Wednesday, December 18, 2013

Affordable Care Act’s Provisions to Reduce Preventable Medicare Patient Hospital Readmissions are a Continued Success

The Affordable Care Act put several programs into place to curb Medicare beneficiaries readmission rates. The readmission rate, a measurement of how many patients are readmitted to the hospital within 30 days of initial discharge, is viewed as an indicator of the quality of care a hospital provides. 

The Centers for Medicare & Medicaid Services (CMS) reported that the average avoidable readmission rate for Medicare beneficiaries under 18% from January - August 2013. This is less than the 19% readmission rate that was the standard for the previous five years.  A 2012 study found that readmission rates were on a decline in 2012. The 2013 preliminary claims data combined with the 2012 data results in an estimated 130,000 fewer hospital readmissions from 2012-2013.

CMS attributes the decline in readmission rates to the improved care programs such as community-based care transition plans and payment incentives such as the Hospital Readmissions Reduction Program helped foster. 

More information on the CMS blog is available here. The study that determined Medicare readmission rates had a meaningful decline is available here. Information on the Hospital Readmissions Reduction Program is available here

Monday, December 9, 2013

Many Hospitals Concerned about Final CMS Payment Rules

The Centers for Medicare and Medicaid Services (CMS) announced a final rule for hospital outpatient services, or the Outpatient Prospective Payment System (OPPS), this November. The CMS estimates that the rule will increase payments for hospital outpatient departments by 1.7 percent. The new rule will be effective January 1, 2014; however, CMS will delay implementation and final configuration of the new 29 comprehensive APCs until 2015.

The rule will create 29 comprehensive Ambulatory Payment Classifications (APCs) to handle payment for device-dependent services and will require direct supervision for a range of outpatient services in critical access hospitals (CAHs). 

This rule combines five payment codes into a single payment code that covers all outpatient clinic visits. The outpatient clinic visits code will include drugs, biologicals, and radiopharmaceuticals used in a diagnostic test or surgical procedure, lab services and device removal procedures. The American Hospital Association believes that the payments will be well below the cost of treatment for complex patients.

The Access to Medical Imaging Coalition is concerned that the rule will dramatically reduce the outpatient payments to hospitals for CT scans and MRI services. The group is concerned because the rule will establish similar reimbursement rates for a CT scan and x-ray image of the same body part even though a CT scan requires more expensive equipment and is more expensive to adminster. 

Many hospitals are concerned about being able to implement the changes required by the rule by January 1, 2014, the date the rule becomes effective. 

Wednesday, December 4, 2013

Enrolling for Coverage in Health Insurance Marketplaces: Tax Credits, Fraud, and the IRS

Many individuals will qualify for tax credits to purchase the required health insurance from the health insurance marketplace in 2014. The Internal Revenue Service is responsible for calculating the tax credits accurately. 

The IRS will use a software program to verify tax credit calculations and assess penalties prior to issuing them to health insurers. However, there is concern about fraud because the agency has not completed a fraud mitigation strategy to prevent people that underestimate their incomes from fraudulently collecting health subsidies. As currently established, the IRS would issue the tax credits prior to verifying income.

The IRS has outlined tax provisions related to the Affordable Care Act here.

The report from the Treasury Inspector General for Tax Administration is available here

Public Health Experts on High Alert with Recent Rise in Spread of Infectious Diseases

A significant decline in immunization rates in the past few years has resulted in a dramatic increase in the number of documented cases of infectious diseases previously thought to be virtually eliminated in the United States has risen considerably. Falling immunization rates are attributed to fears that vaccinations can cause autism that are based on flawed studies that have been discredited.

Public health officials are seeing a rise in diseases such as measles and pertussis, commonly known as whooping cough. Measles was declared "eliminated" in the United States in 2000. This year alone there were 161 cases of measles reported across 16 states. While this increase does not suggest a widespread outbreak throughout the nation, it does present local and state public health systems with the new challenge of identifying and responding to a disease outbreak with shrinking budgets. 

Experts explain that the spread of measles in the US is generally traced to individuals who contract the disease outside the United States and then infects people exposed to the disease who were not vaccinated. For example, in Tuscon, Arizona a Swiss woman who had been traveling in Mexico arrived in an emergency room with measles. It took two days for her to be diagnosed and placed in isolation. During the two-day period before her isolation she infected an unvaccinated hospital staffer and an 11-month-old child who was too young to be vaccinated. The final count of infected individuals was 14 confirmed cases and 363 suspected cases that were a result of exposure to the Swiss traveler's measles. Seven of the 14 confirmed cases were contracted while the individuals were in the care of hospitals for other medical conditions. 

Preventing the Spread of Infectious Disease

  • Early Detection Systems 
    • The Department of Homeland Security recently announced plans to create a real-time disease outbreak alert system that would conduct hourly searches for reports of infectious diseases worldwide and send early warnings to at risk communities with low immunization rates. 
    • Biosurveillance automated monitoring systems could help with the early detection of natural disease outbreaks with modifications such as integrating primary-care physician data with emergency room data.

  • Establish Vaccination Policies
    • To reduce the risk of spreading contagious diseases and limit the numbers of isolations required, health systems should require all staff to be up-to-date with vaccinations of contagious diseases. 

  • Identification and Response
    • Early identification of infectious diseases should be a goal of all health systems. 
    • Once a case is discovered the health system should immediately alert public health officials and other community health systems to aid in rapid identification and limit exposure.
    • Employees should be familiar with the protocols for reporting the infectious disease to local public health officials and health systems. 

Monday, November 25, 2013

Keeping Your Healthcare Plan: Complications and Updates

The Obama Administration repeatedly stated “If you like your healthcare plan, you can keep it,” once the Affordable Care Act is enacted. However, millions of people received cancellation notices from their insurance companies because their policies did not meet the minimum requirements of basic coverage mandated by the Affordable Care Act.

The minimum requirements include coverage for preexisting conditions, hospitalization, prescription drugs, emergency services, maternity and newborn care, mental health and substance abuse services, laboratory services, rehabilitative  services and devices, pediatric services including oral and vision, ambulatory patient services and preventative and wellness services and chronic disease management. The plans that were canceled do not offer coverage for one or many of these conditions. All of the plans on the healthcare exchanges will cover these basic conditions.

On November 14th President Obama held a news conference announcing the decision to allow insurance companies to keep individuals on health insurance plans that do not meet the law’s requirements for an additional year.  The directive does not require insurance companies to allow customers that were already notified of cancellations to come back. It does give insurance companies the discretion to take back customers to offer the non-compliant insurance plans for one more year.

The ‘fix’ caught state insurance regulators by surprise and was not well-received by representatives of some states.  Many states require insurance commissioners to approve policy changes before the insurers will be allowed to reissue the plans. Regulators in six states will not allow consumers with noncompliant insurance plans to renew their coverage for next year. These regulators based their refusal on concerns about the effects on the state health exchanges, the weak benefits the canceled plans offer, and the increased premiums insurance companies were charging individuals that wanted to keep or reenroll in their canceled plans.  

Like many parts of the Health Care Exchange roll out, this aspect is more complicated than advertised. However, the Obama Administration stated that the individuals that lost their plans had ‘subpar’ health insurance and that their coverage would eventually be upgraded to a health insurance plan that includes many more benefits as required under the Affordable Care Act. 

Protecting Patients' Privacy: Data Security Mishaps

Patient privacy is a top priority for the medical community. Patient data should be virtually secured. It is critical that staff understands what security measures are required and how to implement and utilize those methods. 

Last Tuesday the Redwood Memorial Hospital announced that it lost a thumb drive that may have contained information on more than 1,000 patients. This information contained data that could lead to identifying individual patients. The thumb drive was not encrypted.  The hospital notified patients that are potentially affected and set up a hotline to answer questions related to the situation.

There were multiple factors leading to the security failure in this situation. The first, and most obvious breach is that all patient data should be encrypted. The second mistake leading to the leak is identifiable patient data should not travel offsite unless necessary to transfer information.

There are multiple ways to encrypt patient data. Facilities should have network security measures, two-factor authentications for individual computers, and encrypted portable devices.

Important Tips

Monday, November 11, 2013

Subsidizing Indigent Patients on Exchanges: Fraud and Abuse Concerns

Qualified Health Plans Are Not Considered "Federal Health Care Programs"

Many questions surround the implementation of the Affordable Care Act and how it interacts with existing laws. In an effort to gain clarity, Rep. Jim McDermott wrote to the Department of Health and Human Services to inquire about the status of qualified health plans sold on the exchanges under Section 112B of the Social Security Act. Specifically the inquiry was whether the qualified health plans fell under the definition for "federal health care programs." 

The guidance was requested  to determine how the interaction of qualified health plans and other benefits known as beneficiary inducements offered with other federal programs. Rep. McDermott's concern centered around individuals receiving duplicative benefits, and the solvency of the federally-funded programs if individuals were allowed to receive benefits from multiple government healthcare programs. Rep. McDermott argued that receiving all of these benefits would generally be forbidden by the Anti-Kickback Statute or the Civil Monetary Penalty Statute. 

The Department of Health and Human Services (HHS) stated qualified health programs are not considered federal health care programs and the Anti-Kickback Statute is not applicable. HHS addressed Rep. McDermott's concerns regarding the solvency of of the federally-funded program by outlining regulation and provisions that establish oversight procedures and authority of the federal exchange marketplace for health insurance. These procedures, the Affordable Care Act, and the False Claim Act allow HHS and the Office of Inspector General to investigate and issue appropriate civil or criminal penalties to those wishing to cheat the federally-funded program. 

In practice this means that healthcare providers that assist indigent patients by subsidizing their premiums on health exchanges may be able to do so without concern about being prosecuted under the Anti-Kickback Statute. The HHS letter suggests that this extends even if the parties receive a tax subsidy. 

A link to Rep. McDermott's letter to HHS can be found here:

A link to the response letter from HHS can be found here:

Friday, November 1, 2013

Changes to Medical Billing and Coding Requirements

Big changes are coming to the world of medical billing and coding. The introduction of Electronic Medical Record and the 10th edition of the International Classification of Diseases, Clinical Modification and Procedure Coding System (ICD-10) are creating a flurry of activity to ensure a smooth transition. These new developments will affect all medical practitioners’ medical billing and coding and submission of claims. The developers of ICD-10 claim that the new code sets will provide more accuracy in medical coding, which will result in quicker reimbursements and fewer denials.  This will result in better patient care all around.

By October 2014 all ICD-9 code sets used to report medical diagnoses and inpatient procedures must be replaced with ICD-10 code sets. This means that all electronic transactions must use Version 5010 standards to accommodate the ICD-10 codes. Previous versions, Version 4010 and Version 4010 A standards will not accommodate the ICD-10 codes. This should not be a problem for the majority of medical billers because Version 5010 has been required since January 1, 2012.

It is important to note that any claim with ICD-9 codes for services provided on or after the compliance deadline cannot be paid.

The Basics of Preparation

It is important to take several steps before the deadline to make sure the medical billing and coding for each practitioner is up to date. All practitioners that are covered by the Health Insurance Portability Accountability Act are required to transition to ICD-10 code sets.

The software used for EMR and medical billing should be upgraded to a version that incorporates ICD-10. In some cases, hardware upgrades will be necessary. Reaching out to software vendors is an important part of the implementation plan. Ideally the software will be updated and installed with enough time to test it before the compliance deadline.

This is the first in a series of blogs explaining the ICD-10 requirements and ways to have a seamless implementation.

Thursday, October 10, 2013

HeathCare.Gov: Software Making it Hard to Get Health Insurance

Many of the 8.6 million unique visitors to HealthCare.Gov experienced difficulty accessing the website and enrolling in healthcare plans. These difficulties were caused by a limited system capacity and issues with the website’s software.

Reported glitches included not being able to access the registration portion of the website and long wait times for access to agents, brokers and the registration pages. The Department of Health and Human Services said that they were able to expand system capacity this week and will continue to do so in the future to accommodate the high volume of traffic on the website.

The issues with scalability occur when there are more users attempting to access the site than the system has capacity for. This is a hardware issue and may be resolved with adding more hardware that will increase system capacity.

One way the government is addressing this problem is by metering access. The idea is only a certain number of users are allowed to access the site at any given time. Any users that attempt to access the site once the maximum user threshold is reached will be put in a virtual line. These users will be allowed access as other users leave the site.

There are also bugs in the website’s code. These bugs are responsible for the error messages that appear when a user is trying to click various parts of the website but unable to do so. These types of issues will take more time to solve because they are more complex than just adding more physical equipment.

Articles Outlining Healthcare.Gov Software and Traffic Glitches:

Huffington Post: Obamacare Website Glitches Reveal Larger Government Problem

USA Today:Review: a winner despite glitches

Washington Post:A techie walks us through's two big problems

Friday, October 4, 2013

HealthCare.Gov: Website Glitches & Alternatives

The open enrollment period for individuals, families and small businesses to select health insurance plans was highly anticipated.  As expected with any new website or websites with high-traffic volume, there were technical difficulties for users trying to access the marketplaces.  These problems are similar to issues encountered eight years ago with the launch of Medicare Part D.  The department of Health and Human Services reported that HealthCare.Gov had over 2.8 million visitors on the first day the exchange opened.  The live chat assistance option received over 60,000 requests as users navigated the health plans and website.  People interested in healthcare coverage also had the option of calling the consumer hotline; over 81,000 calls were placed the first day. 

Reported glitches included not being able to access the registration portion of the website and long wait times for access to agents, brokers and the registration pages. The Department of Health and Human Services said that it was able to expand system capacity this week and will continue to do so in the future to accommodate the high volume of traffic on the website.

As of October 4, the website ( displays a message that explains, “We have a lot of visitors on the site right now” if the site is experiencing heavy traffic that exceeds system capacity. It then directs you to stay on the page to save your place in line. The site will direct each user to the login page in order that they attempted to access the page. The page also offers the phone number for users wishing to speak with a trained representative and apply over the phone.

Non-technical issues with the marketplaces also exist. In some states small businesses weren’t able to use the SHOP Marketplace on opening day. Additionally, the Spanish-language version of the healthcare marketplaces was unable to accept applications for healthcare coverage. There are also expected delays in Medicaid enrollment with federal insurance exchanges and a few states delayed online enrollment for individual and small-business marketplaces.

Below you will find phone numbers to call as an alternative to using the website for enrollment.  Even under high-volume conditions the website’s pages that outline the insurance plans and answer frequently asked questions generally operate smoothly and are a useful resource for determining plans you may be interested in and your eligibility.

Health Insurance Marketplace Information:

 SHOP Marketplace Information:

Healthcare Marketplace: The Nuts & Bolts

On October 1st, the portal for the more than 30 health insurance exchanges being run by the federal government and the marketplaces operated by 16 states and the District of Columbia, opened to the public for enrolling in healthcare plans  under the requirements of the Affordable Care Act. Enrollment for individuals and families is open from October 1, 2013 – March 31, 2014. Enrollment for small businesses lasts year round. 

The website features two separate marketplaces to purchase insurance plans. The first, widely-publicized, marketplace is the “Health Insurance Marketplace” for individuals and families. The second marketplace is the Small Business Health Options Program, or SHOP Marketplace, available for small business employers with 50 or fewer employees.

Available Plans

The marketplaces offer several choices for employers and individuals to choose from. As with all health insurance plans, individuals and employees will have to pay a monthly premium. Employers may choose to contribute to these premiums to lower the monthly costs for employees. Employers that do contribute to premiums may qualify for a tax credit. You will be able to choose from: Platinum, Gold, Silver, Bronze and Catastrophic health insurance plans. Coverage will begin as early as January 1, 2014. 
The differences in the plans are the price of monthly premiums, deductibles, and copayments and the breadth of available doctors to choose from on each plan.  All the available healthcare plans must cover a specified list of preventative services at no cost.
The catastrophic health insurance plan is only available to individuals under 30 and to some low-income people. Marketplace catastrophic plans cover 3 annual primary care visits and preventive services at no cost. After the deductible is met, they cover the same set of essential health benefits that other Marketplace plans offer.

Health Insurance Marketplace

The Health Insurance Marketplace is the marketplace for individuals and families to purchase health insurance plans. Individuals and families may be eligible for lower costs on monthly premiums and out-of-pocket costs, or get free or low-cost coverage.
Medicare & Medicaid: Individuals covered by Medicare and Medicaid do not need to enroll in the Health Insurance Marketplace and the choices and benefits afforded to these individuals will not change.  Individuals that do not qualify for Medicaid now may qualify for the program in 2014. In many states the eligibility for coverage is expanding to cover more individuals.

Questions about Medicare are addressed here:

Questions about Medicaid are addressed here:

  • At the bottom of the screen you may select your state of residence to learn more about Medicaid expansion in your state.

Health Insurance Marketplace Information:

SHOP Marketplace (Small Business Health Options Program)

The Small Business Health Options Program (SHOP Marketplace) is designed to help employers with 50 or fewer full-time equivalent employees select a healthcare plan. The website allows employers to fill out a single application to compare price, coverage, and quality of plans in a simple straight forward manner that any layperson can understand.  Self-employed individuals will not use the SHOP Marketplace and should instead use the Individual Marketplace.

The SHOP Marketplace also provides information on the small business healthcare tax credit. To qualify for the tax credit the small business must get coverage through the SHOP Marketplace.  The maximum tax credit available is a credit for half of the amount of the premium contribution made by the employer.

SHOP Marketplace Information:

  • Phone number: 1-800-706-7893 (TTY users: 1-800-706-7915).Hours: Monday through Friday, 9 a.m. to 5 p.m. EST

Helpful Links

Tuesday, August 6, 2013

Data Hub for Health Insurance Exchanges nears deadline for security confirmation

HHS Inspector General reports that the data hub intended to support health insurance exchanges will not be “secure” until the day before the exchanges are due to open.
While the report does not state that data security will not be in place, it notes that time is running out.  HHS has said that the data hub will be secure and the exchanges will be up and running as most recently scheduled.  Federally-run health insurance exchanges are due to open October 1, the opening day of open enrollment. 
An earlier timeline had called for the data hub to be designated as “secure” by September 4.  In the meantime, as of Monday, August 5, prospective enrollees may go ahead and create new accounts and begin collecting the required information for enrollment and coverage.  Open enrollment is scheduled for October 1, 2013 through March 2014, with coverage beginning January 1, 2014.
Health insurance exchanges are State-based competitive marketplaces where individuals and small businesses will be able to purchase private health insurance. The hub will help facilitate the access of data by exchanges; enable verification of coverage eligibility; provide a central point for the Internal Revenue Service when it asks for coverage information; provide data for oversight of the exchanges; provide data for paying insurers; and provide data for use in Web portals for consumers.
As explained by CQ HealthBeat: “The hub is the mechanism by which the new health law marketplaces will receive data establishing whether an insurance applicant is a U.S. citizen, what his or her income is, whether the applicant is eligible for subsidies to buy coverage, and the size of those subsidies. It will include links to the Internal Revenue Service, the Department of Homeland Security, HHS, the Social Security Administration and state agencies.”
As such, the role of the Hub is only as a pass-through of information that resides elsewhere, in other data bases.  It is not intended to actually store information.
“It is important to note that the Hub does not store data,” the OIG reports. “Rather it acts as a conduit for exchanges to access the data from where they are originally stored. We evaluated the adequacy of the development and testing of the Hub from a security perspective. We did not review the functionality of the Hub.”
The reports summary notes that the OIG assessed the information technology security controls that CMS is implementing for the Hub, adequacy of the testing activities being performed during its development, and the coordination between CMS and Federal and State agencies during the development of the Hub.  As a conclusion, it notes that “CMS is working with very tight deadlines to ensure that security measures for the Hub are assessed, tested, and implemented by the expected initial open enrollment date for health insurance exchanges of October 1, 2013. If there are additional delays in completing the security assessment and testing, CMS may have limited information on the security risks and controls before the exchanges open.”
As reported by CQ: The OIG document said “several critical tasks remain to be completed in a short period of time, such as the final independent testing of the Hub’s security controls, remediating security vulnerabilities identified during testing, and obtaining the security authorization decision for the Hub before opening the exchanges.”

Go to

USA Today reported this week on the outreach efforts on the part of the U.S. Department of Health and Human Services, including a new government webpage (relaunched as a new website in June), training videos and infographics to help Americans better understand the health insurance exchanges that will open October 1.  
See “A new website will help explain the insurance marketplaces, called exchanges, where Americans will start buying health insurance October 1 under the Affordable Care Act” at The newly revised webpage is  
The announcement came as HHS Secretary Kathleen Sebelius held a phone press conference on Monday, and insisted that the exchanges will be ready for business by that deadline.  Keiser Health News reports: “Health and Human Services Secretary Kathleen Sebelius said in a call with reporters yesterday that the agency is "on target" to open new online marketplaces October 1. She also spoke about personal "Obamacare" accounts which consumers can begin creating now in advance of being able to shop for plans.”
The website is intended to fill the void if what many acknowledge is a lack of easy-to-understand information for would be enrollees. When they launch on October 1, exchanges are expected to provide information on plan choices, plan benefits and premium charges. 
The outreach efforts by HHS also include the opening of a new call center for small business and the opportunity for potential enrollees to create their personal accounts in anticipation of the October 1 launch. CQ Healthbeat News reported that: “Officials said that more than a million people have visited since the website was relaunched in June to begin efforts to educate people about enrolling in coverage. The public can now create a personal account and set up user names and passwords on the site so they are ready when the actual open enrollment begins.” 
The idea is that the potential enrollee who sets up an account now can learn what information will be collected by the October 1 sign up.  The site includes a form that can be used to collect information from employers to complete the coverage applications they will submit to the exchange.

Friday, August 2, 2013

Consider These Facts About The Joint Commission's National Patient Safety Goals

Patient Access is well aware of the National Patient Safety Goals, particularly those identified in NAHAM’s Joint Commission Survey Tool Kit.

So it is worth the reminder how these goals are developed and put into place.  Below are excerpts from a Joint Commission Fact Sheet: “Facts about the National Patient Safety Goals”:

In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program; the first set of NPSGs was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regard to patient safety.

A panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings. The Patient Safety Advisory Group works with Joint Commission staff to identify emerging patient safety issues, and advises The Joint Commission on how to address those issues in NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, and Center for Transforming Healthcare projects. Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders, The Joint Commission determines the highest priority patient safety issues and how best to address them. The Joint Commission also determines whether a NPSG is applicable to a specific accreditation program and, if so, tailors the goal to be program-specific.

The National Patient Safety Goals for each program and more information are available on The Joint Commission website found here:


Consider These 5 Things to Know About Obamacare Premiums in Your State

Consider this from Keiser Health News.  Since Obamacare was passed, concerns have come from many corners that health care premiums would be too expensive for the very Americans the new health care system established by the Affordable Care Act was intended to cover.  Individuals anticipating signing up through the new health care exchanges and small businesses anticipating coverage for employees were particularly concerned. 
Keiser Health News asks “How is a consumer to make sense of this?”
KHN answers with some straight talk worth considering:  Most policy analysts concur that average premiums will go up for younger, healthier people – and that they will get better benefits than they do now – but that rates may fall for older or sicker Americans, as new rules go into effect Jan. 1.   Increases may be offset for many of those buying coverage through tax credits available to people with low and moderate incomes.”
Finally, consider these 5 things when you evaluate anticipated cost of coverage in your state:
1.  Comparing apples to apples is virtually impossible.  The first thing to understand is that policies that will be sold to individuals and small businesses in online marketplaces are brand new and must cover a range of essential benefits that were not always covered in the past. That includes prescription drugs, hospitalization and maternity coverage. Consumers cannot be turned away or charged more because of health problems, as they can now in most states.  Women cannot be charged more than men. In addition, the amount you'll have to pay out of pocket will be capped at $6,350 for singles or $12,700 for families. Currently, almost a third of individual policies have caps that exceed those amounts, according to a report by Kaiser Health News and U.S. News & World Report.  
2. Look for which premiums state regulators are using for their comparisons.  Under the health law, coverage sold through new marketplaces to individuals and small businesses include a range of types, from the lowest-cost bronze plans that have the highest deductibles to higher-premium platinum or gold plans, where you pay fewer out-of-pocket costs.  But premiums are just one part of the cost of health insurance.  When considering a report on rates, ask which type of coverage was highlighted and how much the deductibles and co-payments are.  Was it the low-cost bronze plan price, the slightly higher priced silver plans or the highest priced platinum or gold? Or some combined average?
3. You are not average.  Many of the estimates are based on averages, which really don’t reflect what any individual consumer will pay. Premium prices will vary based on a person’s age, where they live and the insurer they select.  Generally, younger people – especially  those few who are buying high-deductible coverage now -- may see an increase in premiums, while older or less healthy people may see their rates go down.
4. Subsidies will offset costs for many people.  Most people shopping in the new marketplaces are expected to qualify for a subsidy to offset part of the cost of the premiums.  Sliding-scale subsidies will go to those earning between between about $11,590 and $46,000 a year, as individuals. Those who get subsidies will also likely pay a portion of their household income – from 2 percent to 9.5 percent – toward the premium cost.
5. Last, but certainly not least - premium changes are unlikely to affect you at all.  The rates submitted to states and the federal government are for coverage sold to individuals and small businesses with fewer than 50 workers that are not self-insured.  Currently, the vast majority of Americans with insurance coverage get it through their jobs – and they generally work for companies with more than 50 workers.  Large firms already offer coverage similar to what the health law will require insurers to offer individuals and small firms, so little change is expected.  The new rates are most likely to affect people who buy their own coverage. About 15 million do so currently and an estimated 7 million more are expected to do so next year because of the health law.

Thursday, July 25, 2013

Medicare Releases Timeline for Penalty and Bonus Program

Medicare has announced that the quality care model for doctor reimbursement, formerly known as the value based purchasing plan, will go into effect over the next few years. The program will shift medicine away from its current payment system in which doctors are most often paid for each service regardless of their performance. Instead, Medicare will begin to gradually factor quality of care into reimbursement payments for hospitals, nursing homes, physicians, and most other medical providers.
Medicare has already decided that large physician groups, classified as those with 100 or more doctors, nurses, social workers or other health professionals, will gain or lose as much as 1 percent of their pay starting in 2015. Those incentives would double to 2 percent the following year under draft regulations Medicare released this month.
The proposal also would phase mid-sized physicians groups, those with between 10 and 99 health professionals, into the program in 2016 instead of in 2017 as previously proposed. While they would be eligible for bonuses up to 2 percent, they would be shielded from any penalties for that first year.
In 2017, the program would add the remaining doctors in practices of nine or fewer professionals, about 350,000 doctors, according to Medicare’s estimates.
The program would alter quality measures by specialty but many of the of the measures will check to see how often doctors follow basic medical approaches. At least at the start, physicians will be able to select which of Medicare’s measures they want to be judged by. In determining bonuses and penalties, the government also plans to take into account how much each doctor’s average patient costs Medicare, in order to encourage a more judicious use of testing and more aggressive efforts to avert hospitalizations.
Many hospital and medical groups have been advocating for Congress to repeal the provision over fears that the two percent penalty will harm doctors, while the two percent bonus will not provide enough incentive. Groups are also watching movement on the fight to repeal the Sustainable Grown Rate formula, which is supposed to calculate the annual payment rate before the penalties and bonuses. Congress passes a “patch” each year to avoid the SGR cuts.

The original article by Kaiser Health News in collaboration with The Washington Post can be found here

Committee Questions Data Security in Insurance Marketplaces

The House Oversight and Government Reform Subcommittee on Energy Policy, Health Care and Entitlements expressed concerns over security systems that will accompany the healthcare insurance marketplaces in October. The committee is referencing the marketplaces extensive data hubs, but according to the Obama administration, the hubs will not contain customers’ personal data.

Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner told lawmakers that the hub is a routing tool, not a database, and also noted that the application for insurance in the marketplaces does not ask for personal health information. The marketplace IT system will not access or store health information beyond what is routinely used when someone applies for Medicaid, for example. Further, the deputy chief information officer at CMS emphasized that data would only be stores in the hub for a matter of minutes.
The concerns of committee members also extended to how the administration is setting up and testing the hub before it goes live. While the Department of the Treasury is testing the hubs, Alan Duncan, assistant inspector general for security and information technology services, expressed some concerns that the final round of testing would not be done by the launch date of October 1, 2013.
Committee Chairman Darrell Issa (R-CA) also questioned a CMS contract with a British company, the Serco Group, to help handle applications for health coverage in the federally run exchanges. The group is being investigated by the British government in connection with its billing practices, and Issa said the Federal Bureau of Investigation found that the company’s computer system has been hacked, putting Social Security numbers at risk.

The full article is available via CQ here.

Tuesday, July 23, 2013

House Ways and Means Committee Asks for Input on Medicare Proposals

In their continued focus on Medicare, the House Ways and Means committee asked for public comment Friday on draft legislation prosing three modifications to Medicare’s benefits system that were made by the Obama administration. The committee, which has a Republican majority, didn’t necessarily endorse the proposals, but still published them for comments until August 16th.

As reported by CQ, the Congressional Budget Office estimates that the three proposed changes would save more than $60 billion over 10 years. The changes would increase premiums that wealthier beneficiaries pay for services under Medicare Parts B and D, increase the deductible for Part B services, and create a copayment for home health services. Without and changes, the Medicare Trustee Report projects that the trust fund will become insolvent by 2026.

The bill would also increase the lowest income-related premium from 35 percent to 40 percent, and increase the premiums for other income brackets, with a cap of 90 percent at the highest tier. Income thresholds associated with those premiums until 25 percent of beneficiaries are subject to the higher premiums would also be maintained. The proposal would apply a $25 increase to the Part B deductible in 2017, 2019, and 2021 for new Medicare beneficiaries, and would add a new $100 copayment for home health episodes for new beneficiaries beginning in 2017.

Currently, beneficiaries are not required to make a copayment for home health services, which are paid based on a pre-determined daily rate for each 60-day episode of care. The copayment would be preempted if the home health episode was directly preceded by a hospital stay or inpatient post-acute care stay.