye-popping. According to Anthem data, in Manchester a hernia repair ranges in price from $4,026 on the low end to $7,498 on the high end. A colonoscopy could cost $1,450 to $2,973.

“It was a huge eye-opener for us,” says Jane Gile, human resources director for the city government.

It, of course, can also save money for employees who haven’t met their plan’s deductible.

Here’s how the SmartShopper program works. At least 24 hours before a member has a scheduled service, he or she calls a toll-free number or logs on to a Web site to get a list of lower-cost local providers.

If a doctor has referred someone to a location that’s not on the list of cheaper providers, the member can request that the doctor change the referral. If the physician is performing the procedure, the member can ask that the doctor do it at a cheaper location.

After the provider submits the claim and Anthem pays it, the insurer compares the records of online and telephone inquiries made by the member to the SmartShopper program. If the member chose to get care at a low-cost provider identified by the program, he gets a check in the mail within 60 days. (The amount is usually about $100, but it varies with the size of the amount saved.) An employee who has not yet met his annual deductible would also save directly on the cost of the treatment.

If the member wants to stick with his doctor’s initial plan and forgo the cash bonus, no problem. The program is entirely voluntary.

Last year, Harvard Pilgrim Health Care launched SaveOn, a similar program that covers a limited number of services in New Hampshire and that recently expanded into Massachusetts.

Physician groups have some concerns. “It appears as though the decision is being made by the health plan, and tiering of providers is being made simply on an economic basis,” says Scott Colby, executive vice president of the New Hampshire Medical Society.  “We have concerns about giving economic incentives without giving weight and credence to quality measures.”

It’s a fair criticism, insurers concede. Listed providers are licensed and credentialed, but quality indicators such as complication rates aren’t factored in. “It’s a first-generation set of data,” says Eric Schultz, president and chief executive of Harvard Pilgrim Health Care. “We all have a long way to go on performance data.”

Likewise, the Compass SmartShopper FAQ page says, “It is up to you to talk to your doctor or research online at anthem.com to determine your quality requirements.”

For simple diagnostic lab and radiology procedures, choosing providers based primarily on cost is probably fine, says Ha Tu, a senior researcher at the Center for Studying Health System Change, a Washington-based think tank. “But when you start talking about surgery, it’s hard to argue that quality doesn’t vary quite a bit, and people shouldn’t be making these decisions purely on cost.”

Physicians are also concerned that programs such as SaveOn and SmartShopper may hinder care coordination among providers at a time when such coordination is considered key to managing patients’ health and controlling health-care costs.

When the SmartShopper program was introduced, some Manchester city employees were skeptical, says Gile. But many have come around.

Gile herself has used the program three times: twice for screening mammograms and once for a colonoscopy. She had a good experience each time. By choosing a lower-cost provider for the tests, she qualified for cash rewards of a few hundred dollars altogether, she says.

SOURCE:

http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/2012/Cash-Rewards-For-Cheaper-Care-Michelle-Andrews-032712.aspx

The Health Law And The Supreme Court: A Primer For The Upcoming Oral Arguments

Later this month, the high court will consider the fate of the health law. Here are key points to keep in mind while watching the action.

Topics: Supreme Court, Politics, Health Reform

By Stuart Taylor, Jr.

Mar 15, 2012

How big is the constitutional challenge to the Obama health care law, which the Supreme Court will hear on March 26-28?

For starters, it’s big enough for the justices to schedule six hours of arguments — more time than given to any case since 1966. After all, the Affordable Care Act is arguably the most consequential domestic legislation since the creation of Medicare in 1965.

It’s also big enough to attract more briefs than any other case in history. At least 170, including more than 120 “friend-of-the-court” or amicus briefs, have been filed, many of which are joined by 10, 20 or more groups of every imaginable description.

And, finally, it’s big enough to cause the justices to postpone until October half of the 12 cases that they would ordinarily hear in April in order to clear time to get started on the health care opinions that they are expected to issue by the late June, or possibly, early July.

 

What’s it all about?
The immediate issues, in the order the court will hear them, begin with the question of whether the so-called “individual mandate” — which requires that almost all Americans without coverage buy individual health insurance policies or pay fines — is ripe for adjudication now. Or must the case be deferred until 2015 because of the 1867 Anti-Injunction Act, which bars federal courts from ruling on the constitutionality of tax laws before payments are due?

After that come the arguments about what many consider the central issue: whether the mandate, which is unprecedented, should be voided because it represents an unconstitutional exercise of Congress’ powers to regulate commerce and to levy taxes.

Next is what becomes of the law’s hundreds of other provisions, covering 2,700 pages, if the mandate is unconstitutional? Are some or all of them “severable,” meaning that Congress would have wanted them to stand even if the mandate falls? For example, what about the provisions establishing tax credits to help small businesses and individuals buy health insurance and taxing large employers that do not provide full-time employees government-approved coverage?

Apart from those issues, does the law’s expansion of Medicaid violate the sovereignty of the states by effectively requiring them to spend more of their own money or forfeit all of the federal Medicaid money they now receive?

What’s the likely outcome?
Nobody knows. It’s clear that the court’s four more liberal members, like almost all other liberal legal experts, will find the law constitutional in all respects. It’s also clear that conservative Justice Clarence Thomas will vote to strike down much or all of the law. It’s less clear what swing-voting Justice Anthony Kennedy and conservative Chief Justice John Roberts as well as Justices Antonin Scalia and Samuel Alito will do.

Kennedy, Roberts, Alito, and (especially) Scalia — whom the government’s brief quotes five times — have all joined past decisions construing federal regulatory power very broadly. Two respected conservative federal appeals court judges, Laurence Silberman and Geoffrey Sutton, who is one of Scalia’s favorite law clerks, have upheld the law.

What are the major arguments for and against the individual mandate?
Defenders say that the broad constitutional power of Congress to regulate interstate commerce, and the even broader power to “lay and collect taxes,” both provide ample authority for requiring that people buy insurance as part of a comprehensive scheme to end “discriminatory insurance practices that have excluded millions of people from coverage based on medical history,” in the words of a brief by Solicitor General Donald Verrilli.

The same brief also asserts that uninsured people consume $43 billion a year worth of emergency-room and other health care for which they do not pay, costs that are shifted to insurers and that raise insured families’ average premiums by more than $1,000 a year. Critics of the law dispute these numbers.

The 26 states challenging the law (along with a business group and four individuals) say, in the words of a brief by Paul Clement, who was solicitor general under President George W. Bush: “The individual mandate rests on a claim of federal power that is both unprecedented and unbounded: the power to compel individuals to engage in commerce in order more effectively to regulate commerce. This asserted power does not exist. … It is a revolution in the relationship between the central government and the governed.”

Clement also stresses that President Barack Obama and his allies in Congress insisted during the debate before the measure became law that the financial penalty for failing to comply with the individual mandate is not a tax. They should not be allowed, he argues, to “enact legislation that would not have passed had it been labeled a tax and then turn around and defend it as a valid exercise of the tax power.”

The Anti-Injunction Act?
This reconstruction-era statute bars courts from considering the constitutionality of tax laws until payments are due. It will apply here if the court deems the individual mandate’s penalty provision a “tax.”

Because the mandate is not scheduled to take effect until 2014 and the first penalties would not be due until 2015, the federal courts would not yet have jurisdiction to consider the constitutionality of the penalties or the mandate. In other words, consideration of the case would be postponed until 2015, and, therefore, such a decision would convert the biggest case in decades into the biggest anticlimax in Supreme Court history.

Both sides say that the Anti-Injunction Act does not apply. But the court appointed a lawyer as “friend of the court” to argue that it does, as one federal appeals court held. This appointment signaled the court’s care to observe arguable limits on its jurisdiction even when the parties agree that it has jurisdiction.

What are the major arguments on severability?
The government says that if the court strikes down the mandate, it should defer until future cases any ruling on the severability of most other provisions. But, if it does rule on severability, the government maintains that only two other provisions should go down with the mandate. Those are the “guaranteed-issue” and “community-rating” provisions, which bar insurers from denying coverage or charging higher premiums because of medical history. Without the individual mandate, the government says, those provisions would send premiums soaring by creating incentives for healthy people to defer buying insurance until they need health care.

The 26 states argue that the mandate was deemed by Congress to be “necessary to make the other provisions work as intended,” and that the court should strike down the whole law.

The court appointed another friend-of-the-court lawyer to write a brief arguing that a decision striking down the mandate should leave the rest of the law — including guaranteed issue and community rating — intact.

What are the major arguments on Medicaid?
The government asserts that “it is well settled that Congress’s spending power includes the power to fix the terms on which it will disburse funds to the states,” that Congress has repeatedly expanded the state-federal Medicaid program, and that this new expansion will not “impose significantly onerous burdens on the states.”

The 26 states counter that the Medicaid expansion unconstitutionally coerces them because it “threatens States with the loss of every penny of federal funding under the single largest grant-in-aid program in existence — literally billions of dollars each year — if they do not capitulate to Congress’ steep new demands.”

Stuart Taylor, Jr. is an author and contributor to the National Journal and other publications.

SOURCE:

http://www.kaiserhealthnews.org/Stories/2012/March/15/supreme-court-curtain-raiser.aspx

Rules For New Insurance Marketplaces Give Insurers Clout

By Julie Appleby

KHN Staff Writer

Mar 12, 2012

Insurers and other industry representatives will get to fill as many as half the seats on the governing boards for state health insurance exchanges, under final rules for the marketplaces issued today by the Department of Health and Human Services.  At least one seat must be reserved for a consumer representative.

The long-awaited rules are likely to disappoint consumer advocates who would have preferred the governing boards “be dominated by consumers,” said Timothy Jost, who speaks as a consumer advocate before the National Association of Insurance Commissioners and is a professor at the Washington and Lee University School of Law.  But Jost said he is pleased the final rules require at least one consumer representative. “It at least gives a toe-hold,” he said.

But they may also frustrate insurers who had sought to prevent the governing boards from imposing requirements on plans beyond what is included in the 2010 health care law. HHS left that possibility in place, however, writing, “We continue to believe that states are best equipped to adapt the minimum exchange functions to their local markets and the unique needs of their residents.”

The exchanges are seen as a key element in the health law, offering one-stop shops for individuals and small businesses looking to purchase health insurance. They will also help determine applicants’ eligibility for programs such as Medicaid, and for federal subsidies to help them purchase insurance. An expected 21 million people will purchase coverage through the exchanges by 2017, according to Congressional Budget Office projections.

The Obama administration touted the 644-page rules as granting states great flexibility in how they design their exchanges, the types of organizations – nonprofit or public agency – that will oversee them and whether to partner with the federal government to operate parts of it. The rules were published as some states are working to set up exchanges and their governing boards – while others have balked at moving forward until after the Supreme Court rules on the constitutionality of the federal health law, which is expected in June.

Additionally, Monday’s announcement included some “interim” rules, meaning they could be tweaked following a 45-day public-comment period. Those interim rules cover issues such as how quickly states must determine if an applicant is eligible for Medicaid or the Children’s Health Insurance Program, and the role insurance brokers will play in helping low- and middle-income people apply for federal subsidies to buy coverage.

Administration officials said the new rules differ from preliminary regulations in several ways. Earlier guidance had proposed that each exchange be responsible for determining which applicants are eligible for insurance subsidies.  The final rule gives states the option to allow HHS to conduct eligibility review. To determine who is eligible for Medicaid or the Children’s Health Insurance Plan, states can choose their own Medicaid agencies.  It also says states cannot allow insurance agents to determine an applicant’s eligibility for subsidies or Medicaid, which remain government functions. But agents, including those who work for web-based private exchanges, can assist those applicants in sorting through their health plan options.

The rules appear to strike a balance between responding to thousands of comments about earlier proposals and providing more details “so states can move forward,” says Patti Boozang, managing director at Manatt Health Solutions, a law and consulting firm based in New York.

The rules do not explain how the federal government would set up exchanges in states that are unable or unwilling to develop their own marketplaces, with those details promised in future rules. In January, the Obama administration released a report saying about 28 states are “on their way” toward establishing exchanges.  “There’s no new information on how that would work, what the partnership model would look like or what states would have to pay – and that’s all information many states have anxiously awaited,” says Boozang.

Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP), a trade group, said her organization would be reviewing the rule and offering feedback.

“Exchanges will work best if they are true marketplaces that maximize choice and competition so that individuals, families, and small businesses can purchase plans that are right for them,” she said in a prepared statement. “Consumers will be best served if a state exchange adopts an efficient, cost-effective approach that leverages existing health plan resources, utilizes federal resources or guidance where sensible, and relies on the exchange itself to administer key functions.”

The law says the exchanges will start taking applications in Oct. 1,  2013 – and policies purchased through them would take effect Jan. 1, 2014.  States that are allowed to operate their own exchanges must have approval or conditional approval from HHS by Jan 1, 2013, according to the rules.

In a nod to the fact that some states won’t be able to meet that deadline, the final rules say HHS can grant conditional approval to states that show they are likely to be fully operational by October 2013. Details on what it will take to prove that are expected in future rules.

SOURCE:
http://www.kaiserhealthnews.org/Stories/2012/March/12/insurance-exchange-rules-hhs-states.aspx

Consumer Groups Ask Obama To Not Weaken Provisions For Insurance Labels

By Susan Jaffe

January 24th, 2012, 6:03 PM

Leaders from some of the nation’s top consumer and seniors advocacy groups today urged President Barack Obama not to weaken a key consumer provision of his signature health care overhaul law.

The provision requires health insurers and employers to use standardized, easy-to-understand information documents to describe health plan benefits and costs.   These forms would explain how much each plan pays on average for three common medical conditions and include a glossary of insurance terms.

“The summary of benefits and coverage [document] is a vital first step in making consumers better informed and able to make the proper decisions for themselves,” said Stephen Finan, senior director for policy for the American Cancer Society Cancer Action Network, one of the signers of the letter to the president.  In some states, information about providers and other policy details are not disclosed until after a consumer applies for coverage, he said.  Shoppers today, he explained, can get better information about buying a new washing machine than they can about a health insurance policy.

“You pay first and learn later,” he said.

The letter was signed by the chief executive officers of the American Cancer Society, American Heart Association, American Diabetes Association, Consumers Union and AARP, which has 37 million members age 55 and older.

According to the law, the forms are supposed to be distributed starting March 23, but the groups are worried about the administration’s long delay in setting final regulations that spell out how to use the forms. The draft regulations that include the proposed forms were issued in the summer and the administration has been reviewing comments on those. “As the Administration approaches its final decisions on the [summary of benefits and coverage] rule, we strongly encourage you to adhere to the letter of and intent of the Affordable Care Act,” the CEOs wrote.

Although they concede that there’s probably not enough time to meet the March deadline, they would like the forms available for the fall open enrollment season for group insurance plans.   They also urged that the forms be used in both group and individual insurance plan markets, , as the law and proposed rules require, and that they include premium price information as well as several coverage examples.

In comments on the proposed rules, insurance and business trade associations explained how some of these features would be difficult to implement now and asked for further delays.

The new forms were written by a working group of the National Association of Insurance Commissioners, which included industry and consumer representatives along with state insurance regulators and were later incorporated into the administration’s proposed rules.

Erin Shields, a spokeswoman for the U. S. Department Health and Human Services declined to say whether the final rules will favor the positions taken by industry or consumer groups.

“As always, we appreciate this and all feedback and value a constructive dialogue on this important, new consumer protection,” she said.

This entry was posted on Tuesday, January 24th, 2012 at 6:03 pm.

Source:

To view this article by Susan Jaffe for Kaiser Health News in its original context, please visit http://capsules.kaiserhealthnews.org/index.php/2012/01/consumer-groups-ask-obama-to-not-weaken-provisions-for-insurance-labels/

Report says Affordable Care Act will significantly change Kentucky’s spending on uninsured

  • The Urban Institute has released a report (PDF) on how states are progressing toward adopting the federal Affordable Care Act. Kentucky is among the states that “have not yet established exchanges, but have demonstrated significant interest in doing so. Most notably, 17 of the 21 states have received level 1 federal establishment grants, which represent a second round of funding for state exchange development work beyond the initial state planning grants.” When Kentucky enacts ACA, the state will experience the largest percentage drop in the nation (87 percent) for uncompensated spending on care for the uninsured.

  • Source:
    To view this article by Lu-Ann Farrar for Kentucky.com in its original context, please visit http://www.kentucky.com/2012/01/24/2040769/kentucky-news-review-report-says.html#storylink=cpy

This Is The Year Obamacare Takes On Out-Of-Control Health Care Costs

1/19/2012 @ 12:32PM |

By: Rick Ungar

Write down the date. 2012 is the year that some of the more ‘behind the camera’ aspects of the Affordable Care Act will begin to take effect—measures that are designed to primarily impact on the high cost of medicine. Thus, while the measures may not score big headlines, 2012 could well prove to be the most important time frame in the effort to get control of the out-of-control costs that are destroying the American health care system.

Accountable Care Organizations – On January 1, the financial incentives designed to inspire health care providers to form Accountable Care Organizations (ACOs) took effect.

The idea behind an ACO is to bring a number of health care providers, providing different services and specialties, together to better coordinate the care a Medicare beneficiary receives for a variety of conditions. By doing this, the hope is that duplication can be avoided and the improved communication among these providers will increase quality of care and outcomes.

The result is expected to represent just under $1 billion in savings over the next three years.

The reward to providers who form ACOs—and can show improvements in outcomes and cost savings— is a share of the savings they deliver to Medicare. Note that this is not simply a matter of producing cost savings. If the improvements in outcomes are not there, an ACO is not going to profit. Thus, the success of the ACO program would produce a win-win for all involved. Patients will receive better care, providers will earn financial bonuses in success and Medicare will benefit from the savings.


Collection of Data Revealing Treatment Disparities
– It is no secret to anyone that the quality of care received in the United States can be directly tied to one’s race, income and ethnicity. In many cases, it can even be tied to gender.

The ACA intends to do something about this, beginning with the requirement—come March, 2012— that will require increased data collection to highlight this disparity in care and allowing the holes to be plugged in response to what is learned.

“It’s a huge issue,” says Anna Lambertson, executive director of the Kansas Health Consumer Coalition, a statewide advocacy group in Topeka, Kan. “Health disparities include women’s access to health insurance and being charged higher premiums because of gender. If we can find a way to help people navigate the health care system so they are not going to the ER to receive routine care, we can actually lower costs.”

Via Fox Business

As the old saying goes, “knowledge is power”. Having the data to back up the serious problem of disparities in care in America— based on factors that should never be factors— is the first step towards fixing the problem.


Payback:The Insurance Rebates
– With the exception of the Supreme Court decision that will determine whether or not key aspects of the ACA have a future, June will bring this year’s change that is most likely to make headlines – the obligation that health insurance companies who fail to meet the medical loss ratio (MLR) requirements of Obamacare issue rebates to customers. Insurance companies who have failed to spend 80 percent of premium dollars received from individual and small business policy holders (85 percent from large group policies), will be required to send rebate checks to their customers. It is estimated that had the insurance companies been obligated to make such rebates in 2010, the rebates would have totaled about $2 billion dollars.

This requirement will not only put some unexpected cash in the pockets of long-suffering premium payers, it will shine a light on which insurance companies are failing to spend the money you send them on your actual health care.

Value Based Purchasing – Beginning October 1, the Medicare Value-Based Purchasing Program (VBP) will link payments made by Medicare to health care providers to the quality of the outcome they achieve. The program also includes the ‘bundled payments’ you’ve heard so much about.

VBP is more important than you might initially realize. Currently, we have far too many people –about 30 percent of all patients– checking out of hospitals only to check back in a month later. Let that sink in for a moment. Almost one of every three patients who leave a hospital will be back in a month. And we wonder why we spend so much on health care!

And when that patient comes back to the hospital, the hospital once again begins to run up the tab.

Pursuant the rules taking effect in October, this will no longer be the case. If a Medicare participant checks into the hospital for triple-bypass heart surgery, the hospital is going to be paid a set fee for the procedure. If the patient is sent home with insufficient directions to properly care for themselves during the post-surgery period, and is thus required to return to the hospital when things go wrong, the hospital is not going to be paid again. Accordingly, the hospital now has every incentive to do the job right the first time and make sure that the patient has the information necessary to continue improving upon release—including making sure the patient is going to follow-up visits with his or her doctor. The result is a healthier patient and much less spent in recidivist returns to the hospital.


Electronic Health Records
– Also coming on-line in October are the requirements that will force medical providers to get serious about using electronic medical records that will ‘hook up’ physicians to better track the health care their patients have been receiving.

Anyone who has ever been subjected to multiple blood tests as a result of seeing two different physicians within a short time understands how often duplicate tests are performed for no good reason and at great expense.

Now, when a patient goes for an annual physical in May and then is required to see a cardiologist in June, the cardiologist, via an electronic health care records system, will have access to the recent blood test results taken just two months earlier,  allowing the doctor to avoid re-testing.

The potential for savings is huge.

What we see is that 2012 is the year where the ACA begins to seriously take on the high cost of medicine in America – an effort that even the most ardent critic of Obamacare should be supporting.

Whether or not these measures will achieve the desired results remains to be seen. However, the next time someone tries to convince you that health care reform does not tackle our costs problem, I hope you’ll refer them to this data and suggest that their own self-interest requires that they root for these measures to work.

Our health care system really does depend upon it.

SOURCE:
To view this article by Rick Ungar for Forbes, please visit http://www.forbes.com/sites/rickungar/2012/01/19/this-is-the-year-obamacare-takes-on-out-of-control-health-care-costs/

Biggest Bucks In Health Care Are Spent On A Very Few

by for NPR

So you know how on Monday the federal government reported that the $2.6 trillion the nation spent on health care in 2010 translated into just over $8,400 per person?

Well, a different study just released by a separate federal agency shows that second number doesn’t actually mean very much.

Researchers from the Agency for Healthcare Research and Quality looked at the way people actually spend money on health care. They found that half the population spends practically nothing on health care in any given year, while a very few unlucky people account for the lion’s share.

Specifically, in 2009, just 1 percent of the non-institutionalized population accounted for 21.8 percent of all U.S. health spending. And just 5 percent accounted for half the total spending.

Meanwhile, the bottom half of the population accounted for a mere 2.9 percent of total health spending in 2009.

So just who are those high spenders? Sick people, obviously.

But in looking at who remained in that top spending tier in both 2008 and 2009, researchers found that the high spenders were more likely to be:

  • Elderly,
  • Female,
  • White and
  • Covered by public health insurance.

Conversely, those who spent the least were more likely to report themselves as being in good or excellent health and to be younger. They were also more likely to be Hispanic or African-American.

The numbers could have political implications. At the least they help explain why so many people don’t understand the health care system. They either don’t have health insurance or don’t use it if they do.

SOURCE:

To view this article by Julie Rovner for NPR, please visit http://www.npr.org/blogs/health/2012/01/12/145118410/biggest-bucks-in-health-care-are-spent-on-a-very-few