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Saturday, February 28, 2015

Health Care Reform Articles - February 28, 2015

Equitable Financing Plan
For Vermont’s Universal Healthcare System
Written by the
Healthcare Is a Human Right Campaign
February 2015 

1. INTRODUCTION
Healthcare financing is a matter of justice and human rights. The system of private, market-based payment for healthcare has caused a deep crisis of inequity that the state of Vermont must address now. The Healthcare Is a Human Right (HCHR) Campaign presents this proposal for equitable, public healthcare financing because we speak for thousands of people affected by this crisis. Too many people cannot use their limited insurance plans to get adequate care, struggle with high out-of-pocket costs and unpaid bills, and have unmet health needs. People’s health and wellbeing are on the line.
Market-based health insurance financing is profoundly inequitable: low-income people pay proportionally more for healthcare than the wealthy, while making do with low-value insurance plans.1 One in five people are struggling with medical bills, while ten BCBSVT executives are paid up to half a million dollars each.2 This failing system-- with its different and unequal insurance products, different and unequal prices for health services, and different and unequal access to doctors-- costs Vermont a fortune. Healthcare spending is growing faster than the state’s GDP, and this trend will continue if we fail to act.3 We can no longer afford to protect and perpetuate a healthcare system that is both wasteful and unjust.
Vermont is in a prime position to implement a publicly financed healthcare system that guarantees access to care for all, increases equity, and reduces costs. To do so, we do not require new money; we need to share existing payments more equitably. In this report, the HCHR Campaign shows how this can be achieved in Vermont by 2017. We develop an equitable healthcare financing plan that is grounded in Governor Peter Shumlin’s proposals for Green Mountain Care and that provides solutions to the questions raised in his report.4 We present cost and revenue models that demonstrate that it is not only possible, but financially and economically advantageous to implement a publicly financed healthcare system in Vermont.

HUMAN RIGHTS PRINCIPLES FOR HEALTHCARE FINANCING
The HCHR Campaign has built a people’s movement for the human right to healthcare since 2008. Our goal is to realize the human right to healthcare in Vermont by establishing a universal healthcare system that provides healthcare as a public good for all. This system must be guided by the human rights principles of universality, equity, transparency, accountability and participation. We successfully advocated for the incorporation of these principles into Act 48, Vermont’s universal healthcare law, passed in 2011.
Act 48 set Vermont on the road to establishing a publicly financed healthcare system, Green Mountain Care (GMC), by 2017. It did not prescribe a financing mechanism but stated that the “financing of health care in Vermont must be sufficient, fair, predictable, transparent, sustainable, and shared equitably.”5

In 2012, the HCHR Campaign published a healthcare financing report that analyzed the compatibility of various financing mechanisms and revenue sources with human rights standards.6 We used the five basic human rights principles to develop detailed financing standards to guide the design of the GMC financing plan. To ensure universality, financial resources must follow health needs, and the financing plan has to ensure the sufficiency of funds. To ensure equity, financing has to be public, using progressive taxes. Access to care should be free at the point of service. To ensure accountability, transparency and participation, healthcare financing and administration has to move from the private to the public sector and support people’s participation in governance.
Guided by these principles, the HCHR Campaign’s 2012 report proposed a progressive income tax, a wealth tax and a graduated payroll tax on employers to finance GMC. We suggested that decision-makers ground their policy choices in the human rights standards, which are reflected in Act 48. Yet when the Governor’s plan was finally published on December 30, 2014 - missing Act 48’s deadline of January 2013 by almost two years - it was not based on principles. Although the Governor proposed income and payroll taxes for healthcare, these taxes were not designed to function in a sufficiently equitable way. The failure to adequately take into account individuals’ and businesses’ ability to pay contributed to dooming the Governor’s proposals – an unnecessary fate for an otherwise sound plan. Guided by human rights principles, the HCHR Campaign seeks to propose necessary design changes to the Governor’s plan, so that it can be used to guide the implementation of GMC.

HUMAN RIGHTS ASSESSMENT OF THE GOVERNOR’S PROPOSALS
The HCHR Campaign conducted a basic human rights assessment of the Governor’s healthcare financing proposals. By flagging issue areas in need of better solutions, this assessment offers a guide for the development of a financing plan that improves and expands on the Governor’s proposals.
Human Rights Assessment of Governor Shumlin’s Financing Plan:

Universality
Populations included: The Governor’s plan is inclusive, though it carves out the Medicare population in the absence of a federal waiver. It offers no Medicare wrap-around for seniors.
Health services provided: The Governor’s plan excludes dental, vision, hearing and long-term care.

Equity
Out-of-pocket costs: At an actuarial value of 94% GMC greatly improves on commercial plans, but low- income and sick people would still struggle with co-pays. Seniors, in particular, would continue to face high Medicare out-of-pocket costs.
Income Tax: The Governor’s income tax proposal is more equitable than private premiums. However, the tax rate rises rather steeply for middle income people, while payments are capped for the wealthy. Payroll Tax: The Governor’s payroll tax is flat, which means businesses’ contributions are not based on their ability to pay.

Accountability
GMC Operations: The Governor’s proposed public utility model for healthcare administration would enable better regulation but also monopolizes the position of a private insurer and guarantees operating surpluses.
System costs: Public oversight and control of healthcare prices is assumed to happen at a future stage, and savings from such rate setting are not explicitly calculated. Rate setting for drug prices, e.g. through price negotiation, is not included at all.

 Transparency
Income and payroll taxes: Taxes are more transparent than insurance premiums and other hidden fees. System costs: The Governor’s plan assumes administrative costs will have close to commercial-level overheads (7%); and costs will grow at 4% annually. The assumptions and data points behind these projections and trends are unclear. It is unclear what specific savings have been accounted for.

Participation
Health services provided: The Governor’s exclusion of dental, vision and hearing care does not take into account the health needs expressed by Vermont residents in consultations.
GMC Operations: Neither a private contracting arrangement nor a public utility model enables meaningful public participation in governance.
 http://www.nesri.org/sites/default/files/HCHR%20Financing%20Plan%202015.pdf

Economists Throw Weight Behind Universal Health Care in Vermont

'Publicly financed health care systems result in improved health outcomes, lower costs and greater equity,' reads letter delivered Thursday
It is not only possible, but financially and economically advantageous to implement a publicly financed healthcare system in Vermont, according to an open letter signed by more than 100 economists and delivered Thursday to lawmakers at the Vermont State House.
"As economists, we understand that universal, publicly financed health care is not only economically feasible but highly preferable to a fragmented market-based insurance system," reads the letter, whose signatories include Dean Baker of the Center for Economic and Policy Research; Richard Wolff of New School University; and Julie Nelson of the University of Massachusetts-Boston.
It continues: "Health care is not a service that follows standard market rules; it should be provided as a public good. Evidence from around the world demonstrates that publicly financed health care systems result in improved health outcomes, lower costs and greater equity."
In December, Vermont Gov. Peter Shumlin abruptly abandoned his much-lauded plan to create a single-payer healthcare system in the state, saying moving forward with the proposal would be too costly.
But the economists' letter, presented in tandem with a report (pdf) from the the Vermont Workers' Center and the New York-based National Economic and Social Rights Initiative (NESRI), shows that that universal health care can be implemented—affordably—in Vermont within the next few years.
"By moving from private, market-based insurance to public financing of universal care," said Anja Rudiger of NESRI, "we flip the way we pay for care: people contribute based on their ability, so that low- and middle-income people pay a smaller share of their income on health care than the wealthy—the opposite of the current system."
The plan proposes taxing wealthier people's unearned investment income in order to give a bigger break to low- and middle-income families. It also proposes implementing a graduated payroll tax that takes into account the difference between the top 1 percent of wages and the bottom half of wages in each company, thereby requiring large employers and businesses with highly unequal salary structures to pay more than smaller and more wage-equitable businesses.
The letter points out: "Public financing is not a matter of raising new money, but of distributing existing payments more equitably and efficiently. Especially when combined with provider payment reforms, public financing can lower administrative costs, share health care costs much more equitably, and ensure access to comprehensive care for all."
The Healthcare Is a Human Right campaign, which mobilized in Vermont and has since spread across the country, is working with state legislators to introduce a bill for public health care financing, building on the Green Mountain Care proposal that Shumlin ditched last December. That law was passed in 2011 but did not include a financing plan.
Thursday's letter indicates that the grassroots movement has not lost momentum. As the NESRI report declares: "Healthcare financing is a matter of justice and human rights."

Market Guide for Healthcare Payers' Core Administrative Processing Systems

28 January 2015 ID:G00272323
Analyst(s): Constance Sjoquist

VIEW SUMMARY


Payer CIOs need to enhance, append or replace their existing core administrative systems to more effectively compete in an increasingly complex healthcare environment. Vendors are developing newer or re-engineering existing solutions to meet this demand.

Overview

Market Definition

Core administrative processing applications are the main systems of record for all healthcare payer business operations from front-end membership management and claims processing to back-end billing and premium payments. Core administrative systems also provide enterprise business functions, such as membership enrollment, benefits plan and provider management, claims adjudication, repricing and audits, premium billing, regulatory and compliance, reporting, and workflow management.
In most payer organizations, core administrative systems are considered "run the business" enterprise applications and are not managed as strategic technology assets. The value they bring to their clients is not typically promoted to internal or external stakeholders, and so investments in improving these systems are primarily focused on streamlining processes or identifying opportunities to pay claims more accurately or more efficiently. Emphasis is placed primarily on their ability to effectively manage day-to-day operations of a payer's business.
Gartner defines core administrative capabilities within two main categories — standard and differentiator components — which follows Gartner's pace layer approach to application architecture. Standard components include benefits administration, membership management, provider administrative configuration and management, claims processing, rating and underwriting, and premium billing. Differentiator capabilities include enterprise workflows, self-service interfaces, integrated customer service, pricing transparency, and automated business intelligence (BI)/analytics and reporting via dashboards for informed decision making (see Note 1).
While payers may decide existing core administrative solutions satisfy their current expectations, by adding differentiator capabilities, payers can more effectively respond to emerging market demands and opportunities.

Market Direction

Historically, the vendor options for core claims administrative systems have been somewhat limited. A handful of legacy solutions have dominated the payer space for years. Often highly customized to a payer's unique business environment or utilized only for a specific line of business (LOB), core administration systems have been expensive and difficult to replace, upgrade, enhance or consolidate without incurring significant risk or downtime.
In the last several years, an enormous amount of change has occurred in the healthcare market and is impacting payers' requirements of their core administrative solutions. New demands include the need to comply with an increased number of regulatory requirements, manage a growing number of contractual arrangements and support new distribution channels. Payers are finding it necessary to make the shift from a historical group to a largely individual membership base and are seeking new and differentiated capabilities that will help ensure they can remain relevant and competitive.
In response, vendors in the healthcare core administrative space have begun to significantly shift their product strategy or market focus to address new payer challenges. While this has brought about innovation and choice, it has also led to a disparate market, causing confusion over what exactly the essential elements of a core administrative system are. Vendors that once dominated the market have recently merged or have been acquired, causing uncertainty around their future product road maps. Some vendors have completely dropped their product offerings for a particular LOB or have shifted their technology strategy to offer only nonlicensed software solutions.




Doctors say data fees are blocking health reform

The fees are thwarting the goals of a push to digitize health records.

As they move to exchange patient information with hospitals and other health care partners, doctors are suffering sticker shock: The vendors of the health care software want thousands of dollars to unlock the data so they can be shared.
It may take an act of Congress to provide relief.

The fees are thwarting the goals of the $30 billion federal push to get doctors and hospitals to digitize health records. The exorbitant prices to transmit and receive data, providers and IT specialists say, can amount to billions a year. And the electronic health record industry is increasingly reliant on this revenue.

The goal of the 2009 program wasn’t just to move doctors from paper chart to computer. It was also to share the information, improve the quality of patient care and ultimately bring down U.S. health care costs.
Most doctors and hospitals have now switched to electronic health records, or EHRs. But the information is often stuck in computers run by hundreds of competing health care software companies — with incompatible products and scant incentive to make them compatible, or “interoperable,” as the industry calls it.
The additional costs were not foreseen during the bipartisan congressional push to create the federal incentive program. The expense is now imperiling the broad efforts to reform health care and adding to the host of technical obstacles that already hamper the flow of information.
“I believe this to be the biggest threat to the investment the nation has made in health IT,” said David Kendrick, head of Oklahoma’s health information exchange, which links doctors, hospitals and labs in his state. “All the money spent on electronic health records has yielded only a fraction of the value of getting interoperability.”
“It’s like giving everyone cellphones and not putting up a cell tower,” he added.
GOP congressional leaders are usually reluctant to intrude on business practices. But in this case, some GOP lawmakers are considering sanctions on the software vendors.
“Interoperability is what makes an EHR useful,” said Rep. Michael Burgess (R-Texas), a physician who leads the House Energy and Commerce trade subcommittee and is drawing up a bill to enforce data sharing. “It’s unfair that practitioners have to spend money on connections they thought were part of the EHR when they bought it.”

http://www.politico.com/story/2015/02/data-fees-health-care-reform-115402_full.html?print



High Rate of Shopping and Switching in Obamacare Plans Is a Good Sign


For most customers returning to the Obamacare marketplaces this year, it really paid to shop around. New data shows that a large number of them did. That bodes well for those shoppers and the future offerings of the insurance marketplaces.
More than half of people who bought insurance on HealthCare.gov last year explored their options before choosing a 2015 plan, according to a report from the Department of Health and Human Services. Of those 2.2 million who shopped, more than half switched to a new health plan.
Those high rates of shopping and switching are unusualin public health insurance marketplaces. Other government programs that allow customers to shop for health plans have had switching rates close to 10 percent. Indeed, a key policy feature of the marketplace this year was an automatic renewal process, which kept people who did nothing enrolled in the same plan from last year.
There are clear advantages for some people in staying in the same insurance plan from year to year — mainly that you can stick with the same doctors and hospitals. But an Upshot analysis of data from the McKinsey Center for U.S. Health System Reform found that people who bought the most popular plans last year often faced substantial premium increases if they stayed put.
It’s not clear from the government’s report how many people who switched saved money by doing so. But the administration has said that more than 70 percent of all customers could save money by switching, so it’s likely that most of the switchers ended up in a cheaper plan. There may be other reasons to switch, of course — maybe some people didn’t like their plan. And even some of last year’s plans are experiencing some changes that could make them less attractive to existing customers, as a ProPublica analysis published in The Upshot highlighted.


Big Changes in Fine Print of Some 2015 Health Plans



At first glance, the 2015 health plans offered by the Ohio nonprofit insurer CareSource look a lot like the ones it sold this year, in the Affordable Care Act’s first enrollment season.
The monthly premiums are nearly identical, and the deductibles are the same.
But tucked within the plans’ jargon are changes that could markedly affect how much consumers pay for health care. Generic drugs will soon be free, but the cost of expensive specialty medications will increase. Co-payments for visits to primary-care doctors will go down, but those for emergency room trips will be higher.
Millions of people nationwide bought health insurance this year through the federal government’s health insurance exchange, often through the website Healthcare.gov. Now, as they pick plans for next year, they face a complex battery of choices.
They have until Dec. 15 to select a new plan or they’ll be re-enrolled automatically in the one they currently have. Or, if that plan no longer exists, they’ll be enrolled in another product offered by the same insurer, when available. But even if they get the same plan — of the nearly 2,800 health plans offered in 2014, about 1,700 of them will exist in the same form next year — their benefits may not stay the same.

How an Adverse Supreme Court Ruling Would Send Obamacare Into a Tailspin


Even if you don’t receive Obamacare subsidies, you could still be harmed by the Supreme Court case that could take them away.
A court ruling for the plaintiffs in the case, King v. Burwell, would have wide-reaching effects for the individual insurance markets in around three dozen states. The approximately six million people currently receiving subsidies in those states would be hit hard, of course. But so could the millions who now buy their own insurance without subsidies. The results could be surging prices and reduced choice for health insurance shoppers across the income spectrum.
It’s a phenomenon some health policy experts call the “death spiral,” the result of an insurance pool getting smaller and sicker as more healthy people leave an increasingly expensive health insurance market.
The question before the court on Wednesday is whether the federal government can keep distributing subsidies in states that failed to set up their own health insurance marketplaces. For most people receiving subsidies, the full cost of insurance plans would be unaffordable, meaning that only people with the most serious health conditions would be likely to keep buying it.

Undermining Children’s Insurance

By 

Senior Republicans in Congress are seeking major changes to the Children’s Health Insurance Program when the program’s money runs out in September.
Their proposal, labeled a “discussion draft” for legislation yet to be written, could deprive more than a million children of insurance or force their families to pay higher out-of-pocket costs for their coverage. It also would shift costs to states, which would be left holding the bag to pay for the children’s insurance or for the care of the children as uninsured patients.
The draft is being circulated by Senator Orrin Hatch of Utah, chairman of the Senate Finance Committee; Representative Fred Upton of Michigan, chairman of the House Energy and Commerce Committee; and Representative Joe Pitts of Pennsylvania, chairman of the health subcommittee. It threatens to undermine the progress made in reducing the number of uninsured children, gains that came from enrolling more children in Medicaid and in CHIP, which covers children whose families earn too much to qualify for Medicaid.
The Republican proposal would eliminate the Affordable Care Act’s requirement that states keep the family-income eligibility levels stable until 2019, and it could make it harder for families to prove their eligibility. Faced with a loss of federal funds for CHIP, as suggested in the Republican proposal, many states would probably shrink their CHIP programs and reduce their own financial contributions. A result would be fewer children enrolled in the program. The proposal would also eliminate a requirement that states enroll children who are just above the poverty line in Medicaid. This would enable states to move them from Medicaid back to CHIP, where enrollments are often limited by budget caps.
And the proposal would allow states to impose a 12-month waiting period (up from the current 90 days) before children who lose coverage from a parent’s insurance plan can be enrolled in CHIP. That is a very long time for a youngster to go without insurance and the regular care it provides. Many families in that situation will not be able to afford coverage on the new health care exchanges.
http://www.nytimes.com/2015/02/28/opinion/undermining-childrens-insurance.html?hp&action=click&pgtype=Homepage&module=c-column-top-span-region&region=c-column-top-span-region&WT.nav=c-column-top-span-region&_r=0

Before Supreme Court Rules, Florida Considers Future Without Health Subsidies

By 
MIAMI — Sylvia Maltzman, a part-time tutor at a community college in Florida, pays $23 a month for the health insurance she got under the Affordable Care Act. A federal subsidy of about $475 covers the rest, and Ms. Maltzman, who has high blood pressure and arthritis, said she could not afford insurance without it.
So she is prepared to demand that her elected officials, most of them Republicans, do something to help if the Supreme Court rules that people here and in other states that use the federal government’s insurance marketplace cannot receive subsidies. “I would hunt them down, and I would definitely let them know this could very well be fatal for me,” said Ms. Maltzman, 56, a registered Democrat.
Steven Brizuela, a Republican who lives not far from Ms. Maltzman in Miami, sees things differently. Mr. Brizuela, 20, who works at a clothing store and goes to college part time, said he had signed up for health care mostly because the law mandated it. Though he receives a subsidy of about $90 a month, he said he would rather have no insurance because he is healthy and finds his portion of the monthly premium, $45, a burden.
“I’m not going to take it out on them” if the subsidies are struck down, he said, referring to both political parties.
Next week, the Supreme Court will hear arguments in a case, King v. Burwell, that challenges the legality of the subsidies in more than 30 states, including Florida. The case, developed by conservative legal scholars, argues that only people using state-run marketplaces are entitled to subsidies.
If the court agrees — a decision is expected in June — subsidies will disappear in states that do not have their own online marketplaces, almost all of which have Republican-led governments that oppose the law and have resisted creating state exchanges. No state would be more affected than Florida, where more than 1.6 million people have insurance plans under the Affordable Care Act, the most in the nation, and almost all of them receive subsidies.
Yet there is little talk of a Plan B here, such as creating a state-run exchange where subsidies would still be available, if the Supreme Court strikes down the subsidy program. Asked about the case last week at the American Action Forum, a conservative advocacy group, Gov. Rick Scott, a Republican, said, “This is not my program.” He added, “It’s a federal problem.”
Will Governor Scott and other Republicans face a backlash from subsidy recipients if the lawsuit succeeds? The answer is far from clear.

Obamacare threatens to end John Roberts’s dream of a nonpartisan Supreme Court

By Robert Barnes February 2
The first time the Affordable Care Act came before the Supreme Court, its constitutional foundation under attack, John G. Roberts Jr. was its unlikely savior. In a spectacular display of spot-welding, the chief justice joined fellow conservatives on some points and brought liberals on board for others. Roberts was the only member of the court to endorse the entire jerry-rigged thing, and even he made sure to distance himself from the substance of the law. (“It is,” he wrote, “not our job to protect the people from the consequences of their political choices.”) Still, his efforts rescued President Obama’s signature achievement on grounds that many had dismissed as an afterthought.
As long as Justice Anthony M. Kennedy is on the court, he will most often be the decider when the justices split along their familiar ideological fault lines. But, slowly and quietly, Roberts is the one trying to build its legacy. He sees it as somehow exempt from the partisan fugue that long ago enveloped Washington. Justice Stephen G. Breyer has worried that the public might see him and his colleagues as “nine junior-varsity politicians”; public approval of the Supreme Court is falling. But while all of the justices bristle at the notion of a political court, the eponymous head of the Roberts court has the most to lose. After all, its decisions cannot be respected if the court is not respected. “It is a very serious threat to the independence and integrity of the courts to politicize them,” Roberts said at his 2005 confirmation hearings.
Roberts, 60, jokes about the “odd historical quirk” that gives the chief justice only one vote. But he has learned to use the tools that come with the job: He shapes the discussion at conference; he writes the court’s opinion, or assigns it strategically, when he is in the majority; he’s happy to settle for nonthreatening, incremental changes that may bloom later into something more. And last term, what Roberts has described as the chief justice’s “particular obligation to try to achieve consensus” paid off. The share of unanimous decisions soared to 66 percent, a level not seen since the 1940s. The share of 5-to-4 decisions, high during Roberts’s tenure compared with those of other chief justices, fell to 14 percent, the lowest since he joined the court.
And then here comes Obamacare II. In King v. Burwell , to be argued Wednesday, plaintiffs say the text of the law must be interpreted in a way that would neuter it, canceling health insurance subsidies for about 7.5 million Americans in at least 34 states. Can Roberts’s portrayal of the Supreme Court as above politics survive another round with the most partisan issue of the decade?

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Q&A: What's next for Prime Healthcare, Daughters of Charity hospitals
By  AND
Six struggling Catholics hospital in California are up for sale, and their future is in the hands of a fast-growing hospital chain based in the Inland Empire. 
Prime Healthcare Services Inc., a for-profit company with headquarters in Ontario, has offered to buy the financially struggling Daughters of Charity Health System for about $843 million.
On Feb. 20, California Atty. Gen. Kamala D. Harris approved the sale -- with several key conditions. She said Prime Healthcare must keep all of the hospitals open for 10 years, while offering the same services and providing the same amount of charity care for indigent patients as Daughters of Charity has been offering.
Now it's up to Prime Healthcare to decide whether to accept the conditions or walk away. A decision is expected in the next few weeks.
What’s the latest?
Prime Healthcare is reviewing Harris’ decision and all the conditions she imposed. It is also consulting with its lenders and with Daughters of Charity staff to determine whether the purchase is financially feasible. On Feb. 25, the company said a decision “will likely require weeks of analysis.”
Is there a deadline?
Harris didn’t put a deadline on the deal, but Daughters of Charity bondholders expect the deal to close within 45 days of approval, which would be April 6, said Robert Issai, chief executive of Daughters of Charity. “I don’t want to give Prime a deadline, but I will ask them sooner, rather than later, to make a decision."





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Thursday, February 26, 2015

Health Care Reform Articles - February 26, 2015


When the System Fails

By 
I PURCHASED a purple “My Little Pony” at Walmart. I told myself it was to bring a brief smile to a sad little girl’s face. In reality, it was for me. In the overwhelming apparatus that medicine has become, sometimes the patient gets lost. So does the doctor. As the major safety net hospital in our region, my own hospital is arguably better equipped than most to effectively handle the human side of medical care. But even the most experienced institutions face an increasingly uphill battle against the systemic shortfalls of American medicine.
The patient, whom I’ll call Mohammed, was an American citizen, fully employed with health insurance, although with limited English language skills and health literacy. I had been his primary care doctor for seven years, and he came to me about two years ago with a lesion on his scalp after hitting his head on the door. I didn’t know exactly what it was, although my best guess was some sort of post-traumatic injury. I sent him to surgery for another opinion. The surgeon concurred with my diagnosis, but scheduled a biopsy. What I didn’t know was that Mohammed didn’t return for the planned procedure. He was struggling as a new single parent to his two young children who had just arrived from a war-torn African country, while his wife was left behind, her visa delayed by bureaucratic obstacles. He had deferred the biopsy because of his life circumstances without understanding the significance, and without catching anyone’s attention. The ball was dropped, and he fell through the cracks in the mighty apparatus.

Health Secretary Says There’s No Backup Plan if Supreme Court Rules Against Law

Next week, the Supreme Court hears arguments in a case that could upend Obamacare insurance coverage for millions of people. Tuesday, the Secretary of Health and Human Services said there was little the administration could doto limit the impact of such a ruling.
“We know of no administrative actions that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision,” wrote Sylvia Mathews Burwell in a series of identical letters to Republican leaders in Congress.
The message represented a shift in tone from Ms. Burwell, who has been asked repeatedly by reporters and members of Congress what the administration would do in the aftermath of such a decision. In the past, her strategy has been to change the subject. We’re confident we’ll win the case, she’s said, and we’re focused on signing people up for insurance, not planning for a possible loss.
The new message is consistent with her previous stance, but considerably more alarmist in tone. The letter describes the consequences of a court ruling for the case’s plaintiffs: the loss of insurance subsidies for millions of people in a majority of the states, followed by increases in the number of uninsured Americans and instability in insurance markets.

PRESS RELEASE: Study Urges Greater Financial Disclosure by Nonprofit Integrated Health Systems

Little Evidence Backs Up Claims of Cost, Quality Advantages

For Immediate Release: February 25, 2015
Contact: Jill Braunstein at (202) 243-7009
WASHINGTON, D.C.—Based on publicly available information, there is scant evidence to back up claims by large, nonprofit integrated health systems that they deliver higher quality care more efficiently, according to a new study released today from the nonpartisan National Academy of Social Insurance (NASI). The report will be discussed at a 2pm panel on trends in provider consolidation during a Federal Trade Commission / Department of Justice live webcasted workshop on “Examining Health Care Competition.”

Along with a comprehensive review of the academic literature, the study (PDF) included an analysis of publicly available quality and financial information from 15 of the largest nonprofit integrated delivery networks (IDNs) across the country, including Henry Ford Health System in Detroit; North Shore-LIJ Health System in suburban New York; Intermountain Healthcare in Utah/Idaho; Sutter Health in Northern California; BayCare Health System in Tampa/St. Petersburg; and Geisinger Health System in Central Pennsylvania.

The study defined IDNs as vertically integrated health services networks that include hospitals, physicians, post-acute services and sometimes health plans with a stated purpose to coordinate care across the continuum of health services and to manage population health; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums).

"Some of the nation’s finest hospitals and clinical staffs can be found in this fifteen IDN sample.　This analysis was not intended to denigrate these fine institutions or their managements," said Jeff Goldsmith, the study’s lead author, President of Health Futures, Inc., and Associate Professor of Public Health Sciences at the University of Virginia. "Rather, it is intended to address whether the way they have organized care creates measureable benefits to society, or for that matter, to the institutions themselves. If these benefits exist, we could not find evidence of them in their public disclosures, beyond the claimed ‘community benefit’ common to all non-profits."

According to the study, IDNs have "operated under a halo of presumed societal benefits (quality, efficiency, care integration, etc.) for the better part of four decades with remarkably little evidence that these benefits in fact exist. It is still possible that these societal benefits of IDNs exist. But if they do, given the opacity of present IDN disclosure of key operating information, they eluded us in this preliminary investigation. If public policy is to continue fostering IDN growth and development, a more solid evidentiary foundation for this form of medical care organization seems essential. The mere presumption of societal benefits of IDN formation or operations is no longer tenable as a policy principle."

Judge overturns Maine law allowing prescription drug imports

by Jackie Farwell

A federal judge has overturned Maine’s first-in-the-nation law allowing residents to purchase medication by mail from other countries. 
U.S. Chief District Judge Nancy Torresen’s ruling Monday comes more than a year after several Maine pharmacy groups filed suit against the state over the 2013 law, arguing it jeopardizes the safety of the nation’s prescription drug supply and opens the door to counterfeit and tainted medications.
Federal law strictly limits the importing of prescription drugs from foreign countries for personal use. Torresen ruled that Maine infringed on the federal government’s established regulatory authority by allowing drug importation at the state level. Her decision nullifies the law, though the state could potentially appeal.
The law allowed Maine residents to buy prescription drugs from Internet pharmacies in Canada, the U.K., Australia and New Zealand, which the U.S. government deems to have equivalent or greater drug safety and licensing regulations. Those countries, among others, can sell prescription drugs more cheaply because their governments cap prices or negotiate prices with drug makers.
Torresen wrote in her decision that Maine’s “singling out of certain countries from which pharmaceuticals may be imported compromises the tightly regulated structure” set up under federal law and “compromises federal government’s ability to ‘speak with one voice’ when it regulates foreign commerce.”
The three pharmacy groups argued Maine’s law sidestepped the U.S. Food and Drug Administration’s oversight, designed to protect consumers from unsafe medications. Their suit, filed in September 2013, names as defendants Maine Attorney General Janet Mills and Richard Rosen, who has since been named the state’s finance commissioner.
“Maine pharmacists are relieved that Judge Torresen’s ruling ensures the safety of prescription drugs for Mainers by upholding federal laws that are designed to prevent unapproved and substandard drugs from coming into the United States,” said Kenneth McCall, immediate past president of the Maine Pharmacy Association, one of the plaintiffs in the case.
His group was joined by the Maine Society of Health System Pharmacists and the Retail Association of Maine. The drug industry’s largest lobbying group, the Pharmaceutical Research and Manufacturers of America, also sued the state, but Torreson dismissed the organization as a plaintiff in June 2014.
“Maine people can be assured that the prescriptions that are filled by Maine pharmacists are approved medications,” said Curtis Picard of the Retail Association of Maine. “We expect foreign companies to abide by this ruling and federal law and to cease illegally importing drugs into Maine.”
Mills said the issue of drug importation needs further scrutiny, but she did not indicate whether she plans to appeal Monday’s decision.

 As Maine’s uninsured rate drops, Lewiston co-op again woos most Obamacare enrollees

by Lindsay Tice

LEWISTON — Over 66,000 Mainers have signed up for health insurance with Maine Community Health Options, an increase of 65 percent for the state’s only health insurance co-op. 
Of those people, 57,600 got insurance through the federal marketplace established by the Affordable Care Act, also known as “Obamacare.” That means for the second year in a row, MCHO will insure the majority of Mainers on the marketplace.
“(The overall numbers) are right in line with what we had been working towards and what we were projecting, so it’s great to see coming into focus this way,” said CEO Kevin Lewis. 
Co-ops are health insurance companies run by members for members. They were created through the 2010 Affordable Care Act to increase competition among health insurers and to provide consumers with greater choice in the marketplace.
There are 23 co-ops throughout the country. Rating company A.M. Best has said that, as of last fall, Lewiston-based MCHO is the only one making money.
As of Feb. 18, nearly 75,000 Mainers had signed up for insurance through the marketplace, according to the Centers for Medicare and Medicaid Services. About 57,600 of those Mainers chose one of MCHO’s insurance plans, according to preliminary numbers released by the co-op Tuesday. However, MCHO’s figures include only people who have paid their first bill.
With several days left for consumers to pay for March 1 coverage, Lewis expects that MCHO will ultimately be responsible for about 80 percent of the marketplace.
Last year, MCHO had about 83 percent of the marketplace. At that time only two insurance companies shared the marketplace — MCHO and Anthem Blue Cross and Blue Shield. This year, a third insurer, Harvard Pilgrim Health Care, has joined the marketplace.

H&R Block: Taxpayers Following ACA Rules, Refunds Take a Hit

So far taxpayers seem to be indicating true insurance status as refunds dip 17 percent
So far in the 2015 tax season, H&R Block (NYSE: HRB), the world’s largest consumer tax services provider, is seeing a majority (52 percent) who enrolled in insurance via the state or federal Marketplaces paying back a portion of the Advance Premium Tax Credit (APTC). The average amount paid back is $530, decreasing the tax refund on average by 17 percent, according to analysis almost six weeks into the 2015 tax season. In addition, it seems taxpayers are accurately indicating their insurance coverage status as the number of those selecting a penalty and/or qualifying for an exemption is in line with preseason projections.
The analysis by H&R Block, uniquely positioned in the industry as the largest provider offering both assisted and do-it-yourself tax preparation, indicates the data of returns filed to date is in line with three primary preseason expectations:
  • A majority of year-end Marketplace enrolled clients who reconciled using Form 8962 underestimated their household income and therefore must repay a portion of the APTC.
  • The average tax penalty for not having insurance was $172, an indication that most taxpayers are paying more than the flat-fee of $95 per uncovered adult penalty many consumers anticipated.
  • Taxpayers appear to be foregoing hunting down Marketplace hardship exemptions and instead claiming tax return exemptions, especially those which are income based.
“Our data suggests that most taxpayers are accurately indicating their household insurance coverage status,” said Mark Ciaramitaro, vice president of H&R Block health care and tax services. Ciaramitaro said clients “appear to be answering truthfully by paying the tax penalty for being uninsured. We don’t think they are just checking the box that they are covered when they’re not.”
Average refund reduced 17 percentWith many clients relying on 2012 income as a baseline to estimate their 2014 income at the time of the first open enrollment, H&R Block expected that most filers would not accurately estimate their 2014 household income. This income underreporting has led to a majority of Marketplace-enrolled taxpayers paying back a portion of the tax credit. The average tax refund for these taxpayers was almost $3,100 but it was reduced by $530 due to the tax credit reconciliation process.
“The level of payback of the Advance Premium Tax Credit is significant in that it’s costing taxpayers a large percentage of their refund – a refund many of them count on to pay household expenses,” Ciaramitaro said.
Conversely, the analysis also showed roughly one-third of Marketplace enrollees overestimated their 2014 household income, and therefore received an additional premium tax credit of close to $365 on average, which was an additional 11 percent increase resulting in an average $3,816 refund.
H&R Block is assisting clients in its offices by conducting a detailed ACA tax impact analysis to help them understand their personal situation and apply for Marketplace insurance plans with a more accurate household income figure going forward.

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