Friday, August 30, 2013

Star Ratings Tend to Rise With Medical-Management Spending Growth

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. By James Gutman, Managing Editor August 22, 2013 Volume 19 Issue 16 There is a strong correlation between true medical-management expenditures and star ratings achieved by Medicare Advantage plans, according to new data presented by health plan benchmarking specialist Sherlock Co. on Aug. 14. Based on a study of 24 MA plans and their 2013 CMS star ratings, President Douglas Sherlock told a webinar audience, “there is effectively a floor of [medical management] expenses” of $6 per member per month (PMPM) needed to achieve a rating of at least three stars — the rating CMS in the past considered about “average.” The correlation was strongest, according to the Sherlock data, when non-core medical management activities such as precertification, utilization review, health and wellness promotion and medical informatics were removed from the analysis. The result was plotting points closely bunched along a straight upward-sloping line, with star ratings on the vertical axis and the PMPM “medical management subset costs” on the horizontal axis (see table). Estimating the return on investment of medical management is very difficult, Sherlock told the webinar audience, but the data his firm compiled clearly suggest a high ROI for medical management in MA based on bonuses that plans get for earning high star ratings. The plans studied, he said, included both Blues and “independent/provider-sponsored” non-Blues organizations serving a combined 1.8 million MA members. Sherlock used those plans’ 2013 star ratings, which a webinar registrant pointed out are based mostly on 2011 data, and compared them with what the plans reported as medical management costs for this year. He excluded as an “outlier” from the data one plan that had high spending following a history of low ratings. The remaining plans constituted somewhat of an “elite” group, he acknowledged, since they averaged four stars versus a current CMS overall average of 3.4. In the question period, Sherlock readily conceded that the limited-scope analysis did not examine some other aspects of the medical management versus stars relationship that could be illuminating. The model, for instance, didn’t look at the correlation between MA plans’ other administrative expenses and star ratings, or between medical management conducted in-house versus by outside vendors, he noted. Moreover, he said, the study didn’t separate out results of HMO versus PPO MA plans.

Use of sleeping pills highest among older Americans: CDC

By Susan Heavey WASHINGTON | Thu Aug 29, 2013 12:21am EDT (Reuters) - Older U.S. adults, particularly women, are more likely to use prescription sleep medications to try to get the minimum seven hours of sleep experts generally recommend, U.S. data released on Thursday showed. Use of such pills, which include Sanofi SA's Ambien and other similar drugs, was significantly higher for those in their 50s as well as age 80 and older, according to the findings from the Centers for Disease Control and Prevention. Overall about 8.6 million people, or 4 percent of U.S. adults reported recently using sleep medication, CDC's National Center for Health Statistics said in a report. But data showed higher use among middle-aged adults ages 50 to 59 and the elderly. Six percent of those ages 50 to 59 said they had taken a prescription sleep pill in the last 30 days, and 7 percent of those age 80 and older reported such use. In between, the numbers dip slightly below 6 percent for those in their 60s and 70s. In comparison, just 2 percent of those aged 20-39 said they had recently taken a sleep aid. CDC researcher Yinong Chong said people in their 50s could have trouble sleeping because of work and family stress. "It gives the picture of a sandwiched group who has family, not only children but also probably elderly parents but still you're likely to be in the workforce, so you get squeezed at both ends in terms of family responsibility and job responsibility," she said. Sleep may improve when people retire before potential chronic health problems kick in and begin interfering with sleep, Chong said, adding more study is needed. The data also showed that 5 percent of women surveyed said they had recently taken a sleep aid compared to about 3 percent of male respondents, according to CDC's report. Chong said it was not clear why women were more likely to use the drugs. While previous data have tracked prescriptions dispensed for sleep aids, the CDC said its study is the first based on a survey of actual use of such drugs. Researchers for the Atlanta-based health agency's National Center for Health Statistics questioned a sampling of adults age 20 and older about whether they had used prescription sleep aids within the last 30 days and asked participants to show interviewers the prescription medication. "You get how many people are actually using them," Chong said in an interview, noting that prescription data could include multiple prescriptions for one patient or prescriptions that are never filled or even used. "This is actual use." CONTROVERSY OVER LINGERING EFFECTS Prescription sleep aids have become somewhat controversial because their effect can linger even after some patients wake up. The U.S. Food and Drug Administration has begun taking a closer look at sleep drugs, ordering lower-doses for Ambien and similar pills amid concerns that their active ingredient remained in patients' blood the following morning at levels high enough to make driving and other activities dangerous. And just last month, the FDA rejected an experimental sleep drug from Merck & Co Inc, saying the proposed doses were not safe but that a lower-dose version might be acceptable. Not surprisingly, respondents to CDC's study who said they slept five hours or less each night or those diagnosed with a sleep disorder were more likely to report using prescription aids. Additionally, more whites and people with higher levels of education also reported greater use, the agency said. Socioeconomic factors are likely behind those numbers, Chong said, since patients must be able to afford a doctor's care and the medication. According to prescription data from IMS Health, Ambien and other versions of the drug zolpidem was ranked 15th among the most dispensed medications in the United States. (Reporting by Susan Heavey; editing by Julie Steenhuysen and Cynthia Osterman)

Today's Datapoint

$470 million … in venture capital was invested in health care IT during the first half of 2013, the same as the entire year of 2010, according to Greg Vlahos of PwC’s Life Sciences practice

Quote of the Day

Unless a fix is enacted, “the ACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class.” — The heads of three large labor unions warned Senate Majority Leader Harry Reid (D-Nev.) and House Minority Leader Nancy Pelosi (D-Calif.) in a scathing letter.

Delay on ACA Out-of-Pocket Maximum: Blessing or Curse?

By Lauren Flynn Kelly - August 22, 2013 An article that appeared in The New York Times recently called attention to a little-known delay on the implementation of a provision of the Affordable Care Act. This one pertains to out-of-pocket limits on consumer spending and requires health plans and employers to set an overall maximum, as opposed to separate limits for medical and pharmacy expenditures. The one-year grace period allows plan sponsors to delay setting the annual overall spending cap, which includes deductibles and copayments, at $6,350 for an individual and $12,700 for a family, until the 2015 plan year. More information about the grace period, which the Times gripes “was obscured in a maze of legal and bureaucratic language that went largely unnoticed,” is available as part of a series of frequently asked questions about the health care reform law that can be found at the Department of Labor website. As it turns out, those FAQs were issued in February, so this isn’t really news per se, but it’s created a media frenzy of bloggers and journalists bemoaning yet another delayed provision of the Affordable Care Act. And the Times isn’t wrong: The language is confusing. From what I understand, if a group health plan uses more than one benefit service provider, such as a health insurer and a PBM, separate spending caps could be established for major medical expenses and prescription drugs in 2014. The exception does not apply to individual plans. While patient advocates worry that the delay could cause considerable hardship for those with chronic conditions, it may give plan sponsors more time to iron out logistical dilemmas that arise from moving to a separate system of tracking pharmacy and medical out-of-pocket cost maxes to aligning those efforts to track overall expenditures. What administrative difficulties will this provision create for plans, and is the one-year grace period likely to help their efforts to comply?

Thursday, August 29, 2013

New data show antipsychotic drug use is down in nursing homes nationwide

Nursing homes are using antipsychotics less and instead pursuing more patient-centered treatment for dementia and other behavioral health care, according to new data released on Nursing Home Compare in July by the Centers for Medicare & Medicaid Services (CMS). Unnecessary antipsychotic drug use is a significant challenge in dementia care. CMS data show that in 2010 more than 17 percent of nursing home patients had daily doses exceeding recommended levels. In response to these trends, CMS launched the National Partnership to Improve Dementia Care in 2012. “This important partnership to improve dementia care in nursing homes is yielding results,” said Dr. Patrick Conway, CMS chief medical officer and director of the Center for Clinical Standards and Quality. “We will continue to work with clinicians, caregivers, and communities to improve care and eliminate harm for people living with dementia.” The Partnership’s goal is to reduce antipsychotic drug usage by 15 percent by the end of 2013. These new data show that the Partnership’s work is making a difference: • The national prevalence of antipsychotic use in long stay nursing home residents has been reduced by 9.1 percent by the first quarter of 2013, compared to the last quarter of 2011. • There are approximately 30,000 fewer nursing home residents on these medications now than if the prevalence had remained at the pre-National Partnership level. • At least 11 states have hit or exceeded a 15 percent target and others are quickly approaching that goal. The states that have met or exceeded the target are: Alabama, Delaware, Georgia, Kentucky, Maine, North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee and Vermont. The Partnership aims to reduce inappropriate use of antipsychotics in several ways – including enhanced training for nursing home providers and state surveyors; increased transparency by making antipsychotic use data available online at Nursing Home Compare; and highlighting alternate strategies to improve dementia care. Since its launch in early 2012, the goal of the Partnership has been to improve quality of care and quality of life for the country’s 1.5 million nursing home residents. This broad-based coalition includes long-term care providers, caregivers and advocates, medical and quality improvement experts, government agencies, and consumers. For more information on the Partnership’s efforts to reduce use of antipsychotic drugs in nursing homes, please visit the Advancing Excellence in America’s Nursing Homes website:

Young Adults Unaware of ACA Exchanges

Published: Aug 21, 2013 By David Pittman, Washington Correspondent, MedPage Today Only 27% of young adults said they were aware of the Affordable Care Act's health insurance exchanges that are launching Oct. 1, a survey released Wednesday showed. Furthermore, those most likely to benefit from the ACA's exchanges and expanded coverage are the least likely to be aware of the exchanges, the liberal Commonwealth Fund said in the survey "Covering Young Adults Under the Affordable Care Act." Just 19% of young adults who were uninsured in the last year and 18% of low-income adults were aware of the exchanges -- or marketplaces, as they are sometimes called -- according to the survey. "These facts are concerning because young adults as a group have some of the highest uninsured rates and therefore stand to gain a lot from knowing about their options for affordable health coverage," Commonwealth Fund President David Blumenthal, MD, told reporters on a conference call. The low awareness could also be damaging for the ACA as a whole, health experts said, since insurers need the young, healthy premium payers to offset the costs of the older, sicker, and more expensive new enrollees. "If young, healthy people do not enroll, premiums will be much higher for those that do," David Howard, PhD, associate professor of health policy and management at Emory University in Atlanta, told MedPage Today. "Efforts to publicize the exchanges are just getting off the ground, but clearly the federal government and participating states have their work cut out for them between now and January 1, when coverage becomes effective." The exchanges will serve as a forum for the uninsured and small business employees to comparison-shop for plans. While the exchanges are open to all without employer-sponsored coverage, those making between 100% and 400% of the federal poverty line will be eligible for federal tax credits to help defray to cost of insurance. To conduct the survey, the Commonwealth Fund asked 3,530 adults ages 19 to 29 via email to complete an online questionnaire from February 11 to March 14. The survey had a 53.4% response rate. While the numbers for young adult awareness must improve, officials at the Commonwealth Fund said they are confident that young people will eventually come to shop for coverage in the ACA's marketplaces, based on experiences with the universal coverage program in Massachusetts. For example, Wednesday's survey found awareness in the ability to stay on parents' health plans through age 26 increased from an estimated 13.7 million in November 2011 to 15 million in March 2013, when this survey was conducted. "It's possible that young adults' awareness is significantly higher than it was in March," said Sara Collins, PhD, Commonwealth Fund vice president of affordable health insurance. "Over the next 6 months, awareness is likely to increase as more outreach is conducted." The survey identified education level as a factor for the marketplace's awareness. One-third of college graduates were aware of the exchanges, compared with 20% of those with a high school degree or less. The Commonwealth Fund said the results help dispel the notion that young adults don't think they need health insurance. They found 5% turned down coverage because they felt it was unnecessary when offered by an employer. Two-thirds took the coverage and 22% said premiums were unaffordable. Howard said the term "unaffordable" is subjective. "The survey shows that young adults will accept coverage if it is free or heavily subsidized," he said. "However, it does not address the question of how much they are willing to pay for coverage." A total of 82% of young adults who were uninsured at some point in 2013 would be eligible for subsidized insurance through the ACA's exchanges or expanded Medicaid, the Commonwealth Fund found. That's why Collins and Blumenthal were concerned that nearly half of states weren't going to expand their Medicaid programs, leaving potentially millions of young adults without coverage, they said. While the think tank didn't say how many young adults would be shut out of coverage in states where Medicaid isn't being expanded, 28% of those who were uninsured at some point in 2013 made less than the federal poverty level and wouldn't be eligible for the exchange subsidies offered to those making between 100% and 400% of the poverty line.

Employers Not Deserting Health Benefit Arena

Published: Aug 20, 2013 By David Pittman, Washington Correspondent, MedPage Today The percentage of employers offering health insurance to their workers fell only slightly this year compared with last year, according to a large survey released Tuesday. The survey by the Kaiser Family Foundation and Health Research & Educational Trust found that 57% of firms offered health benefits in 2013 -- statistically unchanged from 61% last year and 60% in 2011. The overall drop came mostly from the smallest firms -- those with three to nine workers -- which fell from 50% offering health benefits last year to 45% this year. But that drop was within the survey's margin of error. "Pretty much what we've found this year is what we've found in previous years," lead author Gary Claxton, a Kaiser Family Foundation vice president and director of its Health Care Marketplace Project, said in a call with reporters Tuesday. The report, now in its 15th year, is based on a telephone survey of 2,067 randomly selected public and private employers with at least three workers. The survey was conducted between January and May 2013. "All in all, in this environment with lower premium increases, it's just not one where employers, I think, should be under pressure to try anything radical or dramatically new to control costs," Kaiser Family Foundation's Drew Altman, PhD, said. "It's not an environment where they should be dramatically cutting workers' benefits, which is a message for working people out there." The Kaiser survey, whose results were also published online in Health Affairs, found annual premiums for employer-sponsored family health coverage inched up 4% from last year with workers paying on average $4,565 toward their coverage. Single-coverage premiums rose 5% to $5,884. Meanwhile, workers' wages rose 1.8% and inflation went up 1.1% in the same period. "For me, a 4% premium increase is good news. It's pretty striking," Altman said, adding that in years past, the increases were in double digits. "This is a year with a very moderate rate increase, very moderate." Since 2003, premiums have increased 80% -- nearly three times faster than wages (31%) and inflation (27%). Wellness programs continue to grow in popularity with employers naming them as their favorite cost-saving strategy, "despite the fact that, as far as I know, the literature suggests the jury is out on their effectiveness," Altman said. Almost all employers with at least 200 workers offer at least one wellness program with weight-loss programs (58%), newsletters (60%), lifestyle coaching (57%), classes (50%), and biometric screenings to measure health risks (55%) being more popular aspects. About a third (36%) of large employers offer some kind of financial incentive to participate, such as a lower premium or deductible. More than three-quarters of workers (78%) have an annual deductible -- up from 72% last year and 62% in 2009. While the average deductible for all workers is $1,135, employees at firms with fewer than 200 workers face ones that are nearly twice as high ($1,715) as at large employers ($884). Other notable findings: • 59% of firms with fewer young workers offer health insurance compared to 23% of firms with more young workers • Lower-wage workers pay $1,363 more, on average, toward family premiums than workers at firms with fewer lower-wage workers • Employees who opted for single coverage paid an average of $2,412 toward their premiums "It just underscores that lower-wage working people struggle in our economy, and that's true when it comes to their health coverage too," Altman said. Claxton noted that 23% of employers offering insurance provide a tiered plan to steer employees toward more efficient, higher-quality providers -- up slightly from 20% in 2011 and 15% in 2007. This system has been shown to save money, Claxton said.

Congressional Gridlock Is SNPs’ New Best Friend — for Now

By James Gutman - August 16, 2013 Sometimes you want inertia, as long as it doesn’t last indefinitely. That seems to be the case these days for Medicare Advantage Special Needs Plans (SNPs) in their dealings with Congress. But they’ll need the legislative branch to get out of its gridlocked slumber by the beginning of next year in order to know whether they will be alive long enough to offer products for 2015 and beyond. The friendly inertia now pertains to congressional inactions on the controversial recommendations, adopted in January and submitted to Congress in March, of the Medicare Payment Advisory Commission (MedPAC). In a nutshell, MedPAC wants Congress to phase out most chronic care SNPs by the end of 2016 and allow no new C-SNPs after Jan. 1, 2014, as well as permit only those SNPs for Medicare-Medicaid dual eligibles (D-SNPs) that are fully integrated to get reauthorized. While some of the other MedPAC SNP recommendations are more to the industry’s liking, it’s probably safe to say that adopting none of them would please the SNP Alliance trade group more than would adopting all of them. And none is not only what has happened on the MedPAC recommendations so far, but also what is likely to come out of Congress in the next three months or so, as the at-loggerheads legislators must find a way to act on more pressing matters, such as raising the debt ceiling and keeping the federal government running. But Congress by year’s end — or at least by the very beginning of next year — needs to act to stave off a huge Medicare physician fee cut that would take effect next Jan. 1 under the much-hated Sustainable Growth Rate (SGR) formula. Congress did act in January 2013 to furnish a “doc fix” for this year and has discussed adopting a multi-year fix, which would be favorable for the pay of all MA plans, but there is that slight problem of how the legislators would pay for it. And SNPs usually look to the “doc fix” bill to include their reauthorization, as was the case this January to extend their life through 2014. Without congressional action by next January, SNPs would have a problem, since their applications for 2015 are due to CMS in February 2014. What do you think is likely to happen on the MedPAC SNP recommendations and the SNP reauthorization? Will the general support the SNP concept appears to have in both political parties be enough to get reauthorization again while heading into an election year when health care will be a big issue? Is it enough to thwart the more controversial SNP recommendations of MedPAC, which was created by and reports to Congress but often has its recommendations go unadopted by its overseer? When does congressional inability to agree on much of anything become more of an albatross than an ally for SNPs?

Affording Care: A Medical Student's Story

Published: Aug 24, 2013 | Updated: Aug 25, 2013 By Ben Hartman, MD, Contributing Writer, MedPage Today The Affordable Care Act as approved by Congress required all insurance plans to limit personal out-of-pocket expenses to $6,350 for individual plans and $12,700 for family plans. That requirement was set to kick in next year, but the Obama administration has since extended the time to implement that out-of-pocket cap until 2015. This delay will cover all "grandfathered" group plans: health plans for employees, students, professional groups, trade associations, and labor unions. Three possible scenarios, from financial pain to financial ruin, may ensue as a result of this policy delay. If a plan, which already has out-of-pocket maximums (OPMs) in place, uses a third party administrator (e.g., Express Scripts, Medco) for certain benefits, the insured may be responsible for an additional $6,350/$12,700 for those benefits (usually prescription drug and mental health coverage). This could lead to a doubling of annual out-of-pocket payments: $12,700 for individuals and $25,400 for families. If a "grandfathered" plan uses third parties for both its mental health and prescription drug benefits, this could lead to a tripling of out-of-pocket costs for the policy holder. If the third party administrator forgoes OPMs, the policyholder could pay unlimited copays for their medications and mental health services. Even worse, if the primary insurer (e.g., Aetna, United Healthcare) places an annual limit on its total benefit payouts, then the insured could be responsible for 100% of their medical costs after the provider reaches its annual limit. Confused? I'll try to clear it up with a personal story. In June 2012, I was diagnosed with cancer. My medical school's health plan, Aetna, provided my health coverage. I decided to seek treatment at the Mayo Clinic, which was in Aetna's network. Under my plan, Aetna would pay up to $2 million per condition per policy year for medical services. They would pay up to $100,000 annually for prescription drug costs. My OPM for medical services was $7,500; they didn't offer an OPM for prescription drug coverage. Therefore, once I paid my $300 deductible and $7,500 out-of-pocket expenses, which happened within 3 weeks of my diagnosis, Aetna (kindly) picked up the rest of my tab. To date, Aetna has paid more than $500,000 for my medical care. Unlike many cancer patients, I don't need follow up cancer medications, which are often extraordinarily expensive. Because of this, I haven't exceeded my $100,000 maximum for prescription drugs. But even with good insurance, helpful guidance from Mayo and Aetna, and a solid understanding of the health care industry, I will end up paying at least $15,000 in out-of-pocket costs for my cancer care (this is a combination of medical services and prescription drug costs). It could have been much worse. In the 2010-2011 academic year, my school's insurance plan had an annual limit of $100,000. Today, there are still "grandfathered" university health plans with an annual limit of $100,000, according to the American College Health Association, an organization dedicated to improving the healthcare for university students. For the 2014 academic year, "grandfathered" student health plans, which started between July 1, 2012 and Sept. 23, 2012, can continue to set an annual payout limit of $100,000. If the policy began on or after Sept. 23, 2012, it can have a $500,000 annual limit. Payment for prescription drugs and mental health benefits are included in these annual limits. If my university plan had a $100,000 annual limit, I would owe more than $500,000 in out-of-pocket expenses for my cancer treatment. This is why it's essential to have adequate healthcare -- even for medical students. According to Isabel Goldenberg, MD, medical director of George Washington University's Student Health Center, "Two unique things about this population (students and young adults) are that they don't feel they need insurance because they are young, and it's also a population that has a lot of accidents." For those reasons, this demographic needs extra encouragement to take healthcare coverage seriously. With that in mind, I've devised an acronym that I think will be helpful for anyone who will be entering the health insurance market. I call it: PAID COSTS. • Premiums • Annual Limits • Immunity to illness (Remind yourself that you aren't immune) • Deductibles • Coverage (Will the plan cover my current providers and will it provide nationwide coverage in the event that I need to travel for treatment?) • Out-of-pocket costs • Sickness (What current medical problems do I need my insurer to cover?) • Treatments (What medical treatments do I currently need?) • Symptoms (Am I experiencing any symptoms that need to urgent attention will my insurer cover this problem?) Open enrollment for 2014 is, or will soon be, offered for student, employer, and -- come this October -- ACA exchange plans. Most medical schools don't even teach their students about America's current and evolving healthcare system. Aside from nutrition education, this is probably the most important topic that medical educators ignore. But, as I know, ignorance is far from bliss.

HHS Gives Prizes for Videos Promoting ACA

Published: Aug 21, 2013 By Carrie Feibel , KUHF The "young invincibles" are what health policy wonks call healthy young adults (18-30) who don't see being uninsured as a problem. But it is a problem, at least for the success of the Affordable Care Act. That's why the Department of Health and Human Services (HHS) is spending $30,000 on prizes for a national video contest, in a frank appeal to the YouTube generation. The digital demographic may not know copays from co-insurance, but creating and uploading free "content" practically defines that generation. HHS hopes to tap that creativity and essentially get young adults to market Obamacare to themselves. HHS Secretary Kathleen Sebelius announced the contest during a visit to Legacy, a federally qualified health clinic in Houston. "We're encouraging folks to create a song, or a graphic, or a video about the law's benefits," Sebelius said. "Like staying on their parent's plan until they're 26, not being denied coverage because of a pre-existing health condition." If those topics don't sound super sexy, Sebelius nevertheless seemed confident that the young folks would figure out creative ways to sell it. The contest will also allow people to vote online for their favorites in various categories, and then a grand prize winner will be selected after "a final round of voting and judging" -- presumably by HHS, although the website doesn't specify. If the prize amounts don't seem Hollywood-level (the most anyone can win is $6,500), HHS also noted that the first 100 entrants get a "Stay Healthy" kit, which "includes a t-shirt, first aid kit, sun protection kit and water bottle." In Houston, Sebelius made the announcement before community health workers who had gathered for a training session on how to explain Obamacare to people under 34. The training session was run by Young Invincibles, an advocacy group that represents the interests of young people in the fight for health reform. Sebelius acknowledged that when twenty-somethings wake up in the morning, "health insurance is not the first thing on their minds." But, she says, friends, family members, healthcare providers and trained organizers can educate young adults about the dangers of an accident or sudden diagnosis. She talked about her own two sons. The older son is a lawyer and has insurance; the younger one, John, is 29 and a self-employed "entrepreneurial artist." John attended the Rhode Island School of Design and at one point made the news for designing a controversial board game about prison life. "He now has a master's in fine arts," Sebelius says. "He's trying to knit together a way to pay his bills while he pursues his art. So, I've seen sort of up close and personal how complicated that can be and how difficult that is." Although John does have an insurance policy, Sebelius said "it's always a worry, it's always a problem. He isn't in a plan that he's sure of from moment to moment or day to day. So I know how complicated this can be." Texas Governor Rick Perry released a short written statement dismissing the video contest as a gimmick. "If Obamacare were sound healthcare policy, Secretary Sebelius wouldn't have to resort to video contests and prizes to tempt people to sign up. Texans are already subject to too much costly and burdensome federal regulation, and Obamacare only makes the problem worse." Sebelius also spent part of her visit meeting privately with a select group of Houston politicians and healthcare stakeholders. She said local leaders in major Texas cities understand what the state leaders do not, that Obamacare will bring relief to overburdened local hospitals and property tax payers, who foot the bill for the uninsured. Ed Emmett, a Republican and the county executive for Harris County where Houston is located, stood by Sebelius during a press conference. They were joined by Houston's mayor, Annise Parker, a Democrat. "The law is in place," Emmett said. "People are still arguing about whether it should be repealed or shouldn't be repealed, but it is in place. And in the meantime, here in Harris County we have an inordinate number of underinsured and uninsured people -- who right now the taxpayers of Harris County are paying for [their] healthcare." Emmett said Texas made a mistake in rejecting the health law's provisions to expand Medicaid to allow childless adults and those earning below 133% of the federal poverty level to sign up. The federal government would pick up the tab for the newly eligible for the first 3 years, and gradually decrease to 90% by 2020. "Personally I think leaving that money on the table, those are our taxpayer dollars that are already in Washington. And if we don't reimburse through Medicaid then the local taxpayer has to pick up that tab. So, yes, I think it was a mistake. Costs us twice." Sebelius said it's not too late for Texas to decide to expand Medicaid to cover low-income adults. "We're open to a program that looks uniquely Texan," she said. But the impetus will have to come from hospital leaders, business leaders, and faith leaders fashioning a solution with state legislators. "We're eager to have those conversations but I think they need to start with a Texas group coming together and talking to us," she said. "This is really not a Washington-to-Texas conversation." This article, which first appeared Aug. 20, 2013, is part of a collaboration that includes KUHF, NPR, and Kaiser Health News. It was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

No Shopping Zone: Medicare Is Not Part Of New Insurance Marketplaces

By SUSAN JAFFE AUG 25, 2013 This KHN story was produced in collaboration with While the Obama administration is stepping up efforts encouraging uninsured Americans to enroll in health coverage from the new online insurance marketplaces, officials are planning a campaign to convince millions of seniors to please stay away – don't call and don't sign up. "We want to reassure Medicare beneficiaries that they are already covered, their benefits are not changing and the marketplace doesn't require them to do anything," said Michele Patrick, Medicare's deputy director for communications. To reinforce the message, she said the 2014 "Medicare & You" handbook – the 100-plus-page guide that will be sent to 52 million Medicare beneficiaries next month -- contains a prominent- notice: "The Health Insurance Marketplace, a key part of the Affordable Care Act, will take effect in 2014. It's a new way for individuals, families, and employees of small businesses to get health insurance. Medicare isn't part of the Marketplace." Still, it can be easy to get the wrong impression. "You hear programs on the radio about the health care law and they never talk about seniors and what we are supposed to do," said Barbara Bonner, 72, of Reston, Va. "Do we have to go sign up like they're saying everyone else has to? Does the new law apply to us seniors at all and if so, how?" Enrollment in health plans offered on the marketplaces, also called exchanges, begins Oct. 1 and runs for six months. Meanwhile, the two-month sign-up period for private health plans for millions of Medicare beneficiaries begins Oct. 15. In that time, seniors can shop for a private health plan known as Medicare Advantage, pick a drug insurance policy or buy a supplemental Medigap plan. And in nearly two dozen states, some Medicare beneficiaries who also qualify for Medicaid may be choosing private managed care plans. None of these four kinds of coverage will be offered in the health law's marketplaces. Since many of the same insurance companies offering coverage for seniors will also sell and advertise policies in the marketplaces, seniors may have a hard time figuring out which options are for them. "Over the next six months seniors will be bombarded with information and a lot of it will be conflicting and confusing," said Nick Quealy-Gainer, Medicare task force coordinator for Champaign County Health Care Consumers, an Illinois advocacy group. "Every time there is publicity about the marketplaces, our calls spike," said Leta Blank, director for the Montgomery County, Md., State Health Insurance Assistance Program. While Medicare officials steer seniors away from the marketplaces, there is nothing in the health law that prevents beneficiaries from signing up for markertplace plans, said Juliette Cubanski, of the Kaiser Family Foundation. If they do, they will not qualify for premium tax credits for the marketplace plans. (Kaiser Health News is an editorially independent program of the foundation.) These plans may appeal to wealthy seniors – about 5 percent of Medicare beneficiaries -- who pay higher premiums for Medicare based on their income and assets, said Cubanski. But for the vast majority of seniors, she said, Medicare’s benefit package is better and more affordable compared to marketplace coverage. Confusion about different government health programs could also create opportunities for scams. In Denver, AARP officials received complaints from seniors who were told they would lose their Medicare coverage if they did not divulge their Social Security numbers and other confidential information needed for their new "national health insurance card" under the Affordable Care Act. The Federal Trade Commission issued an alert about such scams in March. "One of the things we are paying special attention to is fraud prevention messages," said Medicare's Patrick. Seniors can be particularly vulnerable to scams "but with all of the changes in the health care landscape, we may need to be even more careful this year." Some Questions From Seniors About Medicare And The Health Marketplaces -- Will I lose Medicare coverage? No. -- Do I need a new Medicare card? No. -- Do I have to re-enroll in my Medicare Advantage or supplement plan through the marketplace? No, these policies are not sold in the marketplaces. -- Will seniors in Medicare have to buy supplemental insurance? No. -- Will they be fined if they don’t buy coverage in the health marketplaces? No, as long as seniors have Medicare Part A, which is free and covers hospitals, nursing homes and hospice -- already have insurance, so they are not subject to the penalty that most uninsured adults under 65 will have to pay. Contact Susan Jaffe at This article was produced by Kaiser Health News with support from The SCAN Foundation.

Older Consumers More Likely To Hold Off Buying New Obamacare Plans

Subsidy Cliff Confronts Those Close to 400 Percent of Poverty SUNNYVALE, Calif., Aug. 27, 2013 /PRNewswire-USNewswire/ -- Older Americans not yet eligible for Medicare are more likely to pay the 2014 penalty rather than purchase health coverage, according to new research from HealthPocket and Deft Research, a market research firm which analyzes the health insurance industry. Researchers found younger consumers are more likely than their older counterparts to purchase insurance in the new health insurance exchanges starting in 2014 because they will be lower income and therefore receive larger subsidies and benefit from lower age-based premiums than older buyers. The analysis findings contrast with what some have previously speculated. With major provisions of the Affordable Care Act (ACA) set to go into effect in January 2014, some of the discussion has been focused on whether young people will purchase health coverage or opt to instead pay a penalty. While the ACA will limit how much an insurer can raise rates due to age (i.e., an older person can only be charged three times more than a younger person), the resulting premium for older consumers presents a major obstacle to affordability. An ACA subsidy analysis found that a 60-year-old with an annual income of $45,000 who chooses a silver plan with a $8,191 price tag will receive a premium subsidy of $3,916. That person will end up paying $4,275 for their annual coverage (about $356 per month). In contrast, a 28-year-old earning $20,000 per year will receive $2,259 in a premium subsidy—resulting in a cost of $1,021 or about $85 per month for a $3,281 silver plan. As his or her income grows, this young consumer would continue to receive a subsidy until his or her insurance premium equaled 9.5 percent of income—or until income totaled $34,500. Lower-income, frequently younger consumers can earn more and still receive subsidies that are adjusted with earnings. However, if the 60-year-old described above making $45,000 earns an additional $1,000 ($46,000, reaching 400 percent of poverty), the subsidy drops to zero. He or she will then pay the full silver plan premium of $8,191—nearly $4,000 more than would be the case if he or she earned just $45,000 in income. By contrast, a 28-year-old would pay $3,281 per year regardless of whether he or she earned $45,000 or $46,000 in that year. "The existing individual health insurance market works very poorly for people who are in their 50s and early 60s but not yet eligible for Medicare because so many of them have pre-existing conditions that have historically caused them to be turned down for coverage," said Steve Zaleznick, executive director for Consumer Strategy and Development at HealthPocket. "While Obamacare guarantees coverage to all applicants—regardless of their health status—the cost of coverage remains a daunting hurdle to those whose rates will be three times the lowest rate charged to young Americans." In an extreme example of this so-called "subsidy cliff," a 60-year-old couple with $62,000 of income will receive a subsidy of $10,492 for health insurance silver plan coverage that costs $16,382. However, that subsidy drops to zero if the couple earns an extra $1,000; so the 60-year-old couple earning an income of $63,000 would pay the full premium amount of $16,382 out-of-pocket. A person in that situation is likely to consider a lower cost bronze plan, but would then be faced with paying greater out-of-pocket costs when using healthcare. "Our research shows it's quite possible that despite the warnings, the ACA will coax younger people into health insurance coverage," said Rich Hamer, principal at Deft Research. "Older people may have a clearer understanding that they are not invincible, but they also have budget considerations that we will need to watch as the law comes into full effect in 2014." The analysis cautions that those at the highest end of the age rating band, and close to the 400 percent of poverty level, will have a particularly difficult time sorting through subsidy issues. As shown with the examples above, incorrect estimates of annual income can mean significant differences with respect to the amount of subsidy provided. The resulting requirement to pay back subsidies has to be understood by consumers—especially those at the higher age rate bands as part of their planning for the ACA. The study was conducted by Deft Research and analyzed in cooperation with HealthPocket. Results are based on 5,084 responses collected nationally in April 2013. Respondents were uninsured and subsidy eligible consumers between the ages of 18-64 years old. Read the report. About Deft Research Deft Research furnishes the healthcare industry with reliable, timely and actionable consumer insights. Their detailed reports, guided discussions and ongoing assistance help clients identify how to best reach, engage, and motivate consumers to act. Deft Research focuses on providing information and insight to drive measurable results. Since 2005, Deft has helped the nation's leading healthcare enterprises gain critical knowledge to confidently navigate the ever-evolving marketplace. Learn more at About HealthPocket is a free website that compares and ranks all health plans available to an individual, family, or small business, so everyone can make their best health plan decision and save on their out of pocket costs. The Company uses only objective data from government, non-profit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. The founders of spent decades pioneering online access to health insurance information and knew they could offer something different that can positively change how people buy and use healthcare in the U.S. Learn more at SOURCE HealthPocket RELATED LINKS

Observation Status:

New Final Rules from CMS Do Not Help Medicare Beneficiaries Effective October 1, 2013, new rules for inpatient hospital reimbursement under the Medicare program[1] make final two sets of proposed rules that the Centers for Medicare & Medicaid Services (CMS) published in the Spring 2013 – the definition of an inpatient hospital stay based on time[2] and a hospital rebilling option.[3] Neither set resolves the problem of Observation Status for Medicare beneficiaries. Observation Status Observation Status refers to the classification of hospital patients as "outpatients," even though, like inpatients, observation patients may stay for many days and nights in a hospital bed, receive medical and nursing care, diagnostic tests, treatments, supplies, medications, and food.[4] The classification of a hospitalized patient as an "outpatient," however, causes many problems for the patient. Without a three-day inpatient hospital stay, the patient does not meet Medicare's requirement for Medicare coverage of a subsequent stay in a skilled nursing facility (SNF).[5] Patients in Observation Status must pay out-of-pocket for their nursing home care, with bills often totaling many thousands of dollars. CMS Response to Observation Status For at least the past three years, CMS has repeatedly expressed concern about Medicare beneficiaries' increasingly lengthy stays in hospitals as outpatients and the impact of the classification on beneficiaries' need for post-acute care in a SNF.[6] Unfortunately, this has not yet translated into action that resolves the issue for beneficiaries. CMS expresses hope that the new final regulations, published August 19, 2013, will "reduce the frequency of extended observation care when it may be inappropriately furnished."[7] Unfortunately, the regulations and CMS's lengthy discussion of them in a section of the preamble entitled "Payment Policies Related to Patient Status" do not resolve the problem of Observation Status for Medicare beneficiaries. CMS explicitly states in the preamble, "[w]hile outpatient time may be accounted for in application of the 2-midnight benchmark, it may not be retroactively included as inpatient care for skilled nursing care eligibility or other benefit purposes."[8] In practice, this means there will still be Medicare beneficiaries who spend three or more days in the hospital who will not qualify for Medicare covered post-acute care at a SNF. Some or all of their time in the hospital will be considered outpatient observation, and not count toward the required three-day stay. A direct and simple solution to beneficiaries' primary problem with observation status lies in bipartisan legislation pending in Congress.[9] The two identical bills would require that all time spent in the hospital – whether called observation or inpatient – be included in calculating the three-day inpatient qualifying hospital stay. Time-based Presumptions 1. Regulatory Requirements A new 42 C.F.R. §412.3(a) provides that a patient "is considered an inpatient of a hospital,…if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner…." The physician orders inpatient status when he or she "expects the patient to require a stay that crosses at least 2 midnights."[10] Stays expected to be shorter than at least two midnights "are generally inappropriate for inpatient admission and inpatient payment under Medicare Part A," unless the surgical procedure is "specified by Medicare as inpatient only under §419.22(n)."[11] The physician's "expectation…should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event."[12] The physician order is part of "physician certification of the medical necessity of hospital inpatient services…."[13] Physician certification, which begins with an order for inpatient admission, requires the physician to certify the reasons for the hospitalization, the estimated time the patient will remain in the hospital, and "plans for post-hospital care, if appropriate."[14] The certification "must be completed, signed, and documented in the medical record prior to discharge."[15] A physician's admission order has "no presumptive weight" and both the admission order and the physician certification "will be evaluated in the context of the evidence in the medical record."[16] CMS intends to provide additional information about what "evidence in the medical record" means in future instructions and manual revisions.[17] 2. Preamble The preamble states repeatedly that a physician admission order cannot be retroactive.[18] But, ambiguously and inconsistently, CMS also describes how physicians should treat outpatient time in making inpatient admission decisions: [W]e expect that the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service. In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary's total expected length of stay. For example, if the beneficiary has already passed 1 midnight as an outpatient observation patient or in routine recovery following outpatient surgery, the physician should consider the 2 midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital. This means that the decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in medically necessary hospitalizations should not pass a second midnight prior to the admission order being written.[19] The preamble discusses two related concepts of "2-midnight presumption" and "2-midnight benchmark," first describing the 2-midnight presumption: Under the 2-midnight presumption, inpatient hospital claims with lengths of stay greater than 2 midnights after the formal admission following the order will be presumed generally appropriate for Part A payment and will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care in an attempt to qualify for the 2-midnight presumption . . . .[20] For purposes of the 2-midnight benchmark, CMS says that medical reviewers may consider all time spent by a patient in the hospital, regardless of how the time is identified: We emphasize that the time the beneficiary spent as an outpatient before the inpatient admission order is written will not be considered inpatient time, but may be considered by physicians in determining whether a patient should be admitted as an inpatient, and during the medical review process for the limited purpose of determining whether the 2-midnight benchmark was met and therefore payment is generally appropriate under Part A [emphasis supplied]. [21] In contrast, for patients not arriving in the hospital through the emergency room (i.e., for patients whose hospitalization is scheduled) "the starting point for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital,"[22] presumably, including observation time. The distinction made between patients who go to the emergency room and those whose hospitalization is planned suggests that CMS's concern with observation status is primarily to do with patients who arrive in the hospital through the emergency room. Hospital Rebilling 1. Regulatory Requirements A new §414.5 is entitled "Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary." Section 414.5(a) authorizes a hospital to rebill Part B if a Part A claim is denied or if the hospital determines after the patient is discharged that the patient's hospital stay should have been billed as outpatient rather than as inpatient. Hospitals must submit Part B claims within one year of providing the service.[23] Of note, CMS reports that more than 300 commenters opposed the proposal to limit rebilling under Part B to claims submitted within one calendar year of service and that only a single commenter supported that proposal. [24] 2. Preamble If a hospital submits a Part B claim for a patient, following the patient's discharge, the patient retains inpatient status for purposes of Medicare coverage of the subsequent SNF stay. CMS provides:[25] the status of the beneficiaries themselves does not change from inpatient to outpatient under the Part B inpatient billing policy. Therefore, even if the admission itself is determined to be not medically necessary under this policy, the beneficiary would still be considered a hospital inpatient for the duration of the stay – which, if it occurs for the appropriate duration, would comprise a 'qualifying' hospital stay for SNF benefit purposes so long as the care provided during the stay meets the broad definition of medical necessity described above [referring the Medicare Benefit Policy Manual, Chapter 8, §20.1][26] However, if the hospital rebills Medicare under Part B, it must refund the Part A deductible and bill the patient for the Part B copayments.[27] CMS rejects commenters' suggestions to give patients an additional standardized notice or a Frequently Asked Question sheet or to add information to the Important Message from Medicare (IM) form, to alert patients at the time of inpatient admission that their status might be changed during, or after, their hospital stay. Describing such notice as "likely [to] create undue confusion and concern for beneficiaries," CMS says that it will engage in an educational campaign for beneficiaries about the final rules. This will include information in the annual Medicare & You publication and Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!.[28] In addition, the Medicare Summary Notice will include new messages.[29] These newly created MSN messages explain that the hospital may submit the claim under Part B and that different cost-sharing may apply. In this manner, we will incorporate the commenters' suggestion on the timing of post-discharge delivery of information regarding billing under Part B for inpatient hospital services, consistent with our approach to delivering notices at a time when the information is most relevant.[30] CMS predicts that more patients will be inpatients under its revised regulations as a result of its new Part B inpatient billing policies.[31] Conclusion Despite the new regulations, observation status will remain a problem for Medicare beneficiaries who need post-acute care in a SNF. Instead we look to the federal legislation and successful resolution of pending litigation brought by the Center for Medicare Advocacy[32] which would resolve the problem of observation status for beneficiaries. For more information, contact attorney Toby S. Edelman ( in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760. ________________________________________ [1] 78 Fed. Reg. 50495, 50906-954 (Aug. 19, 2013). [2] 78 Fed. Reg. 27486, 27644 (May 10, 2013). See CMA, “CMS Addresses Observation Status Again . . . And Again, No Help for Beneficiaries,” (Weekly Alert, May 16, 2013), [3] 78 Fed. Reg. 16632 (March 18, 2013). See CMA, “CMS’ Proposed Rules on Observation Status Would Not Help Beneficiaries” (Weekly Alert, March 28, 2013), [4] See the Center for Medicare Advocacy’s extensive materials on observation status, [5] 42 U.S.C. §1395x(i); 42 C.F.R. §409.30(a)(1). [6] In August 2010, CMS held an Open Door Forum on extended hospital observation stays, CMS repeated the concern in proposed rules for the hospital prospective outpatient payment system, 77 Fed. Reg. 45155 (July 30, 2012); in final rules on the hospital prospective outpatient payment system, 77 Fed. Reg. 68426-433 (Nov. 15, 2012); in proposed rules on A-B rebilling, 78 Fed. Reg., 16632, 16634-634 (March 18, 2013); in proposed rules on time-based presumptions of inpatient status, 78 Fed. Reg.27486, 27644 (May 10, 2013); final inpatient prospective payment rules, 78 Fed. Reg. 50495, 50907 (Aug. 19, 2013). [7] 78 Fed. Reg., 50908. [8] 78 Fed. Reg. 50950. [9] H.R.1179 and S.569, “Improving Access to Medicare Coverage Act of 2013.” [10] 42 C.F.R. §412.3(e)(1). [11] Id. [12] Id. [13] 42 C.F.R. §412.3(c). [14] 42 C.F.R. §424.13(a)(1)-(4). [15] 42 C.F.R. §424.13(b). [16] 42 C.F.R. §412.46(b). [17] 78 Fed. Reg., 50944. [18] 78 Fed. Reg., 50942, [19] 78 Fed. Reg., 50946. [20] 78 Fed. Reg., 50949. [21] 78 Fed. Reg., 50950. [22] 78 Fed. Reg., 50952. [23] 42 C.F.R. §414.5(c). [24] 78 Fed. Reg., 50922. [25] 78 Fed. Reg., 50918. [26] 78 Fed. Reg., 50921. See also “[W]hen the inpatient hospital stay is paid under Part B, the hospital stay remains inpatient from the time of admission and may continue to count towards qualification for skilled nursing facility coverage, and the beneficiary is liable for the Part B inpatient charges.” 78 Fed. Reg., 50934. [27] 78 Fed. Reg., 50918. [28] CMS Product No. 11435, at [29] 78 Fed. Reg., 50919. [30] 78 Fed. Reg., 50919. [31] 78 Fed. Reg., 50936, 50937 (Table 2). [32] Bagnall v. Sebelius, No. 3:11-cv-01703 (D. Ct., filed Nov. 3, 2011),

Delay on ACA Out-of-Pocket Maximum: Blessing or Curse?

By Lauren Flynn Kelly - August 22, 2013 An article that appeared in The New York Times recently called attention to a little-known delay on the implementation of a provision of the Affordable Care Act. This one pertains to out-of-pocket limits on consumer spending and requires health plans and employers to set an overall maximum, as opposed to separate limits for medical and pharmacy expenditures. The one-year grace period allows plan sponsors to delay setting the annual overall spending cap, which includes deductibles and copayments, at $6,350 for an individual and $12,700 for a family, until the 2015 plan year. More information about the grace period, which the Times gripes “was obscured in a maze of legal and bureaucratic language that went largely unnoticed,” is available as part of a series of frequently asked questions about the health care reform law that can be found at the Department of Labor website. As it turns out, those FAQs were issued in February, so this isn’t really news per se, but it’s created a media frenzy of bloggers and journalists bemoaning yet another delayed provision of the Affordable Care Act. And the Times isn’t wrong: The language is confusing. From what I understand, if a group health plan uses more than one benefit service provider, such as a health insurer and a PBM, separate spending caps could be established for major medical expenses and prescription drugs in 2014. The exception does not apply to individual plans. While patient advocates worry that the delay could cause considerable hardship for those with chronic conditions, it may give plan sponsors more time to iron out logistical dilemmas that arise from moving to a separate system of tracking pharmacy and medical out-of-pocket cost maxes to aligning those efforts to track overall expenditures. What administrative difficulties will this provision create for plans, and is the one-year grace period likely to help their efforts to comply?

Hospitals Look for Ways to Fill in Lost Volume From ACOs

By Jill Brown - August 22, 2013 Hospitals are feeling pressure from large payers to develop accountable care organizations (ACOs) — but many struggle with the corresponding drops in hospital utilization and accompanying revenue. Although a few hospitals may see enough shared savings from ACO arrangements to offset some of the pain from reduced utilization, most still will take a hit. But a well-designed ACO can use education and the prospects for shared savings to encourage primary care physicians and specialists to admit patients to the ACO’s in-network hospital, and that could offset some or all of the decreased utilization. And hospitals will see reduced costs with reduced utilization, partly offsetting the negative impact. In addition, many health systems intend to use their ACOs to gain market share, “which can refill the beds emptied by lower use rates,” David Anderson, Ph.D., managing director of health care consulting firm BDC Advisors, L.L.C., tells AIS’s ACO Business News. Jordan Hospital, a 155-bed not-for-profit community hospital in Plymouth, Mass., definitely is feeling the pinch of decreased utilization. “Our occupancy rate is problematic,” says James Fanale, M.D., senior vice president of system development for the hospital. To manage it, Jordan’s ACO is looking for more deals with payers where the ACO can share savings on the upside, Fanale says. What do you think — will shared-savings ACO arrangements, increased market share and lower variable costs generate enough revenue for hospitals to offset lost utilization?

Today's Datapoint

4% … was 2013’s rise in the overall cost of employer-provided health benefits, with a 5% rise for individual plans, according to a survey by the Kaiser Family Foundation and Health Research & Educational Trust, an affiliate of the American Hospital Assn. The survey also found that the percentage of employers providing health insurance was “statistically unchanged” from 2012’s 61% and 2011’s 60%.

Quote of the Day

“The big national [health plan] players are picking the markets where they have enough penetration to generate competitive discounts….In many states, the Big Three [i.e., Aetna, UnitedHealth and Cigna] are simply outgunned by local and regional health plans with a strong Medicaid or Medicare Advantage base.” — Jon Kingsdale, Ph.D., managing director at Wakely Consulting Group and founding executive director of the Massachusetts exchange, told AIS’s Inside Health Insurance Exchanges.

Monday, August 26, 2013

Today's Datapoint

48% … of people who now have individual health insurance coverage will soon be eligible for tax credits, according to a recent analysis by the Kaiser Family Foundation.

Quote of the Day

“While it is too early to publish results, we can confirm significant cost savings for each patient who transitions to home-based infusion or treatment at a Walgreens infusion suite. For example, on average, we expect an infliximab [i.e., Remicade] patient to save approximately $20,000 per year through a site-of-care transition, although some patients can save much more. It is not uncommon for the site-of-care savings to exceed $100,000 per year for patients receiving immune globulin, eculizumab [i.e., Soliris] or other drugs that treat rare diseases. — Mike Ellis, corporate VP of specialty pharmacy and infusion at Walgreens, told AIS’s Specialty Pharmacy News.

Friday, August 23, 2013

New Report Says More Doctors are Accepting Medicare

More physicians are accepting Medicare patients, according to a report released by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) out of the Department of Health and Human Services (HHS). According to the report, which utilized federal survey data and in-person interviews of physicians or office staff between 2005 and 2010, the percentage of physicians who report accepting new Medicare patients was 87.9 percent in 2005 and increased to 90.7 percent in 2012. Although the increase is not statistically significant, the report found that beneficiary access to care has remained high over the past five years. The report also finds that the percentage of physicians who accept new Medicare patients is higher than the percentage of those accepting new private insurance patients. In addition, any increase in the number of providers opting out of the Medicare program was mitigated by the increase in other physicians who accept new Medicare patients. Since 2007, the total number of providers participating in the Medicare program and billing for Medicare services has steadily increased. Joe Baker, President of the Medicare Rights Center, was quoted in a USA TODAY article on the report’s findings. Concerns about physician participation in Medicare become more pronounced with each year that Congress delays the Sustainable Growth Rate (SGR) formula, which direct affects payment to Medicare doctors. Allowing the SGR to go into effect could lead to provider cuts as high as 30 percent. Yet, for the last decade Congress acted annually to avert these drastic cuts. Still, certain providers use this issue as what Mr. Baker calls “a political football.” Mr. Baker says of these providers, “They tell their patients…if Congress cuts my reimbursement 30 percent, I won’t be able to see you.” For now, the findings of the ASPE report should quiet concerns that doctors are leaving the Medicare program because of the SGR or otherwise. Mr. Baker echoed the findings in the ASPE report saying, “There are still plenty of doctors taking Medicare.”

According to a recent survey of physicians:

• 78% said they are not optimistic about independent/small groups surviving • Nearly 75% have either only "heard of" or are "somewhat familiar with" an ACO • 26% said that they "don't know" if they are participating in any "pay-for-performance" programs • More than 50% do not believe government's involvement in health care will lower costs or improve outcomes Source: "athenahealth Physician Sentiment Index(TM) Shows Industry Confusion, Grim Outlook on Future, a Failing Among EHRs, and Struggles for Independent Doctors," athenahealth Press Release, August 12, 2013,

According to a recent survey...

...on average, 48% of nursing jobs and 39% of allied health jobs go unfilled for six weeks or longer, and nursing jobs go unfilled for 12 weeks or longer at 20% of health care organizations. Source: "Extended vacancies taking toll on majority of health care organizations, according to CareerBuilder survey," CareerBulder LLC, August 15, 2013,

Today's Datapoint

46% …was the growth (in number and expenditures) between 2006 and 2010 in referrals for prostate-cancer related intensity-modulated radiation therapy by physicians with an ownership or financial interest in the service, according to a new report from the Government Accountability Office.

Quote of the Day

“With a few exceptions in pockets around the country, the lion’s share of reimbursement today is still FFS. I believe the transition to risk-based methods will be modest, but steady. If I had to estimate, I’d say $1 of every $3 of care provided will incorporate some risk-share or performance-based measure within five years. As for the most popular emerging reimbursement methods, it’s still to be determined, but my bet would be on a combination of capitation and bundled payments with performance-based bonuses. Overall, we’ll soon see which methods become most popular. I believe this will be a function of the level of competition in a given market.” — Joey Dizenhouse, a senior consultant at Towers Watson and a fellow of the Society of Actuaries, said in an interview with AIS’s Health Plan Week.

Wednesday, August 21, 2013

New resources available to help consumers navigate the Health Insurance Marketplace

CMS NEWS FOR IMMEDIATE RELEASE Contact: CMS Media Relations Thursday, August 15, 2013 (202) 690-6145 | New resources available to help consumers navigate the Health Insurance Marketplace HHS awards $67 million to Navigators and recognizes more than 100 organizations as Champions for Coverage Health and Human Services (HHS) Secretary Kathleen Sebelius today announced $67 million in grant awards to 105 Navigator grant applicants in Federally-facilitated and State Partnership Marketplaces. These Navigator grantees and their staff will serve as an in-person resource for Americans who want additional assistance in shopping for and enrolling in plans in the Health Insurance Marketplace beginning this fall. Also today, HHS recognized more than 100 national organizations and businesses who have volunteered to help Americans learn about the health care coverage available in the Marketplace. “Navigators will be among the many resources available to help consumers understand their coverage options in the Marketplace,” said Secretary Sebelius. “A network of volunteers on the ground in every state – health care providers, business leaders, faith leaders, community groups, advocates, and local elected officials – can help spread the word and encourage their neighbors to get enrolled.” Today’s announcement builds upon the significant progress in outreach and education made this summer. Consumers can learn about and enroll in coverage later this fall through HHS launched 24-hours-a-day consumer call center ready to answer questions in 150 languages. More than 1,200 community health centers across the country are preparing to help enroll uninsured Americans in coverage, and a partnership with the Institute of Museum and Library Services will help trusted local libraries be a resource for consumers who want information on their options. In addition, HHS has begun training other individuals who will be providing in-person assistance, such as agents and brokers and certified application counselors. Navigators are trained to provide unbiased information in a culturally competent manner to consumers about health insurance, the new Health Insurance Marketplaces, qualified health plans, and public programs including Medicaid and the Children’s Health Insurance Program. The Navigator funding opportunity announcement was open to eligible private and public groups and people who are self-employed who met certain standards to promote effectiveness, diversity, and program integrity. Navigators will be required to adhere to strict security and privacy standards – including how to safeguard a consumer’s personal information. They’ll be required to complete 20-30 hours of training to be certified, will take additional training throughout the year, and will renew their certification yearly. All types of enrollment assisters – including in-person assistors, Certified Application Counselors, and agents and brokers – are required to complete specific training and are subject to federal criminal penalties for violations of privacy or fraud statutes, on top of any relevant state law penalties. The growing list of Champions for Coverage is one more example of businesses and organizations across the nation pitching in to help consumers understand the coming options for quality, affordable coverage. Champions for Coverage, among others, include: • American Medical Association • League of United Latin American Citizens (LULAC) • NAACP • National Baptist Convention • National Partnership for Women and Families For a list of Navigator awardees or more information about Navigators and other in-person assisters, please visit: Click here to learn more about organizations participating in Champions for Coverage: To become a Champion of Coverage, visit:

Today's Datapoint

60% … of 548 employers surveyed recently by Aon Hewitt are reassessing their long-term retiree health strategies because of the ACA, with 40% of those already making changes directing post-65 retirees to the private individual market, with many of those plans containing a defined-contribution subsidy.

Quote of the Day

“I think it is going to be hard to find compromise [on the ACA’s so-called Cadillac tax, because it] has a long [2018] phase-in, which gives people time to adjust. It starts out quite high. The key is to develop regulations that distinguish plans that are costly because they are very generous from plans that are costly because a lot of sick or old people are covered….” — Henry Aaron, Ph.D., a senior fellow in economic studies at the Brookings Institution, told AIS’s Health Plan Week.

CMA to Congress on Medicare Reform Proposals, Post-Acute Care:

Protect Beneficiaries, Improve Access to Care Post-Acute Care Post-acute care refers to a range of services that support the individual’s continued recovery from illness or injury, or management of a chronic illness or disability. On June 19, 2013 the House Ways and Means Committee and Senate Finance Committee issued a letter to key communities requesting information and ideas on the types of long-term post-acute care reforms that would improve quality and improve program efficiency.[1] The letter requested comments and suggestions on a variety of options for reforming post-acute care, including quality measures, assessment tools, payment modifications, and beneficiary protections. Following a hospitalization or other care for injury or illness, many patients require continued medical care, at home, in the community, or in a specialized facility. Medicare spending on post-acute care in 2011, which included payments to skilled nursing facilities, home health agencies, long-term care hospitals and inpatient rehabilitation facilities, was $62 billion. The cost to the Medicare program of providing post-acute care has made it a target for policy-makers seeking to reduce program spending. The Center for Medicare Advocacy, joined by the National Senior Citizens Law Center, the National Committee to Preserve Social Security and Medicare and the National Consumer Voice for Quality Long-Term Care submitted broad comments with a focus on how to preserve and strengthen post-acute care services for beneficiaries.[2] In particular, the Center stressed that: • Legislative proposals to reform Medicare post-acute care should not be paid for by shifting costs to beneficiaries, including through the imposition of home health co-pays or other restrictions on Medicare home health coverage. • Congress should seek to improve access to post acute (and long-term) care, particularly through the elimination of outpatient therapy caps and the three day prior inpatient hospitalization requirement for coverage of skilled nursing facility care. • Financial incentives seeking to reduce utilization of post-acute care services should be focused on providers, rather than beneficiaries. Often, once beneficiaries seek care and are engaged in the health system, doctors and other medical providers, not patients, drive the number and types of services that are delivered. Beneficiaries should not be held solely or primarily responsible for reducing unnecessary, duplicative or ineffective care. Medicare Reform Proposals The House Ways and Means Subcommittee on Health also solicited input from stakeholders on various draft proposals that seek savings for the federal government in the Medicare program. These proposals include further means-testing Medicare premiums, increasing the Part B deductible, and adding a home health copayment. The Leadership Council of Aging Organizations, which includes the Center, submitted comments in strong opposition to these proposals [3] and any others which produce short-term savings by shifting costs to people who rely on Medicare, half of whom live with incomes under $22,000. Among other facts, LCAO’s comments highlight several key points, including: • More means-testing of Medicare premiums strikes at the heart of the middle class. • Increasing the Part B deductible harms the poorest and deters access to needed care. • Adding a home health copayment deters care for the sickest and increases the need for higher-cost levels of care. LCAO also emphasizes its support of cost-saving solutions that build on system-wide delivery reforms that reduce the rate of health spending by addressing the systemic causes of cost growth, while noting that in recent years, Medicare has led the way in reducing rates of cost growth. Conclusion Policymakers continue to propose cost-saving measures at the expense of Medicare beneficiaries. Once again, the Center for Medicare Advocacy urges Congress to adopt real, common-sense solutions that would reduce costs without harming Medicare and those who depend on it. ________________________________________ [1] Letter from House Ways and Means and Senate Finance Committee to stakeholders seeking input on Medicare post-acute care (June 19, 2013), available at [2] See [3] See

Tuesday, August 20, 2013

Amid Health Law Expansion, Some States Trim Medicaid Rolls

By PHIL GALEWITZ KHN Staff Writer AUG 18, 2013 While millions of adults nationwide will gain Medicaid coverage next year under the federal health law, more than 150,000 people could lose their coverage in the state-federal health insurance program for the poor as four states reduce eligibility. The states planning to make the cuts in January are Maine, Rhode Island, Wisconsin and Vermont. Most people losing access to Medicaid will be eligible for federal subsidies to help buy private coverage in the law’s online insurance marketplaces also starting in January, but advocates worry some will struggle to afford higher premiums and other cost-sharing expenses. "It is sad that as we look to expand coverage to more people, we are taking a step backward and taking away coverage to a significant amount of low income adults," said Linda Katz, policy director with the Economic Progress Institute, a Providence, R.I.-based advocacy group. Kaiser Health News collected enrollment data from the four states. The changes they plan still need federal approval, which is expected. Rhode Island is expanding Medicaid under the health law's provision to cover all childless adults making up to 138 percent of the poverty level. That will add about 45,000 people to the program. These expansion costs are fully covered by the federal government through 2016 and then the state will pay a small portion but no more than 10 percent. At the same time, though, Rhode Island is scaling back its Medicaid eligibility for parents of minor children from the current income threshold of 175 percent of the poverty level to 138 percent, affecting 6,700 people. They will be directed to shop for coverage on the state's insurance marketplace, also called an exchange. Rhode Island, like other states, expects this shift to reduce state spending. That's because states split the cost of Medicaid with the federal government, which picks up about 57 percent of Medicaid spending. But the subsidies in the marketplace are funded totally by the federal government. Meanwhile, in Maine, not everyone being cut from Medicaid will have access to the subsidies to buy private insurance. About 10,000 childless adults in the state, a little less than a third of those losing Medicaid coverage, won't qualify for those federal subsidies because they have incomes below the poverty level, $11,490 for an individual. The health law makes those subsidies available only to people with incomes between the poverty level and four times that amount. The law was written that way because it was assumed all states would expand Medicaid eligibility to cover everyone with incomes up to 138 percent of the poverty level, but the Supreme Court last year made that provision optional. Only about half the states are expanding Medicaid for 2014. Many states led by Republicans have balked at expanding Medicaid, citing how spending for the program has outpaced inflation and even a modest increase in spending over the next decade could be difficult. Stacey Jacobsohn, 52, of Augusta, Maine, is worried about losing her Medicaid coverage particularly since she had a stroke last year. With a $5,000 annual income, she said she will have to rely on her doctors to cut their prices so she can keep seeing them. "It's going to be very hard for me," she said. "It's a lot of fear right now." For the past four years, states have been limited in their ability to reduce the size of their Medicaid programs because of a requirement called "maintenance of effort," which first took effect in the 2009 federal stimulus law that provided billions of dollars to states during the recession as long as they didn't restrict standards for eligibility. That restriction was extended in the 2010 Affordable Care Act. But that provision ends for adults in 2014. That's why Maine next year will be able to reduce its Medicaid coverage for childless adults. In addition, Maine next year plans to reduce eligibility for parents and caretakers from 133 percent of the poverty level to 100 percent of the poverty level, which affects 15,000 adults. Medicaid Cuts Four states are reducing eligibility in their Medicaid program for some groups next year. State Number of people being cut Maine 35,000 Rhode Island 6,700 Wisconsin 92,000 Vermont 19,000 Of these, all will be eligible for federal subsidies in exchanges except for 10,000 childless adults in Maine with incomes below 100 percent of the federal poverty level. They won't be eligible. Maine Gov. Paul LePage, a Republican, says his state can't afford its current Medicaid program nor take on an expanded one, even if all the costs are paid for the first three years by the federal government. LePage this year vetoed a measure passed by the legislature to expand Medicaid under the health law's provision. Supporters of the measure could not get enough votes to override his veto. "Adding non-disabled individuals to our welfare program when we are failing to provide core services to thousands of disabled and elderly Mainers is unacceptable," LePage said in his veto message. In the other two states, the Medicaid cutbacks are the result of the expiration of federal waivers that allowed for demonstration programs designed to expand coverage. In Vermont, about 19,000 people will fall off the Medicaid rolls as the state ends two such initiatives geared toward helping people with incomes as high as 300 percent of the poverty level, or a little more than $34,000. Mark Larson, commissioner of the Vermont Department of Health Access, said the programs are ending to save the state dollars since those populations next year can qualify for federal assistance to buy coverage in the state exchange. Wisconsin would cut more people from Medicaid than any other state as part of a plan advanced by Republican Gov. Scott Walker and still awaiting federal approval. About 92,000 people -- 87,000 parents and caretaker relatives, and 5,000 childless adults with incomes above the federal poverty level -- would lose the Medicaid coverage they previously had as a result of a wavier and be sent to the online insurance marketplace. At the same time, the state is planning to add 100,000 Wisconsin childless adults with incomes below the poverty level to Medicaid. "The governor's reforms balance the need to maintain a strong and sustainable health care safety net with ensuring the greatest number of people possible can afford to remain in the private health insurance market and maintain their independence," according to a statement by the Wisconsin Department of Health. Many of the 92,000 Wisconsin adults losing Medicaid coverage already pay small monthly premiums. It's unclear how much those rates will increase in the online marketplace. "The products designed for the marketplace were never designed for people in these low-income categories," said Donna Friedsam, health policy program director at the University of Wisconsin. "Even with the federal subsidies, the cost sharing will still be quite onerous."

National Average Part D Bid Drops 4.7% For 2014, Upping Risks for PDPs, MA-PDs

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. By James Gutman, Managing Editor August 8, 2013 Volume 19 Issue 15 For what seems to be a variety of reasons, 2014 bids by plans for Medicare Part D products were again aggressive, resulting in a 4.7% drop in the national average monthly bid amount released by CMS late last month to $75.88 from $79.64 for 2013. The results, which surprised several actuaries, especially coming on top of a 6% drop last year (MAN 8/23/12, p. 1), probably mean that the biggest operators of stand-alone Prescription Drug Plans will continue to take market share among auto-enrolled, subsidized PDP beneficiaries from smaller plans. This could threaten the long-term viability of some of those smaller PDPs. The figures also may mean some Medicare Advantage prescription drug (MA-PD) plans, including Special Needs Plans (SNPs), needed to use a short and now-ended reallocation period to reduce some aspects of their supplemental benefits. That’s because they are locked into minimum drug benefits, and their overall bids may have assumed they would get larger subsidies than they actually will in light of the drop in the Part D national benchmark. Separately, CMS also said July 30 that the average PDP premium will be about $31 for 2014, up just slightly from the $30 in 2012 and 2013 (see table, p. 7). This figure includes the expected effect of switches by beneficiaries to lower-priced products, notes Corey Ford, a senior manager at consulting firm Avalere Health LLC. Before such switches are taken into consideration, the base beneficiary premium for 2014 will be $32.42 next year, CMS said, up from $31.17 in 2013. The base premium results from multiplying the national average monthly bid amount by a fraction called the “beneficiary premium percentage.” Part D Average Bid Tumbles Again The difference in 2014 direction for the premium and bid must be primarily a result of what is happening with costs of the catastrophic portion of the Part D benefit, explains Pat Dunks, a principal and consulting actuary in the Milwaukee-area office of Milliman. The catastrophic portion is the 80% of costs paid by the federal government after the beneficiary gets through the “doughnut hole” coverage gap in the Part D benefit and is rising faster than are costs in the portion paid by PDPs, Dunks says. This may be partly because high specialty-drug prices, which often push beneficiaries beyond the doughnut hole, are rising faster than are overall pharmaceutical prices. “I think everybody was surprised” by the big drop in the 2014 average Part D bid amount, which is weighted by enrollment, Dunks tells MAN. He notes that the figure is especially important for auto-assigned PDP beneficiaries since plans bidding below the benchmark for basic coverage qualify for getting low-income subsidy (LIS) beneficiaries, with the amount of the subsidy varying by region. A plan falling within a de minimis amount, which will remain $2 per member per month for 2014, above the benchmark may retain LIS members if the plan agrees to pick up the additional cost itself. Humana, WellCare Bid Below Benchmarks Humana Inc. President and CEO Bruce Broussard, speaking in the company’s July 31 earnings call with investors (see story, p. 3), said the new CMS data mean that Humana was under the benchmark in all but one region, where it was in the de minimis range. Dunks calls the statement by Humana, which has among the lowest-cost PDPs in 2013, “no surprise.” WellCare Health Plans, Inc. CEO Alec Cunningham said in its earnings call Aug. 7 that the company was below the 2014 Part D benchmark in 30 of the 33 regions in which it bid on PDPs, compared with only 14 below-benchmark bids for 2013. The company lost more LIS members than it gained this year, but should reverse that situation in 2014, Cunningham noted. He attributed the turnaround partly to WellCare’s recent introduction of preferred pharmacy networks that lower its drug costs. Dunks says one possible reason for the big drop in the national average bid for PDPs may lie in risk-adjustment changes CMS is instituting on PDP beneficiaries. Those changes may make certain kinds of PDP beneficiaries more attractive to plan sponsors, thereby leading the sponsors to be “more aggressive” in their bids. But which plans did what, he points out, won’t be known — except in the case of self-disclosures such as Humana’s — until CMS releases the full “landscape” PDP files next month. Other factors that could have led to the drop in the average bid, according to Dunks, include more economies of scale achieved by the bigger plans, improved contracting with drug producers — “but inflation [in pharmaceutical costs] isn’t zero” — and formulary changes. He adds, however, that not as many major brand drugs will get new generics in 2014 as has been the case in 2013, so the opportunities for such formulary changes have declined. This leaves another possibility — that plans decided to accept lower profit margins for 2014 to keep members, Dunks says. The results the national average bid trend will have on smaller PDPs may be substantial, he suggests, and could lead them in the future to either negotiate better drug prices or exit the market. Brian Collender, specialist leader in the health actuarial practice at Deloitte, agrees that it will be “kind of tough” on smaller PDPs in the future and says that many of them “might go away” in light of the risk of continuing to compete in the low-premium environment. The Part D benchmark reduction is less of a problem for MA-PDs, he contends, since the inclusion of medical coverage in those products means there are far more dollars in the premiums and less dependence on auto-enrollees. However, even these plans may have had to cut medical benefits if they assumed the direct Part D subsidy would be higher than it turned out to be. MA-PDs had until Aug. 5 to make such benefit changes, which might just involve a “couple of dollars” less in supplementary benefits, such as for dental, vision or gym memberships, he says. Universal American Corp. Chairman and CEO Richard Barasch said in its Aug. 2 earnings call that the new benchmarks would cause the company “to adjust” its MA-PD bids by the deadline. He did not specify the form of the adjustments or where the company’s MA-PD bids stood in relation to benchmarks. Collender tells MAN he expected the national average to go down because of the continuing introduction of low-premium PDPs, “but not this much.” The trend may continue “a few more years,” but “it will have to stop at some point,” he says. He cites several reasons for the trend, including the moves to lower-priced generics and the potential that lower-priced PDPs have to attract younger, healthier seniors as new customers. Unhealthy seniors probably already are in the market and will tend to stick with their plans out of fear of problems if they switch, asserts Collender. But Ford, who says he was “not surprised” by the new average bid benchmark, tells MAN that perhaps the primary reason for the substantially lower figure for 2014 is preferred pharmacy networks and the continuing ability of them to make low-cost PDPs prevalent and feasible. It is the larger plans that have been “driving this trend,” he says, making it harder for smaller plans to compete, even if like Blues plans they have a strong local presence that makes them very competitive on the MA-PD side. View CMS’s July 30 memo on the 2014 national average bid amount by visiting the Aug. 8 From the Editor entry at Source: Avalere Health analysis of CMS’s annual release of the Part D national average bid and base beneficiary premium information. The average beneficiary premium and base beneficiary premium are from CMS’s press releases. Prepared by Avalere Aug. 2, 2013.

Ohio Medicaid costs would surge without expansion

State should also cut costs for current enrollees August 15, 2013 | By Ron Shinkman Ohio is the most populous state whose leadership has yet to decide whether to fully embrace the Affordable Care Act. It stands to lose money if it doesn't expand its Medicaid program, reported the Cincinnati Enquirer. Citing data from a study undertaken by the Health Policy Institute of Ohio and Ohio State University, Ohio would spend $17.4 billion a year on its Medicaid program. That takes into account an average annual spending increase of 7.2 percent and the current 40 percent the state pays to provide Medicaid coverage. Under the ACA, the state's share of payments would never rise above 10 percent, and spending would increase to $14.2 billion a year by 2025, the Enquirer reported. However, the cost increases are pegged to Ohio, reducing its annual Medicaid costs increases to 3.5 percent per year, a cut of more than half from the current cost trends. Expanding Medicaid would cover an additional 366,000 Ohioans, and would take significant financial pressure off of hospitals. However, more than half the states are unlikely to immediately expand their Medicaid programs under the ACA, leaving as many as 60 percent of Americans eligible without coverage. The Ohio study's findings were presented to a state legislative panel. Ohio's lawmakers have yet to vote on expanding the Medicaid program, and the window of being able to do so in time for early 2014 is quickly closing, according to the Enquirer. For more: - read the Enquirer article - here's the study (.pdf) Study: Ohio Medicaid costs would surge without expansion - FierceHealthFinance - Health Finance, Healthcare Finance

Home Care Helps Older Blacks with Depression

Published: Aug 19, 2013 By Cole Petrochko, Staff Writer, MedPage Today Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner Action Points • Note that this randomized trial demonstrated that an intensive, home-based, social worker intervention helped to alleviate symptoms of depression in older African Americans. • Be aware that the cost-efficacy of such interventions has yet to be evaluated. A home-based intervention for depressive symptoms in older African-American patients reduced depression severity, improved knowledge about depression, and raised patients' quality of life, researchers found. Compared with those wait-listed for the intervention, patients who received at-home care saw mean depression scores fall by 2.9 points (95% CI minus 4.6-minus 1.2) on one scale and by 3.7 points (95% CI minus 5.4-minus 2.1) on another scale, according to Laura Gitlin, PhD, of Johns Hopkins University School of Nursing, and colleagues. Those who received home-based care also had significantly improved quality of life, behavioral activation, and anxiety (P<0.001 for each) versus those who had not yet received the intervention, they wrote in the August 20 issue of Annals of Internal Medicine. The authors noted that depression is both common and has "debilitating consequences" in older patients, and that the condition is both under-recognized and under-treated in primary care settings among older African-American patients versus older white patients. White patients are more likely to receive standard depression care and to participate in psychotherapy and other guideline treatments, they wrote, adding that this disparity is due to systemic- and patient-level problems, such as lack of access to care and stigma associated with treatment. The researchers evaluated whether a home-based, social worker-delivered intervention -- which they titled "Beat the Blues" -- would manage depressive symptoms in a population of 208 African Americans ages 55 and older who were randomized to treatment or to a wait list for treatment. Participants in the intervention group received up to 10 1-hour sessions at home that were delivered weekly over the first 4 months and biweekly after that period. Social workers in the intervention offered care management through a "systematic assessment of unmet care needs," referrals to social and medical services, depression education in symptom recognition, education in stress reduction techniques, and education in behavioral activation through identification of personal activity goals and plans to accomplish them. Treatment goals included management of chronic conditions, socialization, exercise, and meeting unmet care needs. Those randomized to the wait list control received no study-based care over the baseline to 4-month study period, though they were offered the at-home intervention after 4 months. Study outcomes included improvement in depressive symptom severity as measured through the Patient Health Questionnaire-9 and the Epidemiologic Studies Depression Scale, as well as improvement of depression knowledge, well-being, quality of life, behavioral activation, anxiety, and functional difficulty. Participants had a mean age of 69.6; most were women (78.4%) and were unemployed (90.9%). Most were unmarried, lived alone, had some financial difficulty, and had no more than a high school education. Most participants also had high blood pressure, arthritis, and high cholesterol; diabetes was also common. Roughly one in five took antidepressants (19.3%) or anti-anxiety drugs (17%). After 4 months of treatment, depressive symptom scores -- as well as secondary outcomes improved for patients in the intervention group versus control participants. Improvements (P<0.001 for all) included: Depression knowledge and efficacy (an 0.3-point improvement) • Well being (0.7 points) • Behavior activation (0.8 points) • Quality of life (0.3 points) • Anxiety (-0.4 points) Functional difficulty scores dropped by 0.2 points, but this difference was not as strong (P=0.014). More patients who received treatment had remission of depressive symptoms compared with those who were wait-listed (43.8% versus 26.9%), and more had clinically meaningful reductions in depressive symptom severity (64% versus 40.9%). After 8 months, participants in the control group who had received at-home treatment "showed benefits ... that were similar to the adjusted benefits from the initial treatment group." Additionally, among those who received treatment in the first 4 months of the study, 68.6% were still in remission at 8 months' follow-up. The authors cautioned that the withdrawal rate was higher in the treatment group than in the wait-listed group. They also noted the study was limited by its use of a single-center, self-reported outcomes, a small study sample, a small number of male participants, and use of a single minority group. The study was supported by the National Institute of Mental Health. Primary source: Annals of Internal Medicine Source reference: Gitlin LN, et al "A home-based intervention to reduce depressive symptoms and improve quality of life in older African Americans" Ann Intern Med 2013: DOI: 10.7326/0003-4819-159-4-201308200-00005.