Tuesday, December 31, 2013
“Ultimately, there is wide acceptance of the goal of ACOs and the means of ACOs to obtain better outcomes. That being said, despite the wide acceptance it’s going to be a painful process….It’s wishful thinking [to think the fee-for-service payment system will be ending in two years]. It is going to take several years and it’s going to take a lot of pain as the details of these programs are worked out. And even then I don’t think FFS will be completely replaced by the kind of innovations that CMS and commercial plans are just now experimenting with.” — Mike Taylor, M.D., president of Medical Audit & Review Solutions in West Chester, Pa., told AIS’s Health Plan Week.
Monday, December 30, 2013
A report from the U.S. Department of Health and Human Services that examined data from the 34 Federally-facilitated and State Partnership Marketplaces finds that out of 2.9 million single young adults ages 18 to 34 who may be eligible for coverage in the Marketplace, 1.3 million (46 percent) could purchase a bronze plan for $50 per month or less after tax credits. In the 34 states, a total of 1.9 million young adults, representing nearly 7 in 10 (66 percent) of the potentially Marketplace-eligible uninsured ages 18 to 34, may be able to pay $100 or less for coverage in 2014. According to the report, an additional 1 million eligible uninsured single young adults may qualify for Medicaid in the states that have opted to expand the program in 2014. Today's report also shows that if each of the 34 states expanded its Medicaid program, the proportion of young adults who could obtain low-cost coverage would be even greater. If each of the 34 states expanded its Medicaid program, 4.9 million uninsured single young adults would be eligible for Medicaid. Source: U.S. Department of Health and Human Services
59 percent of expats said they were unaware of their employer's repatriation assistance and didn't know whether their employer would track what happens to them after they return home. This low awareness score can be translated into dissatisfaction, as expats perceive lack of employer interest in them after their assignment concludes. 78 percent of expats or their family members have accessed medical care while on assignment. Expats under age 34 were considerably less informed about the specifics of their health plans. Source: Cigna
Physicians who were educated outside the United States account for about 25 percent of the U.S. physician workforce, with the largest groups being from India, the Philippines, Pakistan, Mexico and the Dominican Republic. Foreign-born registered nurses account for 12 percent to 15 percent of the total RNs in the United States, with 5.4 percent both foreign born and foreign educated. The largest number of foreign-educated and foreign-educated RNs are from the Philippines, followed by Canada, India, the United Kingdom and Nigeria. Among direct care workers, a category that includes nursing aides and home health aides, foreign-born individuals account for 20 percent to 24 percent of the workforce. The largest numbers of foreign-born direct care workers are from Mexico, the Philippines, Jamaica, Haiti and the Dominican Republic. It is estimated that 20 percent of direct care workers are undocumented immigrants. Source: RAND Corporation
Dual Eligible Beneficiaries Affected in Nine States Where CMS Has Approved Financial and/or Administrative Alignment Demonstrations as of November 2013
Beneficiaries Washington 21,000 Minnesota 36,000 South Carolina 53,600 Virginia 78,600 Massachusetts 90,240 Ohio 115,000 Illinois 135,825 New York 170,000 California(Other Than L.A. County) 256,000 L.A. County 200,000 Total 1,156,265 Source: Kaiser Family Foundation
Most individuals have not taken steps to plan for health care costs in retirement. Across age groups, only about one-third (36%) have tried to estimate how much money they will need to save and have set money aside to cover these expenses in the future. Adults age 60-64 (40%) are just slightly more likely than those age 50-59 (35%) to have money set aside although these differences are not statistically significant. Estimates of the actual costs of health care in retirement vary significantly. More than four in ten adults age 50-64 (42%) believe they will need to accumulate less than $100,000 to cover out-of-pocket health care expenses during their retirement. In addition, sixteen percent believe it will cost less than $50,000 and 15% say they simply do not know. Source: AARP
Profession Annual Media Salary Projected Growth Biomedical Engineer $86,960 62% Dental Hygienist $70,210 38% Occupational Therapist $75,400 33% Optometrist $97,820 33% Physical Therapist $79,860 39% Chiropractor $66,160 28% Speech Pathologist $69,870 23% Pharmacist $116,670 25% Podiatrist $116,440 20% Respiratory Therapist $55,870 28% Medical Records Technician $34,610 21% Physician Assistant $90,930 30% Source: Career Cast
According to the 2013 Healthcare Benefits Trends Benchmark Study by Evolution1's Healthcare Trends Institute, healthcare reform is prompting employers to look at defined contribution health plans and the use of health insurance exchanges in offering employee healthcare benefits in the future. 59.4% of respondents indicated they were somewhat to very familiar with Defined Contribution Plans (DCPs) with a majority of those interested in DCPs for the future considering for 2015. When asked about health insurance exchanges, 62.1% indicated they were somewhat to very familiar with public exchanges and 55.5% were somewhat to very familiar with private exchanges. Source: Evolution1
According to a survey from Intel, more than 70 percent of respondents are receptive to using toilet sensors, prescription bottle sensors or swallowed monitors to collect ongoing and actionable personal health data. Sixty-six percent of people prefer a personalized healthcare regimen designed specifically for them based on their genetic profile or biology. And 53 percent of those surveyed said they would trust a test they personally administered as much or more than if it came from a doctor. The survey revealed an overwhelming majority of people (84 percent) globally would anonymously share their personal health information, such as lab results, if it could lower medication costs or overall cost to the healthcare system. A higher percentage of people said they are more willing to share their health records (47 percent) than their phone records (38 percent) or banking information (30 percent) to aid innovation. Source: Intel
The percentage of young adults with private health insurance coverage increased from the last 6 months of 2010 through the last 6 months of 2012 (52.0% to 57.9%). Except for an increase in the first 6 months of 2011, the percentage of privately insured young adults who had a gap in coverage during the past 12 months decreased from the first 6 months of 2008 through the last 6 months of 2012 (10.5% to 7.8%). The percentage of privately insured young adults with coverage in their own name decreased from 40.8% in the last 6 months of 2010 to 27.2% in the last 6 months of 2012. The percentage of privately insured young adults with employer-sponsored health insurance increased from the last 6 months of 2010 to the last 6 months of 2012 (85.6% to 92.5%). Source: Centers for Disease Control and Prevention, National Center for Health Statistics
Body mass index (BMI) is a measurement of a person's weight adjusted for his or her height, and can be used to screen for possible weight-related health problems. A healthy or normal BMI is 19-24, while overweight is 25-29 and obese is 30 and above. For example, a 5-foot-6-inch person who weighs 117.5 pounds has a BMI of 19, while a person of the same height weighing 279 pounds has a BMI of 45. According to a study published in the journal Obesity, the average annual health care costs for a person with a BMI of 19 was found to be $2,368; this grew to $4,880 for a person with a BMI of 45 or greater. Source: Duke Medicine
According to a study from the Perelman School of Medicine at the University of Pennsylvania, Nearly two-thirds (65 percent) of the nation's leading health care executives say they believe the health care system will be somewhat or significantly better by 2020 than it is today as a result of national health care reform. Additionally, 93 percent believe that the quality of care provided by their own hospital or health system will improve during that time period. Overall, the expected average operating cost reduction was 11.7 percent. These savings could be achieved by such strategies as reducing the number of hospitalizations (54 percent), reducing the number of readmissions (49 percent), and reducing the number of emergency room visits (39 percent). Source: Perelman School of Medicine at the University of Pennsylvania
A WellPoint survey, which examines how Americans (age 45 and older) view dental coverage benefits, reveals that Americans over age 45 understand that good oral care can positively affect their overall heath. However, while 83 percent of Americans surveyed say they have medical coverage (from either an employer or the government), only half as many are covered by dental insurance. And, as baby boomers plan for retirement, those with dental coverage say they need more information about future costs and changes to their dental plan upon retirement. This survey also shows that nine out of 10 older Americans (93 percent) believe good dental care is important to their overall health and that routine dental check-ups can help prevent heart disease and other chronic conditions (90 percent). This awareness contrasts with the fact that only four in 10 older Americans (41 percent) say they currently have dental coverage (from an employer, private and/or supplemental). Furthermore, 32 percent of those without insurance admit to forgoing dental benefits because they have other expenses to worry about. Source: WellPoint
1. Connecting with Leaders- To be lead, you must know what your leaders are thinking 2. Connecting with Followers- As physicians, you are a leader. Whether it ‘s in your office or elswhere 3. Networking- The importance of professional networking cannot be understated 4. It makes me an active learner- All through my education I took notes 5. I can educate the world- This is a grandiose statement, but Twitter makes it real 6. I can attend multiple conferences simultaneously, year round 7. It’s a forum for debate- Healthy debate is part of our lives as physicians 8. My mom taught me to share- We are all online, all the time 9. The world at any given moment- Whenever I have a free moment, Twitter is my go to activity 10. It broadens my mind- In patient care we are emphasizing a team-based approach that values the roles of every individual in a healthcare team Source: Med City News
General Criteria a Health Reimbursement Account Must Meet In Order to be Integrated With Other Group Health Plan Coverage
1. The employer must offer a group health plan that provides coverage beyond excepted benefits 2. The employee receiving the HRA must actually be enrolled in such a group health plan, regardless of whether the employer sponsors that plan 3. Under the terms of the HRA, an employee must be permitted to opt out of and waive future reimbursements from the HRA at least annually 4. Upon termination of employment, either the remaining amounts in the HRA are forfeited or the employee must be permitted to opt out of and waive future reimbursements from the HRA Source: Mondaq
Percentage of Privately Insured Young Adults Who Obtained Their Coverage Through Some Other Family Member
Percentage of Privately Insured Young Adults Who Obtained Their Coverage Through Some Other Family Member 1. Last 6 months of 2012 - 72.8% 2. Last 6 months of 2010 - 59.2% 3. First 6 months of 2008 - 55.6% Source: CDC/National Center for Health Statistics
• 41% of Americans have used urgent care facilities for their health needs • Of those patients, 20% used them for X-rays or lab tests • 12% used them for ongoing care for chronic illness • 5% used them to receive flu shots • 25% of patients returned to the urgent care center for follow-ups Source: "Alternative Care Facilities Are The Preferred Medical Option For Younger Generation," Vitals.com Press Release, November 19, 2013, http://www.vitals.com/posts/press-center/press-releases/alternative-care-facilities-are-the-preferred-medical-option-for-younger-generation
59% of the uninsured have put off medical treatment in the past year because of cost, compared with 25% of those with private health insurance, and 22% of those with Medicare or Medicaid. Source: "Costs Still Keep 30% of Americans From Getting Treatment," Gallup Inc., December 9, 2013, http://www.gallup.com/poll/166178/costs-keep-americans-getting-treatment.aspx
51% of respondents said they set aside more money for potential medical costs than before they had HSAs; 29% say they have more discussions with their doctors about the cost of care; and 13% say they manage their chronic disease more actively. Source: "New Survey Reveals Employees Are More Active in Managing Their Health after Enrolling in a Health Savings Account," Xerox/Buck Consultants Press Release, December 11, 2013, http://news.xerox.com/news/Buck-Consultants-Survey-Reveals-Health-Savings-Accounts-Foster-Active-Health-Management
Texas Department of State Health Services NEWS RELEASE Dec. 20, 2013 Texas Encourages Vigilance in Flu Treatment, Precautions Though recent increases in flu activity are not unusual, Texas issued flu testing and treatment guidance today to doctors and is continuing to encourage everyone to get vaccinated now to protect themselves. The level of flu-like illness is classified as “high” in Texas, and medical providers are seeing an increase in flu in multiple parts of the state. Unusually severe cases of flu-like illness are routinely investigated during the flu season by local health departments in coordination with the Texas Department of State Health Services. H1N1 is the most common circulating flu strain so far this season. This year’s flu vaccine includes protection against the most common flu strains, including H1N1. DSHS advises clinicians to consider antiviral treatment, even if an initial rapid-flu test comes back negative. A negative result does not exclude a diagnosis of flu in a patient with suspected illness. Antiviral treatment is recommended for anyone with confirmed or suspected flu who is hospitalized, has severe or progressive illness or is at a higher risk for complications. “Flu is on the rise and causing severe illness in certain people. It is not unexpected this time of year, but it’s a good reminder for people to get vaccinated and stay home if they’re sick,” said Dr. David Lakey, DSHS commissioner. “Flu can be deadly. People who have not been vaccinated should do so now. It’s the best defense we have.” Flu is a serious disease that kills an average of 23,600 Americans a year, according to estimates from the Centers for Disease Control and Prevention. People over 65, pregnant women, young children and people with chronic health conditions are most at risk for complications, so it’s especially important for them to be vaccinated. Flu cases and flu-related deaths in adults are not required to be reported to DSHS. Healthcare providers are required to report pediatric flu deaths to their local health department within one business day. There are no confirmed pediatric flu deaths in Texas this season. DSHS recommends everyone six months old and older get vaccinated. People should talk to their health care provider about the best type of flu vaccine for them. A nasal spray version is available for healthy people ages 2 to 49 who are not pregnant, and a high-dose vaccine is approved for people 65 and older. Dr. Lakey also urged people to follow standard illness-prevention steps: • Wash hands frequently with soap and water or alcohol-based hand sanitizer; • Cover coughs and sneezes; • Stay home if sick For more information, go to www.TexasFlu.org. DSHS Influenza Health Alert: www.dshs.state.tx.us/news/releases/Influenza-Health-Alert-122013.pdf
Texas Department of State Health Services NEWS RELEASE Dec. 23, 2013 Texas Quitline Can Help Tobacco Users Quit in the New Year Many tobacco users make a New Year’s resolution to give up their habit, and the state’s Quitline is ready to take calls from people looking for help. The Texas Department of State Health Services encourages people who are ready to quit, or are thinking about quitting, to seek assistance and advice by calling the Texas Quitline at 1-877-YES QUIT or visiting www.yesquit.org. Quitline services are available in English and Spanish. Callers to the Quitline, which uses the American Cancer Society’s Quit for Life Program, receive free, confidential counseling services and personalized tools and strategies from trained professionals to help them quit. The www.yesquit.org website has tips, success stories, motivational videos and an online community of people dedicated to quitting and encouraging others to stick to it. People can create an online quitting plan that helps them take steps toward a tobacco-free life. The Texas Quitline was first offered in 2001 and serves about 10,000 people a year. The U.S. Public Health Service’s clinical practice guidelines say that Quitline counseling can more than double a smoker’s chances of quitting. According to the Centers for Disease Control and Prevention, tobacco use is the leading cause of preventable and premature death in the United States. Additional Facts: • More than 24,000 Texans die from smoking or exposure to secondhand smoke each year. • In the United States, nearly 1 in 5 deaths is attributed tobacco use. • Lung cancer is the leading cause of cancer death in the United States for men and women, and 90 percent of lung cancer cases are attributed to smoking. (News Media Contact: Chris Van Deusen, DSHS Press Officer, 512-776-7753)
More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries
U.S. Department of Health & Human Services News Division 202-690-6343 email@example.com www.hhs.gov/news FOR IMMEDIATE RELEASE Monday, December 23, 2013 More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries 123 New Accountable Care Organizations Join Program to Improve Care for Medicare beneficiaries Doctors, hospitals and other health care providers have formed 123 new Accountable Care Organizations (ACOs) in Medicare, providing approximately 1.5 million more Medicare beneficiaries with access to high-quality coordinated care across the United States, Health and Human Services Secretary Kathleen Sebelius announced today. Doctors, hospitals and health care providers establish ACOs in order to work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Since passage of the Affordable Care Act, more than 360 ACOs have been established, serving over 5.3 million Americans with Medicare. Beneficiaries seeing health care providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. ACOs share with Medicare any savings generated from lowering the growth in health care costs when they meet standards for high quality care. “Accountable Care Organizations are delivering higher-quality care to Medicare beneficiaries and are using Medicare dollars more efficiently,” Secretary Sebelius said. “This is a great example of the Affordable Care Act rewarding hospitals and doctors that work together to help our beneficiaries get the best possible care.” “This program puts the control in the hands of physicians and allows them to take the lead in an innovative way to deliver the right care to the right patient at the right time,” said Kelly A. Conroy, executive director of the Palm Beach ACO and South Florida ACO. “We are honored to be a Medicare Shared Savings Program Accountable Care Organization, and after 18 months in the program, can proudly say that we have seen measurable success. We are so impressed with our participating physicians’ enthusiasm towards the cultural shift, and it demonstrates that physicians are primed for the future of medicine.” The ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) evaluates ACO quality performance using 33 quality measures on patient and caregiver experience of care, care coordination and patient safety, appropriate use of preventive health services, and improved care for at-risk populations. The new ACOs include a diverse cross-section of health care providers across the country, including providers delivering care in underserved areas. More than half of ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 1 in 5 ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities. Affordable Care Act provisions have a substantial effect on reducing the growth rate of Medicare spending. Growth in Medicare spending per beneficiary hit historic lows during the 2010-2012 period, and this trend has continued into 2013. Projections by both the Office of the Actuary at CMS and the Congressional Budget Office estimate that Medicare spending per beneficiary will grow at approximately the rate of growth of the economy for the next decade, breaking a decades-old pattern of spending growth outstripping economic growth. The next application period for organizations interested in participating in the Shared Savings Program beginning January 2015 will be in summer 2014. More information about the Shared Savings Program, including previously announced ACOs, is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html For a list of the 123 new ACOs announced today, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2014-ACO-Contacts-Directory.pdf
Friday, December 20, 2013
• 10.4% of the hospital stays were for observation • Mean observation length of stay was 33.3 hours, with 44.4% of stay durations less than 24 hours and 16.5% more than 48 hours • Observation care had a negative margin per stay (−$331) • The inpatient margin per stay was positive (+$2163) Source: "Hospitalized but Not Admitted: Characteristics of Patients With “Observation Status” at an Academic Medical Center," JAMA Internal Medicine, abstract only, November 25, 2013, http://archinte.jamanetwork.com/article.aspx?articleID=1710122&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=ArchivesofInternalMedicine%3ANewIssue11%2F25%2F2013
Wednesday, December 18, 2013
1.9 million customers made it through the process but have not yet selected a plan; an additional 803,077 assessed or determined eligible for Medicaid or CHIP Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that nearly 365,000 individuals have selected plans from the state and federal Marketplaces by the end of November. November alone added more than a quarter million enrollees in state and federal Marketplaces. Enrollment in the federal Marketplace in November was more than four times greater than October’s reported federal enrollment number. Since October 1, 1.9 million have made it through another critical step, the eligibility process, by applying and receiving an eligibility determination, but have not yet selected a plan. An additional 803,077 were determined or assessed eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in October and November by the Health Insurance Marketplace. “Evidence of the technical improvements to HealthCare.gov can be seen in the enrollment numbers. More and more Americans are finding that quality, affordable coverage is within reach and that they'll no longer need to worry about barriers they may have faced in the past – like being denied coverage because of a pre-existing condition,” Secretary Kathleen Sebelius said. “Now is the time to visit HealthCare.gov, to ensure you and your family have signed up in a private plan of your choice by December 23 for coverage starting January 1. It's important to remember that this open enrollment period is six months long and continues to March 31, 2014.” The HHS issue brief highlights the following key findings, which are among many newly available data reported today on national and state-level enrollment-related information: • November’s federal enrollment number outpaced the October number by more than four times. • Nearly 1.2 million Americans, based only on the first two months of open enrollment, have selected a plan or had a Medicaid or CHIP eligibility determination; o Of those, 364,682 Americans selected plans from the state and federal Marketplaces; and o 803,077 Americans were determined or assessed eligible for Medicaid or CHIP by the Health Insurance Marketplace. • 39.1 million visitors have visited the state and federal sites to date. • There were an estimated 5.2 million calls to the state and federal call centers. The report groups findings by state and federal marketplaces. In some cases only partial datasets were available for state marketplaces. The report features cumulative data for the two month period because some people apply, shop, and select a plan across monthly reporting periods. These counts avoid potential duplication associated with monthly reporting. For example, if a person submitted an application in October, and then selected a Marketplace plan in November, this person would only be counted once in the cumulative data. To read today’s report visit: http://aspe.hhs.gov/health/reports/2013/MarketPlaceEnrollment/Dec2013/ib_2013dec_enrollment.pdf To hear stories of Americans enrolling in the Marketplace visit: http://www.hhs.gov/healthcare/facts/blog/2013/12/americans-enrolling-in-the-marketplace.html.
FOR IMMEDIATE RELEASE December 10, 2013 Contact: HHS Press Office 202-690-6343 HHS announces Affordable Care Act mental health services funding $50 million from the health care law will expand mental health and substance use disorder services in approximately 200 Community Health Centers nationwide The U.S. Department of Health and Human Services (HHS) today announced that it plans to issue a $50 million funding opportunity announcement to help Community Health Centers establish or expand behavioral health services for people living with mental illness, and drug and alcohol problems. Community Health Centers will be able to use these new funds, made available through the Affordable Care Act, for efforts such as hiring new mental health and substance use disorder professionals, adding mental health and substance use disorder services, and employing team-based models of care. “Most behavioral health conditions are treatable, yet too many Americans are not able to get needed treatment,” said Health Resources and Services Administration (HRSA) Administrator Mary K. Wakefield, Ph.D., R.N. “These new Affordable Care Act funds will expand the capacity of our network of community health centers to respond to the mental health needs in their communities.” “These new funds will further the Department’s work to develop integrated primary and behavioral health care services to better meet the needs of people with mental health and substance use conditions,” said Substance Abuse and Mental Health Services Administration Administrator, Pamela S. Hyde. It is estimated these awards will support behavioral health expansion in approximately 200 existing health centers nationwide. Over the past year the Obama administration has taken a number of steps to reduce the barriers that too often prevent people from getting the help they need for behavioral health problems. The Affordable Care Act expands mental health and substance use disorder benefits and parity protections for approximately 60 million Americans. The President’s Fiscal Year 2014 Budget includes a new $130 million initiative to help teachers recognize signs of mental illness in students and refer them to services, support innovative state-based programs to improve mental health outcomes for young people ages, and train 5,000 more mental health professionals. For more information please visit: http://www.whitehouse.gov/omb/budget/factsheet/improving-mental-health-prevention-and-treatment-services. The Administration has also finalized rules under the Mental Health Parity and Addiction Equity Act. Because of these parity protections, many insurance plans will now include coverage for mental health and substance use conditions that is comparable to their medical and surgical coverage. The Administration also launched www.mentalhealth.gov a new website featuring easy-to-understand information about basic signs of mental health problems, how to talk about mental health, and how to find help.
More than 25 million Original Medicare beneficiaries received free preventive services through November 2013
CMS NEWS FOR IMMEDIATE RELEASE Contact: CMS Media Relations December 17, 2013 (202) 690-6145 | firstname.lastname@example.org More than 25 million Original Medicare beneficiaries received free preventive services through November 2013 According to new data released by the Centers for Medicare & Medicaid Services (CMS) today, more than 25.4 million people covered by Original Medicare received at least one preventive service at no cost to them during the first eleven months of 2013, because of the Affordable Care Act. Today’s news comes after last month’s announcement showing that the health care law also saved seniors $8.9 billion on their prescription drugs since the law’s enactment. “Thanks to the Affordable Care Act, millions of seniors have been able to receive important preventive services and screenings such as an annual wellness visit, screening mammograms and colonoscopies, and smoking cessation at no cost to them,” said CMS Administrator Marilyn Tavenner. “Prevention and early detection are so vital to ensure that Americans are healthy and Medicare is healthy. The Affordable Care Act makes Medicare stronger and improves the wellbeing of millions of beneficiaries who have taken advantage of preventive services and wellness visits.” Today’s announcement exceeds the comparable figure from last November, when an estimated 24.7 million people with Original Medicare received one or more preventive benefits at no out of pocket costs by this point in time during 2012. When factoring in Medicare Advantage utilization rates and a full year of experience, an estimated 34.1 million people with Medicare took advantage of at least one preventive service in 2012. Moreover, in the first eleven months of 2013, more than 3.5 million beneficiaries with Original Medicare took advantage of the Annual Wellness Visit established by the health care law – a significant increase from the 2.8 million who used this service by this point in the year in 2012. Before the Affordable Care Act, Medicare recipients had to pay part of the cost for many preventive health services. These out-of-pocket costs made it difficult for people to get the important preventive care they needed. For example, before the Affordable Care Act, a person with Medicare could pay as much as $160 in cost-sharing for a colorectal cancer screening. Today, this important screening and many others are covered at no cost to beneficiaries (with no deductible or co-pay). The Affordable Care Act helps tear down a significant barrier for some seniors to staying healthy and helps their care providers prevent, identify and treat problems early. For state-by-state information on utilization of free preventive services for people with original Medicare, please visit: http://downloads.cms.gov/files/Preventive_Services_Utilization_by_State_Jan-Nov_2013.pdf
NEWS RELEASE Dec. 17, 2013 Flu on the Rise in Texas; DSHS Encourages Vaccination, Prevention With flu season ramping up in Texas, the Texas Department of State Health Services reminds people who haven’t gotten a flu shot yet this season not to put it off any longer. The level of flu-like illness is currently classified as “high” in Texas, and medical providers are seeing an increase in flu in multiple parts of the state. Getting vaccinated is the best way for people to protect themselves and their families from the flu during the holiday season, when there is typically an increase in flu cases. DSHS recommends everyone six months old and older get vaccinated. People should talk to their health care provider about the best type of flu vaccine for them. A nasal spray version is available for healthy people ages 2 to 49 who are not pregnant, and a high-dose vaccine is approved for people 65 and older. Flu is a serious disease that kills an average of 23,600 Americans a year, according to estimates from the Centers for Disease Control and Prevention. People over 65, pregnant women, young children and people with chronic health conditions are most at risk for complications, so it’s especially important for them to be vaccinated. Getting vaccinated is the best way to stop the spread of the flu. Additionally, cover all coughs and sneezes, wash hands frequently with soap and water or use hand sanitizer, and stay home if sick. (News Media Contact: Chris Van Deusen, DSHS Press Officer, 512-776-7753)
Tuesday, December 17, 2013
“Some people have suggested that COBRA is dead … and it might be for some employers, but they are still on the hook for sending [COBRA] notices [to outgoing employees]. Even though it might make sense to repeal COBRA [because of ACA provisions], it’s doubtful it will be repealed by this Congress … even if both sides agree.” — Chantel Sheaks, major medical consultant at American Fidelity Administrative Services, LLC, told AIS’s Inside Health Insurance Exchanges.
Friday, December 13, 2013
“The challenge that [new]anti-obesity medications have is one of legacy. The products that have been available in the past haven’t been all that dramatic or effective in weight loss and that sort of stuck in the mind, I believe, of prescribers. So the new products [Belviq and Qsymia] are going to have to demonstrate efficacy before they’re going to get widespread use.” — Craig Oberg, R.Ph., a managing consultant with The Burchfield Group, told AIS’s Drug Benefit News.
By ROBERT PEAR Published: December 9, 2013 WASHINGTON — For months, the Obama administration has heralded the low premiums of medical insurance policies on sale in the insurance exchanges created by the new health law. But as consumers dig into the details, they are finding that the deductibles and other out-of-pocket costs are often much higher than what is typical in employer-sponsored health plans. Until now, it was almost impossible for people using the federal health care website to see the deductible amounts, which consumers pay before coverage kicks in. But federal officials finally relented last week and added a “window shopping” feature that displays data on deductibles. For policies offered in the federal exchange, as in many states, the annual deductible often tops $5,000 for an individual and $10,000 for a couple. Insurers devised the new policies on the assumption that consumers would pick a plan based mainly on price, as reflected in the premium. But insurance plans with lower premiums generally have higher deductibles. In El Paso, Tex., for example, for a husband and wife both age 35, one of the cheapest plans on the federal exchange, offered by Blue Cross and Blue Shield, has a premium less than $300 a month, but the annual deductible is more than $12,000. For a 45-year-old couple seeking insurance on the federal exchange in Saginaw, Mich., a policy with a premium of $515 a month has a deductible of $10,000. In Santa Cruz, Calif., where the exchange is run by the state, Robert Aaron, a self-employed 56-year-old engineer, said he was looking for a low-cost plan. The best one he could find had a premium of $488 a month. But the annual deductible was $5,000, and that, he said, “sounds really high.” By contrast, according to the Kaiser Family Foundation, the average deductible in employer-sponsored health plans is $1,135. “Deductibles for many plans in the insurance exchanges are pretty high,” said Stan Dorn, a health policy expert at the Urban Institute. “These plans are more generous than what’s prevalent in the current individual insurance market, but significantly less generous than most employer-sponsored insurance.” Caroline F. Pearson, a vice president of Avalere Health, a consulting company that has analyzed hundreds of plans, said: “The premiums are lower than expected, but consumers on the exchange will often face high deductibles and high co-payments for medical services and prescription drugs before they reach the cap on out-of-pocket costs,” $6,350 for an individual and $12,700 for a family. Those limits provide significant protection, even though those sums are substantial for most consumers. In addition, the federal website, HealthCare.gov, informs people that they may qualify for subsidies to reduce their out-of-pocket costs if their household income is below 250 percent of the federal poverty level, meaning that it is less than $28,725 for an individual or $48,825 for a family of three. These “cost-sharing reductions” are available for a specific kind of midlevel plan known as a silver plan. People with lower incomes can get more help with out-of-pocket costs, but only if they choose silver plans. Mr. Dorn said the government had not done much to inform people of these potential savings. “Consumers are giving up cost-sharing reductions of enormous value if they enroll in a bronze plan because it has the lowest premium,” he said. Plans in the marketplace are separated into four categories — bronze, silver, gold and platinum — indicating the generosity of coverage, or the share of costs paid by insurance for an average enrollee. Many people buying insurance on the federal and state exchanges are expected to qualify for subsidies. But in the first month, for reasons that are not clear, only 30 percent qualified. The others must pay the full premium and will be subject to the full deductible. Most people shopping in the exchanges are expected to choose bronze or silver plans, which provide less generous coverage than most employer-sponsored plans. A study by Jon R. Gabel and colleagues at NORC, a research organization affiliated with the University of Chicago, found that 65 percent of employees in group health plans had higher-value coverage that would be classified as gold or platinum under the Affordable Care Act. At the same time, most policies in the exchanges are more generous than what people have been buying for themselves in the individual insurance market. Mr. Gabel found that 84 percent of policyholders in the individual market had coverage that was less than or equivalent to the bronze level. James T. O’Connor, an actuary at Milliman, an employee benefit consulting firm, said: “Larger employers generally have more generous coverage than small employers, and small group plans, on average, are richer than what people can typically buy with their own money in the new health insurance exchanges.” Mark A. York, a 60-year-old freelance writer in Hailey, Idaho, said he began shopping after he received a letter saying that his current insurance policy would be canceled because it did not meet the requirements of the health care law. In the exchange, he said, he found policies with premiums similar to what he is now paying, $440 a month, but “the deductibles were so high — $4,000 to $6,000 a year — that it defeats the purpose of having insurance.” Brian H. Snoddy, 35, of Palmyra, Va., said his wife and two children had a policy with a $330 premium and a $2,500 deductible, but it is being canceled. For new plans with comparable coverage on the federal exchange, he said, “the deductibles are way higher, $5,000 or $6,000.” For visits to a medical specialist, many plans on the federal exchange require co-payments of $50 to $75 or more. Federal officials often point to premiums as evidence that the health care law has made insurance affordable. “Nearly six in 10 uninsured Americans can pay less than $100 a month for coverage in the health insurance marketplace,” Kathleen Sebelius, the secretary of health and human services, has said. Higher deductibles are one tool that insurers can use to hold down premiums. Many have also held down premiums on the exchanges by limiting the choices of doctors and hospitals available to consumers in their provider networks. Kellye Norris, 53, of Dallas said that after trying for more than a month, she completed an application on the federal exchange and enrolled in a Cigna plan with a premium of about $500 a month and no subsidies. “My deductible is nearly $3,000, which is ridiculously high, in my opinion,” Ms. Norris said. “But as someone with pre-existing conditions, I’m grateful to be able to buy insurance at all.” http://www.nytimes.com/2013/12/09/us/on-health-exchanges-premiums-may-be-low-but-other-costs-can-be-high.html?pagewanted=all&_r=0
Today, both the Senate Finance Committee and the House Committee on Ways & Means considered legislation to permanently repeal and replace the Sustainable Growth Rate (SGR) formula. Without Congressional action, the SGR calls for sizable cuts to Medicare reimbursements to physicians and other providers. For the last decade, Congress has acted on an annual basis to avert these drastic cuts, commonly known as the “doc-fix.” The legislation considered today would gradually transition Medicare to a system where doctors are paid on the basis of the value of care provided, as opposed to the volume of services ordered. Medicare Rights Center supports transitioning to a reformed payment system that emphasizes value—essentially better quality care at a lower price. Yet, Medicare Rights remains deeply concerned about the future of critical Medicare benefits annually extended alongside the annual SGR patch. Critical among these is the Qualified Individual (QI) program. The QI benefit covers the cost of the Part B premium for Medicare beneficiaries with limited incomes, from about $14,000-$15,500 a year, and less than $7,080 in assets. Amounting to about $105 per month in 2013, this vital assistance helps vulnerable seniors and people with disabilities afford health care costs and other basic needs that they might otherwise go without. Legislation approved by the House Committee on Ways & Means earlier today does not yet address the QI program and other extender programs, while the Senate Finance Committee framework only extends the QI program through 2018. Earlier this week, 112 organizations, including Medicare Rights, urged members of Congress to ensure QI is made permanent alongside a permanent SGR fix. In addition to leaving concerns regarding critical extender programs unresolved, the House and Senate Committees have yet to address how the SGR repeal and replacement policy will be paid for. As these negotiations move ahead, Medicare Rights urges Congress not to shift added costs to people with Medicare.
Thursday, December 12, 2013
...the following percentages of adults, by age group, do not have a primary care physician: • adults aged 18-29: 34% • adults aged 30-49: 25% • adults aged 50 or older: only 16% Source: "Alternative Care Facilities Are The Preferred Medical Option For Younger Generation," Vitals.com Press Release, November 19, 2013, http://www.vitals.com/posts/press-center/press-releases/alternative-care-facilities-are-the-preferred-medical-option-for-younger-generation
Thursday, November 21, 2013
19% of hospital patients who left the hospital against medical advice in 2011 were uninsured, according to a recent report Source: "Overview of Hospital Stays in the United States, 2011," Agency for Healthcare Research and Quality, Statistical Brief #166, Healthcare Cost and Utilization Project (HCUP). November 2013, http://www.hcup-us.ahrq.gov/reports/statbriefs/sb166.jsp
1,100 … simultaneous users was all HealthCare.gov could handle before faltering during a “stress test” performed on Sept. 30, according to a report by Quality Software Services, a subsidiary of UnitedHealth Group that was hired to help build the website.
“Everybody thinks it is the insurers who are making too much money or providers making too much money. But at the bottom line what is really astounding to me is conservative estimates suggest between 30% and 40% of all medical services we deliver in this country don’t need to be delivered — they add no clinical value. That is really not addressed under the ACA.” — Peter Hayes, principal at the consulting firm of Healthcare Solutions, told AIS’s Health Plan Week.
Wednesday, November 20, 2013
21% … is the predicted talent shortage in the next five years for insurance company financial managers, followed by insurance company sales agents (a 14% shortage), systems analysts (11%), actuaries (7%), and claims adjusters (4%), with insurance underwriters projected to be the only talent surplus (at 4%), according to Mercer’s 2013 Insurance Industry External Labor Market Analysis.
“I don’t think I’m stupid enough to go around saying ‘this is going to be like shopping on Amazon or Travelocity, a week before the Web site opens, if I thought it wasn’t going to work.” — President Obama, in response to a question about whether he knew of HealthCare.gov’s flaws prior to its Oct. 1 launch, at his Nov. 14 press conference announcing the proposed one-year delay in cancelling individual plans.
Monday, November 18, 2013
1. United States: 17.9% of GDP - $8,680 per capita 2. Netherlands: 12% of GDP - $5,056 per capita 3. Germany: 11.6% of GDP - $4,338 per capita 4. France: 11.6% of GDP - $3,974 per capita 5. Canada: 11.4% of GDP - $4,445 per capita 6. Switzerland: 11.4% of GDP - $5,270 per capita 7. Denmark: 11.1% of GDP - $4,464 per capita Source: The Motley Fool
Breakdown of Americans That Selected a Qualified Health Plan Through the Marketplace During the First Reporting Period of Open Enrollment
1. 106,185 Americans selected a Qualified Health Plan (QHP) through the Marketplace 2. Of the people who have selected a plan, 79,391 (74.8 percent) enrolled though a state-based Marketplaces 3. Of the people who have selected a plan, 26,794 people (25.2 percent) enrolled though a Federally-facilitated Marketplace Source: U.S. Department of Health & Human Services
According to the Economic Policy Institute, after falling every year since 2000, the share of non-elderly Americans with employer-sponsored health insurance coverage (ESI) essentially held steady between 2011 and 2012, increasing slightly to 58.4 percent. The labor market's slow improvement over the past two years ended the long-standing downward trend in employer-sponsored health coverage, with ESI increasing slightly by 0.1 percentage points in 2012. However, this comes on the heels of eleven years of erosion. 13.7 million fewer non-elderly Americans had insurance through their employers than in 2000, and as many as 29 million more people under age 65 would have had ESI in 2012 if the coverage rate had remained at its 2000 level. Massachusetts had the highest rate of ESI coverage among the under-65 population, at 70.8 percent in 2011/2012. It is followed by New Hampshire (70.0 percent), Connecticut (69.7 percent), Minnesota (69.0 percent), North Dakota (67.6 percent), Maryland (67.3 percent), and Utah (66.3 percent). In contrast, less than half of New Mexico's non-elderly population had ESI, at 47.2 percent. Source: Economic Policy Institute http://www.epi.org/press/public-insurance-health-reform-provisions/
Roughly 275,000 people who tried unsuccessfully to enroll in coverage on the federal exchange in the early days will be receiving email messages from CMS inviting them to try again. The emails won’t all go out at once, however. “We’re sending in waves,” CMS spokesperson Julie Bataille told reporters on Nov. 12. “We want to make sure we’re inviting people back into the system and their experience will be positive one.” She also noted that over the last weekend, technicians took specific steps to improve the hardware and software systems that will “help improve stability” of the website. In addition, Bataille reiterated CMS’s confidence in meeting its deadline to fix the website. “The site is getting better each week and by the end of November, the site will operate smoothly for the vast majority of users,” she said. (Reprinted from AIS’s Health Reform Week's e-News Alert)
Some state-run insurance exchanges are experiencing the same kinds of technical problems that have plagued the federally run exchanges, according to a Nov. 12 New York Times article. For example, in Oregon, the system cannot determine whether individuals qualify for federal subsidies or Medicaid. In Vermont, technical problems won’t allow consumers to pay for the plans they select. In Hawaii, people are still reporting problems on the site that didn’t go live until mid-October. In Maryland, technical problems, including slowness and frequent error messages, prompted the exchange board to let insurers handle payments directly for now. In Colorado, residents had to bypass the website and use a call center to see if they qualified for federal subsidies. Several state-run exchanges, including those in Connecticut, New York and Washington state, are functioning much better than the federal exchange, the Times reported. Customers in these states are able to log in, register and enroll much faster than on HealthCare.gov, it added. (Reprinted from AIS’s Health Reform Week's e-News Alert)
Whether they like it or not, health insurers are now part of a new “fix” for revamping the floundering implementation of President Obama’s health reform law. The president on Nov. 14 made a dramatic and what one insider source calls a “politically necessary” policy shift to allow insurers the option of letting consumers keep health plans that previously had been cancelled because they did not meet stricter Affordable Care Act (ACA) coverage requirements. Health carriers can now extend for one year certain plans that were written off their books for 2014, but must receive state regulatory approval before re-offering coverage already given up for dead, and point these same consumers to other exchange-based options. No one is certain if insurers want to take this step — or if state insurance commissioners will approve any requests, let alone consider what are sure to be new, higher rate requests by carriers seeking to adjust cancelled plans’ premiums to account for medical cost increases in 2014. Already, Washington state Insurance Commissioner Mike Kreidler (D) in a Nov. 14 statement said he had serious concerns with the Obama change and will not permit extensions of cancelled policies that didn’t meet the requirements of the ACA. Kreidler said people with cancelled policies can get better coverage on the state’s public exchange. “I think it is getting in front of reality. I don’t think [Obama] had a choice. They got to the point where they had to do something to allow these existing plans, but it puts the plans in a very difficult spot,” Republican Tom Scully, the CMS administrator from 2001 to 2004 under President George W. Bush and now senior counsel at Alston & Bird, LLP, tells AIS. At least one major carrier, Aetna Inc., said it would try to restart the plans, but cautioned that it would need help. “State regulators will need to allow us to update our policies and secure appropriate rates so we can get these plans back in the market,” Aetna spokesperson Cynthia Michener said in a statement. — Excerpted from Health Plan Week.
“We are seeing 2013 earnings [for health insurers] that are very good, very strong. Guidance numbers are holding up or being improved a bit on all fronts. Utilization is remaining in check, cost cutting is continuing, everything looks great. What we’re hearing though is that the headwinds for 2014 have got people nervous on uncertainty about how the ACA works, how that all plays out, issues about the taxes, the fees.” — Steve Zaharuk, senior vice president at Moody’s Investors Service, told AIS’s Health Plan Week.
Monday, November 11, 2013
Sunday, November 10, 2013
By Tom Murphy NOVEMBER 5, 2013 A securities analyst at Goldman Sachs is predicting that publicly traded insurers' losses on coverage they sell through the new Patient Protection and Affordable Care Act (PPACA) public exchanges will be modest. The analyst, Matthew Borsch, said in a research note that he expects the insurers to report a total of less than $100 million in losses before taxes next year on exchange plans. That could amount to less than 1 percent of the companies' $23 billion in total estimated pretax earnings. "Our forecast for losses seems prudent given the exchange enrollment difficulties so far," Borsch wrote. He expects the problems to be fixed, but he also said the issues add to his expectation that initial enrollment will be lower than expected and skewed toward a higher-risk, costlier-to-insure population. Borsch said a bigger concern for health insurers will be cuts in funding for Medicare Advantage plans. Insurers will receive less reimbursement next year for these plans due to PPACA-mandated support reductions. http://www.lifehealthpro.com/2013/11/05/analyst-estimates-insurer-exchange-plan-losses? eNL=52791b25160ba03f3c000068&utm_source=LifeHealthProBreakingNews&utm_medium=eNL&utm_campaign=LifeHealthPro_eNLs&_LID=97698134
As policymakers consider proposals to slash successful community programs including Medicare and Medicaid, older Americans and their families continue to face barriers to necessary health care, including access to dental coverage and services. A new report from Oral Health America highlights this growing dental crisis for older Americans. According to the report, lack of affordable dental coverage options, provider shortages, and lack of preventive programs in communities across the country are creating serious hardship for older adults. Policy options to improve access and coverage, combined with community outreach and education, would strengthen public health while mirroring overall health care reform efforts to improve care, improve health, and lower long-term costs by investing in preventive care. Older Americans Lack Dental Coverage Despite improvements in oral health for the general population in the past 50 years, older Americans still face high risk of oral disease. The problem is likely to grow as the baby-boomer generation enters retirement: only 2% of boomers who retire do so with access to dental insurance benefits through their former employers or private market dental plans. Lack of dental insurance is a major access barrier to dental care for older adults. Nearly 70% of older Americans currently have no form of dental insurance. Older adults with dental insurance are 2.5 times more likely to visit the dentist on a regular basis. Private insurance, however, remains costly, while coverage for low-income adults on Medicaid is optional for states and limited in those that do offer it. Forty-two percent of states provide no dental benefit or only emergency coverage through adult Medicaid. In states where dental coverage is provided through the adult Medicaid program, getting dental care can still be a challenge for beneficiaries due to low reimbursement rates and provider shortages. In addition, coverage for routine dental care under Medicare – the largest health insurance provider for individuals over 65 – is virtually nonexistent. Less than 1% of dental services are covered by Medicare. In addition, because the services are not covered under Medicare, Medigap insurance, purchased by beneficiaries to supplement Medicare coverage and assist with out-of-pocket costs, does not cover dental services. For older individuals living on fixed or low-incomes, the high cost of dental care deters those who lack insurance coverage from seeking needed treatment. A recent survey revealed that older individuals who earn less than $35,000 a year consider cost as the main factor in deciding whether to seek care. In the same survey, more than half making less than $35,000 reported not visiting a dentist routinely because they lack insurance or cannot afford the costs associated with seeking care. Two-thirds in the same income group said that if faced with the need for common dental procedures such as a crown, implant, or bridge, they would be unable receive the procedure due to cost. Older Americans in poverty are more than 60% more likely to have lost all of their teeth compared to those with higher incomes. Differences in race, income, and disability status also impact older Americans when it comes to oral health and dental care. Poor oral health disproportionately occurs among racial and ethnic minorities, and also in older adults with physical and intellectual disabilities and those who are homebound or institutionalized. Older African-American adults are nearly twice as likely to have periodontitis (gum disease) than their white counterparts. Health Implications Lack of accessible, affordable dental coverage can lead to adverse health outcomes. Data shows, for example, that certain oral conditions including periodontal disease can increase risk for heart attacks and strokes. Conversely, many chronic health conditions can contribute to oral health problems, leading to further complications like those above. The lack of coverage in the largest public insurance programs (Medicare and Medicaid) leaves individuals with few options for accessing needed care. Emergency room visits for dental-related issues among adults over 65 rose from 1 million in 1999-2000 to 2.3 million in 2009-2010. As overall health care system reforms aim to emphasize primary and preventive care and deter costly emergency care, dental care remains neglected by policymakers at a time when the need for attention is greater than ever. Policy Solutions The report highlights several policy solutions to address the dental crisis facing older Americans. Chief among them are the need for expanded coverage in Medicare and Medicaid. Further, adult dental coverage and services should be deemed as "essential health benefits" under the Affordable Care Act to expand access to services for those under 65. The report argues that states need a legal mandate for providing oral healthcare in Medicaid to ensure broad coverage and more equitable provider payment. In addition, the lack of dental coverage in Medicare must be addressed to effectively confront the growing challenge faced by older Americans. Legislation to enact these policy proposals has been introduced in Congress, and includes: • The Comprehensive Dental Reform Act of 2013: Introduced by Senator Sanders and Schatz in the Senate, and Representatives Cummings and Schakowsky in the House, this landmark legislation is the most comprehensive dental care legislation in American history. It extends comprehensive dental coverage to all individuals covered by Medicare, Medicaid, and the Veterans Administration, and would include oral health as an essential benefit as defined under the Affordable Care Act.  • Special Care Dentistry Act of 2011: While this legislation has not been reintroduced in the current session of Congress, it would have extended dental services to millions of individuals by requiring states to provide oral health services to aged, blind, or disabled people under the Medicaid program. The federal government would cover 100% of the cost of this expansion. Conclusion Strengthening community education and outreach and addressing provider payment and shortage issues are critical to addressing the dental crisis faced by older Americans and people with disabilities. The lack of dental coverage in Medicare and Medicaid, and the expense of private insurance options remain barriers to needed care. Solutions that address oral health and access to dental care must be a part of efforts to improve and modernize Medicare and Medicaid. The Center for Medicare Advocacy has fought for expanded dental coverage for Medicare beneficiaries, and continues to advocate for policy changes that improve access to affordable care for older people and people with disabilities. Instead of cutting Medicare, Medicaid, and other critical health care programs serving our nation's most vulnerable individuals, policymakers should work to improve public health and modernize our largest insurance programs by expanding coverage and benefits, including comprehensive dental care. For more information contact Policy Associate Xenia Ruiz (email@example.com) or Policy Attorney David Lipschutz (firstname.lastname@example.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760. ________________________________________  Oral Health America, State of Decay: Are Older Americans Coming of Age without Oral Healthcare?, available at http://www.toothwisdom.org/action  Ibid.  Ibid.  Ibid.  Ibid.  Ibid.  Ibid.  Ibid.  Ibid.  CNN, "Dental crisis could create 'State of Decay'",  Centers for Medicare and Medicaid Services, Chronic Conditions Among Medicare Beneficiaries, 2012 Chartbook, available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf.  Oral Health America, State of Decay.  Legislation available at http://thomas.loc.gov/cgi-bin/bdquery/z?d113:s1522:.  Legislation available at http://thomas.loc.gov/cgi-bin/bdquery/z?d112:hr1606:.  Center for Medicare Advocacy, Fournier v. Leavitt, more at http://www.medicareadvocacy.org/fournier-v-leavitt/.
According to a study from AMN Healthcare, younger nurses (ages 19-39) are more confident about the supply of nurses and their ability to meet the demands of healthcare reform, despite today's shortages. Approximately 45% of younger nurses believe that the shortage has improved during the last five years, while older nurses were less optimistic. The generational differences were even more apparent when asked whether healthcare reform will ensure an adequate supply of quality nurses, with 38% of younger nurses citing confidence compared to 29% and 27% of older nurses ages 40-54 and 55+, respectively. Questions regarding the use of electronic medical records (EMRs), a requirement of the Affordable Care Act, also demonstrated generational differences as younger nurses attributed them to positively influencing job satisfaction, efficiency and patient care. While nearly two-thirds of younger nurses noted EMRs' influence on job satisfaction, that number fell to 51% or lower when older nurses were asked. Further, 60% of younger nurses agreed that EMRs positively influence productivity and time management, compared to just 38% of older nurses. Source: AMN Healthcare
According to a survey of 921 small-business owners and operators from around the country by the National Federation of Independent Business, 64 percent reported that they pay more for insurance premiums per employee in 2013 than they did in 2012. According the NFIB's study, Small Business's Introduction to the Affordable Care Act, the health insurance premium costs incurred by small businesses (employer and employee shares) average $6,721 a month ($80,652 a year). The median cost is about $3,500 every 30 days. Deductibles for beneficiaries of small-business health insurance products also rose in 2013. While two of three (67 percent) of plans maintained deductibles at the prior year's level, another 28 percent increased deductibles; only 4 percent lowered deductibles in their plans. Source: National Federation of Independent Business
Reasons for Americans Not Enrolling in a Health Insurance Plan or Medicaid in October When Visiting The Health Insurance Marketplace
Not certain you can afford plan 48% Still trying to decide which plan you want 46% Thought the deductibles and copayments were too high 42% Website you were using was experiencing technical difficulties 37% Have not been able to find out if you can get financial assistance or Medicaid 29% Not eligible for financial assistance or Medicaid 28% Couldn't find a plan with the doctors you wanted 21% Some other reason 17% Source: The Commonwealth Fund
Friday, November 8, 2013
By James Gutman - November 1, 2013 Even among members of an audience accustomed to expect the unexpected, WellCare Health Plans, Inc.’s announcement Nov. 1 that it was replacing its CEO left some securities analysts shell-shocked. WellCare detailed the ouster of CEO Alec Cunningham on the same day it unveiled very strong third-quarter financial results. And despite what company Chairman David Gallitano, who was named interim CEO, said about the reasons in the quarterly earnings conference call with investors, some analysts were wondering if there is more to the story. Gallitano, a WellCare director since 2009 but chairman just since this May, said in his prepared remarks that “we needed a CEO with a demonstrated track record of leading a business of large scale and leading a company the size and scope we anticipate WellCare will obtain over the next several years. This change is not the result of any other issue.” In the question period, Gallitano elaborated only slightly, praising Cunningham’s ability to get the company to execute smoothly but adding that WellCare now needed someone “more strategic” and new ways of dealing with its “cost structure.” It’s hard to find any criticism about what Cunningham had accomplished. He took a company whose previous top management was indicted for alleged Medicaid fraud in its home state of Florida, rapidly settled the litigation at both the federal and state levels, and achieved steady growth in revenues and net income on both the Medicare Advantage (MA) and Medicaid sides of its business. WellCare even got back in Florida’s good graces, and the company wound up winning eight regions in the state’s recent Medicaid managed care procurement. So what else might be involved here? Securities analyst Brian Wright of Monness Crespi Hardt wondered in a Nov. 1 research note if one factor is that “a company with as much growth ahead of it with an interim CEO becomes a more intriguing acquisition candidate.” But Gallitano, who has been president of a private investment firm for the past 11 years, sought to dampen that speculation, saying the board is not pursuing such a possibility, nor does it intend to. Analyst Carl McDonald of Citigroup Global Markets, also not clear on the reason, mused in a research note the same day, “The board must have been pretty unhappy…since this kind of change creates a significant distraction, particularly for the senior executives hired by Cunningham.” Gallitano himself praised that executive team and said any would-be CEO who wanted to bring in a whole new top management would have a significant red mark against his or her candidacy. What do you think happened to cause the shake-up? Is it a simple case of the company now being at a different stage and needing a different kind of leader? Is it perhaps due to needing someone new to slash costs in the face of the coming MA pay cuts? Will we ever know? http://aishealth.com/blog/medicare-advantage-and-part-d/wellcare-ceos-ouster-leaves-analysts-scratching-their-heads?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=27791780
By Neal Learner - November 4, 2013 Medical cost trends have dropped to historically low levels in recent years. While President Obama has credited the Affordable Care Act for helping to slow the growth rate in medical spending, others counter that the trend is a lingering effect of the 2008 recession, and that the ACA will, in fact, drive up costs going forward. Still, many experts note that certain ACA provisions, such as financial penalties on hospital readmissions under Medicare, have played a role in moderating health care spending. Among recent reports documenting the lower cost trend: • CMS on Oct. 28 said that health care reform efforts are “eliciting significant out-of-pocket savings for Medicare beneficiaries,” and that there will be “zero growth” in 2014 Medicare Part B premiums and deductibles, as well as more than $8 billion in cumulative savings in the Medicare Part D drug coverage gap known as the “donut hole.” • The liberal Center for American Progress on Oct. 21 said that “intense price competition among health plans in the marketplaces for individuals has lowered premiums below projected levels,” and as a result, the federal government will save about $190 billion over the next 10 years. • The 2014 Segal Health Plan Cost Trend Survey on Oct. 10 said the health plan cost trend rates show the slowest growth in 14 years of trend forecasts. For example, the 2014 HMO trend rate projection is 7%, nearly a percentage point lower than HMO projections from 2013 (7.9%). • The CMS Office of the Actuary in the September issue of Health Affairs said the health spending growth rate in 2013 was near 4%. And the expected growth for 2014 is 6.1%, with an average projected growth of 6.2% per year thereafter, the study said. • The nonpartisan Health Care Cost Institute on Sept. 24 said “health care cost growth remained historically low” in 2012, growing 4.0%, slightly lower than the 2011 rate of 4.1%. The effect of the ACA on medical costs is still evolving, says one insurance executive. “It’s fair to say the ACA has some impact on health care costs in both directions,” notes Andrea Walsh, executive vice president of HealthPartners, a Minnesota-based not-for-profit insurer. “In some cases the ACA provisions will help signal the slowing of health care costs that we need to see in this country. And with other provisions, the changes will increase health care costs. It’s not a simple answer.” Joseph Fifer, president and CEO of the Healthcare Financial Management Association, notes that roughly 5% of a health plan’s membership typically accounts for roughly 50% of all medical claims, and that most of the dollars go to managing chronic conditions. Fifer contends this fact doesn’t get enough attention. “What if we focused on much better and much more coordinated care for them?” he says of these members. “Wouldn’t we get a better result for them and a lower cost structure, or take some of the pressure off of the cost side? Where most of the dollars are spent is not getting the attention.” Question: How does the ACA factor into the cost trend, and what factors could really bring costs down? http://aishealth.com/blog/health-reform/health-care-cost-trend-hits-historic-lows-does-aca-get-credit?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=27842997
• 48% of people think the federal government has done a poor job of implementing the Affordable Care Act (ACA) • 32% think the government has done an “only fair” job of implementing the ACA • 47% want to expand the ACA or keep it as is, while 37% want to repeal it • 44% say they still don't have enough information to understand how the ACA will impact them and their families Source: "Healthcare.gov Troubles Don’t Change Public’s View Of Health Law, Poll Finds," Kaiser Health News/Capsules Blog, November 1, 2013, http://capsules.kaiserhealthnews.org/index.php/2013/11/healthcare-gov-troubles-dont-change-publics-view-of-health-law-poll-finds /
“This is about an insurance company manipulating the situation and concealing the facts. We are asking the court to give our clients and everybody else in the same situation the option of going back to their grandfathered policies.” — William Shernoff, an attorney for plaintiffs in a lawsuit against Anthem Blue Cross, told the Los Angeles Times. The suit involves two Calif. residents who claim the insurer misled them into giving up their plans.
Thursday, November 7, 2013
...by Their Resulting Potential Employer Shared Responsibility Liability Amounts 1. AL $29.7 to 445 million 2. ID $12.3 to $18.5 million 3. IA $12.8 to $19.1 million 4. GA $71.7 to $107.5 million 5. LA $51.7 to $77.6 million 6. ME $3.5 to $5.2 million 7. MS $21.7 to $32.6 million 8. NC $65.6 to $98.3 million 9. OK $35.1 to $52.6 million 10. PA $56.7 to $85, million 11. SC $30.4 to $45.7 million 12. SD $5.4 to $8.1 million 13. TX $298.6 to $447.9 million 14. WI $24.1 to $36.1 million Source:Jackson Hewitt Tax Service Inc.
8 Ways to Reduce Federal Health Spending and Improve Prescription Drug Benefits in Medicare and Medicade
1. Modernize Medicaid Pharmacy 2. Create 'Safe Pharmacies' in Part D for Controlled Prescription Drugs 3. Greater Use of Preferred and Limited Pharmacy Networks in Medicare 4. Encourage Chronic Care Pharmacy and Home Delivery in Medicare 5. Allow Medicare Plans to Negotiate Discounts on Every Brand Drug 6. Increase Cost-Sharing Incentives for Part D Low Income Subsidy (LIS) Enrollees to Use 7. Expedite the Approval of Biogenerics 8. Ban a Tax Deduction for Direct-to-Consumer (DTC) Drug Advertising Source: Pharmaceutical Care Management Association (PCMA)
1. The average MA premium is projected to increase by only $1.64 from last year, coming to $32.60. 2. Access to the MA program will remain strong, with 99.1% of beneficiaries having access to a plan. 3. The average number of plan choices will remain about the same and access to supplemental benefits remains stable. 4. Since passage of the Affordable Care Act, average MA premiums are down by 9.8 percent. 5. MA quality continues to improve as over one-third of MA contracts will receive four or more stars, which is an increase from 28 percent in 2013. 6. Over half of MA enrollees are enrolled in plans with four or more stars, a significant increase from 37 percent of enrollees last year. Source: U.S. Department of Health & Human Services
1. More than one-third (34.9%) of adults were obese in 2011–2012. 2. In 2011–2012, the prevalence of obesity was higher among middle-aged adults (39.5%) than among younger (30.3%) or older (35.4%) adults. 3. The overall prevalence of obesity did not differ between men and women in 2011–2012. 4. The prevalence of obesity among adults did not change between 2009–2010 and 2011–2012. Source: CDC/National Center for Health Statistics
1. 55 percent of all physicians had computerized capability to send prescriptions electronically vs. 78 percent of physicians with an EHR. 2. 67 percent of all physicians could view electronic lab results vs. 87 percent of physicians with an EHR. than among younger (30.3%) or older (35.4%) adults. 3. 3.42 percent could incorporate lab results into their EHR vs. 73 percent of physicians with an EHR. 4. 35 percent could send an electronic order to a lab vs. 54 percent of physicians with an EHR. 5. 38 percent could provide clinical summaries to patients vs. 61 percent of physicians with an EHR. 6. 31 percent exchanged patient clinical summaries with another provider vs. 49 percent of physicians with an EHR. Source: U.S. Department of Health & Human Services
89% of participating emergency department clinicians said that having access to a health information exchange (HIE) improved the quality of patient care, and 82% said that access to the HIE saved time, with a mean time savings of 105 minutes per patient Source: "Health Information Exchange Saves $1 Million in Emergency Care Costs for Medicare," American College of Emergency Physicians Press Release, October 14, 2013, http://newsroom.acep.org/2013-10-14-Health-Information-Exchange-Saves-1-Million-in-Emergency-Care-Costs-for-Medicare
of the adjusted cost of acute care for injured patients transported by EMS to hospitals in 7 regions: • The average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital • 34.3% of low-risk patients—those who did not meet field triage guidelines for transport to trauma centers—were transported to major trauma centers, accounting for up to 40% of acute injury costs • Following field triage guidelines to minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions studied Source: "The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers," Health Affairs, abstract only, September 2013, http://content.healthaffairs.org/content/32/9/1591.abstract
According to a recent survey of healthcare providers regarding bundled payment models, which package out- and in-patient costs, professional fees and post-discharge costs related to specific conditions into one payment: • 38% are already working with bundled payments • 24% are not yet working with bundled payments, but plan to do so • 36% are undecided about developing bundled payments • 2% said that they had no intention to offer bundle payment plans Source: "Bundled Payments Increasingly Attractive To Hospitals And Medical Groups: KPMG Survey," KPMG LLP News Release, October 22, 2013, http://www.kpmg.com/US/en/IssuesAndInsights/ArticlesPublications/Press-Releases/Pages/Bundled-Payments-Increasingly-Attractive-To-Hospitals-And-Medical-Groups-KPMG-Survey.aspx
13.5% of emergency department visits in 2009-2010 were for falls, and 29.1% were for injuries of any sort. Source: "Emergency Department Visits by Persons Aged 65 and Over: United States, 2009–2010," Centers for Disease Control and Prevention, NCHS Data Brief Number 132, October 2013, http://www.cdc.gov/nchs/data/databriefs/db130.htm
The number of Americans using mobile phones for health information or tools rose from 75 million in 2012 to 95 million in 2013, according to new research. Source: U.S. mobile health audience jumps to 95 million adults – new research highlights mobile opportunities for pharma marketers, Manhattan Research, October 24, 2013, http://manhattanresearch.com/News-and-Events/Press-Releases/mobile-health-95-million
“What will we know come springtime when we’re doing our 2015 ratings [for product pricing on public exchanges] that we didn’t know when we were doing it for the 2014 rating? The short answer is that we won’t know that much more. At most, carriers will have just three months of claims history by the time they file their 2015 rates.” — Catherine Murphy-Barron, a principal and consulting actuary at Milliman, told AIS’s Inside Health Insurance Exchanges.
$2.55 billion … in federal funds will go to Ohio for its recently approved Medicaid expansion, a “major victory” for Gov. John Kasich (R) over GOP lawmakers who control the Ohio legislature and opposed expansion, making Ohio the 25th state (and eighth with a Republican governor) to accept Medicaid expansion under the ACA.
The Congressional Budget Office (CBO) recently released a revised estimate of the budgetary effects of increasing the Medicare eligibility age from 65 to 67. Its original estimate, released in January 2012, estimated that increasing the eligibility age for Medicare would create a net savings of $113 billion. The revised report drastically reduces the projected savings to $19 billion. The CBO considered a variety of factors in its analysis. It calculated the savings that would be created by increasing the Medicare eligibility age by two months every year starting with people born in 1951 until the eligibility age has reached 67 for people born in 1962 (who turn 67 in 2029).This change would create some savings for Medicare, since fewer people would be eligible. It would also slightly decrease Social Security payments because some people would either delay applying for benefits until they are eligible for Medicare or continue working until they are eligible for Medicare. Yet, increasing the eligibility age will also increase government costs by: • Increasing Medicaid spending for: o People who would have been dually eligible for Medicare and Medicaid under current law will become solely be covered by Medicaid for an additional two years; and o People who would not have qualified for Medicaid when they turned 65, will have Medicaid for an additional two years (assuming Medicaid changes its age guidelines along with Medicare). • Increasing spending for subsidies though the Marketplaces (insurance exchanges) for people who currently do not qualify for subsidies due to Medicare eligibility. The CBO’s new estimate is much lower for a few reasons. First, the population that would no longer qualify for Medicare (people age 65 to 66) is relatively healthy, compared to the rest of the Medicare population. Their coverage would not cost as much as originally projected. Second, many people who are 65 to 66 years of age are still working, or have a spouse who is still working. They are usually covered by employer insurance. If the employer is considered a large employer, its insurance pays primary to Medicare, and their employees can delay enrollment into Medicare Part B until retirement. This means that they add very little coverage costs to Medicare. The CBO’s inclusion of a more complete analysis provides a more accurate picture of the financial effect of increasing Medicare’s eligibility age. The analysis also estimates that this change would cause an additional 550,000 seniors to become uninsured. The CBO’s modified estimates provide further evidence that increasing the Medicare eligibility age would not benefit seniors or significantly reduce government costs. Medicare Rights urges Congress and advocates to seek responsible adjustments to secure Medicare savings, not proposals that merely shift costs to people with Medicare or to states or to employers.
By Danni Santana NOVEMBER 5, 2013 At first glance, the Covered California exchange enrollment system seems to be functioning better -- and more transparently -- than the federal exchanges' HealthCare.gov enrollment site. The California exchange site has managed to bring in about 179,000 coverage applications since enrollment opened to the public Oct. 1. But agents and brokers in California warn against assuming that Covered California is working the way it ought to work. Problems with the California enrollment system include a faulty provider directory, continuing delays with agent certification, continuing delays with final plan approvals, and software bugs. Before the Patient Protection and Affordable Care Act (PPACA) exchange program came along, health plans were not always quick to make individual health plan provider directories available at point of sale. Consumers often had to call their favorite doctors and hospitals to make sure the providers were in network. But consumers generally knew they were dealing with large, well-established carriers with big provider networks. Today, the carriers selling "qualified health plans" (QHPs) through Covered California are holding premiums down by using new, narrow provider networks. In some cases, providers may not know whether they're in those provider networks. Looking at a QHP's online provider directory may be the only practical way to find out which providers are in a network without filing a claim. Managers of Covered California added a provider directory to great fanfare shortly after the enrollment site launch, then uncovered directory system errors, including inaccurate profiles of doctors and hospitals. Covered California took down the directory component of its site for maintenance. At press time, the directory was still not routinely available. Neil Cosby, director of sales at Warner Pacific Insurance Services, said in an interview that the persistence of a huge backlog of agents awaiting certification as exchange agents is another dire enrollment system problem. To get certified, health agents must take an eight-hour class in person, then take a four-hour online class and an online test. Currently, the delays between these steps can last as long as a week or two. Cosby, who teaches certification courses on behalf of Covered California, said exchange managers are working to fix the problems, but thousands of agents who have completed the certification process are still waiting to be integrated into the Covered California system. Alison Gordon, a self-employed health broker in California, said the rollout of the certification process for brokers has been an abomination. “The class I was a part of was not even taught by a broker," Gordon said. "The instructor knew nothing about health. It wasn’t the case for all classes I hear, but it was in mine.” Meanwhile, the agents who are certified may find that they lack the details they need to recommend plans to consumers. The California Department of Insurance, the agency responsible for approving QHP prices and benefits, has failed to issue final approvals. Kathy Hope, a Huntington Beach broker, said the planning of the enrollment program has been ridiculous. “All I’ve been doing is schmoozing with clients hoping they will come back to me,” Hope said. Gordon said only applicants who have low incomes and can qualify for subsidies are getting through the application process. But Covered California isn’t passing the information from the completed applications along to carriers, and she wonders if that's because the carriers themselves lack the final certifications they need to sell coverage through the exchange. “The stats released are bogus," Gordon said. "When they say they got 36,000 calls in one week, it’s because the website isn’t up and working properly.” Producers also see many site errors. After agents and brokers enter the required information, they often receive error messages preventing them from actually using the online portal. The producers then have to send consumers links consumers can use to download paper applications. “I had a client try to enroll without me and was getting the same error messages,” Hope said. “It’s 2013 and people are being asked to fill out applications by hand. That site is too complicated.” Finally, some producers still wonder whether Covered California managers are simply trying to crowd them out of the exchange plan market. Both Hope and Gordon said they believe that Covered California is discouraging consumer use of agents and brokers. Instead, the producers said, exchange managers are encouraging consumers to use "enrollment counselors" who have gone through minimal training and are not required to advise customers, just enroll them in plans. “They recommend use of enrollment counselors and are discriminating against agents who know more,” Hope said. “It’s maddening.” In response, Covered California Spokesman Larry Hicks emphasized how much Covered California values agents, saying agents represent one of the key channels for providing insurance for uninsured Californians. The exchange already has 3,200 agents certified and has about 19,000 more agents in the certification pipeline. Once they're all certified, they will greatly outnumber enrollment counselors, Hicks said. “I apologize for the frustration felt by the agent community in regards to the pace of the certification process and the glitches to our site, but we are working incredibly hard to fix it,” Hicks said. “There is no intent to discourage agents.”
Wednesday, November 6, 2013
“All of [the other issues related to Affordable Care Act implementation] are fine and good, but if the Web site doesn’t work, nothing else matters.” — How President Obama ended regular staff meetings since last spring that were devoted to monitoring progress with ACA implementation, according to a White House official quoted by The Washington Post for a Nov. 3 story.
Monday, November 4, 2013
“Many consumers may not take kindly to losing [the health plan coverage] they have and currently value. From a consumer perspective, sometimes less is more. The situation consumers face today in health care is like forcing a consumer to upgrade to Windows 8 when they are just thrilled with the features and functionality of Windows 7. But the reality is the government is a market leader in health care. Consumers need to work to make their views known in a variety of ways to frame the debate on how ACA evolves to meet the diversity of consumer needs.” — Fred Karutz, senior VP of business development at Connected Health, told AIS’s Health Plan Week.
Friday, November 1, 2013
By Allison Bell JULY 18, 2013 Looming Medicare Advantage plan network and benefits cuts overshadowed health insurance exchange moves today during UnitedHealth Group Inc.'s second-quarter earnings call. UnitedHealth (NYSE:UNH) is reporting $1.4 billion for the latest quarter on $30 billion in revenue, up from $1.3 billion on $27 billion in revenue for the second quarter of 2012. The company ended the quarter providing or administering medical coverage for 45 million people, up from 36 million a year earlier, in part because of the addition of a major TRICARE contract. Enrollment in insured commercial plans fell to 8.1 million, from 9.3 million, and enrollment in commercial self-insured plans increased to 19 million, from 17 million. Gail Boudreaux, the company's executive vice president, said during the earnings call that the company expects to sell coverage through Patient Protection and Affordable Care Act (PPACA) exchanges in about a dozen states in 2014 and sees the exchanges as a huge opportunity over the long term. But executives spent much more time talking about how federal funding cuts could affect their 2014 Medicare Advantage plan line. The Medicare Advantage program gives private companies a chance to sell plans that substitute for the traditional Medicare plan program to Medicare enrollees. Enrollment in the company's Medicare Advantage plans rose to 2.9 mllion in the second quarter, from 2.5 million a year earlier. Stephen Hemsley, UnitedHealth's president, said the company is the largest, fastest-growing player in the Medicare Advantage market. The government is trying to reduce the gap between Medicare Advantage and traditional Medicare program funding, and funding should be at parity by 2016, Hemsley said. Until 2016, "significant underfunding" of Medicare Advantage will put pressure on UnitedHealth to cut plan costs by "shaping" provider networks and trimming benefits, Hemsley said. Once the Medicare Advantage program and traditional Medicare are at parity, Medicare Advantage "will continue to deliver better benefits at lower costs because of effective medical cost management and far better consumer-focused services and technologies," Hemsley said. The benefits reductions could be "fairly broad-based," Hemsley said. In the past, Hemsley said, UnitedHealth Medicare Advantage plans have offered relatively open-access to providers. http://www.lifehealthpro.com/2013/07/18/unitedhealth-expect-narrower-medicare-advantage-ne?goback=% 2Egde_4245113_member_5800998794107576320#%21
Wednesday, October 30, 2013
Reprinted from DRUG BENEFIT NEWS, biweekly news and proven cost management strategies for health plans, PBMs, pharma companies and employers. By Angela Maas, Managing Editor October 25, 2013Volume 14Issue 20 Many health plans and PBMs agree that copay coupons offered by makers of traditional brand-name drugs thwart formulary compliance, and have attempted to combat their use through tactics such as enlarging copay differentials and applying utilization management. But when it comes to coupons and discount programs associated with high-cost specialty drugs, payers are taking a more selective approach, as these programs may improve medication compliance by offsetting a patient’s financial responsibility. UnitedHealth Group’s UnitedHealthcare unit, for one, has launched a widely publicized initiative limiting the coupons, while PBMs like Prime Therapeutics LLC and MedImpact Healthcare Systems, Inc. subsidiary ScriptSave suggest there are ways to embrace them. Whereas the issue around traditional coupons is “rather simple,” addressing specialty drug coupons is “very nuanced,” observes Pat Gleason, director of health outcomes at Prime Therapeutics LLC. “With the small molecule drugs…we feel that coupons simply circumvent the formulary, leading to the use of more branded products when there are equally effective, safe generics that are very inexpensive, and just add cost to the system,” he tells DBN. But the specialty realm presents medication compliance and therapy abandonment concerns that are closely tied to cost share, which is often higher for specialty drugs, even preferred agents, he says. “I understand the philosophy of ‘there’s more skin in the game’ [with higher cost share]. But then you’ve got the corollary issue of, as you get above $150 a month, people may choose to abandon therapy and that’s not what we want,” says Gleason. “We want to help people get the medicine they need to feel better and live well.” As a result, Prime currently allows the use of coupons and patient assistance programs (PAPs) for both preferred and nonpreferred specialty agents, and recently quantified members’ cost savings associated with those discount programs with new research presented at the Academy of Managed Care Pharmacy’s (AMCP) Nexus 2013 conference held Oct. 15-18 in San Antonio. To determine the impact of discount programs, Prime looked at prescriptions filled between January and June 2013 for 17 different specialty drug categories by its own Prime Therapeutics Specialty Pharmacy. That entity created a file for each prescription that contained detailed information on the pharmaceutical manufacturer coupon or PAP amount reimbursed to offset share. The file was then linked back to the PBM claim records to identify pharmacy only claims that were final paid claims. Of the nearly $418 million spent on drugs during the study period, Prime determined that members were responsible for 5.2% — or close to $22 million — of total costs. Coupons and/or PAPs were associated with 47,924 (38.2%) of 125,303 prescriptions and totaled more than $10.6 million (48.6%) of the member share offset. In other words, coupons and PAPs were applied to four out of 10 prescriptions going through the Prime Therapeutics Specialty Pharmacy. Moreover, the cost share for 40% of claims prior to the use of coupons/PAPs was $50 or less, whereas with the coupons, individuals’ cost share dropped below $50 fully 95.6% of the time. “That’s a pretty dramatic shift,” says Gleason. The autoimmune category had the most specialty pharmacy prescriptions and accounted for $153.6 million total paid; the members’ share was $10.5 million (6.8%), of which nearly $8 million (73.4%) was offset by coupons/PAPs. Gleason adds that while the study included PAPs, about 90% of the discounts applied were from coupons. The difference between the two, he explains, is that coupons are directly administered by the pharmaceutical manufacturer, while PAPs are usually administered by a nonprofit third party, sometimes sponsored by a manufacturer but not always, and typically require that the patient have an income below a certain level. Prime Optimizes Use of Specialty Coupons In conducting the study, the PBM was “just trying to get an understanding of what’s happening with specialty coupons in order to build better benefit designs,” explains Gleason. As of now, the PBM is “optimizing” all coupons, applying them to both preferred and nonpreferred formulary agents. “We’re reaching out to the members to encourage them to use the preferred specialty products, but we’re not blocking coupons for the nonpreferred specialty products,” Gleason tells DBN. Also presenting at the AMCP conference was UnitedHealth Group’s UnitedHealthcare unit, which this year began disallowing coupons for six drugs going through its network specialty pharmacies (DBN 12/7/12, p. 1). Effective Jan. 1, the insurer’s network specialty pharmacies stopped accepting coupon cards when a member calls to fill a prescription for one of six drugs: Extavia (interferon beta-1b) and Gilenya (fingolimod) for multiple sclerosis, CellCept (mycophenolate mofetil) for patients receiving transplants, Humira (adalimumab) for rheumatoid arthritis, and Victrelis (boceprevir) and Peg-Intron (peginterferon alfa-2b) for hepatitis C. The action does not impact needs-based assistance programs. Speaking at AMCP and at the Magellan Pharmacy Solutions 10th Annual Oncology Summit held Sept. 19 in Baltimore, Vice President of Pharmacy Management Strategies Lida Etemad, Pharm.D., said the key to a successful implementation was a “high-touch member support campaign” that included letters sent to members 45 days before the new program took effect. If members called the specialty pharmacy to refill one of the included drugs, they were rerouted to a call center, where staffers explained the program. United also gave members the opportunity to have specialty pharmacies reach out to physician offices. An early program analysis revealed the following: • The largest member base was for people taking Humira and CellCept. • “Just under 3,000 members had contact with the specialty pharmacies,” said Etemad. • During contact with the specialty pharmacies, 21% of those members “indicated they would like the specialty pharmacies to do outreach to the physician’s office, while 79% declined outreach.” • Of those turning down the outreach offer, 3% said it was because they had “prior use of a lower-cost alternative,” but the majority said it was because “cost was not a concern.” • One-third of members who authorized outreach and 23% who spoke with their physician on their own switched to a lower-cost alternative. • Overall, said Etemad, “43% of members had an interest in a lower-cost alternative.” Perhaps not surprisingly, “as members’ total pharmacy costs went up, so did the switch rate,” explained Etemad. If members were taking “five or more medications, they were more likely to switch.” Likewise, “the cost share that the member would now face” also had a big impact. For those with a copay of $50 to $60, the switch rate was “just over 10%,” but for those with 25% coinsurance, the switch rate was more than 40%. United will add 25 specialty drugs to the program on Jan. 1, according to Etemad. Therapeutic categories include growth hormone, which will see Genotropin (somatropin [rDNA origin]) added to the list, as well as hepatitis B, hepatitis C, infertility and others. “Regarding other products, we do allow for the adjudication of coupons for products that are lower cost alternatives to the products included in the program,” Etemad clarifies in an email to DBN. While the Prime study concluded that specialty pharmacies should consider optimizing the use of coupons and PAPs in an effort to improve drug adherence, that doesn’t mean Prime won’t consider blocking the use of certain specialty drug coupons in the future. “I think [the United effort] is very interesting. We learned from that program and may very well be doing something similar in the near future,” says Gleason. “But at this point in time, we’re optimizing all coupons.” Plans, Pharma Could Align to Offer Cards Meanwhile, another PBM executive suggests that health plans take a targeted approach when it comes to allowing or disallowing the use of coupons. “I think the knee-jerk response and managed care plans’ frustration is, ‘Oh, you’re screwing up my formulary.’ But I think those cards can be used in a more directed and strategic fashion than today’s shotgun scatter approach,” says Marcus Sredzinski, Pharm.D., executive vice president of pharmacy with the “consumer-focused” PBM ScriptSave, now a wholly owned subsidiary of MedImpact Healthcare Systems, Inc. Sredzinski says he believes there are yet unexplored ways for pharmaceutical manufacturers and plans to work together to “reward” members with discount cards. For example, for specialty conditions like hepatitis C or multiple sclerosis, a plan could “work with the pharmaceutical company [offering] the copay card — maybe even [on] a preferred product in the class — get a patient on board with the product, waive the first copay with the copay card and then track the patient through time,” Sredzinski tells DBN. “So to incent compliance we’ll say, ‘We’ll reduce the cost of the drug at the point of sale through a copay card, so if you pick up the drug on time or you hit a certain biomarker, you get rewarded through a copay waiver or a buy-down in your copay.’” Sredzinski adds that something similar could be done with diabetes patients who show improved A1C levels over time. “I don’t think the marketplace has looked at copay cards in that fashion and it’s something I would like to do,” he says. “Could it upset the formulary balance? Sure, but why not align yourself with [the cards] and work in a different fashion? I think the pharmaceutical companies obviously have the money; in their copay cards they’ve underwritten net value in their marketing budget.” http://aishealth.com/archive/ndbn102513-02?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=27658171