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Does Obamacare Limit Profits for Health Insurance Companies in Your State?

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By Jason Shafrin

One of the provisions in the Patient Protection and Affordable Care Act (a.k.a ACA, a.k.a. Health Reform, a.k.a. Obamacare) is that it limits the profits of health insurance companies. The ACA imposes a minimum medical loss ratio (MLR) on all insurers. The MLR is the amount of money spent on covered person medical care divided by the total revenue received through premiums. There is some debate of what constitutes ‘medical care’ (e.g., do investments in electronic health records count as medical care?), but insurer profits certainly are non-medical.

The ACA requires health insurers in the individual and small group market to spend 80 percent of their premiums (after subtracting taxes and regulatory fees) on medical costs. The corresponding figure for large groups is 85 percent. According to a recent Kaiser tracking poll, 60 percent of the public views the MLR concept favorably, although only 38 percent was aware that the provision is in the ACA. Insurance brokers may be getting squeezed for insurers to meet this amount.

Even though the MLR is a national law, it may not apply in your state. Continue reading…

The States: Friends With (Essential) Benefits

By Linda Bergthold

Since the passage of health reform (Affordable Care Act), many have wondered what would be covered in the benefits offered through the State Exchanges. We have been reassured that the benefits that are “essential” would be comprehensive yet affordable. But essential to whom? What is an essential benefit and who gets to decide? Tough questions. No easy answers.

Last week HHS released a bulletin punting part of the issue to the States. States will have more “flexibility” to determine what is in the essential benefit package. Of course, not complete flexibility. These benefit plans MUST include, at least, the ten categories of benefits that are defined in the law. Those categories include:

Section 1302(b)(1) provides that EHB include items and services within the following 10 benefit categories: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.*

Here are some questions that you might want to know about what is unfolding:

Continue reading…

CLASS-Gate

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By AVIK ROY

I’ve written previously about the looming train wreck from Obamacare’s new long-term care entitlement for the elderly, called the CLASS (Community Living Assistance Services and Support) Act. Democratic Senator Kent Conrad (D., N.D.), you may recall, once described the CLASS Act as “a Ponzi scheme of the first order, the kind of thing that Bernie Madoff would have been proud of.” The Obama Administration strongly supported the CLASS Act’s inclusion in the Affordable Care Act, and Conrad ended up voting for it anyway.

However, the case for the CLASS Act has been rapidly unraveling. In February, HHS Secretary Kathleen Sebelius testified before the Senate Finance Committee, admitting for the first time that CLASS is “totally unsustainable.” Under questioning by Sen. John Thune (R., S.D.), she pointedly refused to rule out an individual mandate that would force everyone to join the program. Though Sebelius assured Thune that she had broad authority to fix CLASS’ structural problems, I obtained a Congressional Research Service report that stated the opposite. In the July/August issue ofForeign Affairs, former White House budget director Peter Orszag proposed an individual mandate as one of “the only solutions” to CLASS’ unsustainability.

So, we’re all in agreement that CLASS is a mess that could cost taxpayers hundreds of billions of dollars. So why was it included in our new health law in the first place?

The reason is simple: budget gimmickry. CLASS will rake in $86 billion in premiums from 2012-2021, but pay out substantially more than that over the long-term, rapidly generating deficits and bankruptcy. However, the Congressional Budget Office can only score the law’s impact over the next ten years, a period in which CLASS “reduces” the deficit. The claim that Obamacare was budget-neutral was critical to winning the approval of skittish moderate Democrats.

And now, today, a new Congressional investigation led by John Thune reveals that the Obama Administration knew all along that CLASS was unsustainable. “As a result of this investigation,” the authors write, “it is now clear that some officials inside HHS warned for months before passage that the CLASS program would be a fiscal disaster. Within HHS the program was repeatedly referred to as ‘a recipe for disaster’ with ‘terminal problems.’”

Continue reading…

The Primary Care Revolt

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By brian klepper

Last Thursday Anna Wilde Mathews of the Wall Street Journal ran an article detailing the activities surrounding primary care’s gradual awakening and mobilization. With Tom McGinty, Ms. Mathews authored a damning expose on the RUC last October that precipitated our efforts against CMS’ 20 year reliance on the AMA’s RVS Update Committee (RUC) for valuation of medical services.

There is the lawsuit by six Augusta, GA primary care physicians, spearheaded by Paul Fischer MD. (See his most recent article below). The suit claims that CMS’ and HHS’ longstanding primary relationship with the RUC has rendered that panel a “de facto” federal advisory committee. That would make it subject to the management and reporting rules of the Federal Advisory Committee Act  – transparent proceedings, representative composition, scientifically valid methodologies – that attempt to ensure the public over the special interest. The fact that CMS has never required the RUC to adhere to those rules presumably means that the relationship is out of compliance with the law.

The American Academy of Family Physicians (AAFP), after declining to join the suit, issued a series of demands: more primary care seats, a sunsetting of rotating sub-specialty seats, a dedicated gerontology seat, seats for non-physicians like patients, purchasers and economists. The RUC has until March to respond. If they reject the demands, the question is whether the AAFP Board will vote to walk, as David Kibbe and I urged them to do when we began this campaign last January.

Continue reading…

Interpreting the Draft Insurance Exchange Regs

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By ROGER COLLIER

The Obama administration’s progress—with just a few stumbles—towards health care reform implementation took another major step this past week. In a carefully chosen small business setting—a Washington DC hardware store—HHS Secretary Kathleen Sibelius released draft regulations for the health benefit exchanges called for by the Affordable Care Act.

The exchanges, required to be established for every state, are predicted to serve some 24 million consumers by 2019 (provided that the ACA is neither significantly changed nor found unconstitutional), with the majority receiving federal subsidies to help pay for coverage.  So far, a dozen states have enacted bills to create exchanges, while in nine states such legislation has failed.

Responding to strident opposition to the ACA requirements from conservatives and from many business owners, Secretary Sibelius emphasized the flexibility of the draft regulations, which would allow considerable variation among states, give participating businesses considerable latitude in coverage selection, and interpret states’ readiness for exchange operation more loosely than implied by the ACA itself.  In describing the intent of the exchanges, she stated that they will “offer Americans competition, choice, and clout.”

Well, maybe, depending on one’s interpretation of the draft regs.

Continue reading…

Calling All Health Innovators: Health Data Palooza

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By Todd Park

This week the Health 2.0 team will be at Health Innovation Week DC, and the biggest event there will be the Health Data Initiative Forum. One day, 50 demos, mixing more government and private data than you can imagine. We’ve been helping at the periphery of the Health data Initiative and we’ll be be having a special session talking more about the Health 2.0 Challenge, including our upcoming work running Challenges for ONC. We’re incredibly excited and enthusiastic, but no one is as enthusiastic as Todd Park! Here’s the CTO of HHS telling you about his brainchild, Health Data Palooza–Matthew Holt

Almost exactly one year ago, we launched a vital new HHS Open Government effort: The Health Data Initiative (HDI). The Initiative was publicly launched by HHS Secretary Kathleen Sebelius, Deputy Secretary Bill Corr, Institute of Medicine (IoM) President Harvey Fineberg, and White House CTO Aneesh Chopra at a forum held at the National Academy of Sciences.

The Health Data Initiative is an incredibly exciting public-private collaboration that is encouraging innovators to utilize data made publicly available by HHS and others to help fuel applications and services that can help improve health and health care. Over the past year HHS has been working very hard to make our data ever more accessible to the public – both publishing brand new data and making more of our existing data machine-readable, downloadable, accessible via application programming interfaces (APIs), free, and vastly easier to find. We’ve launched major new data and information websites (the HealthData.gov community, the Health Indicators Warehouse; and HealthCare.gov).

Equally importantly, we’ve been energetically publicizing our data, through challenges, code-a-thons, and many sessions with innovators of all kinds – educating folks around the country about what data we’ve made available and its potential to help power health  improvement. Innovators from across America are taking our data and are using it to build and power an amazing and rapidly growing array of applications in creative and powerful ways to help advance health. This movement has included entrepreneurs and change makers from all sectors: startups, major businesses, nonprofits, public health, health care delivery system, federal and local government, and academia.

On June 9th, 2011 at the National Institutes of Health, in partnership with the IoM, we will be holding our 2nd Annual Health Data Initiative Forum (or, as I like to call it, our second annual Health Data Palooza!). Continue reading…

Outrage is Easy. Solutions are Hard.

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By MERRILL GOOZNER

The inspector general of HHS reported this week that nearly half of the anti-psychotic drugs fed to the demented elderly in nursing homes are inappropriately prescribed. That’s about one in fourteen nursing home residents.

Forget about cost, which is over a quarter billion dollars a year. “Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” wrote Daniel R. Levinson, the HHS I.G. wrote in his letter to Senators Charles Grassley (R-Ia.) and Herb Kohl (D-Wis.), who asked for the report.

Why is this happening? First, the medication patterns of the frail elderly are not monitored by the Centers for Medicare and Medicaid Services, which is afraid of a backlash from Capitol Hill where doctors and nursing home operators fiercely lobby to protect the hallowed doctor-patient relationship. The drug industry has also, in some cases, paid kickbacks to the pharmacy operators in nursing homes.

But at the root of the issue are the doctors who are faced with caring for these patients. Even though clinical trials have shown the drugs are likely to result in earlier deaths for some of these elderly patients, doctors prescribe them to reduce agitation, as Daniel Carlat, a practicing psychiatrist and purveyor of non-industry-funded continuing medical education, told the New York Times. “Doctors want to maximize quality of life by treating the patient’s agitation even if that means the patient will die a bit sooner,” he said.

As someone who watched his father’s decline with dementia over a ten year period (usually from a distance), I can attest that shortening one’s lifespan is not the crucial issue, especially in the last few years when the personality in the shell of the human being that has survived the loss of cognition has largely disappeared. The first question is whether the anti-psychotics are effective in reducing the outbursts associated with severe dementia, and whether those benefits outweigh the side effects (catatonia?). The second question is whether families have been adequately informed about the risks and benefits of this approach. That the drug companies deploy their marketing arms to stoke sales in this situation is outrageous. But even eliminating their right to do so wouldn’t solve the underlying problem.

Accountable Care Organizations and Antitrust

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By TIM GREANEY

There’s a new PSA test in health care.  Hopefully it will prove more reliable than that other one.

In conjunction with the unveiling of the long-awaited ACO regulation by HHS, the FTC and Department of Justice issued a Joint Policy Statement setting forth their standards for conducting an expedited (90-day) antitrust review of applicants for ACO certification.  The agencies explained that they will evaluate applicants’ market power based on the ACO’s share of services in each participant’s Primary Service Area (PSA) defined as the “lowest number of contiguous postal zip codes” from which the hospital or physician draws at least 75 percent of its patients for its services.   The Statement summarized the antitrust implications of ACOs formed by hospitals or physician groups with large market shares in their markets:

ACOs with high PSA shares may pose a higher risk of being anticompetitive and also may reduce quality, innovation, and choice for both Medicare and commercial patients. High PSA shares may reduce the ability of competing ACOs to form, and could allow an ACO to raise prices charged to commercial health plans above competitive levels.

The antitrust enforcers were properly concerned with the risk that ACOs could become a vehicle for increasing or entrenching provider market power.  Studies by academics, health policy experts and state governments have documented the impact of provider concentration on insurance premiums. Moreover, a post-reform merger wave may have increased the number of hospital and specialty physician markets and many areas are already served by dominant local providers.  Inasmuch as the success of the ACO concept depends on its ability to spur delivery system change, the predictable intransigence of monopolistic providers presents an important issue. In this regard, it is heartening that the extended (and apparently controversial) regulation drafting process produced a result that promises to constrain the growth and exercise of market power.Continue reading…

Beating up on ONC, mostly unjustified

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By Matthew Holt

Earlier this week there was a curious little hearing at Pete Stark’s committee. Much of the Q & A—mind you post the announcement of the final meaningful use rules—was (apparently, as I can’t find the transcript) a beating up on the poor folks at ONC for reducing the barriers towards meaningful use. Here’s Jonathan Hare of upstart privacy/identity/network vendor Resilient explaining that things are not tough enough.

While Jonathan is having a bit of fun here (and, oh by the way, he does actually have a solution for the inadequacies of current HIEs which we’ll be showing you more about in the world of Health 2.0), some of this and the other stuff the ONC folks had to deal with was a little tough. They got a fair amount of abuse from the committee.

Continue reading…

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