Category: Uncategorized

The 834 Problem

Oct 25, 2013• 12

By Robert Laszewski

You have probably already heard that Obamacare has as many backroom problems as problems with the front end consumer web enrollment portal.

Insurance companies participating in the new health insurance exchanges are receiving detailed enrollment information for each of the very few people who have successfully enrolled through the 36 federally run health insurance exchanges.

But the problem is that this enrollment is coming from the government with a very high rate of errors––way beyond anything they can handle manually once the real enrollment volume comes in.

So long as each insurance company is receiving only 10 or 20 enrollments a day––that is what they are receiving now––the high error rate enrollments can be fixed with lots of hands-on effort. If the Obama administration fixes the consumer portal before fixing the 834 problem, the insurance companies could begin receiving thousands of enrollments with high error rates every day.

That would bring the insurance company information technology departments to their knees. It would mean lots of new policyholders could have problems getting their bank accounts properly debited, their claims held up, or health care providers refusing to treat them because they aren’t on the list of covered people.

So this is a very big deal.

An 834 transaction is a technical term for exactly how enrollment information is exchanged, in this case, between the federal government and the health insurance companies.

The 834 transaction represents a computer “benefit enrollment and maintenance document.” It is commonly used by employers, unions, government plan sponsors (Medicare Part D, for example), and insurance marketing organizations to enroll members in a health benefit plan. This current version developed out of the 1996 Health Insurance Portability and Accountability Act (HIPAA). So, it has been around for many years.

This process is where the federal government’s backroom has come off the rails and is in need of an urgent fix.

Round One of the Obamacare Exchange Hearings. Angry Republicans 6 Contractors 0.

Oct 24, 2013• 7

By Charles Ornstein

Today’s House Energy and Commerce Committee hearing/grilling of the contractors behind Healthcare.gov brought a lot of defenses and fingerpointing, but little clarity of when the website will be fixed.

Still, here are some of the more-memorable quotes. The sources are below each.

“I will not yield to this monkey court,” Rep. Frank Pallone (D-N.J.) said when Republican lawmakers tried to talk about online privacy fears. -Politico

“This is not about blame. It’s about accountability,” said Rep. Fred Upton (R., Mich.), chairman of the House Energy and Commerce Committee. “We still don’t know the real picture, as the administration appears allergic to transparency.” – WSJ.com

“CMS [the Centers for Medicare and Medicaid Services] had the ultimate decision to go live or not go live,” said Cheryl Campbell, senior vice president of CGI Federal, the lead federal contractor on the project. “At CGI we were not in position to make that decision. We were there to support the client. It’s not our position to tell clients whether to go live or not go live.” — Washington Post

“Amazon and eBay don’t crash the week before Christmas,” said Rep. Anna Eshoo of California, a Democrat. “ProFlowers doesn’t crash on Valentine’s Day.” – NBC News

“Three weeks after the Web site went live, we are still hearing reports of significant problems. These problems need to be fixed, and they need to be fixed fast,” said Representative Diana DeGette, Democrat of Colorado. -New York Times

“We understand the frustration many people have felt since healthcare.gov was launched. We have been and remain accountable for the performance of our tools and our work product,” said Andrew Slavitt, the group executive vice president for Optum/QSSI, a contractor on the project. – ABC News

Meanwhile, HHS officials may be regretting their decision to give Healthcare.gov visitors the ability to post comments to the site. ProPublica reporters reviewed over 500 comments posted at https://www.healthcare.gov/connect/.

A sampling:

Wrongly Listed As Jailed

“Website said my wife and I were ineligible due to current incarceration. We have never been arrested in our lives, both 63!!!!!!!!!!!!!!!!!!!!!!!,” Fred wrote on Oct. 21.

Health Problems Made Worse

“I have a pre-existing condition …. a-fib…..and actually had an attack after getting frustrated with this confusing mess,” Bill wrote on Oct. 22. (A-fib refers to atrial fibrillation, an abnormal heartbeat.)

Daughter is Not a Daughter Anymore

“I am having difficulty with my account,” Joanna wrote on Oct. 22. “It appears that my daughter was added twice so that I now have two daughters with the same name and social security number. I am unable to delete one of them. Also, the drop down menu that relates to what relationship someone is to another is faulty. I choose that my husband is the father of our daughter and that my daughter is a dependant [sic] to me and my husband. What it actually shows though is that my daughter is a stepdaughter to her father and that my daughter is now both my husband and I’s parent. “

The Sequestration Cuts That Are Harming Health Care

Oct 24, 2013• 2

By John E. McDonough

Between October 1 and 17, the federal government ceased all nonessential operations because of a partisan stalemate over Obamacare. Although it is premature to declare this the greatest example of misgovernance in modern U.S. Congressional history, this impasse ranks highly.

One casualty of the showdown was any consideration of changes to lessen the impact of the across-the-board sequestration cuts that began on March 1. The cuts have caused economic and other distress across the nation, including serious impacts within the health care sector. Nearly eight months into sequestration, we can move beyond predictions and begin to quantify these effects.

Consider the following impacts of sequestration on Federal health agencies and activities:

NATIONAL INSTITUTES OF HEALTH

Cuts to the FY13 budget: $1.71 billion or 5.5%

This includes:

A 5.8% cut to the National Cancer Institute, including 6% to ongoing grants, 6.5% to cancer centers, and 8.5% to existing contracts

A 5.0% cut to National Institute of General Medical Sciences, and a 21.6% drop in new grant awards

Among the effects:

703 fewer new and competing research projects
1,357 fewer research grants in total
750 or 7% fewer patients admitted to NIH Clinical Center
$3 billion in lost economic activity and 20,500 lost jobs
Estimated lost medical and scientific funding in California, Massachusetts, and New York alone of $180, $128, and $104 million respectively.

Dr. Randy Schekman, whose first major grant was from the National Institutes of Health in 1978, said winning this year’s Nobel Prize for Medicine made him reflect on how his original proposal might have fared in today’s depressed funding climate. “It would have been much, much more difficult to get support,” he said. Congresswoman Zoe Lofgren (D-Calif.) noted the irony that because of sequester cuts, NIH funding was reduced for the research that resulted in Yale’s James Rothman sharing in the 2013 Nobel Prize for Medicine.

CIGNA and Me

Oct 24, 2013• 17

By Vik Khanna

I have a challenge for CIGNA CEO David Cordani. Sometime this week, pick up the phone and be a secret shopper. Call your customer service team and ask them the same thing I asked them on a Friday not long ago: does my plan cover and reimburse for flu shots, and at which participating providers in my area? This is managed care and wellness 101. Just not at CIGNA.

Customer service rep A says shots are covered and reimbursed, but she cannot confirm any place in St. Louis as a par provider that would bill the plan directly for payment. Her stubborn refusal to grasp the meaning of “par provider” was infuriating. She repeatedly reads a list of potential providers (all national companies, such as Walgreens) and then tells me I must call each location to discern its billing practices.

Wrong. Just plainly and simply wrong because they’re all signed to national contracts. Then, while both my German Shepherds headed for cover in another room, she hung up on me. (I was angry but never profane or malevolent.)

Undaunted and now even more frustrated, I call customer service again. Customer service rep B says: shots covered fully and each location noted previously is a par provider that will accept assignment. Done, right? Not yet. Customer service rep A calls me back.

She has not, however, learned anything in the intervening 15 minutes, as she returns to her home base of ignorance with the accuracy of a GPS. Finally, I demand a supervisor. With the supervisor comes enlightenment and lower blood pressure.

Is Healthcare.gov the Future? I Ask a Futurist

Oct 24, 2013• 8

By Charles Ornstein

Ian Morrison is a health care futurist. Companies, trade groups and nonprofits call on him to speak about trends in health care and offer prognostications of what the future brings. I’ve heard him speak a few times and his knowledge and sense of humor drew me in right away.

Last Friday, I tweeted a story written by Anna Gorman and Julie Appleby,friends at Kaiser Health News about hundreds of thousands of consumers receiving cancellation notices from their insurance companies on account of the Affordable Care Act. I was surprised to learn that Morrison was one of them.

I emailed him to find out more. This is what he told me: Until 2011, Morrison paid for his health coverage from a company on whose board of directors he served. The company was sold and he was insured through COBRA until this March. As he tells it, Blue Shield of California “didn’t want a badly behaved 60 year old Scotsman,” so he got coverage through a preferred-provider organization offered by the insurance company Health Net through a Farm Bureau program.

“No kidding,” he says, he’s no farmer.

Two weeks ago, he received a letter canceling that plan for reasons similar to those cited in the Kaiser story. He subsequently applied for coverage—not through Covered California, the state’s new health insurance marketplace, but directly through Blue Shield. Because of the Affordable Care Act’s ban on discriminating based on pre-existing conditions, the insurer must take him.

Here’s a Q&A I had with Morrison by email (edited for clarity with his approval).

.Gov Prices May Not Add Up

Oct 24, 2013• 5

By The THCBist

A THCB Reader in Michigan writes:

“The rates listed on the Healthcare.gov/Michigan site are inaccurate “estimates.” Being unable to apply on the website due to glitches, I simply go on the site to view plans for my husband and me. Based on our locality, “estimates” shown are about $250 – $600 for bronze and silver plans. We even see some gold plans for about $460.

But when I telephone the insurance companies (Aetna, Humana, BCBSM, HAP) for details and quotes, suddenly the costs of the same plans are $950 – $1750! Obviously, the “estimates” are disingenuous, probably reflecting prices that are available only to very young adults with no medical history.

An estimate is not an estimate unless it is close to what the final price is expected to be, not one-half or one-third the final price. Insurance companies need to list the estimates on the .gov website by range, rather than a single rate. For example, if a policy can be sold for as little as $250 or as much as $950 depending on the particulars of each insured, that policy estimate needs to read $250 – $950. Until insurance companies do this, they are, effectively using a bait-and-switch sales technique, which is illegal.”

If you’ve had a bad or good experience attempting to buy health insurance on the state or federal exchanges, we’d like to know about it. E-mail us at ed****@***************og.com.

THCB Calendar: Graph Analysis and Big Data Principles

Oct 24, 2013• 1

What: Join healthcare data journalist Fred Trotter‘s lecture on graph theory and find out how to translate healthcare issue into solvable graph problems.

When: Thursday, October 24th at 2pm PT/5pm ET (TODAY).

Where: Sign up here.

Health 2.0 Europe: Creation Healthcare’s Daniel Ghinn

Oct 24, 2013

By Harriet Messenger

Harriet Messenger – How has social media transformed our lives? And how do you see it transforming health care?

Daniel Ghinn – Social media is transforming our lives in so many ways. I think all the benefits we’re getting through social media are now happening in health care. For example, social media is great for connecting people who share experiences, this is greatly beneficial in health care – whether it’s bringing patients together or building strong communications between health care providers.

It enables us to learn from one another, to get support and to share ideas in ways that would never have been possible in the non-digital communities that we lived in before the explosion of digital.

HM – Who is using social media? Is it patients, health professionals, pharmaceutical companies?

DG – To some extent it is probably a reasonable generalisation to say everybody, but in so many different ways. Patients, I believe, led the digital health revolution. Patients coming together, collaborating, sharing experiences and learning from each other on how to connect with other diverse areas.

Health 2.0 Europe: Med Digital’s Felix Jackson

Oct 23, 2013• 1

By Harriet Messenger

Harriet Messenger – New technologies are allowing pharmaceutical companies to be in direct contact with patients. How is this transforming the industry and what are the opportunities and the pitfalls?

Felix Jackson – Nothing has really changed with regards to how pharmaceutical companies can interact with their patients. We’ve always been able to provide information for patients. In fact it’s a regulatory requirement that pharmaceutical companies provide patient information. What’s changed is that the digital framework enables them to do this much more conveniently online and much more powerfully. The places that I’m seeing theses changes are places like disease awareness, where pharmaceutical companies are using digital awareness to raise education and information about a certain disease and when to go and seek treatment from a doctor. Also in their support of patients post prescription. So when a patient is prescribed a drug and needs detailed information on that drug, pharmaceutical companies are doing quite a lot of work to provide that information digitally.

HM – And are there pitfalls to this at all?

FJ – Yes, one of the problems with digital, is that it is very global and so traditionally the pharmaceutical companies are regulated on a geographical basis, by country, and traditionally that has been quite easy to control, handing out leaflets in a specific geography. Now with the Internet, if you put something online it can be accessed from all sorts of different parts of the world and that can cause issues. However, I don’t think those problems are that major. If you think it through, it’s about how you are aiming and targeting that activity and if you’re aiming at UK patients and filter websites in the UK then it’s very easy to control, or at least easier than some companies worry about.

In Medicine, More May Not Be Better

Oct 23, 2013• 4

By Haider Javed Warraich, MD

The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.

But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.

Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?

Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.

But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.

In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.

Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).

On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.