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Monday, May 26, 2014

Health Care Reform Articles - May 26, 2014

What a Medicaid expansion would have meant for Maine’s poor adults

By Sara Rosenbaum, Special to the BDN
Posted May 25, 2014, at 5:59 a.m.
A May 19 BDN OpEd by Maine House Republican Leader Ken Fredette congratulates opponents of Maine’s Medicaid expansion for a job well done. One can become quite jaded about the news in today’s slash-and-burn political environment. But it is still jarring when a leading elected official charged with protecting the well-being of a state’s population trumpets his party’s success in pushing more than 24,000 of the state’s poorest residents into a health coverage gap, with all of the terrible consequences that can follow.
His self-congratulatory essay over barring coverage for tens of thousands of low-income residents came only days after publication of a major study that examined the impact of Massachusetts’ Medicaid expansion and that offers the strongest findings yet regarding Medicaid’s role in reducing mortality among low-income adults.
I write as someone who has worked to improve Medicaid over the course of my career. I also write as a resident of Virginia, which Fredette invoked as another state in which reform is faltering, largely because of our own version of this deeply disturbing pattern of conduct by elected leaders who appear determined to prevent life-saving improvements in health care for the poor. We are a bigger state; in our case, the coverage gap would approach 200,000 residents. But the human toll of saying “no” to Medicaid is the same, regardless of the number of people whose lives and health are on the line.
The words used by Fredette, like those of Virginia’s Medicaid opponents, are meant to conjure up every negative image that political consultants can dream up. Each phrase is carefully chosen to achieve that special “dog whistle” effect — sending coded messages without having to come right out and smear real people.
For its opponents, Medicaid is not the nation’s largest public health insurance program; instead, it is “welfare” for “able-bodied” “young men” — words that demean and stigmatize Medicaid and the thousands of hardworking people who stand to benefit from its help. But the characterization of Medicaid as “welfare” hits not only those people who would have gained from its coverage but also those who currently receive assistance, including, ironically, the very people with disabilities about whom Fredette professes such concern.
The effort to conjure up distasteful imagery through the use of the “m” word — men — is remarkable. Who knew that providing men with affordable health care was shameful? Expanding Medicaid to help men, in Fredette’s world, is a reason to kill the expansion rather than a step toward ensuring healthy husbands and fathers. Do we imagine that Fredette and others opposed to Medicaid expansion because it might help men ever would expose their own families to the risk of having a father, a husband or an adult son without the means to secure necessary health care?
Another common tactic in Medicaid opposition politics is the false choice. Fredette attempts to invoke the need for long-term care reform as a reason not to insure poor adults. Somehow 26 other states and the District of Columbia — all of which struggle with the immense challenge of making Medicaid work for their most disabled and vulnerable residents — have managed to pursue long-term care improvements and Medicaid expansion for low-income adults. By contrast, Maine has chosen to leave more than $2.2 billion on the table even though it is eminently possible to both expand coverage for the poor and work to improve long-term care.
And then there is the misrepresentation. Fredette claims that the Medicaid expansion is unnecessary and that the “vast majority” of people who need coverage can buy it on the exchange “for just a few dollars a month.” This cavalier assertion is meaningless for the 24,390 people who, according to the Kaiser Family Foundation, are too poor to qualify for subsidies. Eligibility for premium subsidies in Maine does not begin until household income reaches the federal poverty threshold ($19,780 for a family of 3 in 2014). These more than 24,000 people will be turned away simply because their incomes will not meet the exchange threshold. They will be left with nothing.
I hope that both Virginia and Maine will come to their senses; people’s lives literally are on the line. More importantly, I hope that we can move past the tragic situation in which we increasingly find ourselves — one in which senior, elected lawmakers literally take pride in causing this much harm to their own state residents.
Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy at the Milken Institute School of Public Health at the George Washington University in Washington, D.C.


High deductible plan member — figuring out how much care will cost

Individual, , , 
By 
As someone with a high deductible healthcare plan, how can I best estimate my out-of-pocket cost for a medical procedure prior to incurring the expense?
My insurer does not make this information available.  All I want to know is, what the negotiated rate in-network is for a particular procedure.  In my experience, providers can tell me the “list” price, but that usually bears little resemblance to the actual amount I have to pay.
Trying to Be Savvy
Dear Trying to Be Savvy,
Insurers consider their in-network fee schedule to be top secret. And many hospitals and doctors are not equipped or informed themselves.  You are finding the limits of consumer driven health care decisions.  You are expected to make good decisions and take costs into account as a medical care consumer, yet no one can tell you what you will be paying.
There are various credible sources for national average costs for certain common surgeries or other procedures.  Try the CDC’s FASTSTATS   for some useful data.  Your state may also have data; do a web search with your state’s name and “all payer claims data base”.  This should lead you in the right direction.
At worst, you can plan to pay your maximum out-of-pocket. This is your deductible plus your “coinsurance”, which is a percentage of your bills that you pay after you have paid your up front deductible. If it comes in lower, you can celebrate.

Lawsuit accuses Blue Cross and Blue Shield parent of funneling profit to execs


By Tribune staff reporter
2:06 p.m. CDT, May 22, 2014


The parent company of Blue Cross and Blue Shield of Illinois has been hoarding excess profits and using that money in part to enrich its executives, a class action lawsuit filed in Cook County Circuit Court alleges. 
Health Care Service Corp., a nonprofit mutual insurance company that operates Blue Cross and Blue Shield plans in Illinois, Texas, Oklahoma, New Mexico and Montana, is accused of breaching its contracts with members by accumulating excess profits of about $4.9 billion.  Instead of disbursing that money to its health insurance members either through a paid dividend, reduced prescription drug costs or lower premiums, the company paid out nearly $100 million in bonuses to its top 10 executives from 2011 to 2013, according to the suit.

The complaint was filed Monday by Babbitt Municipalities Inc., a Chicago-based benefits administration company that conducts business as Group Benefits Associates and works primarily with labor unions. It seeks certification as a class action that would include all policyholders in HCSC’s fully insured business, which totaled about 8.5 million members as of Dec. 31.

Lauren Perlstein, a Health Care Service spokeswoman, declined to comment on the case, saying the company is “in the process of analyzing the pending litigation.”

Health Care Service booked net income of at least $1 billion in each  2010, 2011 and 2012. In its last full fiscal year, 2013, the company posted income of $684.3 million.

The suit alleges that Health Care Service accumulated $10.3 billion in its capital reserve as of Dec. 31, nearly double the amount it should have had on hand at that time. The company needed only $5.4 billion on hand, the equivalent to about three months of claims expenses, according to the suit.

Instead, the company accumulated an additional $4.9 billion, which “obliterates its purpose as a nonprofit mutual corporation and exceeds the bounds of proper business judgment,” the suit says. In effect, Health Care Service is conducting its operations  as a for-profit enterprise that provides no “substantial mutual benefit to its members,” according to the suit.

“The point we’re trying to make is that even under the most generous scenario, the most they can keep is three months (of claims expenses), and they’re keeping almost double that,” said Jay Edelson of Edelson PC, the Chicago law firm representing Babbitt. “We think it’s clearly against the law.”        
http://www.chicagotribune.com/business/breaking/chi-blue-cross-and-blue-shield-lawsuit-20140522,0,82609.story

Hospitals Look to Health Law, Cutting Charity


By 
Hospital systems around the country have started scaling back financial assistance for lower- and middle-income people without health insurance, hoping to push them into signing up for coverage through the new online marketplaces created under the Affordable Care Act.
The trend is troubling to advocates for the uninsured, who say raising fees will inevitably cause some to skip care rather than buy insurance that they consider unaffordable. Though the number of hospitals tightening access to free or discounted care appears limited so far, many say they are considering doing so, and experts predict that stricter policies will become increasingly common.
Driving the new policies is the cost of charity care, which is partly covered by government but remains a burden for many hospitals. The new law also reduces federal aid to hospitals that treat large numbers of poor and uninsured people, creating an additional pressure on some to restrict charity care.
In St. Louis, Barnes-Jewish Hospital has started charging co-payments to uninsured patients, no matter how poor they are. The Southern New Hampshire Medical Center in Nashua no longer provides free care for most uninsured patients who are above the federal poverty line — $11,670 for an individual. And in Burlington, Vt., Fletcher Allen Health Care has reduced financial aid for uninsured patients who earn between twice and four times the poverty level.
By tightening requirements for charity care, hospital executives say, they hope to encourage eligible people to obtain low-cost insurance through the subsidized private plans now available under the law.
“Do we allow our charity care programs to kick in if people are unwilling to sign up?” said Nancy M. Schlichting, chief executive of the Henry Ford Health System in Detroit. “Our inclination is to say we will not, because it just seems that that defeats the purpose of what the Affordable Care Act has put in place.”
But advocates for the uninsured point out that many Americans avoided obtaining coverage in the inaugural enrollment period of the Affordable Care Act this year because they found the plans too expensive, even with subsidies. Many uninsured people also remain unaware of the new insurance options, And immigrants who are in the country illegally are not even eligible to apply.


“Certainly we want to encourage people who have new access to affordable coverage to take advantage of it,” said Sidney D. Watson, a professor at St. Louis University’s Center for Health Law Studies. “But I think we’re all going to have to do a lot to get that message out, and there will always be people who won’t have the option.”
http://www.nytimes.com/2014/05/26/us/hospitals-look-to-health-law-cutting-charity.html?hp

I.R.S. Bars Employers From Dumping Workers Into Health Exchanges

By 
WASHINGTON — Many employers had thought they could shift health costs to the government by sending their employees to a health insurance exchange with a tax-free contribution of cash to help pay premiums, but the Obama administration has squelched the idea in a new ruling. Such arrangements do not satisfy the health care law, the administration said, and employers may be subject to a tax penalty of $100 a day — or $36,500 a year — for each employee who goes into the individual marketplace.
The ruling this month, by the Internal Revenue Service, blocks any wholesale move by employers to dump employees into the exchanges.
Under a central provision of the health care law, larger employers are required to offer health coverage to full-time workers, or else the employers may be subject to penalties.

Many employers — some that now offer coverage and some that do not — had concluded that it would be cheaper to provide each employee with a lump sum of money to buy insurance on an exchange, instead of providing coverage directly.
But the Obama administration raised objections, contained in an authoritative question-and-answer document released by the Internal Revenue Service, in consultation with other agencies.
The health law, known as the Affordable Care Act, builds on the current system of employer-based health insurance. The administration, like many in Congress, wants employers to continue to provide coverage to workers and their families.
“I don’t think that an employer-based system is going to be, or should be, replaced anytime soon,” President Obama said recently, when asked if the law might speed the erosion of employer-sponsored insurance.
When employers provide coverage, their contributions, averaging more than $5,000 a year per employee, are not counted as taxable income to workers. But the Internal Revenue Service said employers could not meet their obligations under the health care law by simply reimbursing employees for some or all of their premium costs.
Christopher E. Condeluci, a former tax and benefits counsel to the Senate Finance Committee, said the ruling was significant because it made clear that “an employee cannot use tax-free contributions from an employer to purchase an insurance policy sold in the individual health insurance market, inside or outside an exchange.”
If an employer wants to help employees buy insurance on their own, Mr. Condeluci said, it can give them higher pay, in the form of taxable wages. But in such cases, he said, the employer and the employee would owe payroll taxes on those wages, and the change could be viewed by workers as reducing a valuable benefit.
Andrew R. Biebl, a tax partner at CliftonLarsonAllen, a large accounting firm based in Minneapolis, said the ruling could disrupt arrangements used in many industries.
“For decades,” Mr. Biebl said, “employers have been assisting employees by reimbursing them for health insurance premiums and out-of-pocket costs. The new federal ruling eliminates many of those arrangements by imposing an unusually punitive penalty.”
When an employer reimburses employees for premiums, the arrangement is known as an employer payment plan. “These employer payment plans are considered to be group health plans,” the I.R.S. said, but they do not satisfy requirements of the Affordable Care Act.
http://www.nytimes.com/2014/05/26/us/irs-bars-employers-from-dumping-workers-into-health-exchanges.html?contentCollection=us&action=click&module=NextInCollection&region=Footer&pgtype=article

Health Site Under Fire, Nevada Alters Path

By 
WASHINGTON — The board of Nevada’s problem-plagued online health insurance exchange voted Tuesday to end its contract with the vendor in charge of building it and to rely on the federal enrollment system for at least a year.
The board voted unanimously to sever ties with the vendor, Xerox, which had a $72 million contract to build the Nevada exchange and has been paid $12 million to date. The exchange has been riddled with problems, including billing and enrollment errors that led to a class-action lawsuit by 200 customers who said they paid for exchange plans but still have no coverage.
About 46,000 people had signed up for private coverage through the exchange as of May 10 — far fewer than the original enrollment target of 118,000.
Nevada is joining a string of other states that have scrapped their exchange contractor and switched course after determining there were too many problems to fix in time for the next enrollment period, which starts Nov. 15. Oregon abandoned its botched exchange website last month after spending $248 million on it, and will use the federal exchange instead. The Associated Press reported Tuesday that federal prosecutors have subpoenaed state records for a grand jury investigation of that state’s failed exchange.
Maryland, too, is abandoning its exchange, but is turning to software developed for Connecticut’s successful exchange. Massachusetts decided this month that its exchange website was unusable and that it would buy an off-the-shelf system instead, while also holding open the possibility of joining the federal exchange for a year if the new system is not ready in time for the next enrollment period. Preparing for both options will cost an estimated $121 million.
Nevada’s governor, Brian Sandoval, is one of the few Republican governors who embraced both a state-based exchange and an expansion of Medicaid under President Obama’s Affordable Care Act. He remains a popular leader in his increasingly Democratic state, which has seen much more success with people signing up for Medicaid under the law. About 190,000 have been found eligible for the program so far through the exchange, according to Xerox. A spokesman for Mr. Sandoval said that Xerox had “failed to perform its contractual duties,” adding, “The board made the best decision it could under these difficult circumstances.”
http://www.nytimes.com/2014/05/21/us/health-site-under-fire-nevada-alters-path.html?src=rechp

Prosecutors Investigating Grants for Health Site in Oregon

By 
SEATTLE — Unworkable technology pushed Oregon’s health care exchange to the brink, making it the first state to abandon its self-administered system in favor of the federal exchange. But now prosecutors are following the money.
Grand jury subpoenas, issued last week by the United States attorney’s office in Portland and released on Tuesday by Gov. John Kitzhaber of Oregon, have demanded all records, including email correspondence and memos related to the application or receipt of federal funds that might have been used in developing, building or administering the state’s website.
Oregon had received $305 million in federal grants to build its exchange, according to the Congressional Research Service, but the flaws were so profound that residents were never able to negotiate through it without human help. Despite system problems, more than 81,000 people were able to enroll for private coverage, some of which was done using paper applications.


The subpoenas home in on materials — including emails, meeting minutes, texts and notes — related to performance meetings called “gate reviews,” where status reports on the state exchange were presented to officials from the federal Centers for Medicare and Medicaid Services. The grand jury also demanded purchase orders, invoices and statements of work by Oracle, the private contractor that built the site, and all correspondence between 10 current and former executives of Cover Oregon, the website’s manager, and Oregon Health Authority, which oversees other health care programs.
Mr. Kitzhaber pledged his full cooperation. The governor, a Democrat, is up for re-election this fall, and Republicans have pledged to use Cover Oregon’s travails in the campaign against him.

“The governor is committed to a thorough review of Cover Oregon to ensure the appropriate accountability and oversight for the public investment,” said Liani J. Reeves, general council in the governor’s office, in a letter on Monday to the United States attorney in charge of the case.
http://www.nytimes.com/2014/05/22/us/prosecutors-focus-on-federal-money-used-for-oregons-failed-health-care-website.html?src=rechp

Insurers Once on the Fence Plan to Join Health Exchanges in ’15

In a sign of the growing potential under the federal health care law, several insurers that have been sitting on the sidelines say they will sell policies on the new exchanges in the coming year, and others plan to expand their offerings to more states.
“Insurers continue to see this as a good business opportunity,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. “They see it as an attractive market, with enrollment expected to ramp up in the second year.” Eight million people have signed up for coverage in 2014, and estimates put next year’s enrollment around 13 million.
In New Hampshire, for example, where Anthem Blue Cross is the only insurer offering individual coverage on the state exchange, two other plans, both from Massachusetts, say they intend to offer policies next year. Harvard Pilgrim Health Care, a nonprofit insurer with 1.2 million members, said it expected to participate in the exchanges in both New Hampshire and Maine for the first time and to add Connecticut to the mix in 2016.
UnitedHealth Group and Cigna, which were notable in their caution about the exchanges last year, are expected to enter more markets this year. In Washington State, United is among four new insurers that have told state regulators they are interested in offering plans in 2015.
Cigna’s chief executive, David Cordani, said in an interview that the company’s “bias” was to expand beyond the five states where it now offers coverage on the exchanges. But he cautioned that the company, which sells plans mainly through large employers, would be selective about picking new markets. “We don’t see it as a land-grab opportunity,” he said.
Assurant Health, a unit of a for-profit specialty insurer in New York, sold policies off the exchanges in 41 states last year and said it now intended to offer plans in some exchanges. Assurant is joining the exchanges “to serve more consumers and provide additional choice for customers purchasing on and off the exchange,” Mary Hinderliter, a spokeswoman, said in an email. “We are evaluating exchanges on a state-by-state basis and continue to finalize our strategy,” she said.
Companies must decide in the coming weeks whether they want to participate in the online exchanges run by the federal government, and states may have their own deadline
http://www.nytimes.com/2014/05/26/your-money/health-insurance/insurers-once-on-the-fence-plan-to-join-health-exchanges-in-15.html?hpw&rref=health

Is physician burnout really a problem?

By Dr. Suzanne Koven

  | GLOBE CORRESPONDENT   MAY 26, 2014
The doctor will see you now — but he or she won’t be happy about it.
At least that’s what the popular news site, The Daily Beast, contends. An item published last month grimly titled “How Being a Doctor Became the Most Miserable Profession” cited high suicide rates among physicians and increasing numbers of doctors retiring early and leaving medicine for the corporate world as evidence of widespread misery among my colleagues. Loss of respect and autonomy, decreased insurance reimbursements, and larger administrative burdens — some imposed by new medical documentation requirements under the Affordable Care Act — are said to contribute to our alleged burnout.
Also last month, an editorial appeared in The Wall Street Journal titled “A Doctor’s Declaration of Independence.” An orthopedic surgeon called for physicians to say, essentially: “We’re mad as hell and we’re not going to take it anymore!” Dr. Daniel F. Craviotto Jr. claimed: “I don’t know about other physicians but I am tired — tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces.”
Craviotto recommended radical action by doctors, such as refusing to accept insurance, including Medicare, until our grievances are addressed.
I have mixed feelings about these articles, and many similar recent ones touting how awful my job has supposedly become.
On the one hand, I feel validated. There’s no question that practicing medicine isn’t as much fun as it was even five years ago. New regulations and restrictions issued by government agencies, insurance companies, and professional organizations mean I now spend time I’d rather spend with patients checking boxes, populating templates, and dialing 800 numbers.
Also, because of decreasing reimbursements, physicians are now under pressure to see patients more quickly than ever before. A primary care doctor now spends an average of 12 minutes with each patient. That’s not much time in which to see someone with a long list of complex medical problems and medications and numerous questions and complaints — not to mention a life story, tricky family dynamics, and photos of grandchildren to share.
More busywork combined with shorter visits make me feel perpetually rushed, which makes both me and my patients unhappy. Studies show that a rushed physician is more likely to make mistakes. A more pernicious effect is that when a doctor is in a hurry he or she is less likely to fully engage a patient.
For example, not long ago, I met a new patient who had a fairly simple medical history but who’d suffered much pain and loss. I found myself resisting the temptation to save time by not probing those emotions too deeply, even though I knew that doing so would forge a bond between us, a bond that would help me be a better doctor to this patient — the kind of bond that is, to me, the most satisfying part of medicine.

Health insurance rates may affect Nov. election

Healthcare overhaul and insurance rates will carry political weight before the midterm elections.

The Associated Press
The wild hikes in health insurance rates that blindsided many Americans in recent years may become less frequent because of the health care overhaul.
Final rates for 2015 won’t be out for months, but early filings from insurers suggest price increases of 10 percent or more. That may sound like a lot, but rates have risen as much as 20 or 30 percent in recent years.
The rates that emerge over the next few months for 2015 will carry considerable political weight, since they will come out before Republicans and Democrats settle their fight for Congressional control in next fall’s midterm elections. Republicans are vowing to make failures of the law a main theme of their election push, and abnormally high premiums might bolster their argument.
In addition to insuring millions of uninsured people, the other great promise of the massive health care overhaul was to tame the rate hikes that had become commonplace in the market for individual insurance coverage.
Some nonpartisan industry watchers say smaller price increases may come in the years to come, even though it’s still early in the law’s implementation. They point to competition and greater scrutiny fostered by the law as key factors.
Public insurance exchanges that debuted last fall and were created by the law make it easier for customers to compare prices. The overhaul also prevents insurers from rejecting customers because of their health.
That means someone who develops a health condition like high blood pressure isn’t stuck in the same plan year after year because other insurers won’t take her. She can now shop around.
The Urban Institute, a nonpartisan policy research organization, said in a recent report that competition will help restrain individual insurance prices next year.
And it could have a lasting impact once the new markets for coverage stabilize in a few years, said Larry Levitt, an insurance expert with the Kaiser Family Foundation, which analyzes health policy issues.
“Now if a plan tries to raise premiums a lot, people can vote with their feet and move to another plan,” Levitt said.

Maine Nursing Homes Struggle to Stay Afloat
05/23/2014   Reported By: Jennifer Mitchell

It's no secret that Maine's more than 100 nursing homes have been chronically underfunded. MaineCare pays the bills for about 70 percent of nursing home patients. But Mainecare rates don't cover the full cost of nursing care. And at some nursing homes, the shortage has become so serious that several have warned that they may have to close. Gov. Paul LePage and lawmakers can't agree on how to address the $12 million problem. In the meantime, nursing homes like the two Jennifer Mtichell visited recently, are struggling to provide shelter, food, and treatment for Maine's oldest citizens.



The day is just getting started at this facility in Caribou. Some people are sitting in wheelchairs watching TV, others are in their rooms seated behind tray tables, as nurses bustle about to see how residents have fared during the night. 

"This is the time of day where people are getting bathed and dressed," says administrator Phil Cyr (right), who starts each morning like this. 

Phil Cyr: "You're looking sharp today!"

Junior: (Inaudible)

Phil Cyr: "Oh you are? You are? OK. Junior is a resident here. Has been for how long?"

Junior: "Eleven and a half."

Phil Cyr: "Eleven and a half years you've been here? Yup. Junior had a stroke."

The residents of nursing facilities such as this one will need six or seven hours of professional care each day. They need help eating their meals, walking to the day room, going to the toilet, and taking sometimes complicated regimens of medication. 

And they may also die here. They're too frail to care for themselves, says Cyr, and need more care than many working families are able to provide - or afford themselves.

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