Thursday, November 21, 2013


19% of hospital patients who left the hospital against medical advice in 2011 were uninsured, according to a recent report Source: "Overview of Hospital Stays in the United States, 2011," Agency for Healthcare Research and Quality, Statistical Brief #166, Healthcare Cost and Utilization Project (HCUP). November 2013,

Today's Datapoint

1,100 … simultaneous users was all could handle before faltering during a “stress test” performed on Sept. 30, according to a report by Quality Software Services, a subsidiary of UnitedHealth Group that was hired to help build the website.

Quote of the Day

“Everybody thinks it is the insurers who are making too much money or providers making too much money. But at the bottom line what is really astounding to me is conservative estimates suggest between 30% and 40% of all medical services we deliver in this country don’t need to be delivered — they add no clinical value. That is really not addressed under the ACA.” — Peter Hayes, principal at the consulting firm of Healthcare Solutions, told AIS’s Health Plan Week.

Wednesday, November 20, 2013

Today's Datapoint

21% … is the predicted talent shortage in the next five years for insurance company financial managers, followed by insurance company sales agents (a 14% shortage), systems analysts (11%), actuaries (7%), and claims adjusters (4%), with insurance underwriters projected to be the only talent surplus (at 4%), according to Mercer’s 2013 Insurance Industry External Labor Market Analysis.

Quote of the Day

“I don’t think I’m stupid enough to go around saying ‘this is going to be like shopping on Amazon or Travelocity, a week before the Web site opens, if I thought it wasn’t going to work.” — President Obama, in response to a question about whether he knew of’s flaws prior to its Oct. 1 launch, at his Nov. 14 press conference announcing the proposed one-year delay in cancelling individual plans.

Monday, November 18, 2013

7 Countries With the Highest Health Care Costs

1. United States: 17.9% of GDP - $8,680 per capita 2. Netherlands: 12% of GDP - $5,056 per capita 3. Germany: 11.6% of GDP - $4,338 per capita 4. France: 11.6% of GDP - $3,974 per capita 5. Canada: 11.4% of GDP - $4,445 per capita 6. Switzerland: 11.4% of GDP - $5,270 per capita 7. Denmark: 11.1% of GDP - $4,464 per capita Source: The Motley Fool

Breakdown of Americans That Selected a Qualified Health Plan Through the Marketplace During the First Reporting Period of Open Enrollment

1. 106,185 Americans selected a Qualified Health Plan (QHP) through the Marketplace 2. Of the people who have selected a plan, 79,391 (74.8 percent) enrolled though a state-based Marketplaces 3. Of the people who have selected a plan, 26,794 people (25.2 percent) enrolled though a Federally-facilitated Marketplace Source: U.S. Department of Health & Human Services

Employer-Sponsored Health Insurance Coverage Trends

According to the Economic Policy Institute, after falling every year since 2000, the share of non-elderly Americans with employer-sponsored health insurance coverage (ESI) essentially held steady between 2011 and 2012, increasing slightly to 58.4 percent. The labor market's slow improvement over the past two years ended the long-standing downward trend in employer-sponsored health coverage, with ESI increasing slightly by 0.1 percentage points in 2012. However, this comes on the heels of eleven years of erosion. 13.7 million fewer non-elderly Americans had insurance through their employers than in 2000, and as many as 29 million more people under age 65 would have had ESI in 2012 if the coverage rate had remained at its 2000 level. Massachusetts had the highest rate of ESI coverage among the under-65 population, at 70.8 percent in 2011/2012. It is followed by New Hampshire (70.0 percent), Connecticut (69.7 percent), Minnesota (69.0 percent), North Dakota (67.6 percent), Maryland (67.3 percent), and Utah (66.3 percent). In contrast, less than half of New Mexico's non-elderly population had ESI, at 47.2 percent. Source: Economic Policy Institute

Roughly 275,000 people who tried unsuccessfully to enroll in coverage

Roughly 275,000 people who tried unsuccessfully to enroll in coverage on the federal exchange in the early days will be receiving email messages from CMS inviting them to try again. The emails won’t all go out at once, however. “We’re sending in waves,” CMS spokesperson Julie Bataille told reporters on Nov. 12. “We want to make sure we’re inviting people back into the system and their experience will be positive one.” She also noted that over the last weekend, technicians took specific steps to improve the hardware and software systems that will “help improve stability” of the website. In addition, Bataille reiterated CMS’s confidence in meeting its deadline to fix the website. “The site is getting better each week and by the end of November, the site will operate smoothly for the vast majority of users,” she said. (Reprinted from AIS’s Health Reform Week's e-News Alert)

Some state-run insurance exchanges are experiencing the same kinds of technical problems

Some state-run insurance exchanges are experiencing the same kinds of technical problems that have plagued the federally run exchanges, according to a Nov. 12 New York Times article. For example, in Oregon, the system cannot determine whether individuals qualify for federal subsidies or Medicaid. In Vermont, technical problems won’t allow consumers to pay for the plans they select. In Hawaii, people are still reporting problems on the site that didn’t go live until mid-October. In Maryland, technical problems, including slowness and frequent error messages, prompted the exchange board to let insurers handle payments directly for now. In Colorado, residents had to bypass the website and use a call center to see if they qualified for federal subsidies. Several state-run exchanges, including those in Connecticut, New York and Washington state, are functioning much better than the federal exchange, the Times reported. Customers in these states are able to log in, register and enroll much faster than on, it added. (Reprinted from AIS’s Health Reform Week's e-News Alert)

Whether they like it or not, health insurers are now part of a new “fix”

Whether they like it or not, health insurers are now part of a new “fix” for revamping the floundering implementation of President Obama’s health reform law. The president on Nov. 14 made a dramatic and what one insider source calls a “politically necessary” policy shift to allow insurers the option of letting consumers keep health plans that previously had been cancelled because they did not meet stricter Affordable Care Act (ACA) coverage requirements. Health carriers can now extend for one year certain plans that were written off their books for 2014, but must receive state regulatory approval before re-offering coverage already given up for dead, and point these same consumers to other exchange-based options. No one is certain if insurers want to take this step — or if state insurance commissioners will approve any requests, let alone consider what are sure to be new, higher rate requests by carriers seeking to adjust cancelled plans’ premiums to account for medical cost increases in 2014. Already, Washington state Insurance Commissioner Mike Kreidler (D) in a Nov. 14 statement said he had serious concerns with the Obama change and will not permit extensions of cancelled policies that didn’t meet the requirements of the ACA. Kreidler said people with cancelled policies can get better coverage on the state’s public exchange. “I think it is getting in front of reality. I don’t think [Obama] had a choice. They got to the point where they had to do something to allow these existing plans, but it puts the plans in a very difficult spot,” Republican Tom Scully, the CMS administrator from 2001 to 2004 under President George W. Bush and now senior counsel at Alston & Bird, LLP, tells AIS. At least one major carrier, Aetna Inc., said it would try to restart the plans, but cautioned that it would need help. “State regulators will need to allow us to update our policies and secure appropriate rates so we can get these plans back in the market,” Aetna spokesperson Cynthia Michener said in a statement. — Excerpted from Health Plan Week.

The Coming Exchange Revolution Has Little to Do With Obamacare

“We are seeing 2013 earnings [for health insurers] that are very good, very strong. Guidance numbers are holding up or being improved a bit on all fronts. Utilization is remaining in check, cost cutting is continuing, everything looks great. What we’re hearing though is that the headwinds for 2014 have got people nervous on uncertainty about how the ACA works, how that all plays out, issues about the taxes, the fees.” — Steve Zaharuk, senior vice president at Moody’s Investors Service, told AIS’s Health Plan Week.

Monday, November 11, 2013

Today's Datapoint

3.3% … will be the increase in 2014 payments to Medicare Advantage plans on an enrollment-weighted basis as a result of improved star ratings scores, according to John Gorman, executive chairman of Gorman Health Group, LLC.

Sunday, November 10, 2013

Analyst estimates insurer exchange plan losses

By Tom Murphy NOVEMBER 5, 2013 A securities analyst at Goldman Sachs is predicting that publicly traded insurers' losses on coverage they sell through the new Patient Protection and Affordable Care Act (PPACA) public exchanges will be modest. The analyst, Matthew Borsch, said in a research note that he expects the insurers to report a total of less than $100 million in losses before taxes next year on exchange plans. That could amount to less than 1 percent of the companies' $23 billion in total estimated pretax earnings. "Our forecast for losses seems prudent given the exchange enrollment difficulties so far," Borsch wrote. He expects the problems to be fixed, but he also said the issues add to his expectation that initial enrollment will be lower than expected and skewed toward a higher-risk, costlier-to-insure population. Borsch said a bigger concern for health insurers will be cuts in funding for Medicare Advantage plans. Insurers will receive less reimbursement next year for these plans due to PPACA-mandated support reductions. eNL=52791b25160ba03f3c000068&utm_source=LifeHealthProBreakingNews&utm_medium=eNL&utm_campaign=LifeHealthPro_eNLs&_LID=97698134

New Report: Expanded Dental Coverage Needed to Confront Health Crisis

As policymakers consider proposals to slash successful community programs including Medicare and Medicaid, older Americans and their families continue to face barriers to necessary health care, including access to dental coverage and services. A new report from Oral Health America highlights this growing dental crisis for older Americans. According to the report, lack of affordable dental coverage options, provider shortages, and lack of preventive programs in communities across the country are creating serious hardship for older adults.[1] Policy options to improve access and coverage, combined with community outreach and education, would strengthen public health while mirroring overall health care reform efforts to improve care, improve health, and lower long-term costs by investing in preventive care. Older Americans Lack Dental Coverage Despite improvements in oral health for the general population in the past 50 years, older Americans still face high risk of oral disease. The problem is likely to grow as the baby-boomer generation enters retirement: only 2% of boomers who retire do so with access to dental insurance benefits through their former employers or private market dental plans.[2] Lack of dental insurance is a major access barrier to dental care for older adults. Nearly 70% of older Americans currently have no form of dental insurance.[3] Older adults with dental insurance are 2.5 times more likely to visit the dentist on a regular basis. Private insurance, however, remains costly, while coverage for low-income adults on Medicaid is optional for states and limited in those that do offer it. Forty-two percent of states provide no dental benefit or only emergency coverage through adult Medicaid.[4] In states where dental coverage is provided through the adult Medicaid program, getting dental care can still be a challenge for beneficiaries due to low reimbursement rates and provider shortages. In addition, coverage for routine dental care under Medicare – the largest health insurance provider for individuals over 65 – is virtually nonexistent. Less than 1% of dental services are covered by Medicare. In addition, because the services are not covered under Medicare, Medigap insurance, purchased by beneficiaries to supplement Medicare coverage and assist with out-of-pocket costs, does not cover dental services.[5] For older individuals living on fixed or low-incomes, the high cost of dental care deters those who lack insurance coverage from seeking needed treatment. A recent survey revealed that older individuals who earn less than $35,000 a year consider cost as the main factor in deciding whether to seek care.[6] In the same survey, more than half making less than $35,000 reported not visiting a dentist routinely because they lack insurance or cannot afford the costs associated with seeking care. Two-thirds in the same income group said that if faced with the need for common dental procedures such as a crown, implant, or bridge, they would be unable receive the procedure due to cost.[7] Older Americans in poverty are more than 60% more likely to have lost all of their teeth compared to those with higher incomes.[8] Differences in race, income, and disability status also impact older Americans when it comes to oral health and dental care. Poor oral health disproportionately occurs among racial and ethnic minorities, and also in older adults with physical and intellectual disabilities and those who are homebound or institutionalized.[9] Older African-American adults are nearly twice as likely to have periodontitis (gum disease) than their white counterparts. Health Implications Lack of accessible, affordable dental coverage can lead to adverse health outcomes. Data shows, for example, that certain oral conditions including periodontal disease can increase risk for heart attacks and strokes.[10] Conversely, many chronic health conditions can contribute to oral health problems, leading to further complications like those above.[11] The lack of coverage in the largest public insurance programs (Medicare and Medicaid) leaves individuals with few options for accessing needed care. Emergency room visits for dental-related issues among adults over 65 rose from 1 million in 1999-2000 to 2.3 million in 2009-2010.[12] As overall health care system reforms aim to emphasize primary and preventive care and deter costly emergency care, dental care remains neglected by policymakers at a time when the need for attention is greater than ever. Policy Solutions The report highlights several policy solutions to address the dental crisis facing older Americans. Chief among them are the need for expanded coverage in Medicare and Medicaid. Further, adult dental coverage and services should be deemed as "essential health benefits" under the Affordable Care Act to expand access to services for those under 65. The report argues that states need a legal mandate for providing oral healthcare in Medicaid to ensure broad coverage and more equitable provider payment. In addition, the lack of dental coverage in Medicare must be addressed to effectively confront the growing challenge faced by older Americans. Legislation to enact these policy proposals has been introduced in Congress, and includes: • The Comprehensive Dental Reform Act of 2013: Introduced by Senator Sanders and Schatz in the Senate, and Representatives Cummings and Schakowsky in the House, this landmark legislation is the most comprehensive dental care legislation in American history. It extends comprehensive dental coverage to all individuals covered by Medicare, Medicaid, and the Veterans Administration, and would include oral health as an essential benefit as defined under the Affordable Care Act. [13] • Special Care Dentistry Act of 2011: While this legislation has not been reintroduced in the current session of Congress, it would have extended dental services to millions of individuals by requiring states to provide oral health services to aged, blind, or disabled people under the Medicaid program. The federal government would cover 100% of the cost of this expansion.[14] Conclusion Strengthening community education and outreach and addressing provider payment and shortage issues are critical to addressing the dental crisis faced by older Americans and people with disabilities. The lack of dental coverage in Medicare and Medicaid, and the expense of private insurance options remain barriers to needed care. Solutions that address oral health and access to dental care must be a part of efforts to improve and modernize Medicare and Medicaid. The Center for Medicare Advocacy has fought for expanded dental coverage for Medicare beneficiaries, and continues to advocate for policy changes that improve access to affordable care for older people and people with disabilities.[15] Instead of cutting Medicare, Medicaid, and other critical health care programs serving our nation's most vulnerable individuals, policymakers should work to improve public health and modernize our largest insurance programs by expanding coverage and benefits, including comprehensive dental care. For more information contact Policy Associate Xenia Ruiz ( or Policy Attorney David Lipschutz ( in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760. ________________________________________ [1] Oral Health America, State of Decay: Are Older Americans Coming of Age without Oral Healthcare?, available at [2] Ibid. [3] Ibid. [4] Ibid. [5] Ibid. [6] Ibid. [7] Ibid. [8] Ibid. [9] Ibid. [10] CNN, "Dental crisis could create 'State of Decay'", [11] Centers for Medicare and Medicaid Services, Chronic Conditions Among Medicare Beneficiaries, 2012 Chartbook, available at [12] Oral Health America, State of Decay. [13] Legislation available at [14] Legislation available at [15] Center for Medicare Advocacy, Fournier v. Leavitt, more at

Registered Nurse Views on Changes to Their Profession from Healthcare Reform by Generation

According to a study from AMN Healthcare, younger nurses (ages 19-39) are more confident about the supply of nurses and their ability to meet the demands of healthcare reform, despite today's shortages. Approximately 45% of younger nurses believe that the shortage has improved during the last five years, while older nurses were less optimistic. The generational differences were even more apparent when asked whether healthcare reform will ensure an adequate supply of quality nurses, with 38% of younger nurses citing confidence compared to 29% and 27% of older nurses ages 40-54 and 55+, respectively. Questions regarding the use of electronic medical records (EMRs), a requirement of the Affordable Care Act, also demonstrated generational differences as younger nurses attributed them to positively influencing job satisfaction, efficiency and patient care. While nearly two-thirds of younger nurses noted EMRs' influence on job satisfaction, that number fell to 51% or lower when older nurses were asked. Further, 60% of younger nurses agreed that EMRs positively influence productivity and time management, compared to just 38% of older nurses. Source: AMN Healthcare

Small Business Premiums Costs and Deductible

According to a survey of 921 small-business owners and operators from around the country by the National Federation of Independent Business, 64 percent reported that they pay more for insurance premiums per employee in 2013 than they did in 2012. According the NFIB's study, Small Business's Introduction to the Affordable Care Act, the health insurance premium costs incurred by small businesses (employer and employee shares) average $6,721 a month ($80,652 a year). The median cost is about $3,500 every 30 days. Deductibles for beneficiaries of small-business health insurance products also rose in 2013. While two of three (67 percent) of plans maintained deductibles at the prior year's level, another 28 percent increased deductibles; only 4 percent lowered deductibles in their plans. Source: National Federation of Independent Business

Reasons for Americans Not Enrolling in a Health Insurance Plan or Medicaid in October When Visiting The Health Insurance Marketplace

Not certain you can afford plan 48% Still trying to decide which plan you want 46% Thought the deductibles and copayments were too high 42% Website you were using was experiencing technical difficulties 37% Have not been able to find out if you can get financial assistance or Medicaid 29% Not eligible for financial assistance or Medicaid 28% Couldn't find a plan with the doctors you wanted 21% Some other reason 17% Source: The Commonwealth Fund

Friday, November 8, 2013

WellCare CEO’s Ouster Leaves Analysts Scratching Their Heads

By James Gutman - November 1, 2013 Even among members of an audience accustomed to expect the unexpected, WellCare Health Plans, Inc.’s announcement Nov. 1 that it was replacing its CEO left some securities analysts shell-shocked. WellCare detailed the ouster of CEO Alec Cunningham on the same day it unveiled very strong third-quarter financial results. And despite what company Chairman David Gallitano, who was named interim CEO, said about the reasons in the quarterly earnings conference call with investors, some analysts were wondering if there is more to the story. Gallitano, a WellCare director since 2009 but chairman just since this May, said in his prepared remarks that “we needed a CEO with a demonstrated track record of leading a business of large scale and leading a company the size and scope we anticipate WellCare will obtain over the next several years. This change is not the result of any other issue.” In the question period, Gallitano elaborated only slightly, praising Cunningham’s ability to get the company to execute smoothly but adding that WellCare now needed someone “more strategic” and new ways of dealing with its “cost structure.” It’s hard to find any criticism about what Cunningham had accomplished. He took a company whose previous top management was indicted for alleged Medicaid fraud in its home state of Florida, rapidly settled the litigation at both the federal and state levels, and achieved steady growth in revenues and net income on both the Medicare Advantage (MA) and Medicaid sides of its business. WellCare even got back in Florida’s good graces, and the company wound up winning eight regions in the state’s recent Medicaid managed care procurement. So what else might be involved here? Securities analyst Brian Wright of Monness Crespi Hardt wondered in a Nov. 1 research note if one factor is that “a company with as much growth ahead of it with an interim CEO becomes a more intriguing acquisition candidate.” But Gallitano, who has been president of a private investment firm for the past 11 years, sought to dampen that speculation, saying the board is not pursuing such a possibility, nor does it intend to. Analyst Carl McDonald of Citigroup Global Markets, also not clear on the reason, mused in a research note the same day, “The board must have been pretty unhappy…since this kind of change creates a significant distraction, particularly for the senior executives hired by Cunningham.” Gallitano himself praised that executive team and said any would-be CEO who wanted to bring in a whole new top management would have a significant red mark against his or her candidacy. What do you think happened to cause the shake-up? Is it a simple case of the company now being at a different stage and needing a different kind of leader? Is it perhaps due to needing someone new to slash costs in the face of the coming MA pay cuts? Will we ever know?

Health Care Cost Trend Hits Historic Lows, But Does the ACA Get the Credit?

By Neal Learner - November 4, 2013 Medical cost trends have dropped to historically low levels in recent years. While President Obama has credited the Affordable Care Act for helping to slow the growth rate in medical spending, others counter that the trend is a lingering effect of the 2008 recession, and that the ACA will, in fact, drive up costs going forward. Still, many experts note that certain ACA provisions, such as financial penalties on hospital readmissions under Medicare, have played a role in moderating health care spending. Among recent reports documenting the lower cost trend: • CMS on Oct. 28 said that health care reform efforts are “eliciting significant out-of-pocket savings for Medicare beneficiaries,” and that there will be “zero growth” in 2014 Medicare Part B premiums and deductibles, as well as more than $8 billion in cumulative savings in the Medicare Part D drug coverage gap known as the “donut hole.” • The liberal Center for American Progress on Oct. 21 said that “intense price competition among health plans in the marketplaces for individuals has lowered premiums below projected levels,” and as a result, the federal government will save about $190 billion over the next 10 years. • The 2014 Segal Health Plan Cost Trend Survey on Oct. 10 said the health plan cost trend rates show the slowest growth in 14 years of trend forecasts. For example, the 2014 HMO trend rate projection is 7%, nearly a percentage point lower than HMO projections from 2013 (7.9%). • The CMS Office of the Actuary in the September issue of Health Affairs said the health spending growth rate in 2013 was near 4%. And the expected growth for 2014 is 6.1%, with an average projected growth of 6.2% per year thereafter, the study said. • The nonpartisan Health Care Cost Institute on Sept. 24 said “health care cost growth remained historically low” in 2012, growing 4.0%, slightly lower than the 2011 rate of 4.1%. The effect of the ACA on medical costs is still evolving, says one insurance executive. “It’s fair to say the ACA has some impact on health care costs in both directions,” notes Andrea Walsh, executive vice president of HealthPartners, a Minnesota-based not-for-profit insurer. “In some cases the ACA provisions will help signal the slowing of health care costs that we need to see in this country. And with other provisions, the changes will increase health care costs. It’s not a simple answer.” Joseph Fifer, president and CEO of the Healthcare Financial Management Association, notes that roughly 5% of a health plan’s membership typically accounts for roughly 50% of all medical claims, and that most of the dollars go to managing chronic conditions. Fifer contends this fact doesn’t get enough attention. “What if we focused on much better and much more coordinated care for them?” he says of these members. “Wouldn’t we get a better result for them and a lower cost structure, or take some of the pressure off of the cost side? Where most of the dollars are spent is not getting the attention.” Question: How does the ACA factor into the cost trend, and what factors could really bring costs down?

According to a poll taken on October 17th through 23rd:

• 48% of people think the federal government has done a poor job of implementing the Affordable Care Act (ACA) • 32% think the government has done an “only fair” job of implementing the ACA • 47% want to expand the ACA or keep it as is, while 37% want to repeal it • 44% say they still don't have enough information to understand how the ACA will impact them and their families Source: " Troubles Don’t Change Public’s View Of Health Law, Poll Finds," Kaiser Health News/Capsules Blog, November 1, 2013, /

Quote of the Day

“This is about an insurance company manipulating the situation and concealing the facts. We are asking the court to give our clients and everybody else in the same situation the option of going back to their grandfathered policies.” — William Shernoff, an attorney for plaintiffs in a lawsuit against Anthem Blue Cross, told the Los Angeles Times. The suit involves two Calif. residents who claim the insurer misled them into giving up their plans.

Today's Datapoint

17 million … people who are now uninsured or who buy individual insurance will be eligible for premium tax credits in 2014 under the Affordable Care Act, according to a new study by the Kaiser Family Foundation.

Thursday, November 7, 2013

States That Do Not Plan On Expanding Medicaid Their Resulting Potential Employer Shared Responsibility Liability Amounts 1. AL $29.7 to 445 million 2. ID $12.3 to $18.5 million 3. IA $12.8 to $19.1 million 4. GA $71.7 to $107.5 million 5. LA $51.7 to $77.6 million 6. ME $3.5 to $5.2 million 7. MS $21.7 to $32.6 million 8. NC $65.6 to $98.3 million 9. OK $35.1 to $52.6 million 10. PA $56.7 to $85, million 11. SC $30.4 to $45.7 million 12. SD $5.4 to $8.1 million 13. TX $298.6 to $447.9 million 14. WI $24.1 to $36.1 million Source:Jackson Hewitt Tax Service Inc.

Obesity Rates by Age Group

1. 20-39 - 30.3% 2. 40-59 - 39.5% 3. 60+ - 35.4% 4. All Adults Over 20 - 34.9% Source: CDC/National Center for Health Statistics

8 Ways to Reduce Federal Health Spending and Improve Prescription Drug Benefits in Medicare and Medicade

1. Modernize Medicaid Pharmacy 2. Create 'Safe Pharmacies' in Part D for Controlled Prescription Drugs 3. Greater Use of Preferred and Limited Pharmacy Networks in Medicare 4. Encourage Chronic Care Pharmacy and Home Delivery in Medicare 5. Allow Medicare Plans to Negotiate Discounts on Every Brand Drug 6. Increase Cost-Sharing Incentives for Part D Low Income Subsidy (LIS) Enrollees to Use 7. Expedite the Approval of Biogenerics 8. Ban a Tax Deduction for Direct-to-Consumer (DTC) Drug Advertising Source: Pharmaceutical Care Management Association (PCMA)

Medicare Advantage Trends for 2014

1. The average MA premium is projected to increase by only $1.64 from last year, coming to $32.60. 2. Access to the MA program will remain strong, with 99.1% of beneficiaries having access to a plan. 3. The average number of plan choices will remain about the same and access to supplemental benefits remains stable. 4. Since passage of the Affordable Care Act, average MA premiums are down by 9.8 percent. 5. MA quality continues to improve as over one-third of MA contracts will receive four or more stars, which is an increase from 28 percent in 2013. 6. Over half of MA enrollees are enrolled in plans with four or more stars, a significant increase from 37 percent of enrollees last year. Source: U.S. Department of Health & Human Services

Recent Key Trends and Statistics on Obesity

1. More than one-third (34.9%) of adults were obese in 2011–2012. 2. In 2011–2012, the prevalence of obesity was higher among middle-aged adults (39.5%) than among younger (30.3%) or older (35.4%) adults. 3. The overall prevalence of obesity did not differ between men and women in 2011–2012. 4. The prevalence of obesity among adults did not change between 2009–2010 and 2011–2012. Source: CDC/National Center for Health Statistics

Top 5 mobile medical device security risks (according to the DHS)

1. Insider: The most common ways employees steal data involved network transfer, be that email, remote access, or file transfer 2. Malware: These include keystroke loggers and Trojans, tailored to harvest easily accessible data once inside the network 3. Spearphishing: This highly-customized technique involves an email-based attack carrying malicious attack disguised as coming from a legitimate source, and seeking specific information 4. 4.Web: DHS lists silent redirection, obfuscated JavaScript and search engine optimization poisoning among ways to penetrate a network then, ultimately, access an organization’s data 5. Lost equipment: A significant problem because it happens so frequently, even a smartphone in the wrong hands can be a gateway into a health entity’s network and records Source: U.S. Department of Health & Human Services

Electronic Health Records as a Predictor of Physician's Electronic Exchange Capability

1. 55 percent of all physicians had computerized capability to send prescriptions electronically vs. 78 percent of physicians with an EHR. 2. 67 percent of all physicians could view electronic lab results vs. 87 percent of physicians with an EHR. than among younger (30.3%) or older (35.4%) adults. 3. 3.42 percent could incorporate lab results into their EHR vs. 73 percent of physicians with an EHR. 4. 35 percent could send an electronic order to a lab vs. 54 percent of physicians with an EHR. 5. 38 percent could provide clinical summaries to patients vs. 61 percent of physicians with an EHR. 6. 31 percent exchanged patient clinical summaries with another provider vs. 49 percent of physicians with an EHR. Source: U.S. Department of Health & Human Services

According to a recent study

89% of participating emergency department clinicians said that having access to a health information exchange (HIE) improved the quality of patient care, and 82% said that access to the HIE saved time, with a mean time savings of 105 minutes per patient Source: "Health Information Exchange Saves $1 Million in Emergency Care Costs for Medicare," American College of Emergency Physicians Press Release, October 14, 2013,

According to a recent study

of the adjusted cost of acute care for injured patients transported by EMS to hospitals in 7 regions: • The average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital • 34.3% of low-risk patients—those who did not meet field triage guidelines for transport to trauma centers—were transported to major trauma centers, accounting for up to 40% of acute injury costs • Following field triage guidelines to minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions studied Source: "The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers," Health Affairs, abstract only, September 2013,


According to a recent survey of healthcare providers regarding bundled payment models, which package out- and in-patient costs, professional fees and post-discharge costs related to specific conditions into one payment: • 38% are already working with bundled payments • 24% are not yet working with bundled payments, but plan to do so • 36% are undecided about developing bundled payments • 2% said that they had no intention to offer bundle payment plans Source: "Bundled Payments Increasingly Attractive To Hospitals And Medical Groups: KPMG Survey," KPMG LLP News Release, October 22, 2013,

For patients aged 65 and older

13.5% of emergency department visits in 2009-2010 were for falls, and 29.1% were for injuries of any sort. Source: "Emergency Department Visits by Persons Aged 65 and Over: United States, 2009–2010," Centers for Disease Control and Prevention, NCHS Data Brief Number 132, October 2013,


The number of Americans using mobile phones for health information or tools rose from 75 million in 2012 to 95 million in 2013, according to new research. Source: U.S. mobile health audience jumps to 95 million adults – new research highlights mobile opportunities for pharma marketers, Manhattan Research, October 24, 2013,

Quote of the Day

“What will we know come springtime when we’re doing our 2015 ratings [for product pricing on public exchanges] that we didn’t know when we were doing it for the 2014 rating? The short answer is that we won’t know that much more. At most, carriers will have just three months of claims history by the time they file their 2015 rates.” — Catherine Murphy-Barron, a principal and consulting actuary at Milliman, told AIS’s Inside Health Insurance Exchanges.

Today's Datapoint

$2.55 billion … in federal funds will go to Ohio for its recently approved Medicaid expansion, a “major victory” for Gov. John Kasich (R) over GOP lawmakers who control the Ohio legislature and opposed expansion, making Ohio the 25th state (and eighth with a Republican governor) to accept Medicaid expansion under the ACA.

CBO Updates Estimate of Budgetary Effects of Raising Medicare Eligibility Age

The Congressional Budget Office (CBO) recently released a revised estimate of the budgetary effects of increasing the Medicare eligibility age from 65 to 67. Its original estimate, released in January 2012, estimated that increasing the eligibility age for Medicare would create a net savings of $113 billion. The revised report drastically reduces the projected savings to $19 billion. The CBO considered a variety of factors in its analysis. It calculated the savings that would be created by increasing the Medicare eligibility age by two months every year starting with people born in 1951 until the eligibility age has reached 67 for people born in 1962 (who turn 67 in 2029).This change would create some savings for Medicare, since fewer people would be eligible. It would also slightly decrease Social Security payments because some people would either delay applying for benefits until they are eligible for Medicare or continue working until they are eligible for Medicare. Yet, increasing the eligibility age will also increase government costs by: • Increasing Medicaid spending for: o People who would have been dually eligible for Medicare and Medicaid under current law will become solely be covered by Medicaid for an additional two years; and o People who would not have qualified for Medicaid when they turned 65, will have Medicaid for an additional two years (assuming Medicaid changes its age guidelines along with Medicare). • Increasing spending for subsidies though the Marketplaces (insurance exchanges) for people who currently do not qualify for subsidies due to Medicare eligibility. The CBO’s new estimate is much lower for a few reasons. First, the population that would no longer qualify for Medicare (people age 65 to 66) is relatively healthy, compared to the rest of the Medicare population. Their coverage would not cost as much as originally projected. Second, many people who are 65 to 66 years of age are still working, or have a spouse who is still working. They are usually covered by employer insurance. If the employer is considered a large employer, its insurance pays primary to Medicare, and their employees can delay enrollment into Medicare Part B until retirement. This means that they add very little coverage costs to Medicare. The CBO’s inclusion of a more complete analysis provides a more accurate picture of the financial effect of increasing Medicare’s eligibility age. The analysis also estimates that this change would cause an additional 550,000 seniors to become uninsured. The CBO’s modified estimates provide further evidence that increasing the Medicare eligibility age would not benefit seniors or significantly reduce government costs. Medicare Rights urges Congress and advocates to seek responsible adjustments to secure Medicare savings, not proposals that merely shift costs to people with Medicare or to states or to employers.

Producers: California not exchange paradise

By Danni Santana NOVEMBER 5, 2013 At first glance, the Covered California exchange enrollment system seems to be functioning better -- and more transparently -- than the federal exchanges' enrollment site. The California exchange site has managed to bring in about 179,000 coverage applications since enrollment opened to the public Oct. 1. But agents and brokers in California warn against assuming that Covered California is working the way it ought to work. Problems with the California enrollment system include a faulty provider directory, continuing delays with agent certification, continuing delays with final plan approvals, and software bugs. Before the Patient Protection and Affordable Care Act (PPACA) exchange program came along, health plans were not always quick to make individual health plan provider directories available at point of sale. Consumers often had to call their favorite doctors and hospitals to make sure the providers were in network. But consumers generally knew they were dealing with large, well-established carriers with big provider networks. Today, the carriers selling "qualified health plans" (QHPs) through Covered California are holding premiums down by using new, narrow provider networks. In some cases, providers may not know whether they're in those provider networks. Looking at a QHP's online provider directory may be the only practical way to find out which providers are in a network without filing a claim. Managers of Covered California added a provider directory to great fanfare shortly after the enrollment site launch, then uncovered directory system errors, including inaccurate profiles of doctors and hospitals. Covered California took down the directory component of its site for maintenance. At press time, the directory was still not routinely available. Neil Cosby, director of sales at Warner Pacific Insurance Services, said in an interview that the persistence of a huge backlog of agents awaiting certification as exchange agents is another dire enrollment system problem. To get certified, health agents must take an eight-hour class in person, then take a four-hour online class and an online test. Currently, the delays between these steps can last as long as a week or two. Cosby, who teaches certification courses on behalf of Covered California, said exchange managers are working to fix the problems, but thousands of agents who have completed the certification process are still waiting to be integrated into the Covered California system. Alison Gordon, a self-employed health broker in California, said the rollout of the certification process for brokers has been an abomination. “The class I was a part of was not even taught by a broker," Gordon said. "The instructor knew nothing about health. It wasn’t the case for all classes I hear, but it was in mine.” Meanwhile, the agents who are certified may find that they lack the details they need to recommend plans to consumers. The California Department of Insurance, the agency responsible for approving QHP prices and benefits, has failed to issue final approvals. Kathy Hope, a Huntington Beach broker, said the planning of the enrollment program has been ridiculous. “All I’ve been doing is schmoozing with clients hoping they will come back to me,” Hope said. Gordon said only applicants who have low incomes and can qualify for subsidies are getting through the application process. But Covered California isn’t passing the information from the completed applications along to carriers, and she wonders if that's because the carriers themselves lack the final certifications they need to sell coverage through the exchange. “The stats released are bogus," Gordon said. "When they say they got 36,000 calls in one week, it’s because the website isn’t up and working properly.” Producers also see many site errors. After agents and brokers enter the required information, they often receive error messages preventing them from actually using the online portal. The producers then have to send consumers links consumers can use to download paper applications. “I had a client try to enroll without me and was getting the same error messages,” Hope said. “It’s 2013 and people are being asked to fill out applications by hand. That site is too complicated.” Finally, some producers still wonder whether Covered California managers are simply trying to crowd them out of the exchange plan market. Both Hope and Gordon said they believe that Covered California is discouraging consumer use of agents and brokers. Instead, the producers said, exchange managers are encouraging consumers to use "enrollment counselors" who have gone through minimal training and are not required to advise customers, just enroll them in plans. “They recommend use of enrollment counselors and are discriminating against agents who know more,” Hope said. “It’s maddening.” In response, Covered California Spokesman Larry Hicks emphasized how much Covered California values agents, saying agents represent one of the key channels for providing insurance for uninsured Californians. The exchange already has 3,200 agents certified and has about 19,000 more agents in the certification pipeline. Once they're all certified, they will greatly outnumber enrollment counselors, Hicks said. “I apologize for the frustration felt by the agent community in regards to the pace of the certification process and the glitches to our site, but we are working incredibly hard to fix it,” Hicks said. “There is no intent to discourage agents.”

Wednesday, November 6, 2013

Today's Datapoint

10% to 15% … of the contracts UnitedHealth Group’s UnitedHealthcare unit has with physicians participating in the insurer’s Medicare Advantage network will be terminated by the carrier effective Feb. 1, 2014, according to the New Jersey Star-Ledger.

Quote of the Day

“All of [the other issues related to Affordable Care Act implementation] are fine and good, but if the Web site doesn’t work, nothing else matters.” — How President Obama ended regular staff meetings since last spring that were devoted to monitoring progress with ACA implementation, according to a White House official quoted by The Washington Post for a Nov. 3 story.

Monday, November 4, 2013

Today's Datapoint

70% … of Medicare’s nearly 1,200 regional Prescription Drug Plans on the market now offer a preferred pharmacy arrangement, according to estimates by Pembroke Consulting’s President Adam Fein, Ph.D., in his blog.

Quote of the Day

“Many consumers may not take kindly to losing [the health plan coverage] they have and currently value. From a consumer perspective, sometimes less is more. The situation consumers face today in health care is like forcing a consumer to upgrade to Windows 8 when they are just thrilled with the features and functionality of Windows 7. But the reality is the government is a market leader in health care. Consumers need to work to make their views known in a variety of ways to frame the debate on how ACA evolves to meet the diversity of consumer needs.” — Fred Karutz, senior VP of business development at Connected Health, told AIS’s Health Plan Week.

Friday, November 1, 2013

Expect narrower Medicare Advantage networks

By Allison Bell JULY 18, 2013 Looming Medicare Advantage plan network and benefits cuts overshadowed health insurance exchange moves today during UnitedHealth Group Inc.'s second-quarter earnings call. UnitedHealth (NYSE:UNH) is reporting $1.4 billion for the latest quarter on $30 billion in revenue, up from $1.3 billion on $27 billion in revenue for the second quarter of 2012. The company ended the quarter providing or administering medical coverage for 45 million people, up from 36 million a year earlier, in part because of the addition of a major TRICARE contract. Enrollment in insured commercial plans fell to 8.1 million, from 9.3 million, and enrollment in commercial self-insured plans increased to 19 million, from 17 million. Gail Boudreaux, the company's executive vice president, said during the earnings call that the company expects to sell coverage through Patient Protection and Affordable Care Act (PPACA) exchanges in about a dozen states in 2014 and sees the exchanges as a huge opportunity over the long term. But executives spent much more time talking about how federal funding cuts could affect their 2014 Medicare Advantage plan line. The Medicare Advantage program gives private companies a chance to sell plans that substitute for the traditional Medicare plan program to Medicare enrollees. Enrollment in the company's Medicare Advantage plans rose to 2.9 mllion in the second quarter, from 2.5 million a year earlier. Stephen Hemsley, UnitedHealth's president, said the company is the largest, fastest-growing player in the Medicare Advantage market. The government is trying to reduce the gap between Medicare Advantage and traditional Medicare program funding, and funding should be at parity by 2016, Hemsley said. Until 2016, "significant underfunding" of Medicare Advantage will put pressure on UnitedHealth to cut plan costs by "shaping" provider networks and trimming benefits, Hemsley said. Once the Medicare Advantage program and traditional Medicare are at parity, Medicare Advantage "will continue to deliver better benefits at lower costs because of effective medical cost management and far better consumer-focused services and technologies," Hemsley said. The benefits reductions could be "fairly broad-based," Hemsley said. In the past, Hemsley said, UnitedHealth Medicare Advantage plans have offered relatively open-access to providers. 2Egde_4245113_member_5800998794107576320#%21