Monthly Archive: September 2014

Underinsured ACA enrollees strain community health centers | Modern Healthcare

When the ACA was enacted, leaders of community health centers were excited about the prospect of their previously uninsured patients getting coverage and having their levels of uncompensated care drop. But they were surprised when many of their lower-income patients bought bronze plans with high cost-sharing and started coming in seeking treatment on a sliding-scale fee basis. Previously, sliding-scale fees were used mostly by uninsured people who had to pay their own bills.

The centers say this has had a negative impact of their finances. “The use of the sliding fee scale due to the inability to pay required co-pays impacts the community health centers’ uncompensated-care costs, which are not declining as rapidly as contemplated by some policymakers,” said Mary Leath, CEO of Community Health Centers of Arkansas.

The squeeze is being felt even in states that have expanded Medicaid to adults with incomes up to 138% of poverty, which has provided community health centers in those states with more paying patients. Deb Polun, director of government affairs at the Community Health Center Association of Connecticut, said the lowest deductibles for bronze plans in her state are about $4,000, which is not affordable for lower-income patients.

via Underinsured ACA enrollees strain community health centers | Modern Healthcare.

This is an interesting development that points to some potential implications:

1. Lower income households are mistakenly choosing high deductible bronze metal tier plans that are ill suited to their economic resources and health statuses — particularly among people who are frequent users of primary care services — because they don’t understand how out of pocket cost sharing works and believe health plans are all inclusive.

2. These households should be but are not being directed toward silver metal tier plans that feature cost sharing subsidies for households earning up to 250 percent of federal poverty. If so, this suggests state health benefit exchanges and those who help people choose individual plans such as insurance agents need to do a better job ensuring consumers are getting adequate information in order to choose the best metal tier plan for their circumstances.

3. Lower income households are deliberately selecting bronze plans in order to benefit from their lower premiums, knowing they can get low cost primary care on a sliding scale fee basis from community health centers.

4. Lower income households are overestimating their incomes and should be enrolled in Medicaid programs if eligible instead of exchange plans. California’s state-operated exchange, Covered California, has switched some plan year 2014 enrollees from exchange plans to Medicaid when income redeterminations for plan year 2015 found some households earning too little to qualify for an exchange plan.

The item reports bronze health plan issuers are denying claims submitted by CHCs, which are then written off as uncompensated care. This raises the question of the type of care for which reimbursement is requested since preventative services are not subject to cost sharing and are included in plans at all metal tiers of coverage.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Employers shouldn’t be in the wellness business

Many American employers are looking to establish employee wellness programs – something that Princeton University health care economist Uwe E. Reinhardt believes they shouldn’t be doing. People should be aware of their health and what they need to do to improve and preserve it. But their health status is not — nor should it be — the responsibility of their employers, Reinhardt said in this interview with Managed Care. (Reinhardt’s comments on this topic begin at 15 minutes into the interview)

Just as government price controls instituted during World War II incented employers to offer health plans for their employees and led to today’s system of employer-based coverage as the norm for most working age Americans, Reinhardt takes a similar view of wellness programs. “I think in America, employers stumbled into this by default,” Reinhardt observed. “I think it’s sad, very sad. Employers should not be doing it.”

I agree with Reinhardt. Health maintenance is ultimately a personal responsibility and not that of one’s employer, health plan and for the vast majority of people, their health care providers. Most human beings naturally tend toward health at all life stages if they live in a healthy environment and engage in health enhancing behaviors relative to diet, plenty of vigorous exercise that raises the heart rate and getting 7 to 8 hours of sleep every night.

Rather than set up formal wellness programs, employers should support people’s decisions to engage in these behaviors and provide them to ability to do so while recognizing everyone has their own personal journey toward health.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Uwe Reinhardt on future of U.S. healthcare: No single payer, end of Medicaid

About halfway into this interview with Managed Care, Princeton University health care economist Uwe Reinhardt prognosticates where the U.S. health system is headed in the post-Patient Protection and Affordable Care Act era. And it’s not Canadian-style single payer where a government monopsony pays providers.

However, Medicaid as a public payer could go away in a three-tiered system foreseen by Reinhardt and replaced with publicly financed providers: public clinics and hospitals. Potentially accelerating Reinhardt’s prediction are significant challenges states are experiencing ensuring those eligible for Medicaid get timely, continuous coverage and have access to a sufficient pool of providers. These challenges have been heightened by expanded ACA Medicaid eligibility in some states and difficulties complying with the ACA mandate that state health benefit exchanges employ a single, electronic application process for both commercial exchange plans and state Medicaid programs.

For most people in private insurance plans, Reinhardt predicts the growth of reference pricing where payers set a standard reimbursement for common procedures or medications. Providers would not be reimbursed above reference price level but could opt to charge more and give patients the option of paying the difference out of pocket. Reinhardt sees higher relative prices charged for procedures and medications compared to other nations as the primary reason why U.S. health care costs are often double or more that of other countries for the same procedure or medication.

The third and top tier of the future U.S. health system is concierge or “boutique” medicine where those who can afford it have their own personal physician on retainer.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Covered California official concerned over provider network volatility, enrollee access

As California’s health benefit exchange marketplace, Covered California, prepares for Plan Year 2015 enrollment in November, at least one of its board members is openly concerned whether plan enrollees will have predictable access to in-network health care providers.

At a Covered California board meeting this week, Board Member Kim Belshé observed there has been a “steady drumbeat” of media accounts of Plan Year 2014 enrollees having difficulty finding physicians willing to accept Covered California plans. Belshé pointed to an aggravating factor of what she described as nearly real time changes to plan network provider rosters. California Executive Director Peter Lee noted some plan issuers are updating their network provider lists as frequently as weekly.

That introduces a degree of uncertainty that devalues the plans by robbing enrollees of the peace of mind that they will be able to see a network provider without running the risk of being turned away or having to pay more for care from a non-network provider. With the use of smaller networks in order to hold down premium rates, the likelihood that a provider isn’t in a given plan’s network increases.

It appears to come down to money and specifically provider reimbursement rates. Media accounts such as this one point to provider dissatisfaction over reimbursement rates for Covered California plans. This San Jose Mercury News item explains:

Many doctors are upset about the discounted reimbursement rates that insurers have imposed on them to keep premiums low on the Covered California exchange. The new rates — as much as 30 percent lower than those paid by nonexchange plans — took effect Jan. 1, when the new health care plans of hundreds of thousands of Californians kicked in.

The Patient Protection and Affordable Care Act and California law require health plan issuers that offer plans both on and off the California exchange to offer off exchange plans at the same price as exchange plans. But there is no requirement that provider networks be the same among the plans. California law effective June 16, 2014 allows plan issuers to factor provider networks into setting premium rates. Narrower networks can decrease rates but with the tradeoff of access to a wider pool of providers that affords enrollees a greater level of certainty a given provider may be in their plan network.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

GAO report points to low Medicaid reimbursements as impetus for “Arkansas plan”

A recent critical assessment of Arkansas’s use of federal Medicaid dollars to subsidize the purchase of commercial individual health plans by low income people through the state’s health benefit exchange indicates a lack of health care providers willing to accept standard Medicaid reimbursement played a key role in the move. The repurposing of the Medicaid funding was authorized under a 3-year-long demonstration project waiver issued in the U.S. Department of Health and Human Services (HHS) in 2013.

The U.S. Government Accountability Office (GAO) issued a report earlier this month criticizing the waiver as contrary to HHS’s policy of requiring such waivers not incur costs beyond existing state Medicaid program expenditures. The report concluded that $4 billion HHS approved for the demonstration project was approximately $778 million more than the state would have spent for adult beneficiaries under its then-existent Medicaid program. HHS disagrees with the report’s conclusion, contending GAO too narrowly analyzed HHS’s budget neutrality policy governing Medicaid demonstration programs and Arkansas’s Medicaid cost data and failed to take into account the effect of Medicaid program expansions.

The stated policy intent of the demonstration is to ensure access to care and continuity of coverage since individuals could stay enrolled in the same health plan regardless of whether their coverage is financed through Medicaid or federal subsidies. The GAO report noted that according to Arkansas’s waiver application, the state’s network of Medicaid providers was at capacity. “By purchasing [exchange qualified health plan] coverage for newly eligible [Medicaid] beneficiaries, the state suggested it could improve access to care because beneficiaries would have access to expanded provider networks” through commercial plans sold on the exchange.

The GAO report takes issue with “questionable assumptions about provider payment rates,” noting the demonstration program projected the cost of expanding Medicaid without the demonstration assumed Arkansas would have had to pay its Medicaid providers rates comparable to private insurance payment rates—significantly higher rates than the rates the state was paying its [Medicaid] fee for service (FFS) providers—to ensure access for newly eligible beneficiaries.

For example, the report noted, the state assumed that it would have to pay 67 percent above its Medicaid reimbursement rate for primary care services and 10 percent above Medicaid reimbursement rates for higher-cost services such as inpatient and long-term care. “HHS approving officials told us that they thought the state’s underlying concern about the insufficient capacity of the state’s Medicaid provider network was valid given a projected 25 percent increase in the number of individuals covered under the state’s Medicaid program,” the GAO report states.

HHS has approved similar demonstration waivers for Iowa and Pennsylvania, allowing those who would otherwise be eligible for Medicaid coverage to purchase coverage through those state’s health benefit exchanges. Interest has also been shown by New Hampshire and active negotiations underway between HHS and Utah.

“Arkansas’s demonstration may prove an important test of whether using Medicaid funds to finance coverage offered through exchanges will improve access to care and continuity of coverage for the adult population that the demonstration aims to cover,” the GAO report concludes. “However, the increasing use of demonstrations has shifted a significant portion of federal Medicaid funds into financing care that is not subject to all of the federal Medicaid requirements. While HHS policy requires that demonstrations be budget-neutral and therefore not increase the costs to the federal government, we have had long-standing concerns about the Department’s ability to ensure budget neutrality given HHS’s flexible approach towards approving spending for new demonstrations.”


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

New Anthem Blue Cross plan takes on Kaiser – LA Times

Overall, Vivity will comprise 6,000 doctors and 14 hospitals across the seven health systems.But Anthem wants to work with these medical centers to keep as many patients as possible from ever setting foot inside the hospital.

“Under the current model, hospitals want to keep occupancy rates up,” said Pam Kehaly, Anthem’s west region president and a key architect of this deal. “This is in complete opposition to that. For this joint venture to succeed, we have to keep occupancy rates down.”

Susan Ridgely, a senior policy analyst at the Santa Monica think tank Rand Corp., said these hospitals are probably betting that they can attract enough new patients and referrals through Vivity to offset the gradual decline in inpatient admissions.via New Anthem Blue Cross plan takes on Kaiser – LA Times.

Anthem Blue Cross is adopting an accountable care organization (ACO)-like strategy in Southern California where it and hospitals jointly benefit from reducing costly patient admissions. It reverses the current economic model in which health plan issuers and hospitals have conflicting interests to one based on the principle that enhanced access to lower cost care is better for both payers and providers than costlier hospital admissions. An innovative development worth watching.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Pre-diabetes, diabetes rates fuel national health crisis

Americans are getting fatter, and older. These converging trends are putting the USA on the path to an alarming health crisis: Nearly half of adults have either pre-diabetes or diabetes, raising their risk of heart attacks, blindness, amputations and cancer.

Federal health statistics show that 12.3% of Americans 20 and older have diabetes, either diagnosed or undiagnosed. Another 37% have pre-diabetes, a condition marked by higher-than-normal blood sugar. That’s up from 27% a decade ago. An analysis of 16 studies involving almost 900,000 people worldwide, published in the current issue of the journal Diabetologia, shows pre-diabetes not only sets the stage for diabetes but also increases the risk of cancer by 15%.

“It’s bad everywhere,” says Philip Kern, director of the Barnstable Brown Diabetes and Obesity Center at the University of Kentucky. “You almost have the perfect storm of an aging population and a population growing more obese, plus fewer reasons to move and be active, and fast food becoming more prevalent.”

via Pre-diabetes, diabetes rates fuel national health crisis.

The health insurance crisis is a population health status crisis that is at its base an individual lifestyle crisis. That lifestyle crisis is ultimately a cultural crisis since cultural values influence lifestyle choices. In the 1970s and 1980s, exercise and fitness were cool. Hopefully they will come back in style — and soon.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

N.Y. limits average health insurance increases to 5.7%

ALBANY – The state on Thursday approved an average 5.7 percent rate increase for health insurers in 2015, spurning their request for a 13 percent hike.

Insurers in July cited growing costs in their rate requests. But the state Department of Financial Services set the rate and said it would be an average of 5.7 percent for individual plans, saying it will save customers about $1 billion next year.

Overall, the agency contended that rates will remain 50 percent lower than they were prior to state’s health care exchange that started Jan. 1. Nearly 1 million New Yorkers enrolled in the health exchange. The next enrollment period starts Nov. 15 for coverage starting on Jan. 1.

For small-group insurance, insurers wanted a 13.9 percent increase. The state reduced it to 6.7 percent.

via N.Y. limits average health insurance increases to 5.7%.

This development could have implications for California which like New York operates a state-based health benefit exchange that actively negotiates premium rates with health plan issuers.

A measure on California’s General Election ballot in November, Prop. 45, would bring the Golden State in line with New York and a majority of states that require health plan issuers obtain prior regulatory approval before using rates.

Prop. 45 has raised concerns among opponents as well as the state’s health benefit exchange, Covered California, of potential disruption of the individual and small group health insurance market if plan issuers decide they can’t live with approved premium rates lower than those filed. That could possibly lead to plans being withdrawn from regions or all of the state as threatened by the New York state Health Plan Association in this story.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Controlling Health Care Costs Through Limited Network Insurance Plans: Evidence from Massachusetts State Employees

We find that distance traveled falls for primary care and rises for tertiary care, although there is no evidence of a decrease in the quality of hospitals used by patients. The basic results hold even for the sickest patients, suggesting that limited network plans are saving money by directing care towards primary care and away from downstream spending. We find such savings only for those whose primary care physicians are included in limited network plans, however, suggesting that networks that are particularly restrictive on primary care access may fare less well than those that impose only stronger downstream restrictions.

via Controlling Health Care Costs Through Limited Network Insurance Plans: Evidence from Massachusetts State Employees.



Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

Wellness isn’t at the office

We spend the majority of our waking hours at work. The office environment has a great deal of influence over the shape and structure of our lives. While the doctor’s visit is where many health conversations start, it is rarely where they continue to live. Workplaces have the opportunity to keep this conversation going. As Catherine Baase, Global Director of Health Services for The Dow Chemical Company, states, “The workplace, through its established culture, can have greater long-term impact than the visit with your doctor, the reach of government and even the sphere of your family. It is the secret sauce to driving outcomes — and an essential factor in achieving population health.”

Influence also stems from an organization’s ability to create an ecosystem of health around an individual. While a doctor’s advice often fails to stick because it gets drowned out in our hectic lifestyle, workplaces can support an individual’s adherence to health everyday by surrounding an employee with a physical and social environment that makes health the simple and meaningful choice. At USAA, it’s hard to ignore the physical representation of health. The company has made it so convenient it’s become part of the fabric of the organization with amenities, such as bike stations, BMI testing rooms, indoor and outdoor walking paths, stairway signs estimating calories burned for use, energy rooms, healthy food and a massive gym. Culturally at USAA, health has been woven in, with departments competing to collect healthy points. The reward—a sense of group pride—is a compelling force to action and holds people accountable. When we bump up against these attitudes and resources day in and day out at the workplace, they influence our perspectives on health.

via Reach and influence: Why corporate wellness programs really do work.

I respectfully disagree with the notion that workplaces are the magic bullet for encouraging health promoting behaviors to ward off preventable, lifestyle-related chronic conditions that cost organizations billions in health care costs and lost productivity. Yes, knowledge workers do spend the majority of their waking hours at work. But the daily — and needless — commute of 40 to 120 minutes to sit in an office for 8 hours is one of the worst things we can do for our collective health.

The more sensible — and less costly for both organizations and their members — approach is to leverage information and communications technology to shift away from the overarching centralized commuter office culture. Treat staff as adults and let them manage where and when they get their work done. That way, they’ll have more freedom and freed up time from ditching the daily commute to hit the (real, not office mini) gym, walk, run, swim, and cycle on their own schedules. If organizations want their members to adopt health promoting behaviors, they need to give them maximum freedom and support to make that choice. And they’ll likely benefit from reduced real estate and health care costs, lower turnover and higher staff attraction and retention.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

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