From the Did You Know category today: the state of Indiana is challenging a key provision of the ACA having to do with the medical loss ratio for insurers. That’s the amount by which insurance premiums are set a certain degree of cost implementation for overhead. The ACA requires the insurer to spend 80 percent on healthcare delivery, or else pay a fine. Indiana is pursuing a federal waiver from this proviso. Healthcare consumer advocacy weighs in.

Indiana’s application is based on state politicians’ ideological opposition to health reform, not the realities of the state’s health care market … As the MLR regulations make clear, there must be a credible threat to the stability of the individual marketplace in order to grant a waiver. Indiana has demonstrated no such threat. We urge [HHS] to reject Indiana’s application.

Indiana is the only state in the country to request that consumer high deductible health plans be exempted from MLR provisions unconditionally. HHS will ultimately decide on the matter. | LINK

Related posts:

1. During Open Enrollment, Time to Reflect on Reform’s Medicare Advantage Provision A major provision in the healthcare reform law, the restrictions...
2. Critics of Reform Law Try Different Strategy on Heels of DC Gathering At the recent governors’ meeting on the Hill, the president...
3. California’s Largest Insurer to Delay Premium Rate Hikes The ACA is essentially a year old this week. Californians...

The president can take some solace in a new report highlighting a positive aspect of the ACA — the increase in young adults with insurance coverage. According to the Nat’l Center for Health Statistics, approximately 1 million adults between the ages of 19 and 25 obtained coverage in the first three months of 2011 under the new reform law. Amid a continuing faltering economy, young adults appear to be taking advantage of the ACA provision which allows such coverage to continue to the age of 26 under parental policies.

Under- and unemployed adults in this age range could produce results that seem to contrast those above, but, as the report points out, piggybacking on parents’ plans has resulted in a coverage lifeline of sorts, as the unemployment rate of the 18-25 demographic grew by at least 7 percent from 2006-2010. This suggests a direct affect of the ACA’s key coverage provision in the demo. Amid GOP cries and promises for repeal should they take executive control in ’12, why isn’t Obama trumpeting this statistic?

Related posts:

1. Study: 20% of Young Adults Suffer from a Personality Disorder The years spent in college can be among the most...
2. For Young Adults, Playing Doctor Has a Whole New Meaning A 19-year old who uses vigorous exercise to sweat off...
3. Young Adult Coverage Provision under ACA Beats Fed’s Expectations It’s that time of year again. Graduation. In the spirit...

HHS is scaling back its July 1 date it set to enforce new policies concerning insurance claims denials and reviews. According to the agency, states need more time to “adhere to requirements” — much to the frustration of patient advocacy groups and to the benefit of Insurance. Policyholders had 4 months in which to prepare appeals arguments previously under yet-to-be-instituted reform rules. Now it’s just 2 months.

Essentially, the Obama administration’s new rules give beneficiaries less time to prepare an appeal, less information about the reason for the denial and limitations on which denials can be appealed. Patients can still appeal if their coverage is canceled by an insurer, and decisions by external review panels are still in effect. External reviews will now start on January 1 of next year. The external review process is key to healthcare consumerism under the reform law, as patients have never before been required to complain to an independent review panel since individual states never entered into this regulatory aspect of reform until now.

Now that insurers have some breathing room until the initiation of this process and consumers have a narrower window of appeals action, the only question is who this move truly benefits in the long run. Expect to hear more concern from advocacy groups on matters of not only the delay of policy enaction, but also the apparent loss of protections as a result of a srinkwrapped appeals process. | PDF link to HHS document concerning new rules

Related posts:

1. New Rules under Reform Promise Smoother Appeals Process for Claim Denials Got a gripe with your health insurer? You may be...
2. Insurance Companies Get Reprieve on Certain Administrative Rules, Consumer Groups Worry The Obama administration is delaying [PDF] the implementation of certain...
3. Florida Appeals Court Sets Date for Arguments Surrounding Reform Law’s Constitutionality The date has been set: 6/8/11. That’s when the 11th...

A group of states with a combined population of just under 50 percent of the U.S. population is trying to circumvent the process by which insurers publish premium rates before those published rates reach the marketplace. Ordinarily, individual states would have to receive the approval from their regulatory bodies (insurance commissioners) to review and approve or disapprove rates before they are published in the market. Doctor Pundit readers may recall that one of California’s major insurers, Wellpoint, lowered rate increases after intense media and political pressure forced smaller increases by approx. 7 percentage points.

That state’s IC action has led its lawmakers to consider applying the same statutes to group and individual plans on the open markets. The entire Wellpoint saga couldn’t have come at a worse time for the insurer. With an Arnold Schwarzenegger-approved massive budgetary deficit amid a national slumping economy and presidential push for reform going in high gear, the provider became the poster child for insurance reform in the overall drive of the Obama admin’s push for healthcare reform — garnering critical public support in advance of the law — in the process. States and the HHS would have the power to scrutinize insurance providers considering increases of 10 percent or more.

Insurers are quick to criticize this latest managed care regulatory act, accusing governments of focusing on perceptions of profits by insurers instead of what truly drives healthcare costs — healthcare delivery and utilization. Looks like they may have to get used to things playing out this way, as other states — such as Connecticut, Maine, Massachusetts and New Mexico — are either rejecting rates or adopting legislation to give state insurance commissioners additional rate review authority. | LINK

Related posts:

1. Citing Insurers’ Rate Hikes, Obama Takes Message for Reform to Public Again Any momentum gained by President Obama when the issue of...
2. PA Governor Announces Investigation of Insurers’ Rate Hikes It apparently takes a financial stimulus of a different kind...
3. HHS Desires Insurer Rate Review HHS is issuing guidelines on the process of reviewing rate...

The SCOTUS announced yesterday that it will not fast track a Virginia appeals court ruling on the unconstitutionality of the reform law regarding its mandate on individual coverage. One year later, another provision of the ACA — the earmark of government funds (approx. $5B) to set up high-risk pools — continues to enroll healthcare consumers, but not exactly at a breakneck pace.

Previous to President Obama’s signing of the reform bill into law, those with high-risk conditions were flat-out rejected for coverage and had to search for alternative means to pay for care (Medicaid, OOP expenses). With the law’s provision in place, those who are able to qualify for such pools are having a much easier go of things, but are running into roadblocks — many of them political.

In (mainly red) states where governors may not support the reform law on constitutional grounds, the adoption rate is much lower among potential policyholders. In many liberal strongholds, however, PR surrounding the availability of pools is benefiting heavily from support of those (mainly blue) states’ chief executives and positive word of mouth. Since high risk pools are run by private insurers, premiums can also be a barrier to entry for many potential healthcare consumers, as well.

In spite of more aggressive awareness campaigns, development of more coverage options, and lowering of drug copays, enrollment in these pools still remains awfully low. As the Republicans begin to make this issue one of rejection by the American people on the subject of reform, Obama should give serious thought to on how best to move this provision forward. Twenty-fourteen^[1] is still quite a ways away. | LINK

1. After 2014, insurers will be barred from denying coverage on the basis of pre-existing conditions and federal subsidies will help low- and middle-income people buy insurance.

Related posts:

1. MN Governor Rejects Participation in National Reform Effort Involving High-Risk Pools California Governor Schwarzenegger is throwing his support behind healthcare reform...
2. A Tale of Two High-Risk Insurance Pools While many states, like Minnesota, aren’t interested in creating high-risk...
3. Many Uninsured in Illinois to Apply for Coverage During Transition under Reform Illinois will offer this week the first-in-the-nation coverage plan for...

A healthcare informatics company issues a report today that I really do not find surprising. The trends of Pharma of late are much fewer fast-tracked medications in the pipeline, decreased NDAs for many novel and like-classed (so-called “me-too” drugs) medications, and — are you ready for this? — much greater healthcare consumer spending on generics, which, according to the report, now make up almost 80 percent of the pharma marketplace.

It would be too easy to blame this on the economy. At the root of this and other findings detailed in the report are forces more complex in the healthcare economy than just the principles of supply and demand. After all, while there are fewer patient visits and greater demand by providers and health systems for payments by third parties, you can bet that Pharma still manages to turn a profit. Just take a look at the volume of sales by therapeutic areas: anti-cancer drugs continue to lead the way.

The top five therapy classes were: oncologics, with $22.3 billion in 2010 spending; respiratory agents, at $19.3 billion; lipid regulators, at $18.7 billion; antidiabetes drugs, at $16.9 billion; and antipsychotics, at $16.1 billion. Growth in spending among these classes ranged from 0.9 percent for lipid regulators to 12.5 percent for antidiabetes medications.

Although consumers, third party payers, hospitals, and providers all appear to be embracing quality provisions as a way to control costs, it is somewhat less clear what this pharmacologic austerity will ultimately mean for the management of chronic disease and how that will impact the cost of healthcare over the next 10 years. | LINK [PDF] to IMS report

Related posts:

1. Report: Pharma Company Covered Up Known Cardiovascular Risks of Drug GSK (then known as SmithKline Beecham) knew in a 1999...
2. Report: Minnesota’s Pharma Disclosure Laws Fail to Provide Audit Mechanism Policy wonks, regulatory agencies, legislators, and just about any interested...
3. CMS Releases Annual Healthcare Spending Report with Unsurprising Results The effect of the Great Recession spared no sector, including...

Hard to believe it’s been 25 years. In the spring of 1986, I was still pondering my top two career choices: medicine and civil engineering, anxiously awaiting an eventual scholarship to my undergraduate institution, and just simply trying to make the most of waning days of carefree bliss as a senior high school student.

All the while, there were changes afoot in healthcare — changes that would eventually affect me and my chosen career path. It all had to do with the way the healthcare system was treating its poorest patients, fundamentally shifting policies that are really taken for granted today in the grand scheme of 21st century reform.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed as part of a larger bill — the Omnibus Budget Reconciliation Act — that year. It was a non-discrimination statute designed to guarantee patient stabilization in emergency medical cases regardless of the patient’s ability to pay and to prevent involuntary patient transfers for financial concerns and not via medical protocols (patient dumping). Little did Congress know at the time, that this law placed the onus of care coordination in emergent situations on hospitals — which had no choice but to develop policies that would have to contain costs for such guaranteed care.

Because of this legislation, healthcare providers had a responsibility to provide for the system’s sickest patients. States had no choice but to formulate solutions to a growing crisis in care delivery. EMTALA legislation set the stage for major changes in Medicare and Medicaid policy — not to mention exposing massive pitfalls in medicolegal scenarios paving the way for future discussions on tort reform as it applied to controlling healthcare costs in individual states.

There is no doubt that the core principles behind EMTALA provide a framework for the president’s initiatives on healthcare delivery — that all citizens are guaranteed care regardless of the ability to pay. The challenge for proponents of reform and the ACA in its entirety is to build upon that notion while supporting business models that guarantee supply of such care –something much easier said than done at this point in the timeline of U.S. healthcare policy.

Related posts:

1. Tuesday Newswire: MN Nurses Overwhelmingly Approve Move to Strike & More It’s on. The mega union only needed 66%. They got...
2. For Obama, Defense of Reform Law in Next Congress Is an Uphill Battle Yesterday the president announced invitations to the House speaker and...
3. Physicians Tackle So-Called ‘Heavy Utilizers’ to Control Acute Care Costs A pretty interesting piece on the role some hospitals are...

The Obama administration is delaying [PDF] the implementation of certain rules under the new reform law that will enable protections for patients-consumers who wish to appeal claim denials or coverage reductions made by insurance companies. Originally, federal officials were supposed to start enforcement of rules which appear to benefit insurance companies, at least in the short term.

Requirements that Insurance provide increased information outflow via translation to other languages for the benefit of non-English speaking consumers and reductions in the amount of time insurance companies must review denials in “urgent” cases are chief among the rules being delayed under reform.

Patient advocacy groups are scrambling to ensure these rules eventually see the light of day, while insurance companies look for more reasons to balk at administrative requirements by the federal government they see as carrying an increased cost to implement — citing issues [PDF] as mundane, yet labyrinthine, as diagnostic codes and patient surveys as administrative and logistical barriers too high to overcome in the timeframe required under ACA rollout.

Stalling tactic by Insurance to forestall patient protections before they’re even out of the gate? Or earnest re-evaluation of internal policies that requires more time to sort out cost concerns that insurance companies say they need in order to benefit consumers under reform?

Related posts:

1. Insurance Companies Increase Donations to Fight Breadth of Public Option in Reform Just because there’s a congressional recess this month doesn’t mean...
2. New Rules under Reform Promise Smoother Appeals Process for Claim Denials Got a gripe with your health insurer? You may be...
3. Obama Slightly Shifts Tone on Reform Costs; Sebelius Continues PR Assault on Insurance As the midterm election season plows on in full force,...

The one year anniversary of the ACA is giving many time to reflect on its passage and what it really means for the future of healthcare delivery in the foreseeable future. One thing’s for certain — the controversy surrounding it on all sides will not be going away any time soon. Whereas the public is portrayed in the media as being, at worst, “evenly divided”^[1] on the issue (just like every other manufactured boilerplate lately — take your pick), many supporters are saying that the reform law’s original form and intent will eventually get the full support of the American public.

Detractors, not to be outdone, are more emboldened than ever to make this issue a Campaign ’12 one — and a very potent issue, at that. Although the road to the ACA’s passage was characterized by cogent and passionate debate on most levels, the labels applied by opponents — both Republican and Democratic — seemed to take center stage, almost screaming out to any fence-sitters to give up on lobbying for it. In the end, however, the bill survived threats of “death panels”, Tea Party protests, and GOP-stoked fears that ironically warned of the insolvency of Medicare should the measure become law.

The controversy surrounding the reform law is not over by a long shot. Even as healthcare consumers, states, insurance companies, pharma companies, and the federal government hunker down to to accept their roles in the wake of the law, its current incarnation will only be preserved if sound implementation by 2014 overcomes the political rhetoric on the left and right. If the most salient effects of the law — increasing access via exchanges, eradication of pre-existing condition denials, closure of the Medicare Part D doughnut hole, and eliminating coverage and payment inequities in Medicare Advantage plans — remain intact by mid-decade, perhaps the most beneficial result will be that healthcare consumer will receive high-quality, cost effective healthcare delivery without giving the means to this end even a fleeting second thought.

1. Actually, in comparison to those who want the law expanded or remain as is, only 1 in 5 want some sort of repeal — be it piecemeal, or full. Source here.

Related posts:

1. For Obama, Defense of Reform Law in Next Congress Is an Uphill Battle Yesterday the president announced invitations to the House speaker and...
2. Happy New Year from Doctor Pundit, Minor Predictions on 2011 As one year changes into another and Doctor Pundit steps...
3. Study: Levels of Health Reform-Related Funds Continue to Shape Debate A GOP congressman accepting almost $100K in healthcare industry-related donations...

What exactly is an accountable care organization? Interestingly, the term is as much a catch-all for reform as it is a strict rubric for quantifying certain efforts of reform. The potency of ACOs lie mostly in the controversy that surrounds their implementation with many organizations fearing bureaucratic power grabs at the hands of a mighty few. Hopefully Don Berwick will be able to shed some light on their necessary function with respect to reform.

ACOs are the subject of great debate, and many in the health policy world are eagerly following Centers for Medicare & Medicaid Services Administrator Don Berwick’s every move, waiting for the moment he’ll announce the rules defining what an ACO actually is. …  Berwick said in a speech Tuesday that the pending rules on ACOs will be out very soon, and he said that all the agencies — HHS, CMS, the Department of Justice and the Federal Trade Commission — are working hard to coordinate [...]

The CMS chief probably knows that his comments on the subject will not quell the issues surrounding ACOs, but will only add to the overall debate surrounding them. Although ACOs do have a place in reform, what many organizations chose to do with his guidelines only mean better efforts at reform in a general sense. Foundations for change have to occur and start somewhere. Berwick’s definition and classification of this reform tool is as good a place as any. | LINK

Related posts:

1. GOP’s “Pledge to America” Looks to Score Points on Anti-Reform With the GOP takeover of the House complete, as expected,...
2. CMS Chief Gets Hands Dirty, Rolls Out Obama Admin’s Quality Reform Plans Ten years. Ten billion dollars. That is the level of...
3. Medicare Bonuses Part of Study of Quality under Reform One of the trends of reform in the new year...