Tag Archive: California

Amid slower growth, California’s Obamacare exchange cuts proposed spending – LA Times

Many Californians who signed up in 2014 were closer to the federal poverty line and often paid just a few dollars a month for health insurance, thanks to generous federal subsidies.The remaining uninsured were closer to the cutoff for those federal dollars, meaning they had to pay more of the premium themselves.”Those people may just be doing the math, and they simply cannot afford the premiums,” (Caroline) Pearson, senior vice president at Avalere said. (Covered California Executive Director Peter) Lee said the exchange is planning to survey consumers who have left the exchange to get a clearer picture of what’s happening in the market.

Source: Amid slower growth, California’s Obamacare exchange cuts proposed spending – LA Times

Lee told The Times his organization’s impression is few people are shunning exchange plans due to cost concerns. The survey should scrutinize a potential financial pain point: those in 50+ age rating bands who pay higher premiums and who earn more than 250 percent of federal poverty level (FPL) and particularly those earning between 300 and 400 percent of FPL.

Under Section 1401(b)(3) of the Patient Protection and Affordable Care Act, these households must pay between 8.05 and 9.5 percent of their incomes toward the premium cost of the index plan (second lowest silver-rated plan for a given plan year) compared to between 3.0 and 8.05 percent at lower income levels. The subsidies may be working well for those earning 250 percent or less of FPL but not as well for older Californians earning between 250 and 400 percent of FPL. Nearly half of Covered California enrollees for plan years 2014 and 2015 were age 45 and older. Also, some older Californians near the 400 percent FPL cut off for advance premium tax credit subsidies might have been offered subsidies too small to keep them in a Covered California plan and opted to purchase plans sold in the off-exchange market.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Obama administration concerned over QHP provider network volatility

“The impact of inaccurate provider directories on consumers can be devastating, especially on those consumers who need to carefully examine networks for specific subspecialists, cancer centers or children’s hospitals,” the American Medical Association told state insurance officials in a recent letter endorsed by dozens of health care provider and patient groups.But insurers say that the problems might not be easy to fix, and that doctors are partly to blame for the directory errors. Insurers “are unable to guarantee the accuracy of the provider’s status” in a directory because doctors often “stop accepting particular health plans’ members off and on throughout the year and fail to notify the plan in a timely manner,” America’s Health Insurance Plans, the chief lobby for the industry, said in a letter to the Obama administration.

Source: White House Moves to Fix 2 Key Consumer Complaints About Health Care Law – NYTimes.com

I previously wrote about the volatility within provider networks serving qualified health plans (QHPs) sold on the state health benefit exchanges and how it generates uncertainty that undermines the value of these plans. This New York Times story points to a potential underlying cause: providers exercising discretion at the point of service on whether to accept QHP coverage. Beneath that are likely tensions between health plan issuers and providers over reimbursement rates. Accepting QHPs — which employ narrow provider networks to hold down premium rates — could mean more patients but less income overall for providers relative to the increased patient workload.

As The Times reports, the Obama administration is concerned the uncertainty over the accuracy of provider networks calls into question their adequacy and plans to pressure QHPs in the federal marketplace to update their provider directories at least once a month under the pain of $100 a day penalties for each plan member adversely affected by directory inaccuracies. Pending California legislation, SB 137, would require provider directories be updated weekly.

If plan issuers begin feeling the heat of fines from federal and state regulators, the matter could up in the courts as they seek redress from contracted providers who refuse to honor QHPs. The plan-provider relationship in the post Affordable Care Act environment is shaping up to be major point of friction in the implementation of the law that bears watching closely.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

ER Visits Continue to Rise Since Implementation of Affordable Care Act – May 4, 2015

WASHINGTON, May 4, 2015 /PRNewswire-USNewswire/ — Three-quarters of emergency physicians report that emergency visits are going up, according to a new poll.  This represents a significant increase from just one year ago when less than half reported increases.  Rather than trying to keep people out of emergency departments, policymakers need to recognize the value of this model of medicine that people want and clearly need, according to the American College of Emergency Physicians (ACEP).

Most of the respondents to the poll report little or no reductions in the volume of emergency visits due to the availability of urgent care centers, retail clinics and telephone triage lines.  About 90 percent of more than 2,000 respondents also say the severity of illness or injury among emergency patients has either increased (44 percent) or remained the same (42 percent).

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These data correlate with another new report issued by Health Policy Alternatives, which found that efforts by policymakers and health insurance plans to drive Medicaid patients out of emergency departments and into primary care are not working.  More than half of providers listed by Medicaid managed care plans could not offer appointments to enrollees, despite a provision in the ACA boosting pay to primary care physicians treating Medicaid patients.  The median wait times was 2 weeks but over one-quarter of providers had wait times of more than a month for an appointment.

“There is strong evidence that Medicaid access to primary care and specialty care is not timely, leaving Medicaid patients with few options other than the emergency department,” said Orlee Panitch, MD, FACEP, chair of EMAF and emergency physician for MEPHealth in Germantown, Maryland.

The report — commissioned by the Emergency Medicine Action Fund  (EMAF) — is titled “Review of the Evidence on the Use of the Emergency Department by Medicaid Patients and the Evolving Role of Emergency Medicine Physicians.”

Source: ER Visits Continue to Rise Since Implementation of Affordable Care Act – May 4, 2015

The increase in non emergent ED visits correlates with the experience in Massachusetts after that state expanded access to private and Medicaid coverage in 2006, serving as a template for the federal Patient Protection and Affordable Care Act that became law four years later. According to state data, emergency room visits rose by 9 percent from 2004 to 2008, to about 3 million visits a year. Both the ACA’s and Massachusetts’ reforms on the payor side postulated more access to coverage would translate to fewer people turning to the ER for non emergent care.

But Nancy Turnbull, a senior lecturer at the Harvard School of Public Health, told the Boston Globe the increase in Massachusetts was due to lack of access to primary care — not coverage. “I don’t think the increase has anything to do with health care reform,’’ she said. “It’s much more reflective of [primary care] access problems.”

The ACEP poll notes Medicaid patients aren’t benefiting from the growth in channels providing convenient access to primary care such as retail clinics and telemedicine aimed at those covered under commercial insurance plans who want to consult with a provider outside usual office hours. Instead, it points to a population health basis, suggesting Medicaid patients are in poorer health and suffering from chronic conditions that flare up and require urgent attention that is most readily available at hospital EDs. The poll results also point up a need for community health clinics to play a larger role in serving Medicaid patients and in the management of their chronic conditions and helping improve their overall health status, particularly given that many private providers don’t accept Medicaid patients.

Separately, California Healthline reports ED visits by California Medicaid beneficiaries increased by 50 percent between 2013 and 2014 when that state’s Medicaid expansion took effect.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

California health benefit exchange rebrands SHOP, possibly setting stage for merger of individual and small group exchanges

California could be setting the stage to merge its individual and small business health benefit exchanges by moving to rebrand its Small Business Health Options Program (SHOP) under the brand name of its individual exchange, Covered California. It will be dubbed Covered California for Small Business, according to this report by the Sacramento Business Journal.

State health benefit exchange SHOPs serve small employers — currently those employing 50 or fewer employees and those with 100 or less starting for plan years beginning in 2016.

Section 1311(b)(2) of the Patient Protection and Affordable Care Act gives states the option to merge their individual and SHOP exchanges. States may also merge their individual and small group markets under Section 1312(c)(3) of the law “if the State determines appropriate.” California law establishing the state’s exchange mandates it report to the Legislature by December 1, 2018, on whether to exercise that option taking into account the potential impact on premium rates paid by individuals and small employers in a merged market as compared to keeping the markets separate.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Policy tension over restricted exchange open enrollment emerges in California

A primary element of the Patient Protection and Affordable Care Act’s reforms of the individual health insurance market is the elimination of medical underwriting and requiring health insurers to accept all applicants for coverage regardless of their medical history and condition, including pregnancy.

For plans sold on the state health benefit exchange marketplace, Section 1311(c)(6) of the law requires the federal government to determine limited to annual open enrollment periods such as those used in large employer group health plans. In addition, Section 2702(b) of the Public Health Safety Act allows health plan issuers selling plans outside the exchange marketplace to restrict enrollment to open or special enrollment periods. Individuals and families can enroll outside these periods only if, for example, they move to another state, lose employer-sponsored coverage or change their family status. Changes in health status are not excepted.

A request this week by California’s U.S. senators, Dianne Feinstein and Barbara Boxer urging their state’s health benefit exchange, Covered California, to add pregnancy to the list of exceptions to the open enrollment timeframe reflects an emerging policy tension point in the implementation of the Affordable Care Act’s individual market reforms.

Nicole Evans of the California Association of Health Plans cautioned “[i]f we start to provide exceptions for people to wait to get coverage until they have a need, you could be undermining the goals of the Affordable Care Act.”

The rationale for restricting enrollment to specified periods of the year is to deter opportunistic enrollment by those who might purchase coverage only when they have a health crisis requiring costly medical treatment and allowing it to lapse once their course of care is completed. Supporters of this policy might argue that allowing enrollment at any time (such as permitted for small group insurance and Medicaid) would convert an insurance product sold in the private market into something more like a government mandated (and subsidized for those who qualify) benefit.

A contrary view is expressed by Anthony Wright, executive director of the consumer nonprofit Health Access California. Wright suggests ending specified open enrollment periods would bring more generally healthy people into coverage offsetting any potential adverse selection, noting those in poor health have the greatest motivation to obtain coverage and are likely already in the risk pool. Wright’s position is reinforced by analysis of 2014 plan year enrollment indicating that those with costly, chronic medical conditions and who might have been denied coverage in the past were among the first to sign up for 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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Burgeoning enrollment in California’s Medicaid program raises tensions between administration, lawmakers over access to care, provider reimbursement rates

California Gov. Jerry Brown took a cautious approach on expanding Medicaid eligibility under the Patient Protection and Affordable Care Act. It was well into 2013 and not long before the start of the new fiscal year (July 1) and the October 1, 2013 launch of open enrollment in that state’s exchange marketplace, Covered California, before Brown approved legislation authorizing the Medicaid expansion. Even though the federal government would initially be covering most of the cost of the expansion, Brown was concerned about the overall growth of the state’s Medicaid program, Medi-Cal.

With good reason. Kim Belshé, who served as Health & Human Services Agency secretary in the previous administration of Gov. Arnold Schwarzenegger, warned in 2009 that even with a $10 billion infusion of supplemental federal cost share funding provided by the American Recovery and Reinvestment Act of 2009, “California cannot afford the Medicaid program as currently structured and governed by federal rules and requirements.” In other words, it’s a budget buster.

In 2013, Brown was at odds with his fellow Democrats in the Legislature who wanted to increase reimbursement rates paid to medical providers unhappy with low reimbursement rates. Since providers can opt not to accept Medi-Cal, they argued, it’s critical that they have sufficient incentive to do so to allow Medi-Cal enrollees adequate access to health care. Brown didn’t go along with boosting provider reimbursement rates that year, reasoning the state was still on the road to recovering its fiscal health after tax revenues were severely crimped in the 2008-09 recession.

Now two years later, Medi-Cal enrollment has jumped to more than 12 million, covering nearly 1 in 3 Californians and following the pattern seen in other states where Medicaid enrollments are outpacing by 2 to 1 sign ups for subsidized commercial health plans sold though state health benefit exchanges. The burgeoning enrollment has heightened the pre-existing tensions between Brown and legislative Democrats over increasing Medi-Cal provider reimbursement rates, as the Los Angeles Times reports in this story on two measures that would reverse the recession-era cuts in provider reimbursement rates.

As The Times reports, those tensions surfaced in this blunt exchange between the chair of the Senate Health Committee, Ed Hernandez (D-West Covina), and Jennifer Kent, director of the state Department of Health Care Services, at a hearing this week. Hernandez asked Kent to respond directly as to whether Medi-Cal patients have the same access to doctors as presumably more affluent Silicon Valley workers covered by commercial health plans.

“Yes or no?” he said.

“Yes,” Kent said.

“I don’t think so,” Hernandez replied.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Top health care issue shifts from coverage in 2014 to provider access in 2015

For implementation of the Patient Protection and Affordable Care Act, 2014 was the year of increasing medical coverage. The rate of those lacking coverage in 2014 fell to its lowest level in seven years, driven in large part by states that have fully implemented the law, California Heathline reported this week. States that fully implemented the ACA saw their uninsured rates decline by almost twice the rate as states that did not do so, according to the story.

For 2015, the focus is shifting to how well expanded coverage ensures access to and payment for care. In California – a state that has fully implemented the Affordable Care Act by establishing its own state health benefit exchange and expanding Medicaid eligibility – these issues are coming into full play.

Underlying them are economic tensions in both commercial individual coverage and Medicaid. In the former, they arise from the tradeoff of narrow provider networks in commercial individual health plans in order to keep premium rates down, particularly in exchange qualified health plans that must offer standardized benefits. (Narrow networks have also increased patients’ risk of medical bankruptcy due to “balance billing” when they receive care and particularly emergency care from providers outside of their plan’s network as Kaiser Health News reports). Provider resistance to the high volume/lower reimbursement model of these networks is manifesting in complaints from those enrolled in exchange plans that their coverage is being declined when they seek care amid provider network volatility and churn. That has drawn attention in all three branches of government as California Healthline reported earlier this month:

California has addressed the issue on all fronts, from consumer groups launching suits against insurers over allegedly inadequate provider networks, lawmakers taking legislative action and state regulators implementing immediate policy changes.

In October 2014, Gov. Jerry Brown (D) signed a bill (SB 964) that increased oversight of insurers’ provider networks by authorizing the state Department of Managed Health Care to review insurers’ annual report on timeliness compliance. More recently, state Sen. Ed Hernandez (D-West Covina) has proposed a bill (SB 137) that would require insurers to update their provider directories on a weekly basis, among other requirements.

Meanwhile, Insurance Commissioner Dave Jones (D) released regulations on Jan. 5 that his office said were designed “to address the deficiencies in the market we have been seeing.”

Department of Insurance officials noted that they have received complaints from consumers about difficulty getting doctor appointments, traveling long distances to access in-network care and encountering erroneous provider directories. Relatedly, multiple suits have been launched against Anthem Blue Cross and Blue Shield of California over the issue.

In the Medicaid segment that covers about 1 in 3 California residents, burgeoning enrollments are outstripping available providers. As with commercial individual coverage, provider dissatisfaction with reimbursement rates is widely considered a key contributing factor. A California Healthcare Foundation study issued in August 2014 found the ratio of primary care physicians to Medi-Cal enrollees in 2011 and 2013 (35 to 49 per 100,000 enrollees) fell well short of the federal Health Services and Resource Administration’s guidelines of 60 to 80 per 100,000 enrollees. “Without a large increase in the number of primary care physicians participating in Medi-Cal or another means of increasing efficiency in primary care, such as greater use of nonphysician clinicians or phone and electronic visits, Medi-Cal beneficiaries are likely to have difficulty accessing primary care,” the study concludes.

While low Medi-Cal reimbursement rates are linked to the lack of access to PCPs, the study notes it did not find an association with unmet health care needs or preventative services. It also suggested a greater role for community health centers since they receive higher Medi-Cal reimbursement rates than private practice physicians.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

California readies strategies to address rising unfunded health care costs of retired state workers

The Los Angeles Times reports California Gov. Jerry Brown plans to address the growing unfunded liability of health care for retired state workers when he releases his 2015-16 fiscal year budget in January. That comes on the heels of a report by California State Controller John Chiang showing the unfunded liability of providing health and dental benefits for retired state workers is $71.8 billion, up $7.2 billion from $64.6 billion as of June 30, 2013. An actuarial study accompanying the report found retirees are living longer than expected, thereby imposing higher than expected liability on the state, which pays these costs as they are incurred.

State and local governments are concerned over burgeoning retiree health costs as they work to regain their financial footing following the sharp economic downturn of the previous decade. Two articles last year by Bloomberg and Governing magazine discuss a cost control strategy of directing retirees who don’t yet qualify for Medicare to state health benefit exchanges where many public pensioners would qualify for federal tax subsidies. This could represent a sizable portion of retirees since many public sector workers retire well before they turn 65 and become eligible for Medicare, often in their early 50s.

There is no indication that the strategy has widely caught on or that it is under consideration by Brown, a fiscal conservative who has been a strong supporter of California’s state-run exchange. If Brown were to propose the idea in his 2015 draft budget, it would likely generate strong resistance from California’s politically powerful state employee unions.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Blue Shield pares individual market presence in California localities

From Fremont, Monterey, Nevada City and Point Reyes Station, wealthy and poor areas alike can no longer buy an individual insurance policy from Blue Shield. The gaps are particularly felt in Northern California, in areas where there is only one choice of insurer in the exchange.

“I have had clients from other areas of California, and they live in the bay area or here or there, and I do it for them and, wow, there’s six insurance companies or seven insurance companies,” says Lomas. “I think that was when I first realized how truly we were getting the shaft up here.”

Blue Shield of California declined an interview, but said it’s not selling in certain areas because it couldn’t find enough providers willing to accept payments that would keep premiums low. The company also said it is not selling in areas where there is no contracted hospital within 15 miles.

via After Blue Shield Pulls Out of Zip Codes, Consumers See Limited Insurance Options – capradio.org.

When networks narrow, it can be hard to find enough providers in a given local market willing to work for lower narrow network reimbursement rates employed to hold down premium rates. This development shows how difficult it is for health plans to achieve both affordable premiums and access to providers and what happens when that balance can’t be struck and the network begins to fray.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

Aetna, Hill Physicians Medical Group and Dignity Health’s Hospitals and Medical Foundation Form Accountable Care Collaboration in Northern California

The agreement features a new payment model to reward Hill Physicians and Dignity Health for meeting quality, efficiency and patient satisfaction measures, including:

  • The percentage of Aetna members who get recommended preventive care and screenings;
  • Better management of patients with chronic conditions, such as diabetes and heart failure;
  • Reductions in avoidable hospital readmission rates; and
  • Reductions in emergency room visits.

via Aetna, Hill Physicians Medical Group and Dignity Health’s Hospitals and Medical Foundation Form Accountable Care Collaboration in Northern California – The Health Section.

 

This agreement affects Aetna’s group market; the insurer withdrew from California’s individual health insurance market as of 2014.

The move follows by two weeks the unveiling of an individual market Accountable Care Organization (ACO) formed by Anthem Blue Cross and 6,000 doctors and 14 hospitals across seven Southern California health systems.

 


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 fpilot@pilothealthstrategies.com or call 530-295-1473. 

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