Tuesday, June 30, 2015

Supreme Court to consider who owns healthcare claims data

Modern Healthcare reports that The U.S. Supreme Court will hear a case next term on whether a self-funded insurer should have to turn over certain information to the state of Vermont.

The Court announced Monday, June 29, that it would hear Gobeille v. Liberty Mutual Insurance Co. The Supreme Court's new term will begin in October. The case will likely be heard in November or December.

FInd the article, Who controls the data? US Supreme Court agrees to hear healthcare case, by Lisa Schencker here:  http://www.modernhealthcare.com/article/20150629/NEWS/150629889?utm_source=modernhealthcare&utm_medium=email&utm_content=externalURL&utm_campaign=am

In the case, the state of Vermont argues it needs certain data from Liberty, such as claims, member eligibility and other issues, to help it improve the cost and effectiveness of healthcare.

Liberty Mutual, however, argues that the federal Employer Retirement Income Security Act, known as ERISA, protects it and its third-party administrator from having to hand over the information, which is otherwise required by the state. 

The 2nd U.S. Circuit Court of Appeals already ruled that ERISA, which regulates traditional pensions and other employer-provided benefits, takes precedence over state law, meaning Liberty Mutual's third-party administrator shouldn't have to turn over the data. 

But the US Solicitor General's office, representing the federal government, argues the case has national consequences:

“With the encouragement of the federal government, other states are establishing similar healthcare databases to help improve health outcomes for their citizens, and thus the question presented has national importance.”

“If States are unable to acquire such data from self-insured ERISA healthcare plans, their databases will be significantly less comprehensive and thus not as useful in developing health policy at both the state and national levels.”

The state of Vermont argues that it needs access to such data to to create consumer-oriented websites, conduct research on healthcare outcomes or track access to specialists.

“As healthcare costs continue to skyrocket and place enormous pressures on state budgets, the States have an urgent need to take advantage of the 'great potential' … offered by all-payer claims databases.”

Liberty Mutual argues that ERISA pre-empts state law regarding the collection of data: 

“In addition to protecting the interests of beneficiaries, Congress intended to protect plans and employers with self-funded plans (and, ultimately, employees and beneficiaries as well) from the burdens of complying with conflicting state laws by reserving the field of employee benefit plans for federal regulation.”

Monday, June 29, 2015

What next for Affordable Care Act?

The Kaiser Health News identifies the next 5 hurdles the ACA must clear -

Medicaid Expansion. About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.Spacer

Anemic Enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.Spacer

Market Stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.Spacer

Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.Spacer

Political Resistance. The Supreme Court's ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.

Kaiser Health News writers Julie Appleby, Mary Agnes Carey, Phil Galewitz and Jordan Rau contributed to this report.  Find the article here: http://khn.org/news/five-hurdles-ahead-for-obamacare/

King v Burwell: Supreme Court upholds Affordable Care Act

The Washington Post provided this overview of the Supreme Court ruling in King v. Burwell.

In considering the health-care law, the justices were asked to interpret a passage that said the tax credits are authorized for those who buy insurance on marketplaces that are “established by the state.”

But federal exchanges were authorized for states that did not set up their own, and the Obama administration argued that millions of people served by a federal marketplace were entitled to the subsidies, too.

The court agreed that that was the only way the law would work and that, although the legislation’s wording was problematic, Congress’s intent was clear.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible we must interpret the Act in a way that is consistent with the former, and avoids the latter,” Roberts wrote.

Joining the chief justice in the majority were Justices Anthony M. Kennedy, Ruth Bader Ginsburg, Stephen G. Breyer, Sonia Sotomayor and Elena Kagan. Opposing the decision were Justices Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr.

Find the entire article by Robert Barnes here: http://www.washingtonpost.com/politics/courts_law/obamacare-survives-supreme-court-challenge/2015/06/25/af87608e-188a-11e5-93b7-5eddc056ad8a_story.html?wpisrc=nl_politics&wpmm=1.

A brief analysis of the votes reads:

In the 6-to-3 decision, Chief Justice John G. Roberts Jr. delivered a sympathetic affirmation of what has become known as Obamacare, and his legal reasoning seemed to insulate the 2010 law against the legion of opponents who want to undermine the program before it takes hold in American life.

Kennedy’s position in the majority was particularly significant. In 2012, he was one of four justices who would have found the entire law unconstitutional.

Scalia said Roberts, who wrote the decision in 2012 that saved the Affordable Care Act from that challenge, has performed “somersaults of statutory interpretation” to preserve the law.

“We should start calling this law SCOTUScare,” he said. The comment drew laughter as Scalia emphasized his disagreement with the decision by reading part of his dissent from the bench.

The two cases, Scalia said, “will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites.”

Chief Justice John Roberts wrote for the majority.  Here is the Post analysis:

There seemed to be a different tone to Roberts’s opinion this time. In 2012, he distanced the court from the legislation, writing, “It is not our job to protect the people from the consequences of their political choices.”

But in Thursday’s opinion, the language was more sympathetic. The complicated program “grew out of a long history of failed health insurance reform,” Roberts noted. He added that it was designed “to ensure that anyone who wanted to buy health insurance could do so.”

He acknowledged the disjointed way the law was written. It “contains more than a few examples of inartful drafting. . . . Congress wrote key parts of the act behind closed doors, rather than through the traditional legislative process,” Roberts wrote.

But rather than simply focusing on the phrase “established by the state,” Roberts said the court had to look at the intent of the entire law.

“The statutory scheme compels us to reject petitioners’ interpretation because it would destabilize the individual insurance market in any state with a federal exchange, and likely create the very ‘death spirals’ that Congress designed the act to avoid,” Roberts wrote.

He rejected the challengers’ argument that Congress intended to give the states an incentive to create their own exchanges.

To agree, Roberts said, would require rewriting the statute. “The states likely would have created their own exchanges in the absence of the IRS rule, which eliminated any incentive that the states had to do so.”

Some legal experts had thought the court might find the law ambiguous and thus simply uphold the Internal Revenue Service rule that said those who buy insurance on the federal exchange are entitled to the subsidies, in the form of tax credits, just as those who buy on a state exchange are. The court’s precedents call for deference to an agency when the law is unclear.

But crucially, Roberts said this was not a decision for an agency to make. He said the court needed to look at the law as a whole and concluded that even though the legislation’s language might be murky, its intent was clear.

Find the opinion here: https://kaiserhealthnews.files.wordpress.com/2015/06/kingvburwell-decision.pdf.

Monday, June 22, 2015

Hospital ERs charging for non-emergency visits

This from News9.com in Oklahoma City: OU Medical Center ER to charge fee for non-emergency visits (http://www.news9.com/story/25496818/ou-medical-center-er-to-charge-fee-for-non-emergency-visits)

Thank you for a NAHAM member for sharing this!  What do you think?  Will this have ramifications for patient access? 
The report reads as follows –
Doctors will decide if you are there for a real emergency. If not you can stay and pay or leave. O.U. Med has found it cares for 50,000 people each year in the emergency room. Forty percent of which do not actually require emergency care, causing overcrowding and O.U. Med to implement a new program.
The report tells of an emergency room incident twelve years ago when a mother of four children had a seizure while driving. She died on impact and the four children where rushed to the hospital. One son had to be taken to OU Medical Center in Oklahoma City but that ER was overcrowded so his son was flown to Tulsa.  That left the father scrambling: Four children in three locations. OU Med, officials hope they've found the cure to problems like this.
"Our ER needs to spend time with our high risk, real emergency patients and not with the low risk non-emergency patients," said Dr. Steinhart with OU Medical System.  OU Chief Medical Officer Dr. Curt Steinhart insures OU's new screening program.  "Fully compliant to federal law and no risk to patients," said Dr. Steinhart.
Under the new program, patients will enter the ER and go through a screening. If it's a true emergency, the patient stays. If not, there will be a copay or out-of-pocket charge of $200.  "An amount that will focus on them really deciding do they need to be seen here and now," said Dr. Steinhart.
If the patient doesn't want to pay, then OU Med will provide a list of nearby urgent care clinics.
"Not only is the ER the wrong place for these patients but it's not as good as care and it's more expensive," said Dr. Steinhart.
O.U. Med is not the first hospital in the nation to use this program, which has drawn some criticism from advocates stating in a published report, "this strategy could discourage patients from going to the ER for true emergencies."
Here is a list of when you should go to the Emergency Room according to OU Medical Center:
Here are warning signs of a medical emergency, according to the American College of Emergency Room Physicians (ACEP) and OU Medical Center.
  • Chest pain or upper abdominal pain that lasts at least two minutes
  • Uncontrolled bleeding
  • Sudden or severe pain
  • Coughing or vomiting blood
  • Difficulty breathing, shortness of breath
  • Sudden dizziness, weakness, or change in vision
  • Severe or persistent vomiting or diarrhea
  • Change in mental status such as confusion
  • Difficulty speaking
  • Unusual abdominal pain
  • Suicidal or homicidal thoughts
  • Changes in vision
  • Fever or flu-like symptoms (a patient may have severe flu and require hospitalization)
  • Allergic reactions (some are severe and may be life-threatening)
  • Broken bones
  • Animal bites (these can be significant in some cases)
Here is the list of when you should go to Urgent Care:
An urgent care facility is a doctor-staffed, walk-in medical facility that offers an alternative when there isn't an emergency and you don't have access to your personal doctor. It is generally more expensive than seeing your own physician but less expensive than an emergency room visit. The center usually has immediate access to simple laboratory procedures. OU Medical Center recommends an urgent care facility visit for:
  • A sprained ankle
  • Ear infections
  • Minor burns or injuries
  • Coughs, colds, sore throats
When to call you doctor (primary care physician)
  • If you think a person needs emergency treatment at a hospital, it's sometimes helpful to first call your doctor for advice. Do this only if you have the time and the doctor is immediately available. If not, then you should call 911 or go to the nearest hospital. Your doctor can advise you as to whether an emergency situation actually exists. 
  • If there is time to spare, then you should see your doctor first. Remember, a doctor's visit won't be as expensive as a hospital's emergency treatment. And it won't tie up vital emergency medical services. The doctor may also decide that the condition can be treated in his or her office or at home. This saves your time and the hospital's time, and reduces overall health care costs. 
Please note: nothing in this blog is intended to be medical advise from NAHAM News. 

What affects would adverse Affordable Care Act ruling have on healthcare coverage?

We would like to know your thoughts.  The Supreme Court is poised to issue a ruling on the pending challenge to the Affordable Care Act.  Specifically, and perhaps too simply put, can the federal government provide subsidies for healthcare coverage in those who have enrolled in the federal government-sponsored HealthCare.gov.

Here are two short notes from articles fowarded by a NAFEM member:

What a Supreme Court ruling against ObamaCare would look like: http://www.vox.com/2015/6/3/8722289/king-burwell-map

The Supreme Court could decide this month that the financial help 6.4 million Americans receive to cover their health insurance costs are illegal — sending premium costs skyrocketing as much as 650 percent in states with some of the poorest residents.

The case, King v. Burwell, would affect people in the 36 different states that use Healthcare.gov as their marketplace. But the pain won't be felt equally.... The real losers in a ruling against Obamacare: the states that have the most people enrolled under the law and where incomes are low.

Take Florida, for example: an estimated 1.3 million people there are currently getting Obamacare tax credits. The financial help works out, on average, to $294 per person. And if the Supreme Court decides to take those tax credits away, premiums will increase by more than threefold. On average, they'll spike 359 percent.

Contrast that with Pennsylvania, a state that tends to have higher-income enrollees who get less financial help (Obamacare tethers the size of insurance subsidies to an individual's income; people who earn less get more). There, premiums would definitely increase; they'd go up an estimated 177 percent as people there lost, on average, a $229 tax credit.

Millions will lose tax subsidies — and lots of them live in Texas, Florida, and North Carolina
And this from another article. Study: Premiums would rise $3,300 if court rules against ObamaCare

Millions of people who buy insurance through ObamaCare could be forced to pay an average of $3,300 more in yearly premium costs if the Supreme Court strikes down subsidies this month, according to a study released Tuesday.

That steep cost increase would apply to every customer enrolled through HealthCare.gov.

Four states — Mississippi, Maine, Alaska and Wyoming — would face increases of $4,000 or more, according to the study by Avalere Health that offers the latest warning about the potential impact of the ruling.

“Exchange enrollees are currently subsidized at a very high rate,” said Elizabeth Carpenter, director at Avalere. “As a result, many individuals would likely find exchange premiums unaffordable without the tax credits provided under the law.”

In addition to the potential price explosion, a ruling against ObamaCare could also cause major disruptions across the market.

People who can no longer afford coverage but are in generally good health would be more likely to drop out. That could “materially impact the risk-pool in both 2015 and future years,” the study warns.                                                                     

And many of the customers seeking cheaper options may no longer be able to re-enroll in their previous health plans.

About one-third of people who would be affected by the ruling previously had employer-sponsored insurance.      

While some may be able to rejoin their plans, “reports from insurance companies indicate that many small employers may have stopped offering coverage after exchanges launched in 2014,” according to the study.

“We can’t assume that consumers will simply be able to return to previous sources of coverage if subsidies are struck down,” said Dan Mendelson, CEO at Avalere. “The ACA [Affordable Care Act] has fundamentally shifted the insurance market, and the elimination of subsidies would mean the vast majority of those adversely affected will struggle to maintain access to care.”

Friday, June 12, 2015

Is the Affordable Care Act providing the coverage Congress intended?

Reuters reports, "Despite Obamacare, gap health insurance market explodes".  Find the article here: http://www.reuters.com/article/2015/06/03/us-usa-health-gapinsurance-idUSKBN0OJ1G220150603

Despite the promise of coverage through the Affordable Care Act (ACA), the number of people applying for non-compliant, short-term health insurance policies was up more than 100 percent in 2014, according to new data available from companies who broker these policies.

This type of health insurance, short-term, low-cost coverage for major medical events like hospital stays, with high deductibles and out-of-pocket costs, is the kind that the ACA was supposed to upgrade. These plans are also subject to denial if applicants have pre-existing conditions. For example, they do not offer coverage for preventive care or maternity care.

The Reuters report also notes that the ACA does not count these gap plans as qualifying health insurance, so people who have them are subject to penalties for being uninsured.

Accounting for much of the jump are individuals who somehow missed the ACA open enrollment period. More than 11.7 million consumers signed up for ACA coverage through February of this year; however, the Reuters article cites a health insurance broker for these gap policies to point out that people missed the ACA enrollment "mostly because of poor communication between consumers, the government and insurance companies". Those who missed the opportunity to sign up and did not have a qualifying event now have to wait until the next open enrollment period to try again, so they need an insurance plan to bridge the gap.

The same brokers report new signups from retirees looking for low-cost plans to tide them over until Medicare kicks in at 65: Purchasing insurance as a 50-year-old on healthcare.gov can be expensive.  "There are people who have looked at the prices and it makes more sense to buy short term."

But the largest constituency of gap policies are is young, healthy people seeking low-cost catastrophic coverage. Those aged 18 to 34 account for 57 percent of one broker's buyers. A typical policy could cost around $100 a month, depending on the state of residency and the features of the plan.

With a promise of coverage, how well is the Affordable Care Act doing?

Kaiser Health News notes that while most now agree that the ACA has helped Americans who were previously uninsured gain coverage, it's hard to actually measure how much improvement the ACA has had on coverage.

Read the brief report, "Is the Uninsured Rate the Lowest Ever?" here: http://khn.org/news/is-the-uninsured-rate-the-lowest-ever/.

The Administration asserts that “Nearly one in three uninsured Americans have already been covered — more than 16 million people -– driving our uninsured rate to its lowest level ever.”

Those who say the ACA has done well point to periodic polling by the Gallup organization.

According to KHN:

The 11.9 percent uninsured rate (among adults) Gallup reported in April for this 2015 first quarter is the lowest measured since it’s been keeping track. But Gallup has been measuring only since 2008.  Others point to a survey conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention – also found an uninsured rate of 11.9 percent for the first three-quarters of 2014. That was down from 16 percent in 2010, the year the ACA became law.  But that survey changed its methodology back in 1997, which was well after employers had begun shedding coverage for workers and families.

Wednesday, June 3, 2015

Kaiser Health News Morning Briefing

The Kaiser Health News, in "Insurers Seek Hefty Rate Increases For Obamacare Plans," reports:

In the three dozen states that are using healthcare.gov as their health law insurance marketplace, insurers are requesting widely different rate increases -- often in the double digits -- which reportedly are driven by factors such as the high cost of drugs and better data on the health status of customers, according to information released Monday by the federal government.

Here are summaries of various articles that can be accessed from the KHN article.
The New York Times: Seeking Rate Increases, Insurers Use Guesswork

In a sign of the tumult in the health insurance industry under the Affordable Care Act, companies are seeking wildly differing rate increases in premiums for 2016, with some as high as 85 percent, according to information released on Monday by the federal government for the 37 states using HealthCare.gov as their exchange. The data from the Centers for Medicare and Medicaid Services included only proposed rate increases of 10 percent or more, and federal officials emphasized that it would be months before final rates were set. Regulators in some states have the authority to overrule rate increases they deem to be too high. (Abelson, 6/1)

The Wall Street Journal: More Health-Care Insurers Seek Big Premium Increases

The Obama administration published more information Monday about hefty premium increases for 2016 sought by large insurers selling plans under the health law. Major carriers from around the country are proposing big increases in the premium rates paid by consumers who buy insurance policies on their own. (Radnofsky and Armour, 6/1)

Politico: Insurers Seek Double-Digit Obamacare Hikes

Health insurers are asking federal and state regulators to sign off on double-digit rate hikes for hundreds of Obamacare plans next year, increases that are being driven by skyrocketing drug costs and better data on how healthy or sick their customers are. On Monday, the Obama administration posted proposed premium hikes from a wide range of carriers — including major players like Blue Cross and Blue Shield plans — and their rate requests provide the most comprehensive preview yet of what insurers expect for the 2016 enrollment season. (Demko, 6/1)

The Associated Press: Many Health Insurers Go Big On Initial 2016 Rate Requests

Dozens of health insurers say higher-than-expected care costs and other expenses blindsided them this year, and they're going to have to hike premiums for individual policies well-beyond 10 percent for 2016. The proposed double-digit hikes would apply to plans sold on the health insurance exchanges created under President Barack Obama's law, as well as individual coverage sold through brokers and agents. (Murphy, 6/1)

The Detroit Free Press: Some Michigan Insurers Seeking Hefty Price Hikes

Several health insurers in Michigan are seeking double-digit rate hikes for plans they sell to individuals, as industry representatives cite pricey drugs and pent-up demand for health care among the newly insured. Insurance giant Blue Cross Blue Shield of Michigan is requesting permission for an average 11.3% jump in rates and 9.7 % jump in its Blue Care Network plans. Those plans cover 310,000 individuals in the state. (Reindl and Erb, 6/1)

The Charlotte Observer: Blue Cross Proposing 25.7% Rate Hike For ACA Plans In NC

Blue Cross and Blue Shield of North Carolina, the state’s largest health insurer, said Monday it is seeking an average 25.7 percent rate increase for customers covered under the Affordable Care Act. The proposed rate hike is double last year’s 13.5 percent increase approved for Blue Cross, an indication that health insurance costs continue to rise despite the federal health care law. The Affordable Care Act was enacted in 2010 to expand coverage and also to stem runaway health care costs. (Murawski, 6/1)

Chicago Tribune: Some Steep Increases In Health Premiums Expected In Illinois In 2016

Health insurance premiums could rise more than 30 percent next year for some people in Illinois who have bought individual plans, a hefty increase that insurers say is driven by the costs of members' medical bills. The largest average rate increases in the state were proposed for certain plans offered by Blue Cross and Blue Shield of Illinois, Coventry Health Care and Assurant Health, according to a list of proposed increases exceeding 10 percent that was posted Monday on the healthcare.gov website. (Venteicher, 6/1)

High-Deductible Coverage and the Underinsured: The Next Healthcare Crisis?

Are the underinsured the next healthcare crisis?  That's the question posed by John Commins for HealthLeaders Media (May 21, 2015): Underinsured May be the Next Healthcare Crisis.

President of the Commonwealth Fund, David Blumenthal, MD has some interesting observations of the high-deductible plans being used to expand coverage to millions of Americans who otherwise could not afford coverage:

"The financial health insecurity that comes from being underinsured is substantial and puts people's health and well-being at risk."

And a report co-authored by Sara Collins and others for the Commonwealth Fund found that 31 million adults ages 19-64 with health coverage were under-insured in 2014.

"Someone is underinsured if their out-of-pocket costs excluding premiums over the 12 prior months are equal to 10% or more of household income," Collins says, "or if their out-of-pocket costs excluding premiums are equal to 5% or more of household income if their income is under 200% of the federal poverty level, which is about $23,000 for an individual and $47,000 for a family of four, of if their deductible is 5% or more of household income."

As premiums increase, deductibles increase, and healthcare costs increase, the under-insured fall deeper into the healthcare affordability hole.

Former insurance executive Wendell Potter is quoted as saying that high-deductible plans are a windfall for commercial insurance providers. "To them right now this is an ideal scenario," Potter says. "They are collecting premiums, which continue to go up every year, but every year they are shifting more of the costs to the consumers."

The Commonwealth Fund report's findings are in line with a Families USA report this month which also found that that one-in-four people who bought non-group health insurance in 2014 went without needed care because they couldn't afford it. That report blamed deductibles of $1,500 or more as the leading cause for the skipped care.

The consequences of this are the under-insured postpone healthcare when they need it or delay filling prescriptions and avoiding preventative care tests and strategies.

What are you seeing at your hospital?  How prevalent are high-deductible plans and how often do we see these under-insured arriving at ER rather than for elective tests and procedures?