Here’s a convenient talking point for the Obama campaign as it begins to coalesce its message surrounding healthcare reform spending under the ACA: enrollment in Medicare Advantage is up since the beginning of the current decade, while premiums have been on the decline. HHS Sec’y Sebelius attributes this to the core provisions within the ACA allowing stipulations of bonus payments based upon quality, changes to enrollment periods, new medical loss ratio requirements and penalties, and the power for CMS to reject plan bids.
According to Humana’s last quarterly report, it bought two Medicare Advantage contractors in the third quarter of last year and enrollment increased over the past 12 months. Wellpoint also acquired an Advantage contractor in 2011 and saw increased enrollment.
While it may be a little premature to trumpet reform to this sector of Medicare spending by the government as being a permanent fixture of ACA implementation, it does highlight the need to revisit the drama surrounding payments to providers in FFS plans. Will the doc-fix ever be truly fixed? Bipartisan Senate and House members tasked with establishing a permanent end to reimbursement cuts to physicians will have their work cut out for them starting today — apparently considering everything from repeal of the SGR in its current form for Medicare spending to the use of war funds to finance such a permanent patch. Should be interesting.
The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.
“Flexebility” is the key, according to Secretary Kathleen Sebelius.
The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.
Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK
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
The requirement that new insurance provisions and services under reform and HHS rules provide the gamut of preventive womens’ healthcare services will also cover the infamous morning-after pill. Other required free services under the new rules include all birth control methods approved in the U.S., domestic violence screening, and support for breastfeeding.
The HHS noted that not every health insurance plan must comply with the new directive, however. “The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services,” the agency said.
Perhaps most significantly, the rules prohibit charging a co-payment, co-insurance or deductible for this type of healthcare delivery — raising questions as to the feasibility for the feds to include such a provision in the short term. Medicare will also foot the bill for both dual-eligibles and dedicated beneficiaries. | LINK
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
Getting the word out about all the preventive services available to Medicare beneficiaries is about as easy as wiping out fraud within CMS completely. But that’s not stopping HHS from pulling out all the stops in an effort to curtail future spending on preventable medical problems.
On Monday, HHS Secretary Kathleen Sebelius announced that the agency was launching a publicity campaign, known as “Share the News, Share the Health” to alert Medicare patients, their doctors and their relatives that the services are available at no charge. “Our job is to make sure every single Medicare beneficiary in the country knows,” Sebelius said.
Chalk it up to a (political) campaign by the federal government to get patients knowledgeable and accepting of the benefits afforded them under the reform law. Overall, this effort is a good thing. At its most superficial, it is a way to catch disease earlier, implement higher quality care delivery for less ill patients sooner, and it represents a time saver for the primary care physician, freeing him from informing the beneficiary in order to make the most of the covered physician service/visit. More profound, however, is the stark effect this initiative could have on patient empowerment — as only slightly more than 10 percent of beneficiaries takes advantage of at least one of the covered preventive medical screenings and services.
President Obama has issued policy guidance on the extension of healthcare benefits under Medicaid for gay couples.
Under the new guidance, dated June 10, states have the option to allow healthy partners in a same-sex relationship to keep their homes while their partners are receiving support for long-term care under Medicaid, such as care in a nursing home.
This is significant, because, as the article states, states have the ability to seize property to pay for overdue medical charges once a beneficiary’s ability to pay is exhausted. The presence of a spouse in a married relationship living on that property would prevent liens and seizures from taking place, allowing Medicaid benefits to kick in. The same-sex partner living in the home would abort any power the state would have in realizing payments under those alternative conditions for beneficiaries receiving long term care services.
Sometimes it only takes a troubling incident — which is then propelled front and center into the nation’s consciousness — to formulate advocacy. AZ congresswoman Gabrielle Giffords’s close call with death at the hands of a mentally ill individual is about as high profile a case as an advocate for change can seize to create awareness.
It’s no surprise, then, that key members of her staff are raising the awareness level of care surrounding traumatic brain injury, or TBI. While this is not a new issue by any means — it has usually been relegated to also-ran status in the eyes of healthcare policy watchers and lawmakers alike, as a by-product of the cost of care to the problem’s biggest cohort, the military veteran — it is getting a new lease on life.
[A] “central component” of Giffords’ therapy regimen is cognitive rehabilitation therapy, a costly medical treatment designed to retrain the brain to do basic tasks. Such treatment … may be available to Giffords, but it is out of reach for thousands of U.S. troops whose health coverage doesn’t include it. The Pentagon’s health care program, Tricare, has refused to cover it but does cover certain types of therapy — such as speech and occupational therapy — which can be a part of cognitive rehabilitation therapy.
HHS Secretary Sebelius is the initial target of this newfound campaign brought by Giffords’s staffers, as they seek to expand such offerings under the military’s Tricare plan. It’ll be a steep hill to climb; such coverage can average $8000 – $10000 for acute hospital cares/day, and at least $1500 daily in LTC costs outside of that acute care. Adovcates, acknowledging this, will also press current Sec’y of Defense Gates to expand coverage for such services. Good thing Giffords’s office also clarifies that this advocacy is a “first step” as far as cost of delivery is concerned — noting that the range of coverage for comprehensive TBI acute care and rehab would not extend the range of “essential benefits” for servicemembers under Tricare. | LINK
A couple of lawmakers want to have their say in how Medicare Advantage plans are rewarded for quality care. As part of reform, the absolute numbers of MA programs have been truncated and budgets increasingly scrutinized. Sen. Orrin Hatch (R-UT) and Rep. Dave Camp (R-MI) support the utilization of bonus payments to high quality private insurers in MA plans, but they want to be the ones who help decide the value and range of distribution of those payments. (Those bonus payments, HHS says, are part of Medicare demonstration projects to ensure quality.)
The ACA is essentially a year old this week. Californians should be celebrating the fact that something that really has nothing to do with Obama’s reform in a direct sense will be making their pocketbooks less lighter. Anthem, the state’s BS provider, will not increase copays and deductibles for the time being.. Okay, it looks like the calm before the storm, as consumers will have at least another year to consider alternatives to coverage under this carrier — the largest in California. Not to be outdone by the luster of the moment, HHS Sec’y Sebelius offered her congratulatory two cents on the “consumer victory”, citing it as “another example of how increased transparency and oversight benefit consumers.”
While it is politically correct on some level to spin this announcement as a victory for consumers and an olive branch at the hands of Insurance in this age of “greater transparency”, the end result is the same: delayed rate increases, still escalating healthcare delivery costs, and the requirement to account for it. As states scramble for ways to create alternative markets for consumers to receive services (waivers/exemptions to the reform timeline), it’s clear that conventional wisdom on the eventual rate hikes is very much intact — and GOP legislators will do everything in their power to make sure the market for coverage is not obscured by increased reform-influenced oversight on premium rates in individual states.
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.
