What the Hill? The Latest in Healthcare News from Capitol Hill

Posted on May 16, 2012 by Linda Ringquist

Here are some of the latest stories from Capitol Hill according to The Hill. The original stories may be found by accessing http://thehill.com/blogs/healthwatch/.

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Obama administration announces plan to fight Alzheimer’s Released from the Health and Human Services Department (HHS), there is a plan for the prevention and treatment of Alzheimer’s which will encompass clinical trials and training for doctors. The release date is 2025. “This is a national plan, not a federal one, because reducing the burden of Alzheimer’s will require the active engagement of both the public and private sectors”, according to HHS Secretary Kathleen Sebelius.

Sequestered cuts keep K Street on high alert According to lobbying disclosure records, several interests lobbied on the budget sequestration last quarter. Defense contractors as well as healthcare groups were closely monitoring the budget cuts proposed for next year. The proposed budget cuts include a reduction of $123 billion in payments to Medicare providers. According to Ken Raske, president and CEO of the Greater New York Hospital Association, “the budget cuts will add to the financial burden on the healthcare system. This could be a compounded horror show for the hospitals The spending cuts could hinder hospitals providing care to patients.

Nurse practitioners push for bigger role as coverage expands Nurse practitioners are pushing to expand their role in healthcare. The American Academy of Nurse Practitioners (AANP) states their role should become more important as Obama’s healthcare law pushes through. The new law will provide coverage to millions of people which will increase the importance of nurse practitioners.

Senator Leahy hopeful that John Roberts will vote to uphold health law Before the court heard arguments in the healthcare case, Supreme Court Chief Justice John Roberts was mentioned as a potential swing vote. “I thought I saw a chief justice who understands the importance of this case to all Americans, including those millions who would otherwise continue without health care insurance and access to affordable health care”, Senate Judiciary Committee Chairman Patrick Leahy said in a floor speech. The court is supposed to make a decision next month whether the healthcare law, which requires everyone to purchase insurance, is constitutional or not. If the mandate is nixed, the court will have to decide whether the entire law will be nixed or if the rest will pass.

Study: Insurers to lose $1 trillion if health law struck down According to the Bloomberg Government, at stake in the Supreme Court’s decision on healthcare reform is nearly $1 trillion of the insurance industry’s total revenue through 2020. “It’s a confirmation of, one, how much money we’re spending as a nation on healthcare, and two, how much is riding on this court case and the Supreme Court’s decision”, according to Matt Barry. “You’re talking about an amount of money here that can affect the economy, not just an industry. The revenue would come from both the expansion of Medicaid and from additional subsidies to individuals purchasing insurance. The Supreme Court is expected to issue a decision by the end of June 2012.

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Consumer-Driven Health Plans – What Should You Consider When Choosing?

Posted on May 15, 2012 by Linda Ringquist

According to the Bureau of Labor Statistics, the combination of a pretax payment account with a high-deductible health plan is what is commonly referred to as a consumer-driven health plan (CDHP).⁷ In terms of payment methods, CDHPs are composed of a three tier payment system

A savings account
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Out-of-pocket payments
Insurance plan.

The first tier is a pretax account that allows employees to pay for services using pretax dollars. The account may be funded by the employer or the employee, depending on the type of account. The funds from this account can be used to satisfy the insurance plan deductible. The second tier is the difference, or the “coverage gap,” between the amount of money in the individual’s pretax account and the deductible. The amount that is not covered by the pretax account must be covered by the insured. If health care expenses exceed the deductible amount, then the third tier, the high-deductible health insurance plan, kicks in.

In an article from the URAC website, there are ten things to be considered when evaluating and choosing consumer-driven health plans and products.

Is the information regarding the consumer health driven plan available in a variety of formats and media? Is the information available in different languages as applicable? Is the information written in such a way that it can be understood easily, including to those who may have mental or physical impairments or disabilities?
Are all of the costs laid out in a manner in which deductibles, out-of pocket expenses, tax consequences and benefits are clear?
Does the information indicate clearly the details of the plan, including benefits and coverage, customer satisfaction results, and a directory of providers?
Is wellness and prevention data readily available and easily accessible?
Do you have access to a Health Risk Assessment which is evidence-based, reviewed by the organization’s top clinical staff, and provide feedback as to the health status and any recommendations to improve the current health status?
Does the plan provide data explaining the enrollees role and responsibility for making their own decisions for health care? Are there additional expert resources available to the enrollee to help answer any additional questions.
Are there specific instructions as to how to access assistance on a 24/7 basis through different media such as phone, email, and in person?
Is there a method for requesting a detail of the cost and quality for each provider?
Does the health plan provide assistance in making financial decisions about coverage gaps, managed care or review processes necessary for coverage and how to seek care once the personal health account has been exhausted?
Does the health plan reach out to those with chronic diseases to educate them about how to most effectively manage their health care?

BHM Healthcare Solutions specializes in URAC accreditation and URAC consulting. For more information regarding URAC accreditation assistance, please visit the URAC page of our website or call for a fee consultation call BHM at 1-888-831-1171 today!

Success of PCMH Could Mean Expansion

Posted on May 10, 2012 by Kathleen Rand

Patient-centered medical home (PCMH) projects implemented by Independence Blue Cross (IBC) and BlueCross BlueShield of Tennessee (BCBST) have been so successful in improving patient outcomes and keeping medical costs under control that they are looking to increase the programs to more primary care physician (PCP) practices and into other therapy areas as well like behavioral health, cardiology and oncology.

Under the PCMH model, PCPs lead care teams to keep members healthy by using registries to track conditions and ensure that they receive needed care —essentially creating a hands-on approach. And physicians are also rewarded with a per-member per-month (PMPM) fee and other shared savings based on the health outcomes their patients achieve.

In fact, PCMH-focused practices will be eligible for shared savings beginning next year under the Affordable Care Act requisites. To illustrate, a practice with 1,000 chronic care patients could potentially net between $10,000 and $12,000 in shared savings and performance bonuses.

While the PCMH model incorporates many different elements, these five key points more than likely led to the success of the Tennessee Blues’ PCMH effort:

(1) Better access to physicians because of improved after-hours consultation and appointment scheduling for chronic care patients.

(2) Care coordinators at practice sites such as a licensed practical nurse – coordination is supported by total health management services and interactive reporting.

(3) IT infrastructure development to improve health information exchange and communication, resulting from a business stipend for IT efforts such as electronic health records and disease registries.

(4) Improving outcomes and performance measurement through metrics such as fewer emergency department visits and lower inpatient utilization, improving the financial management of healthcare for providers over the long term.

(5) Controlling cost efficiency through reporting to practices on utilization and cost metrics, and providing incentives to physicians through performance bonuses and shared savings.

These insurers realized that building a PCMH is a way to stabilize and grow the PCP network, boost patient outcomes, and improve access to care.

BCBST found that members enrolled in a PCMH had less emergency room utilization and lower inpatient admissions compared with non-PCMH members. It appears that PCMHs are proving a better pattern of utilization and cost efficiency due to the fact that patients are more engaged with their physicians and care coordinators.

Move Fast or Slow on Insurance Exchanges…

Posted on May 5, 2012 by Kathleen Rand

CEOs of health plans are in an interesting position as the Supreme Court deliberates the viability of the healthcare reform law and as the election approaches. That is to say, what approach should they take: should they plow ahead to get ready for the changes coming in 2014, or take their time with big decisions?

If the Supreme Court upholds the constitutionality of the reform law, Congress will be less likely to change or dismantle the law until after the elections. Therefore, it would make sense for insurers to move ahead now since the major changes such as insurance exchanges take effect in the beginning of 2014. Organizations need time to get ready for these exchanges and it would be too late if some sort of planning doesn’t take place imminently. Although not directly correlated to the insurers’ game plan but still pertinent to decision-making, another potential reason for not waiting for the Supreme Court and the election results is related to the states – states need to prepare for these insurance exchanges in order to get the subsidy payments tied in with the reform provisions.

However, some contend that insurers should wait – not jump into any costly decisions. They will have to consider getting subsidies for qualified beneficiaries from the government but that should not affect the timing of planning. The decision from the Supreme Court is less than two months away and then insurers will have 15 months after that to decide whether to even participate in the insurance exchanges. That is assuming that the exchanges are not overthrown and that the insurance reforms are kept intact – otherwise there would be very little motivation to be in the exchanges at all.

Healthcare Reform: Insurance Rate Battle Brewing

Posted on May 1, 2012 by Kathleen Rand

For the nearly two years, medical utilization has been lower. When combined with regulatory analysis, reductions in administrative expenses and more pressure on providers to improve effectiveness, many health insurers have been able to hold rate increases to single digits.

But that could change if utilization increases. Any rate increase could be met with much regulatory scrutiny. By June 1, HHS intends to publish state-specific thresholds for rate increases in the small-group and individual markets, and has been working with the National Association of Insurance Commissioners to determine what to look at when determining state-specific thresholds. In some cases, state thresholds could be higher than 10%.

The threat of federal rate review might have some health insurers calculating rate increases more carefully and negotiating lower reimbursement rates from providers more aggressively. It is possible that the new federal oversight might not have much of a direct impact on coverage costs, but could help to reveal the underlying medical costs, which is a factor in driving up premium increases.

Some believe that the additional level of federal oversight is redundant and will add cost to the product they want to moderate. They believe that rate review should be left at the state level. Last year, CMS’s Center for Consumer Information and Insurance Oversight (CCIIO) determined that seven states — Alabama, Arizona, Idaho, Louisiana, Missouri, Montana and Wyoming — lack the resources and/or authority needed to properly regulate the individual and small-group markets. In three other states, Iowa, Pennsylvania and Virginia, federal regulators can review only the small-group market while state regulators are responsible for the individual market. In some states, small-group insurance products had not previously required rate.

When it comes to rising coverage costs, insurance companies are an easy target. Regulators are limited in what they can do to control rate hikes – until there is a more meaningful delivery system. That is to say, changing fee-for-service medicine into something like a value-based purchasing model.

Regardless of the federal oversight, rates will push higher over the next several years because there is no pressure on provider charges to decrease. The cost shifting that is occurring by hospitals to the commercial sector is because of the reductions in reimbursements from Medicare and Medicaid. A possible solution: governmental regulation of the hospital rates that are charged to commercial health plans.

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Increased Support for Primary Care Initiatives

Posted on April 28, 2012 by Kathleen Rand

Pateints and providers fit better under medical home model.

Primary care is vital to improving care, promoting health and reducing overall system costs, yet it has been rather under-funded and under-valued in the past. A primary care practice is a key point of contact for patients’ health care needs. With healthcare reform, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and enabling them to spend more time with their patients. Recently, healthcare providers have been investing in primary care.

Initiatives offered as a result of the Affordable Care Act, like Accountable Care Organizations and Patient-Centered Medical Homes will give doctors better means to work with and help patients. In fact, medical home concept has led to the introduction of a program which will allow organizations to seek specific accreditation, i.e., URAC PCHCH Accreditation program. Additionally, these programs ensure that providers can do the following:

Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Primary care practices that embrace the medical home concept will deliver intensive care management for these patients with high needs. By engaging patients directly, patient-centered medical homes and accountable care organizations can create a plan of care that uniquely fits each patient’s individual circumstances and values.
Because health care needs and emergencies are not restricted to office operating hours, medical homes must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need.
Primary care practices will have the ability to engage patients and their families in active participation in their care. Medical homes have the ability to centralize communication and enable providers and patients the benefit of a ‘whole picture’ approach – a patient becomes much more than a string of independent, unrelated symptoms.
Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Medical homes and accountable care organizations will work with the patient and his/her family to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

Insurance Exchanges Pivotal to Reform Law

Posted on April 25, 2012 by Kathleen Rand

The success of the reform law could depend largely on how effective state exchanges are in determining eligibility and enrolling and retaining members. There is an idea of a ‘no-wrong-door’ enrollment system through which millions of people will go and have their eligibility determined in real-time and have a top-notch customer experience. In fact, in various states, members of the state exchange board are working with state and county agencies to redefine the eligibility and enrollment processes.

Some don’t believe that the exchanges will have an impact on coverage costs – there is an expectation that rates will come down once insurance exchanges are operational. That remains to be seen. And along with ensuring that the exchange directs people to the most appropriate coverage, exchanges also need to ensure continuity of care.

Fluctuating income could cause some people to shift between Medicaid and subsidized coverage. There does not seem to be much clarity as to the insurance exchange could ensure that someone who is in the middle of treatment doesn’t have to switch health care providers.

Some safety net providers, such as free clinics, community health centers and various grant-funded programs, will need to study commercial insurance because some of their Medicaid patients will gain coverage through the exchange.

As insurers strive to build these exchanges, providers will continue to focus on developing accountable care organizations and patient-centered medical health homes. How they will integrate in the marketplace will be interesting to watch as it unfolds.

ACO – The Basic Concept

Posted on April 23, 2012 by Kathleen Rand

Under the healthcare reform law, an Accountable Care Organizations (ACO) is a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve with Medicare. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO is like a patient-centered medical home where the patient and providers are true partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

Networks of individual practices of ACO professionals,
Partnerships or joint ventures arrangements between hospitals and ACO professionals, or
Hospitals employing ACO professionals, and
Other Medicare providers and suppliers as determined by the Secretary.

The law requires each ACO to include health care providers, suppliers, and Medicare beneficiaries on its governing board. The ACO must take responsibility for at least 5,000 beneficiaries for a period of three years, also suggested in the law.

The law links the amount of shared savings an ACO may receive to its performance on quality standards. The rule proposes quality measures in five key areas that affect patient care: patient/caregiver experience of care; care coordination; patient safety; preventive health; and at-risk population/frail elderly health.

The ACA sets out proposed performance standards for these measures and a proposed scoring methodology, including proposals to prevent providers in ACOs from being penalized for treating patients with more complex conditions.

Furthermore, any patient who has multiple doctors probably understands the frustration of fragmented and disconnected care:, duplicated medical procedures, lost or unavailable medical charts or having to share the same information over and over with different doctors. Accountable Care Organizations , like patient-centered medical homes, are designed to lift this burden from patients, while improving the partnership between patients and doctors. Doctors can provide better care because they will have better information about their patients’ medical history and can communicate with a patient’s other doctors. Medicare beneficiaries whose doctors participate in an ACO will still have a full choice of providers and can still choose to see doctors outside of the ACO. Patients choosing to receive care from providers participating in ACOs will have access to information about how well their doctors, hospitals, or other caregivers are meeting quality standards.

PCHCH Medical Homes More Prevalent

Posted on April 19, 2012 by Kathleen Rand

Model of PCHCH

URAC’s PCHCH Auditor Certification is offered to healthcare management organizations desiring to provide independent PCHCH practice assessment audits of healthcare practices. URAC PCHCH standards provide the essential foundation for providers, payers, and patients to collaborate in enhancing quality healthcare services across the continuum through shared accountability in a patient-centered health care home. URAC’s PCHCH Auditor Certification provides assurances to healthcare practices that their auditors are licensed, qualified and specially trained health professionals who understand the complexities of care coordination. The URAC PCHCH Auditor Certification requires URAC Core Accreditation, assuring that the auditing organization meets desirable standards of operation and quality management prior to performing practice audits. URAC provides the certified auditor with access to and training on tools that support verification that a practice successfully meets a baseline percentage of select URAC PCHCH essential standards.

Simultaneously, the Commonwealth Fund—a private foundation that aims to promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency—launched a four-year, $6 million initiative to help primary care safety net clinics become high-performing patient-centered medical homes. As a result, in May 2009, 68 health clinics in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania have agreed to transform the clinics into person-centered medical homes. In addition, five regional coordinating centers (RCCs) have been formed to oversee the clinic’s transformation efforts. The five RCCs were selected to participate in the demonstration project, and each partnered with about 15 preexisting safety net clinics in their state. These collaboratives will receive technical assistance on practice re-design topics such as enhanced access, care coordination, and patient experience. To be eligible for participation, partner clinics had to provide comprehensive primary care services, including preventive care and immunizations, ambulatory care, and other common services. However, clinics did not need to provide on-site mental health or dental care in order to be considered comprehensive. The RCCs receive funding from Qualis Health’s Commonwealth Fund grant.

It is anticipated that at the end of the initial grant period all 68 health clinics will be unequivocally recognized as models of excellence. The participating centers will receive training to support the health centers’ efforts to improve the coordination of information and care between primary and specialty care or community provider organizations; to use information technology to identify patients with unmet needs; to improve care for those with chronic conditions; and to systematically obtain feedback from patients for quality improvement.

Employers Are Anxious about Reform Mandates

Posted on April 17, 2012 by Kathleen Rand

Healthcare Compliance concern for employers

Most employers but especially those with numerous lower-paid employees are getting worried about the combined effect of upcoming healthcare reform law provisions that they fear would hurt their competitive position. While these employers do not seem to be planning to drop employee health coverage completely they are exploring strategies that could reduce the impact of the changes on them — and affect health insurers in the process.

Another concern for employers relates to the provisions requiring auto-enrollment in coverage for full-time workers. Both the administrative aspects and the reaction from employees who are having deductions taken from their pay without authorizing them is a viable source of apprehension. Furthermore, employers cite worry about both the requirement that plans must pay at least 60% of actuarial value for covered services and that all employees working more than 30 hours per week must be eligible for health coverage.

Consequently, employers may change their work-force strategy so that they have fewer employees working more than 30 hours per week and therefore requiring health coverage while others might consider making part-time workers eligible for the health plans of full-time employees. Generally employers don’t want to reduce health coverage, but they are prepared to lower the value if competitor employers do. 32% of employers plan to reduce spending on dependent health coverage.

Under the Affordable Care Act, employers have financial liabilities if their coverage is deemed not affordable or not meeting the minimum value. However, one problem the employers are facing in preparing for this is that the affordability and minimum-value concepts have not yet been adequately defined. Health coverage is deemed unaffordable if it costs more than 9.5% of household income. Employers of low-wage workers are concerned that if they made coverage affordable to workers under the 9.5% requirement, it might not be affordable to the employers. Additionally, employers fear that their employees may decide not to buy health coverage costing 9.5% of their income.

Again, in general, employers are not looking to drop coverage, but are very concerned with such requirements as coverage for part-time workers. Many of them are interested in developing a new insurance product for those workers that both is affordable and in compliance with the healthcare reform law’s requirements.

But small employers also now know that these employer mandates apply only to those with more than 50 workers – hence, employers may think long and hard before they hire that 51st worker.