Category: Uncategorized

Insurance Exchange Budgets: How Much is Needed?

Jan 19, 2011• 3

By ROGER COLLIER

It’s coming up to four months since the Department of Health and Human Services awarded more than $50 million in grants to states and US possessions for health insurance exchange planning and development, and the money is now starting to be spent. $50 million seems like a fair amount of cash, but it’s generally understood that this is just a down payment on the cost of exchanges. So how much might a state expect to spend?

Although neither complies exactly with the requirements of PPACA, the exchanges in Massachusetts and Utah provide some clues as to how much a state might have to spend in order to have a successful functioning exchange.

The Massachusetts Connector meets the PPACA requirements quite closely (not surprisingly given that PPACA drafters used it as a model), and has been operational for four years. It offers on-line enrollment to small groups and to both subsidized and unsubsidized individuals. There are now approximately 155,000 subsidized CommCare enrollees and close to 40,000 unsubsidized enrollees.

The Connector has been quite generously funded. An initial state appropriation provided $25 million in planning and development funds, while operations costs are funded through per-enrollee levies on participating health plans. Current levy rates are 4-4.5 percent (comparable to insurance broker renewal rates), giving the Connector an operations and ongoing enhancement budget of more than $40 million a year to pay for some 45 staff, consultants, and IT and other contractors.

Health Care Georgians Deserve

Jan 19, 2011• 1

By GAYATHRI SURESH KUMAR, MD

As a physician who works at Grady Memorial Hospital, I am regularly reminded of the implications of poor access to health care.

One of my regular patients had been suffering from diabetes and hypertension for five years. She was a single, dedicated mother who had been working long hours at a local grocery store to provide for her 15-year-old daughter. She understood that good health meant that she could perform better at work, and the earnings she received from her work would help her provide a stable home for her daughter. Therefore, she did whatever it took to keep herself healthy — monitored her diet, took her medicines diligently and visited the physician regularly.

Things changed one day when during one of her visits to my clinic she said, “Doc, I just lost my job. I don’t have insurance anymore. Medicaid denied me coverage even though they said it was OK for my daughter to have insurance. I can’t pay my co-pays to see you anymore. I may not see you next time.” I was horrified.

A mother who wanted nothing more than to be as healthy as possible for her child should be able to receive care. The health care system in our country that should be serving patients exactly like this one is preventing patients from receiving the care they need and deserve.

In many cases, access to health care coverage is not within the control of patients nor their physicians, resulting in significant consequences. That is, if they don’t obtain coverage, many of our patients will succumb to their (many preventable) illnesses if they don’t have access to their physicians or cannot pay for their medications. My patient’s future could be a testimony to this.

What further confounded me was that Medicaid denied my patient.

Minimum Essential Benefits

Jan 18, 2011• 5

By MICHAEL TURPIN

The Affordable Care Act is officially under construction. The framework for the minimum mandatory levels of benefits offered through state exchanges is now being researched and will soon be ready for prime time debate.

The Institute of Medicine, a non-partisan research group, has been retained by Health and Human Services to conduct public and private planning sessions to help shape final recommendations on what standard levels of benefits should be required as a “floor” for all health plans.

The queue of industry and special interest groups increases daily as stakeholders wade in to offer personal perspectives on why certain levels of benefits should be considered as “essential”. The stories will be heart wrenching as individuals plead for broader coverage terms and looser definitions of medical necessity to cover a range of therapies treating orphaned or difficult conditions that do not neatly fit into today’s definitions of coverage. The unfortunate fact also remains that the average consumer expects “essential coverage” to be synonymous with open access, comprehensive coverage, minimal out-of-pocket cost sharing and an affordable price tag. In effect, everyone wants a Cadillac when the nation can barely afford a Corolla.Continue reading…

HPHC Goes Its Way, Thoughtfully

Jan 18, 2011• 10

By PAUL LEVY

Lots of people are thinking about the form of payments between insurance companies and providers for health care services, but it is also important to think about how each such approach would be marketed as an insurance product to the population.

The payment model that gets the most attention is capitated, or global payments, combined with accountable care organizations. In this environment, an average annual budget is established for each person served by an integrated health care delivery system (ACO), and that budget is shared among the providers according to some mutually agreed upon arrangement.

But the insurance product that would accompany this kind of payment scheme is often left without much of a description. As I have talked with insurance executives, they often fail to explain how they would offer consumers a desirable choice for a product based on this payment plan. Instead the main focus seems to be on shifting risk from the insurer to the providers, reducing the amount of unnecessary expenses, and sharing the benefits of those changes between the insurance company and the providers. Over time, the theory goes, the cost curve is slowed and premiums go up less quickly. But, it remains unclear what the role is for consumer in this scheme.

What Most Needs Repealing and Replacing

Jan 18, 2011• 39

By JOHN GOODMAN, PhD

Tomorrow night the House of Representatives will debate the repeal of the Patient Protection and Affordable Care Act (ACA), what many call “ObamaCare.” Some critics complain that this is a futile exercise because there is little chance of short-term success. But that’s the wrong way to look at it.

At the time of its passage, most members of Congress had no idea what was in the ACA. Nancy Pelosi was more correct than she realized when she said, “We have to pass it to see what’s in it.” Even now, we don’t know half of “what’s in it,” but we know enough to have an intelligent debate. Ideally, tomorrow night’s proceedings will be educational — in a way that the debate last spring was not.

In anticipation of the event, representatives from the National Center for Policy Analysis, the Heritage Foundation, the American Enterprise Institute, the Cato Institute and the American Action Forum will conduct a briefing on Capitol Hill tomorrow at noon. Our goal: to discuss ten structural flaws in the Affordable Care Act. We believe each of these is so potentially damaging, Congress will have to resort to major corrective action even if the critics of the ACA are not involved. Further, each must be addressed in any new attempt to create workable health care reform.

Putting the Patient First, Literally

Jan 18, 2011• 3

By ADRIAN GROPPER, MD

Interoperability is front and center, again. Stage 1 of HITECH was about health records for doctors. Stage 2 is about interoperability. The President’s Council of Advisors on Science and Technology (PCAST) report is all about interoperability. At a recent state medical society meeting, the most animated questions by physicians to Dr. Blumenthal were about the lack of interoperability in electronic health records.

While HITECH is designed to regulate the behavior of technology vendors, it is struggling to encourage doctors to accept the result. Growing interest in ACOs may, at last, drive doctors to demand effective interoperability, and using the patient as a principal or intermediary can jump-start the clinical integration they seek.

For more than 5 years, interoperability has been approached from the perspective of doctors and hospitals. The results speak for themselves. As we process the innovations proposed by PCAST and consider the specifics of Stage 2 regulations, it’s time to put patients first and technology second by giving patients (and their designated agents) convenient access to their health records in their choice of electronic formats including Blue Button, CCR and CDA. Market forces will take care of the rest. Experience with Blue Button and the Direct Project shows that patient-centered and secure, directed exchange avoid the privacy and policy issues that delay technological approaches to interoperability.

Comment on the PCAST Report

Jan 18, 2011• 3

By MARGALIT GUR-ARIE

This comment is not in response to the specific questions posed by ONC, which seem to presume a certain validity of the PCAST report. This comment is respectfully raising several basic questions, which in my opinion, the PCAST reports either did not address or circumvented. With this in mind, you may choose to continue reading, or not.

I would like to start by clarifying that I am now, and always have been, a strong proponent and supporter of appropriate computerization of medical records, HIT in general and the resulting opportunities for expanded clinical research. For the purpose of full disclosure, I have no financial or any other, interests in any HIT vendor.

1. Where does clinical data reside today?

Providers – As we all know, there are massive amounts of paper based medical records residing within the walls of providers of all shapes and types. In addition to paper based records, there is a significant (and growing) amount of medical records maintained in electronic format by mostly large providers, but smaller ones as well. The vast majority of these records are created and stored in document format (scanned, dictated, typed, annotated, handwritten, transcribed, etc.). A small portion of this data is stored in structured format, mostly if not all, in relational databases. The most common discrete data elements are demographics, insurance details, diagnoses (ICD-9), procedures (CPT), vitals, and here and there lab results, immunizations, medications, some histories and relatively rarely, findings.

A Necessary Compromise

Jan 18, 2011

By ROBERT LASZEWSKI

This week’s House health care repeal vote is little more than a political stunt–everyone knows the effort will die in the Senate.

But, when the day is done the only way for the Republicans to do anything with the new health law will be to work out a compromise—repeal before the 2012 elections is impossible and it isn’t very likely after the 2012 elections. Even if the Republicans sweep the White House and both houses of Congress in 2012, it is highly unlikely they will have the 60 Senate votes needed for a full repeal.

So, in the end, a compromise will be needed.

During the past week, more than one Democrat has indicated an interest in at least looking at compromise amendments to the health care bill—particularly on the individual mandate. But so far, Republicans are showing no signs of being interested in fixing what they say is a bill so bad it should only be repealed.

The House vote will take place against a backdrop of increasing debt and enormous fiscal challenge. In recent days, the national debt passed the $14 trillion mark—that is $45,300 for every person in the country!

Half of our national debt was added in just the last six years. The debt was “only” $7.6 trillion in January 2005 and $10.6 trillion the day President Obama was inaugurated just two years ago.

Repeal is Irresponsible

Jan 17, 2011• 1

By LUCAS RESTREPO, MD

“The primary ethical issue of modern medicine and public health is the outcome gap,” write Paul Farmer and Nicole Gastineau Campos in an essay published in 2004. Entrenched in “growing social inequalities,” this gap is immediately evident to every physician: poverty is inversely proportional to health. “The growing gap,” they elaborate, “constitutes the chief human rights challenge of the 21^st century.” The proliferation of people who never experience abuse of their civil rights, but lack access to medical care, has damaging societal implications: “what does it mean when an African-American neonate does not have ready access to a neonatal intensive care unit?” The answer is that “[w]henever more effective technologies are introduced there will be, in the absence of an equity plan, a growing outcome gap.”

Around the country, this gap is exploding. Surviving an illness may sometimes depend on the good will of kids. I kid you not. Carlos Olivas, Jr., a 12 year-old boy, in view that Arizona’s cuts to Medicare meant certain death to a man who he had never met named Francisco Felix, decided to help, raising money in the street. Carlos’ empathy toward Mr Felix―at least in part―originates from the thought of finding his father (who has cirrhosis) in a similar situation.

A sense of responsibility toward others, as exhibited by this young man, is the foundation of all societies. Carlos is an exemplary citizen, proof that the Social Contract is an intuitive concept. His behavior is strictly rational: today, I’m strong and can help the weak; tomorrow, when I’m not as strong, someone will help me.