A major provision in the healthcare reform law, the restrictions of formerly unregulated payments to private carriers in Medicare Advantage programs, seems to be taking hold without a hitch. Although somewhat early in the game — the new rules of MA reimbursements, ushered in during the first GWB administration in 2003 as part of the Medicare Modernization Act — have not brought fears of decreased access to market-based care, as Republicans had long argued. Instead, the opposite has happened.
Beginning in 2012, Medicare will begin lowering payment to Medicare Advantage providers to even the playing field between original Medicare and Advantage plans. But plans generally aren’t leaving because of healthcare reform, experts say. The Centers for Medicare & Medicaid Services is offering bonuses to plans that perform well, which should soften the cuts and keep good providers in the marketplace.
Beneficiaries still have ample choice of programs in many communities and are enrolling steadily. Still, the jury is out on this reform work-in-progress. Leading insurance lobbies still predict an overall decline in MA plan participation by the mid ’10s, and the drop-dead date for much of reforms unfettered provisions (2014) will bring the first substantial signs of just how far the federal government’s reach in private penetration of FFS Medicare will affect premium levels (and, by extention, access to care) for millions of Boomers crossing that magic threshold for the first time. | LINK
The lobby AHIP spent close to $90M in an effort to rally Insurance and the GOP to fight the public option provision in President Obama’s battle for health reform. The funds were paid to the U.S. Chamber of Commerce and easily exceeded its entire budget for the previous year. According to the COC spokesman, the funds were meant to “advance a market- based health-care system and advocate for fundamental reform that would improve access to quality care while lowering costs”. Of course, this information is made public by law. Minnesota-based UnitedHealth is just one of the major players involved in the effort to dethrone the public option as a provision in the final passed legislation. | LINK
With the GOP takeover of the House complete, as expected, one of the main talking points to emerge as a possible new reality for Obama and the White House is the following catch phrase — repeal of the healthcare reform law. The ACA is a certain target for the new Congress come January; the question is — to what degree of undo does the GOP want out of the newly enacted reform law?
Well, for one thing, accountability. Although Insurance has essentially made it through the bill’s passage into law unscathed, Republican lawmakers will certainly use their new bedfellows to get at what the party feels are points that were suppressed at the hands of the Obama administration in guaranteeing reform — for starters: actual cost data for small businesses to provide coverage for employees, problematic stats upon which the feds based cancellation of many Medicare Advantage programs, and greater understanding behind Obama’s recess appointment to CMS chiefdom, Donald Berwick.
Of course, the degree to which repeal is realized in the next Congress depends on Obama’s enhanced veto power. | LINK to full PDF | UPDATE: Likely House Speaker’s response to reform law’s current state. LINK
Efforts to inspire fiscal reform as part of the overall healthcare reform initiative includes tightening up the medical loss ratio Insurance uses to shore up its revenues. The issue has been a major point of contention between the Obama administration and the insurance marketplace, with the former claiming healthcare cost savings and the latter fearing a decrease in funds available to maintain operations and viability in a highly competitive sector of the economy.
State insurance commissions have forwarded specs on what exactly will be considered appropriate uses for the MLR with respect to patient coverage toward HHS Sec’y Sebelius; it appears that the feds want these diverted profits to be earmarked for healthcare delivery with the least amount of administrative influence as possible. With respect to those uses of MLR earmarked funds,
…among those that would not: nurse hotlines that do not deal directly with patient care, efforts to reduce fraud, and insurance brokers’ commissions.
And a provision by the feds that
would have enabled [insurers] to lump together spending on their plans across states for the purposes of meeting the medical loss ratio, rather than being required to calculate it on a state-by-state basis.
Insurance lobbyists do not appear to be supporting these MLR diversion strategies initially — citing disruptions in patient care and the federalization of spending on insurers that cut individual states from the role of the middleman in determining administrative markups for insurers. | LINK
The theory of the moral hazard hypothesis goes something like this: moral hazard occurs when a party isolated (set-off) from risk may react differently than it would if it were fully exposed to the risk. In the case of risk aversion, insurers are stepping up concerns that families will seek coverage under new reform laws only after their children fall ill. They contend that the ability to keep this from happening will contain costs and premium increases.
The White House seemed to be waiting for the line to be drawn in the sand before responding to this potential reform-killing measure — that is, until Insurance essentially threatened ending children-only plans under reform altogether in some states.
Some state insurance commissioners expressed concern that, without an open enrollment period that was widely communicated, people might wait until their children got sick to enroll them in coverage, causing plans’ costs to increase. And we were concerned when last week, some indicated that insurance companies would choose to stop offering policies for children rather than cover kids with pre-existing conditions.
HHS has since clarified the administration’s position on this matter issuing an advisory stating the formation of open enrollment periods, outside of which coverage will not be provided. Now, the distinction between children with congenital and pre-existing conditions and those with acquired, high-cost diagnoses is more clearly defined — for the purposes of the insurance companies, that is. | LINK
Got a gripe with your health insurer? You may be in luck. Under the new reform law, President Obama is making it easier to file appeals and have them evaluated because of a rejected claim. Prior to reform, the appeals process differed among insurers, adding to the bureaucratic “justification” for the rather phlegmatic approach to such issues in the past.
Now, consumers will appeal directly to the insurer. If they’re denied a second time, they can go to an independent reviewer whose decision is binding. Health plans must pay the cost of outside appeals, and if they’re overruled, they must cover the disputed claim in full. Consumers can also use the appeals process if their coverage gets canceled. The program will benefit almost 90M policyholders by the law’s totality in 2014. | LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
