Penalties

In the aftermath of the recent election, virtually all commentators were quick to conclude that ObamaCare has been saved. The health reform law can now go forward and Republicans are powerless to stop it.

The trouble is: ObamaCare is a deeply flawed piece of legislation. Its defects are so huge that Democrats are going to want to perform major surgery on it in the near future, even if the Republicans stand by and twiddle their thumbs.

That raises this question: What changes need to be made in the legislation to turn it into a health reform that solves existing problems without creating even more serious new problems? Here are six essential short term fixes:

Subsidize all insurance the same way. The way the government subsidizes health insurance under the current system is arbitrary and unfair. Employees with employer-provided insurance get that benefit tax free — a subsidy that is worth almost half the cost of the insurance for middle-income families. However, there is almost no subsidy available for people who must purchase insurance on their own. They must pay taxes on their income and then buy the insurance with what’s left over.

Under ObamaCare the subsidies become even more arbitrary. Although the new law creates generous tax credits for low and moderate income families who must buy their own insurance in newly created health insurance exchanges, the subsidy in an exchange can be as much as $12,000 higher than the same family will get if the same insurance is obtained through an employer!

Continue reading “Repairing ObamaCare”

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As a cardiac electrophysiologist, I’m pretty far removed from public policy.  But I have to admit that I was interested in the latest move by CMS to cut their Medicare payment rates to hospitals by invoking pay cuts for hospital readmissions.  The Chicago Tribune‘s article is enlightening and filled with some interesting anecdotes after the first round of pay cuts were implemented:

(1) The vast majority of Illinois hospitals were penalized (112 of 128)

(2)  Heart failure, heart attack, and pneumonia patients were targeted first because they are viewed as “obvious.”

(3) “A lot of places have put a lot of work and not seen improvement,” said Dr. Kenneth Sands, senior vice president for quality at Beth Israel.

(4) Even the nation’s #1 Best Hospital (according to US News and World Report) lost out.

So what’s a hospital to do?

Continue reading “Out of the Box Thinking on Avoiding Hospital Readmissions. Stop Trying”

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From reading recent headlines, one might easily get the impression that hospitals are resistant — or at least ambivalent — in their pursuit and adoption of accountable care initiatives.

Are Hospitals Dragging their Feet on Accountable Care?

Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”

KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”

Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”

The Bigger Picture

Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative?

The answer from the headlines above might suggest “no”, but I believe the correct answer is “not yet, but it’s inevitable”.  Hospitals are feeling the heat, but it’s just not yet hot enough to jump off the platform and abandon existing business models.

Continue reading “Are Hospital Business Models on a Burning Platform? Not Yet, But It’s Inevitable.”

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UNTIL TODAY, many health care providers questioned whether HHS and the Office of Civil Rights (OCR) would ever issue any significant penalties for violations of the HIPAA Privacy Rule. However, will OCR ever be able to collect the penalties.

Today, HHS Office of Civil Rights (OCR) announced a civil money penalty (CMP) of $4.3 million against Cignet Health of Prince George’s County, MD for violating the HIPAA Privacy Rule. This is the first ever civil money penalty issued by OCR for a violation of the HIPAA Privacy Rule. It is significant not only because it is the first – but also because of the size of the penalty and the basis for the violation.

OCR issued a Notice of Final Determination on February 4, 2011, outlining the procedure for payment of the $4.3 million civil money penalty. The Notice of Final Determination also indicates that Cignet failed to request a hearing on the matter or reach settlement with OCR. Prior to the issuance of the final notice, OCR had issued a Notice of Proposed Determination on October 20, 2010, which details the basis for the penalty, details the findings of fact, grounds for violation of HIPAA, and calculation of the penalty amount. Continue reading “OCR Imposes $4.3M Penalty for Violation of HIPAA/HITECH Privacy Rule”

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Most of the recent attention on the 2010 health care reform legislation has focused on the individual mandate. After two federal court rulings upholding the mandate, a third federal judge—in Virginia—ruled that the Constitution does not allow the government to require the purchase of insurance as part of regulating an interstate commerce market. Simultaneously, Congressional Republicans have reiterated their intention of preventing the individual mandate from being implemented, regardless of the constitutionality of the provision.

One interesting response to the resulting media coverage came in the form of a Kaiser Health News article [http://www.kaiserhealthnews.org/Columns/2010/December/121410laszewski.aspx] suggesting that the issue might be overblown since, even if the mandate were implemented, it would be relatively unsuccessful in leading the uninsured to purchase coverage. Unfortunately, the article misinterprets some of the legislative language, not entirely surprisingly given the complexity of the mandate provision. Following are clarifications of the mandate and associated requirements, and a somewhat more careful look at the mandate’s possible impact.

A Brief Summary of the Mandate

The individual mandate requires almost all legal residents of the United States to have at least a defined level of health care coverage. Those lacking such coverage will be subject to a penalty to be paid as part of tax filing. Exclusions are made for members of certain religious groups, Indian tribes, incarcerated individuals, and those whose income is below the tax filing threshold or inadequate to pay for coverage. To assist those with lower incomes but not eligible for Medicaid or SCHIP, the legislation provides for both premium credits and cost-sharing subsidies. Continue reading “The Individual Mandate: Another Look at the Penalty Trade-Off”

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Matthew Holt
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Munia Mitra, MD
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Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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