Thursday, January 23, 2014

Why Privately Insured Seek Care in Emergency Departments

Patients' perception of the severity of their medical problem and who they first contact for help or advice are the factors most associated with whether they seek emergency care, according to a Center for Studying Health System Change (HSC) study based on the National Institute for Health Care Reform's (NIHCR) 2012 Autoworker Health Care Survey. Nearly a quarter of respondents (23%) reported having an urgent medical problem in the three months before the survey, and almost half (44%) of those with an urgent condition ultimately went to an emergency department for treatment. Of people with an urgent problem, nearly half first contacted their regular source of care-typically a primary care clinician-and those patients were less likely to go to emergency departments, the study found. Source: Center for Studying Health System Change (HSC)

Most Boomers Mistakenly Think Affordable Care Act Covers Long-Term Care Costs

Nationwide Financial Retirement Institute annual survey shows boomers’ estimates for long-term care costs drop by more than 50 percent in one year Nationwide January 21, 2014 10:30 AM COLUMBUS, Ohio--(BUSINESS WIRE)-- More than seven in 10 affluent baby boomers mistakenly think the Affordable Care Act will cover their long-term care (LTC) costs in retirement. The Nationwide Financial Retirement Institute’s annual survey, released today, also reveals that while boomers desperately want to receive LTC in their home, few are adequately planning for the costs – and many are not planning at all. According to the poll conducted by Harris Interactive of 801 Americans over 50 with at least $150,000 in household income, only 28 percent know that the Affordable Care Act does not cover LTC costs. Nearly half say they are worried about becoming a burden to their families, but 54 percent say they would rather die than live in a nursing home. “Neither the Affordable Care Act nor Medicare will help America’s workers pay their long-term care costs,” said John Carter, president and chief operating officer of Retirement Plans, Nationwide Financial. “Virtually no one wants to end up in a nursing home, but few are planning for long-term care costs. And if they have to rely on Medicaid, they may not have a choice.” According to the poll, affluent boomers expect their LTC costs to be on average $36,220 annually. That is less than half of what they estimated in 2012 ($78,920). The reality is by 2030 – the year the last of the baby boomers will reach retirement age – the cost of a nursing home (which is just one form of LTC) is expected to reach $265,000 per year. 1 “This drastic drop could be due to the media’s focus on the Affordable Care Act and people’s misconceptions about what it covers,” Carter said. “The reality is we can’t count on someone else to fix this problem. We will have to fund our own long-term care costs in retirement.” According to the survey, 71 percent of affluent pre-retirees want to receive LTC in their own home, but fewer than half think they will actually receive LTC in their home. Two in five think they will end up in an assisted living facility, and one in 10 think they will be in a nursing home. Opportunity for advisors Industry figures show many are in denial that they will ever need LTC, so they never plan for it. However, the U.S. Department of Health and Human Services estimates that 70 percent of Americans over age 65 will need LTC during their lifetime. 2 Nearly four in five (78 percent) say that when they hear the term “long-term care” they think of nursing home care. In actuality, nearly half of all LTC happens at home, with a little over a quarter (27 percent) taking place in a nursing home and 24 percent in adult day care. 3 “The most common mistake a financial advisor makes is his or her approach to the discussion. When an advisor says the words ‘long-term care,’ the client often hears ‘nursing home,’” said Kevin McGarry, director of the Nationwide Financial Retirement Institute. “This often causes the client to shut down. Instead, advisors should say: ‘Let’s talk about ways we can keep you in your home longer.’” “The next step is to get a fact-based estimate of what those long-term care costs may be and work to build a plan from there,” McGarry said. “Four in five advisors say they know if they can have these discussions, their clients will be more likely to stay with them.” Financial advisors can visit to learn more. Methodology: The 2013 Health Care and Long-term Care Costs Study was conducted online within the U.S. by Harris Interactive on behalf of Nationwide Financial between Sept. 24 and Oct. 1, 2013. The respondents comprised a representative sample of 801 U.S. adults aged 50 or older with annual household incomes of $150,000 or higher. Results were weighted to the U.S. General Online Population of adults by sex, race/ethnicity, education and region. Respondents for this survey were selected from among those who have agreed to participate in Harris Interactive surveys. Because the sample is based on those who were invited to participate in the Harris Interactive online research panel, no estimates of theoretical sampling error can be calculated. About Nationwide Nationwide Mutual Insurance Company, based in Columbus, Ohio, is one of the largest and strongest diversified insurance and financial services organizations in the U.S. and is rated A+ by both A.M. Best and Standard & Poor’s. The company provides customers a full range of insurance and financial services, including auto insurance, motorcycle, boat, homeowners, pet, life insurance, farm, commercial insurance, annuities, mortgages, mutual funds, pensions, long-term savings plans and specialty health services. For more information, visit Life insurance is issued by Nationwide Life Insurance Company or Nationwide Life and Annuity Insurance Company, Columbus, Ohio. Nationwide, Nationwide Financial, the Nationwide framemark, Nationwide YourLife and On Your Side are service marks of Nationwide Mutual Insurance Company. 1 Life and Health Advisor, “Don’t Let Your Clients Get Blindsided By Unexpected LTC Costs,” 2010 2 LTCI’s Revolutionary Evolution, Nov. 1, 2011, Life Insurance Selling 3 American Association for Long-term Care Insurance (AALTCI) 2011 Sourcebook Contact: Nationwide Charley Gillespie, 614-249-5701

Wednesday, January 22, 2014

Now Hear This!

Posted by Medicare Made Clear Tue, Dec 24, 2013 @ 09:00 AM This time of the year can be filled with festive gatherings. But some settings can get loud and make it hard for people who have trouble hearing. Some people with hearing loss start to avoid social situations. But isolation may lead to feelings of loneliness and depression. There can be many reasons for hearing loss. It’s possible for parents to pass it on to their children. Other causes may include: • Loud noises. • Head injuries. • Ear infections. • Certain medications. People with mild to moderate hearing loss are least likely to use hearing aids.1 Some of their reasons include concerns about looking old, and the cost. Many insurance plans, including Medicare Part B, do not cover the cost of hearing aids, fittings or screening tests. The exception is when your doctor thinks your hearing loss may be due to a recent injury or illness. Under those circumstances, your doctor’s order for hearing tests may be covered by Medicare. Your deductible and copay may apply. Some Medicare Advantage (Part C) plans offer coverage for hearing aids and screening tests. Insurance plan coverage for hearing aids varies. Review your Summary of Benefits and Coverage to find out if you are covered. If you are covered, you may have to follow certain rules, or buy from approved suppliers. In some cases, Medicaid, the U.S. Department of Veterans Affairs, or state programs may offer financial assistance or reduced cost hearing aids. If you or a loved one has trouble hearing, it’s a good idea to talk with your doctor. Hearing loss is not just inconvenient; it’s a serious health condition. Older adults with hearing loss are five times more likely to get dementia than people with normal hearing.2 Life is full of beautiful sounds like church bells and children’s laughter. Make sure you don’t miss a minute of it. Better hearing may lead to a better life! For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. 1. The American Speech-Language-Hearing Association, 2013 2. Archive of Neurology, Feb 2011 Resources: State Benefits Guide: Learn how to apply for your state’s financial assistance programs. Read about Medicare Part B coverage for hearing aids and diagnostic tests NIDCD: The National Institute on Deafness and Other Communication Disorders Y0066_131212_081905 Accepted

Today's Datapoint

8.7% … of Medicare Advantage premiums in 2012 were devoted to median administrative costs, according to Sherlock Co.’s annual survey of health plan administrative expenses.

Quote of the Day

“The biggest [compliance risk in the year ahead] is electronic health records. I saw one that was 500 pages for just six days. It was not articulated in a very good way and kept repeating lab values. There was a lot of stuff written that was not germane to what an auditor might look at, and auditors won’t infer.” — William Malm, senior data projects manager at Craneware in Atlanta, told AIS’s Report on Medicare Compliance.

Monday, January 20, 2014

Today's Datapoint

63% … of the 7 million uninsured non-elderly people in California are now eligible for either Medicaid or subsidized coverage through the state’s exchange, according to information posted recently by the Kaiser Family Foundation.

Quote of the Day

Narrow network products that often don’t include out-of-network coverage are “likely to result in increased member complaints and litigation regarding access to providers…and pressure on plans to expand the networks. The likely result will be some increase in the network sizes, more products with out-of-network coverage, but ultimately, consumers will likely adjust as they view the cost differences in those products.” With expanded choices, “the market can answer whether consumers value provider choice over lower cost.” — Jack Rovner, a founding attorney and member of The Health Law Consultancy in Chicago, told AIS’s Inside Health Insurance Exchanges.

Friday, January 17, 2014

According to a recent survey:

• 80% of patients say they would be less frustrated if they knew how long their wait time would be • 45% of patients wait less than 15 minutes to see a doctor, and 85% are seen in 30 minutes or less • Although 97% of patients are frustrated by waiting to see a doctor, only 22% would pay a small fee to see the doctor more quickly Source: How to Treat Patient Wait-Time Woes: IndustryView 2013, Software Advice, December 16, 2013,

What Liberals Don’t Get About Single Payer

By Ezra Klein Jan 8, 2014 5:01 PM CT (Corrects reference to foreign health systems similar to Obamacare in paragraph 9.) Documentarian Michael Moore greeted the introduction of Obamacare with an admission many liberals will cheer. “Obamacare is awful,” he wrote. Its awfulness, Moore said, stems from “one fatal flaw: The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go.” Like Moore, I’d prefer a more nationalized health-care system. But his analysis relies on a common mistake that distorts both the benefits of single-payer systems and the deficiencies peculiar to Obamacare. Insurers are the bogeymen of American health care. That’s in part because they do a lot of the unpopular stuff: They’re the ones who charge you money for health care, who say you can’t get something you want, who your bosses blame when they deduct more money from your paycheck to cover health costs. And it’s hard to see what value they add to the system. Yet the problem with the Affordable Care Act isn’t the insurance industry. In fact, the main benefits of nationalized health care can be achieved in systems with hundreds, even thousands, of for-profit insurers. Insurers aren’t even where the big money goes. In 2009, Forbes ranked health insurance as the 35th most profitable industry, with an anemic 2.2 percent return on revenue. To understand why the U.S. health-care system is so expensive, you need to travel higher up the Forbes list. The pharmaceutical industry was in third place, with a 19.9 percent return, and the medical products and equipment industry was right behind it, with a 16.3 percent return. Meanwhile, doctors are more likely than members of any other profession to have incomes in the top 1 percent. In general, Americans don’t use more health care than citizens of other countries. But we pay a lot more for the health care we do get. Data gathered by the International Federation of Health Plans show that an MRI costs, on average, $1,121 in the U.S. and $363 in France. An appendectomy costs $13,851 in the U.S. and $4,782 in Switzerland. A birth by cesarean section costs $3,676 in the U.S. and $606 in Canada. A bottle of Nexium -- a common acid-reflux drug -- costs $202 in the U.S. and $32 in the U.K. The dirty truth about American health care is that it costs more not because insurers are so powerful, but because they’re so weak. There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers. Yet all these countries pay vastly less for drugs, surgeries or doctor visits than Americans do. Why? Because in every case the government sets prices for health-care services and products. Insurers in Switzerland don’t negotiate drug prizes with Pfizer. The Swiss government simply sets its drug prices and lets Pfizer decide whether to sell in Switzerland -- or not. “The problem is that in the U.S. payers are fragmented while in other countries they are unified even if there are many insurers,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University. In the U.S., insurers negotiate with hospitals and drug companies on their own -- and they pay more as a result. In fact, because of their weak negotiating position they frequently use whatever price Medicare is paying as a baseline and then, because they lack the power to strike a similar deal, add a percentage on top. Joshua Gottlieb, an economist at the University of British Columbia, found that when Medicare increases what it pays for a service by $1, private insurers increase their payments by $1.30. That leaves the U.S. with the worst of both approaches: Prices aren’t set by the market, but they also aren’t set by the government. Consequently, Medicare’s negotiating power is weakened by the threat that drug companies or hospitals will opt to do business only with higher-paying private insurers. We simultaneously miss out on the efficiency of a purely private system and on the savings of a purely public one. If insurers lose on negotiating with medical providers, however, they’re much better than the government at innovating on insurance design. Co-pays and deductibles aren’t popular, but they work. Many insurers are experimenting with ways to create incentives for better health, including using personal technology -- everything from e-mails to smartphone cameras. (The disastrous introduction of the Obama administration’s website hardly instills confidence in the government’s capacity to exploit digital medicine with similar efficiency.) “Single payer isn’t a panacea,” said Uwe Reinhardt, a health economist at Princeton University. “The magic they have is setting rates. But neither Medicare nor Canada has done anything innovative on the delivery side. Taiwan is trying a little bit but not a whole lot. By and large they just pay bills.” The limitations of single-payer systems became clear during the health-care debate, when the Congressional Budget Office projected that premiums for a public option would be higher than premiums for private insurance -- unless a public option could avail itself of Medicare’s pricing power. A health-care system that followed international best practices would direct the government to set rates. Or it would let insurers band together and negotiate rates collectively -- a practice called “all-payer rate setting.” But it wouldn’t need to eliminate private insurers. It’s good for consumers to have a choice of insurers, who have real incentives to innovate and devise better ways to keep customers healthy and costs down. It’s health-care providers -- not insurers -- who have too much power in the U.S. system. As a result, they have the most to lose if health-care prices fall. But, as is often the case, political power flows in part from popularity. So politicians who routinely rail against for-profit insurers are scared to criticize -- much less legislate against -- for-profit hospitals, doctors or device manufacturers (though drug companies come in for a drubbing now and then). These are the people who work every day to save our lives, even if they make us pay dearly for the privilege. (Ezra Klein is a Bloomberg View columnist.)

Quote of the Day

“Carriers that initially were reticent [about private insurance exchanges] are now saying that in five years, this will be the way every company purchases their benefits. We are on the cusp now of a seismic shift in the way people ascertain their health insurance.” — Alan Cohen, co-founder and chief strategy officer for Liazon Corp., a developer of private exchanges that was acquired by Towers Watson in November, told AIS’s Inside Health Insurance Exchanges.

Today's Datapoint

35% … more mammograms were performed year-over-year by Anthem Blue Cross of California’s four ACO partners, which also achieved a 44% increase in appropriate prescribing of antibiotics for bronchitis treatment.

Alcohol Consumption as a Cause of Death in The Americas

Men accounted for 84% of all deaths in which alcohol was a necessary cause. However, the ratio male/female varied widely among countries. The risk of a man dying from an alcohol fully-related cause in El Salvador was 27.8 times higher than that of a woman, 18.9 in Nicaragua and 14.8 in Cuba. On the low end of the scale, the male mortality risk was 3.2 times higher than the female mortality risk in Canada and the USA, and 4.3 in Peru. The risk of dying from alcohol consumption also differed by age group. In Argentina, Canada, Costa Rica, Cuba, Paraguay and the USA, the highest mortality rates were seen among those aged 50-69 years. In Brazil, Ecuador and Venezuela, the rates started increasing from 40-49 years of age, remained stable, and then dropped after age 70. Mexico showed a different pattern, the risk of death escalating throughout life and reaching its peak after age 70. Each of those countries has a life expectancy of over 70 years. Source: Addiction

Wednesday, January 15, 2014

According to a baseline study of early Accountable Care Organizations (ACOs)

...ACO patients had 5.8% lower total costs of care than non-ACO patients ($7,694 vs. $8,164). Source: 'Analysis of Early Accountable Care Organizations Defines Patient, Structural, Cost, and Quality-of-Care Characteristics," The Commonwealth Fund, January 6, 2014,

CMS wants to overhaul Medicare broker comp

By Allison Bell JANUARY 6, 2014 The Centers for Medicare & Medicaid Services (CMS) wants to make big changes in the way private Medicare plans pay agents and brokers. CMS, an arm of the U.S. Department of Health and Human Services (HHS), has included agent and broker compensation proposals in a batch of regulations that are set to appear in the Federal Register Friday. In the regulations, CMS deals with matters such as the rules governing Medicare wellness program incentives and provisions meant to prevent and attack fraud. In the Medicare producer compensation sections, officials talk about how plans pay the agents and brokers who sell Medicare Advantage plans -- commercial, CMS-subsidized plans that replace traditional Medicare coverage -- and Medicare Part D prescription drug plans. CMS wants to come up with a "fair market value" limit for producer compensation every year, officials say in a preamble to the proposed regulations. Officials suggest that the first fair market value might be $400 per year. A plan could pay a first-year commission that was any amount less than or equal to the fair market value limit, officials say. In the second year and later years, the commission could be up to 35 percent of the fair market value limit in effect during that calendar year. If a producer sold a plan in 2014, for example, and collected a commission equal to $400, or 100 percent of the fair market level, in 2014, and the fair market value level rose to $500 in 2015, the second-year commission would be $175, or 35 percent of $500, not 35 percent of $400, officials say. Today, many plans pay a renewal commission of 50 percent of the first-year commission during policy years two through seven, then a renewal commission of 25 percent of the first-year commission in later years, officials say. Setting all renewal commissions at 35 percent of the fair market value limit would simplify commission calculations. Officials say they also want to cap referral fees for producers at $100. CMS recommended a $100 limit in a memo in 2011. Today, carriers handle referral fees in different ways, and that creates an uneven playing field, officials say. Comments on the draft regulations are due March 7.

CMS: 4 Facts About Declining Readmissions Rates for Medicare Beneficiaries

1. Between 2007 and 2011, the all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries held constant at around 19% 2. The Medicare all-cause 30-day readmission rate fell to 18.5% in 2012 3. Between Jan.1st and Aug. 31st, 2013, the Medicare all-cause readmission rate was less than 18% 4. Utah, the only state in which Medicare readmissions rates did not decline, already had one of the lowest readmissions rates in the country Source: The CMS Blog, December 6, 2013

According to a recent report:

• “Consumer-driven” and high-deductible health plans now cover 28% of those with health insurance • 9.7% of the population is enrolled in a consumer-driven health plan (CDHP) • Enrollment in high-deductible health plans (HDHPs) increased from 16% in 2012 to 18% in 2013 Source: "HSA Enrollments Grow, Health Reimbursement Arrangements Shrink," Employee Benefit Research Institute (EBRI), December 17, 2013,

HHS strengthens community living options for older Americans and people with disabilities

The Centers for Medicare & Medicaid Services (CMS) issued a final rule today to ensure that Medicaid’s home and community-based services programs provide full access to the benefits of community living and offer services in the most integrated settings. The rule, as part of the Affordable Care Act, supports the Department of Health and Human Services’ Community Living Initiative. The initiative was launched in 2009 to develop and implement innovative strategies to increase opportunities for Americans with disabilities and older adults to enjoy meaningful community living. Under the final rule, Medicaid programs will support home and community-based settings that serve as an alternative to institutional care and that take into account the quality of individuals’ experiences. The final rule includes a transitional period for states to ensure that their programs meet the home and community-based services settings requirements. Technical assistance will also be available for states. “People with disabilities and older adults have a right to live, work, and participate in the greater community. HHS, through its Community Living Initiative, has been expanding and improving the community services necessary to make this a reality,” said HHS Secretary Kathleen Sebelius. “Today’s announcement will help ensure that all people participating in Medicaid home and community-based services programs have full access to the benefits of community living.” In addition to defining home and community-based settings, the final rule implements the Section 1915(i) home and community-based services State Plan option. This includes new flexibility provided by the Affordable Care Act that gives states additional options for expanding home and community-based services and to target services to specific populations. It also amends the 1915(c) home and community-based services waiver program to add new person-centered planning requirements, allow states to combine multiple target populations in one waiver, and streamlines waiver administration. For more information about the final rule, please visit: Sheets For more information regarding the Home and Community-Based Services available under Medicaid, please visit: For more information regarding the Community Living Initiative, please visit:

Today's Datapoint

3.7% … was the increase in health care spending in the U.S. in 2012, the fourth year in a row of near record slow growth, according to a new CMS Office of Actuary report that appeared in the January issue of Health Affairs.

Tuesday, January 14, 2014

Age Distribution of Health-Exchange Enrollees Compared to Age Distribution of Uninsured

Uninsured Population in 2012 Enrollees Through Dec. 28 Under 18 12% 6% 18-24 16% 9% 25-34 25% 15% 35-44 19% 15% 45-54 17% 22% 55-64 11% 33% Source: The Wall Street Journal, Health Sign-Ups Skew Older, Raising Fears of Higher Costs, January 14, 2014

Feds shift Medicaid costs to states

By Allison Bell JANUARY 7, 2014 New health market figures show that private health insurers held spending growth down in 2012. The figures also show that the federal government put some of its Medicaid spending burden on the shoulders of state and local governments that year. Anne Martin, an economist in the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS), and other researchers in the office have included the figures in the government's latest national health expenditures accounts report. Total national health expenditures increased 3.7 percent in 2012, to $2.8 trillion. Spending growth was up slightly from 3.6 percent, but about the same as it's been since 2009. Overall gross domestic product (GDP) grew 4.6 percent. Private health insurers spending increased 3.2 percent, to $917 billion. The only major source of payments that spent less in 2012 was the federal Medicaid funding program. Federal Medicaid spending fell 4.2 percent, to $238 billion. State and local governments increased their spending on Medicaid 15 percent, to $183 billion. The major payer with the second highest spending growth rate, Medicare, had a spending growth rate of just 4.8 percent. The researchers also found that spending on health insurance grew at a moderate rate. The net cost of health insurance -- the difference between the amount consumers, employers and others paid for health insurance and the amount carriers spent on health care -- increased 4.2 percent, to $164 billion. The rate of growth was down from 4.5 percent in 2011 and 10.4 percent in 2010, but it was up from a 1.8 percent decrease in 2009.

According to tracking interviews with more than 1,500 uninsured Americans from Dec. 1-29 2013:

• 26% of uninsured Americans have visited a health insurance exchange website • Of these, 59% said their experience was negative and 39% said their experience was positive • Among uninsured Americans who have visited an exchange, 24% say they went to a federal exchange, 20% to a state exchange, 17% to both, and 37% are unsure Source: U.S. Uninsured Still Rate Exchange Experience Negatively," Press Release, January 2, 2014,

Today's Datapoint

59% … of the inpatient claims reviewed by recovery audit contractors during the first year of a three-year prepayment review demo had improper payments.

Monday, January 13, 2014

According to a recent study

...the monthly adjusted cost during the year following hospitalization for an inpatient surgical procedure was $400 higher for current smokers and $273 higher for former smokers, compared to those who never smoked. Source: "Smoking Status and Health Care Costs in the Perioperative Period: A Population-Based Study," JAMA Surgery, abstract only, January 1, 2014,

National Health Expenditure Growth

According to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary, overall national health expenditures grew at an annual rate of 3.7 percent in 2012, marking the fourth consecutive year of low growth. Health spending as a share of gross domestic product fell slightly from 17.3 percent in 2011 to 17.2 percent in 2012. Private health insurance spending growth remained low. Private health insurance spending continued to grow at a low rate, increasing 3.2 percent in 2012 compared to 3.4 percent growth in 2011. Medicare spending growth continued to be low. Despite a large uptick in Medicare enrollment, Medicare spending growth slowed slightly in 2012, increasing by 4.8 percent compared to 5.0 percent growth in 2011. Total Medicare spending per enrollee grew by only 0.7 percent in 2012. Medicaid spending continued to grow at a historically low rate. Total Medicaid spending grew 3.3 percent in 2012. While an increase over 2011, this increase still represents historically low overall growth rates tied to improved economic conditions, as well as efforts by states to control costs. Prescription drug spending growth was low. Retail prescription drug spending slowed in 2012, growing only 0.4 percent as the result of numerous drugs losing their patent protection, leading to increased sales of lower-cost generics. Nursing home spending growth slowed. Spending for freestanding nursing care facilities and continuing care retirement communities increased by only 1.6 percent in 2012, down from 4.3 percent growth in 2011, due to a one-time Medicare rate adjustment for skilled nursing facilities. Source: Centers for Medicare & Medicaid Services

National Health Expenditures: Average Annual Percent Change from Previous Year

1. 1970 - 10.6% 2. 1980 - 13.1% 3. 1990 - 11.0% 4. 2000 - 6.6% 5. 2001 - 8.4% 6. 2002 - 9.7% 7. 2003 - 8.6% 8. 2004 - 7.2% 9. 2005 - 6.8% 10. 2006 - 6.5% 11. 2007 - 6.3% 12. 2008 - 4.7% 13. 2009 - 3.8% 14. 2010 - 3.8% 15. 2011 - 3.6% 16. 2012 - 3.7% Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group

Influenza Health Alert

Website Update Notice DADS has issued the following Provider Alerts or Bulletins: Influenza Health Alert On December 20, 2013, the Texas Department of State Health Services (DSHS) issued an influenza health alert. Influenza is now widespread across the state, and influenza-like illness activity continues to increase. The DSHS Health Alert is available at While most people recover from influenza within one to two weeks, others may develop significant complications that can lead to hospitalization and even death. In most years, people over the age of 65, pregnant women, young children and people with chronic health conditions are most at risk for complications. This year the prevailing H1N1 strain is causing severe illness in otherwise healthy mid-aged adults. Immunization is the single best method for preventing influenza and reducing the risk of complications. It is not too late to get the flu vaccine, and DSHS recommends everyone over the age of 6 months be vaccinated, especially healthcare workers to prevent transmission to others. The prevailing strain is contained in this year's vaccine. Antiviral treatment, when started within 48 hours of the onset of illness, may reduce the risk of complications and death, while possibly shortening the length of hospitalization. According to DSHS, antiviral treatment is recommended for anyone with confirmed or suspected influenza who is: • Hospitalized, • Has a severe, complicated or progressive illness, or • Is at higher risk for complications from influenza. Other resources for further information regarding influenza and the influenza vaccine include: • Centers for Disease Control and Prevention (CDC) Seasonal Flu page • Texas Department of State Health Services • Department of Aging and Disability Services -- Texas Quality Matters


'They said they weren't sure he existed' Published: 01/05/2014 at 8:38 PM Joe Kovacs is an award-winning journalist and, since 1999, executive news editor of WND. He is the author of two best-selling books: "Shocked by the Bible: The Most Astonishing Facts You've Never Been Told" and its 2012 sequel, "The Divine Secret: The Awesome and Untold Truth About Your Phenomenal Destiny." Sen. Rand Paul, appearing on ABC’s “This Week” program Sunday, blasted the system as “a mess,” saying his own son was incorrectly enrolled in Medicaid, and that he’s unsure if his own family is actually covered now. “At this point, I’m unsure,” Paul, a Republican, told host George Stephanopoulos. “The other day, I actually tried to get my son signed up through the Kentucky exchange, you know, that the Democrats have said is so good. And I have here my son’s Medicaid card,” he said waving the card. “We didn’t try to get him Medicaid, I’m trying to pay for his insurance. But they automatically enrolled him in Medicaid. For a month, they wouldn’t talk to us because they said they weren’t sure he existed. He had to go down to the welfare office, prove his existence. “Then the next thing we know, we get a Medicaid card. So, really, most of the people in Kentucky are automatically being enrolled in Medicaid. I’m trying to pay for insurance and can’t pay for it. And I’m uncertain now whether I’m enrolled in D.C. and/or Kentucky. And it’s a mess.” Despite Paul’s criticism, ABC News noted enrollments in Kentucky have surged since the launch of the exchange in October, going up 40 percent after Thanksgiving, and forcing state administrators to hire extra call-center workers and application processors. “I keep getting an error code every time I go in,” Paul complained. “It will not let me edit my policy to try to make sure that my family is covered. So, no, I think it’s really – this is an unfolding disaster that I don’t think gets better any time soon.”

Humana Warns Of "Adverse Obamacare Enrollment Mix"

Michael Krieger of Liberty Blitzkrieg blog, Thought the incredibly unpopular Obamacare health plan (the most epic disaster story was the woman who was touted as a success by president Obama, and then later kicked off her plan) had put most of its problems behind it? Think again. Yesterday, after the stock market close, health insurer Humana warned that the “risk mix” of those who have signed up for the program will be “more adverse than previously expected.” In plain english what this means is that only old and sick people, who will the vast majority of the health care services, are signing up, while younger generations with piles of student debt, a couch in their parents’ basements and no jobs decide to ride things out uninsured, unable to afford the elevated premiums. Honestly, I can’t blame them, as I just received my own 12% rate hike the other day. Happy New Year to you too Barry. From Investor’s Business Daily: Humana said the “risk mix” of its ObamaCare exchange members will be “more adverse than previously expected,” the latest evidence that the health reform is attracting mostly older, sicker Americans than originally projected. The health insurer, in an SEC filing late Thursday, cited the Obama administration’s unilateral 11th hour decision to let people stay on plans that had been cancelled due to ObamaCare regulations, though most insurance companies said this would be impossible. The White House was reacting to political anger of President Obama’s “if you like your plan, you can keep it” vow. Humana made no mention of the administration’s late December decision to let people with cancelled plans avoid the individual mandate tax penalty in 2014. Those who choose to forgo insurance presumably will be younger and healthier. The White House has refused to give any information regarding the age or health status of people signing up on the federal site, saying that it is "proprietary." Data from some state-run exchanges have suggested fewer “young invincibles” are signing up. The ObamaCare exchanges need young, healthy people to make up a significant share of enrollees. If not, the plans may be more costly for insurers, potentially creating a premium rate death spiral. But the Obama administration plans to use “risk-corridor” and “risk-adjustment” payments to offset much of insurance companies’ unexpectedly high costs. Such taxpayer bailouts via higher taxes for all Americans may keep insurers from hiking premiums in 2015 or simply bowing out of the exchanges. “Premium rate death death spiral.” Call me crazy, but I’m not itching to find out what that means…

Quote of the Day

“The best way to avoid a readmission is to avoid an admission, which means in the Medicare world identifying the frail, elderly living at home and providing the necessary supports to [help them] stay there. [When hospitalizations occur, the focus of plans must shift to] giving members immediate help after discharge.” — William MacBain, senior vice president at Gorman Health Group LLC, told AIS’s Health Plan Week.

Today's Datapoint

52% … of the adult population in the U.S. will have diabetes or prediabetes by 2020, according to estimates by UnitedHealth.

Owner selling restaurant to help waitress with brain tumor

BY DAN COOK January 10, 2014 At the Kaiserhof Restaurant and Wunderbar in Montgomery, Texas, you can get knackwurst served with sauerkraut, pan fried potatoes and German mustard for $11.95, the huhnerfrakasse (a creamed chicken dish with mushrooms, asparagus and rice) for $13.50, or the special of the day: the entire restaurant for $1.3 million. Yes, Montgomery’s only true German restaurant is up for sale, in part because the owner wants to help one of his employees to get medical help she and her family can’t afford. The story of Michael De Beyer’s offer to sell his restaurant to defray 19-year-old Brittany Mathis’s treatment for a brain tumor has spread quickly. First told on a local Houston TV station, De Beyer’s announcement that he would sell his place in part to help his waitress and her family has been picked up by Yahoo! and other online news outlets as well as TV stations worldwide. It has also touched off a raging controversy surrounding De Beyer’s motivations for taking such a step. Lionized by one segment of the media community as “the best boss ever,” another more cynical element has questioned just about everything about De Beyer’s “good deed.” Is he using Mathis’ condition to try to publicize his repeated efforts to sell the restaurant? How much would he actually contribute to her medical treatment once the restaurant is sold? Is there a romantic link between the two? And on and on. Not surprisingly, the Patient Protection and Affordable Care Act has been dragged into the mix. Much of the negative spin some have put on the story revolves around the fact that Mathis has no health coverage, and as of Jan. 6, hadn’t applied for coverage under the act. Critics have pointed out that she could receive coverage despite her pre-existing condition under the act. In fact, women of her age are one of the primary targets of Obamacare. Overlooked in the online debate about De Beyer’s motives and Mathis’s failure to seek coverage is the fact that anyone who has to be treated for a brain tumor faces enormous costs beyond what any insurer would pay. It isn’t known what Mathis’ exact diagnosis is — she and her family say they’ve been given the cold shoulder by the local medical community and don’t really know what sort of treatment they’re looking at yet. They’ve been told she has “a ping pong ball sized tumor,” the Courier newspaper in Montgomery reported. So far, that’s it. Generally speaking, most brain tumor patients incur significant costs that fall outside of general health insurance reimbursements. Many items related to any disability they may experience before and during treatment could become out-of-pocket expenses, including transportation needs, special diets, drugs to control pain and other side effects, the use of home-health aides and caregivers, and lost wages due to the inability to work. Families suffer financially as well if they are forced to miss work to care for a loved one or have to drain their savings to pay for non-reimbursed costs. Mathis will almost surely have coverage via the PPACA within days given the furor over her failure to apply. Then, many of her expenses will be covered. But for a family of restaurant workers (both her mom and a sister also work for De Beyer), the non-reimbursable costs of her treatment could be devastating. That’s where De Beyer comes in. In the wake of the massive publicity around his generous offer, he will almost certainly underwrite some of those expenses, regardless of his motives. Watch for both Mathis and De Beyer to become poster children of the emerging PPACA healthcare era.

Wednesday, January 8, 2014

CMS proposes program changes for Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015 (CMS-4159-P)

CMS proposes program changes for Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015 (CMS-4159-P) On January 6, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule with comment period that would strengthen protections, improve health care quality and reduce costs for Medicare beneficiaries with private Medicare Advantage (MA) and Part D prescription drug plans in Contract Year (CY) 2015. Among the technical and program changes this rule proposes are new criteria for identifying protected classes of drugs, revisions that promote competition in Part D plans, changes to the regulatory definition of negotiated prices, and changes to ensure that plan choices are meaningful for beneficiaries. This fact sheet discusses the major provisions of the proposed rule. The proposed rule would save $1.3 billion over the five years 2015 – 2019 if finalized. Summary of Proposed Changes New criteria for drug categories or classes of clinical concern: In the first year of the Medicare prescription drug benefit, CMS implemented a policy that required all Part D plans to include on their formularies “all or substantially all” Part D drugs within six drug classes—antineoplastics, anticonvulsants, antiretrovirals, antipsychotics, antidepressants, and immunosuppressants. The Affordable Care Act later codified this policy, and allowed CMS to specify criteria for identifying protected classes through notice and comment rulemaking. CMS proposes to change the categories or classes of Part D drugs of clinical concern using criteria established through this notice and comment rulemaking. Under the proposed criteria, CMS would require formulary inclusion of all drugs within the antineoplastic, anticonvulsant, and antiretroviral drug classes (subject to proposed exceptions), but would no longer require all drugs from the antidepressant and immunosuppressant drug classes to be on all Part D formularies. A Although antipsychotics do not meet the criteria, they will remain protected at least through 2015 while CMS evaluates additional considerations and the need for any other formulary exceptions. Increased competition: In response to anti-competitive tactics that have contributed to inconsistencies in bidding, payments, and market price signals for Medicare Part D plans, the rule proposes to revise the regulatory definition of negotiated prices to require all price concessions from pharmacies to be reflected in negotiated prices. The proposed rule would require greater cost savings for beneficiaries in return for offering preferred cost sharing so that sponsors cannot incentivize use of selected pharmacies, including the sponsors’ own related-party pharmacies that charge higher rates than their competitors. More meaningful plan choices: In order to ensure that beneficiaries have better access to health plan services with meaningfully different benefits and transparent costs, and because the Affordable Care Act’s closing of the “donut hole” has reduced the need for plans offering enhanced benefits, CMS proposes that Prescription Drug Plans Sponsors offer no more than two Part D plans in the same service area. CMS seeks comments on ways to ensure that a plan sponsor’s basic Part D bid represents its lowest-premium plan offering. This provision would not be effective until 2016. The proposed rule would also prohibit MA plans from offering new plans that simply replace plans CMS has required to be terminated or consolidated due to low enrollment. Improving payment accuracy: The proposed regulation also would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. Improved MA risk-adjustment data validation (RADV) audit process: The proposed rule would strengthen RADV by streamlining the RADV audit process by combining error rate calculation appeals and medical record review-determination appeals into one combined process. Expanded Part D data sharing: CMS proposes to expand the release of unencrypted prescriber, plan and pharmacy identifiers contained in prescription drug event (PDE) records to give researchers broader access to health care data. This would support CMS’s growing role as a value-based purchaser of health care. The release of this data would still be subject to CMS’s “minimum necessary,” “legitimate researcher” and “non-release for commercial purposes” policies as required by law. Expanded prevention and health improvement incentives: The rule proposes to expand rewards and incentive programs that do not discriminate against any MA beneficiaries that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness. Fraud and abuse: Section 6405 of the Affordable Care Act requires that physicians and non-physician practitioners who order durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) or certify home health care must be enrolled in Medicare. The statute also permits the Secretary to extend these Medicare enrollment requirements to physicians and non-physician practitioners who order or certify all other categories of items or services in Medicare, including covered Part D drugs. CMS is proposing to require that physicians or non-physician practitioners who write prescriptions for covered Part D drugs must be enrolled in Medicare for their prescriptions to be covered under Part D. For a fact sheet on CMS’ strategy to prevent fraud and abuse under Part D, please see: CMS welcomes public comments to these proposed program changes; they will be accepted from all stakeholders through the close of business 60 days after the date of display of the proposed rule in the Federal Register. CMS will consider these comments in developing the final rule, which will generally be effective for Contract Year 2015 operations. The proposed rule will be published in the Federal Register on January 10, 2014. CMS will accept comments on the proposed rule until March 7, 2014. For more information, please see: # Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.

CMS Strategy to Combat Medicare Part D Prescription Drug Fraud and Abuse

Prescription drug abuse is a serious and growing problem nationwide. Unfortunately, the Medicare Part D prescription drug program (Part D) is not immune from the abuses associated with this nationwide epidemic. The Centers for Medicare & Medicaid Services (CMS) takes this problem seriously and is taking steps to protect Medicare beneficiaries and the Medicare Trust fund from the harm and damaging effects associated with prescription drug abuse. CMS’ fraud and abuse strategy for Part D is data driven and focuses on the validation and analysis of Part D claims data (Prescription Drug Event, or PDE, data) that CMS receives from Part D sponsors. We are leveraging CMS’ access to all PDE data and using it to guide our anti-fraud efforts and share the results of our analysis with Part D plan sponsors, law enforcement agencies and pharmacy and physician licensing boards, as appropriate, so this information can assist our joint efforts to combat fraud and abuse. A centerpiece of this strategy that focuses on protecting beneficiaries is the identification of Part D enrollees who have potential opioid or acetaminophen overutilization issues that indicate the need to implement appropriate controls on these drugs for the identified beneficiaries. In addition, data analysis is employed to identify prescribers and pharmacies that may warrant further action to curb fraudulent or abusive activities. With the proposed rule issued January 6, 2014, CMS seeks to provide the agency with new tools to employ when problematic prescribers and pharmacies are identified. The key provisions of the proposed rule are discussed below, as are the ongoing CMS actions to combat fraud and abuse. Fraud and Abuse Provisions in the CY 2015 Policy & Technical Changes to the Medicare Advantage and Prescription Drug Program Proposed Rule Require that Prescribers of Part D Drugs Enroll in Medicare: Section 6405 of the Affordable Care Act requires that physicians and non-physician practitioners who order durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) or certify home health care must be enrolled in Medicare. The statute also permits the Secretary to extend these Medicare enrollment requirements to physicians and non-physician practitioners who order or certify all other categories of items or services in Medicare, including covered Part D drugs. CMS is proposing to require that physicians and non-physician practitioners who write prescriptions for covered Part D drugs must be enrolled in Medicare for their prescriptions to be covered under Part D. Impact of Proposal: Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals. Permit Revocation of Medicare Enrollment for Abusive Prescribing Practices and Patterns: CMS is proposing to add authority to revoke a physician’s or eligible professional’s Medicare enrollment if: • CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive and represents a threat to the health and safety of Medicare beneficiaries or otherwise fails to meet Medicare requirements; or • His or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked; or • The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs. Impact of Proposal: Providing CMS the authority to revoke such prescribers’ Medicare enrollment and would help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse. Provide Direct Access to Part D Sponsors’ Downstream Entities: The proposed provision would provide CMS, its antifraud contractors, and other oversight agencies the ability to request and collect information directly from pharmacy benefit managers, pharmacies and other entities that contract or subcontract with Part D Sponsors to administer the Medicare prescription drug benefit. Impact of Proposal: The provision would streamline CMS’ and its anti-fraud contractors’ investigative processes. Currently, it can take a long time for CMS’ contractors who are often assisting law enforcement to obtain important documents like invoices and prescriptions directly from pharmacies, because they must work through the Part D plan sponsor to obtain this information. This proposal is designed to provide more timely access to records, including for investigations of Part D fraud and abuse, and responds to recommendations from the Department of Health and Human Services (HHS) Office of Inspector General. Improve Payment Accuracy: The proposed regulation also would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. Impact of Proposal: The provision would codify and clarify rules regarding when Part D and MA plan sponsors must report and return overpayments. Results of Ongoing CMS Actions Against Part D Fraud and Abuse Reduction in the number of Medicare beneficiaries receiving coverage for prescription drugs that threaten their health and safety. The Medicare Part D Overutilization Monitoring System (OMS) was fully implemented on July 31, 2013, to help CMS ensure that sponsors have established reasonable and appropriate drug utilization management programs to assist in preventing overutilization of prescribed medications. CMS provides quarterly reports to sponsors on beneficiaries with potential opioid or acetaminophen overutilization issues identified through analyses of PDE data and through beneficiaries referred by the CMS Center for Program Integrity (CPI). Sponsors are required to respond to CMS within 30 days on the status of the review for each beneficiary case. The principle performance metric for OMS is the number and percentage of acetaminophen and opioid overutilizers. An initial comparison with 2011 PDE data pre-dating the implementation of OMS shows there has already been a substantial reduction in the number of acetaminophen and opioid overutilizers in Medicare Part D. OMS July 31 Report Summary Compared to 2011 Analysis PART D OMS SUMMARY CY 20111 CY 2013 through June1 Count (1/1/2011 to 12/31/2011) % of Part D Population % of Product Utilizers Count (1/1/2013 to 6/30/2013) % of Part D Population % of Product Utilizers All Part D Enrollees 31,485,287 36,742,129 Total APAP Utilizers 9,450,190 30.01% 7,382,443 20.09% Beneficiaries with Potential APAP Issues 150,760 0.48% 1.60% 31,245 0.09% 0.42% Total Opioid Utilizers 8,783,979 27.90% 9,056,058 24.65% Beneficiaries with Potential Opioid Issues 22,222 0.07% 0.25% 4,351 0.01% 0.05% Beneficiaries with CPI Referrals2 N/A 13 1 The OMS July 2013 reports included analysis of PDE data with dates of service from January 1, 2013 to June 30, 2013, and received by June 30, 2013. The CY 2011 analysis used PDE with dates of service from January 1, 2011 to December 31, 2011, and received by June 2, 2012. 2 Beneficiaries with CPI referrals were not subject to Part D oversight until mid-2012. CPI referral cases may originate several years prior to being sent to Part D for follow-up with plan sponsors. Increased Law Enforcement and other referrals resulting from proactive data analysis: To date, for FY 2013, CMS has made 60 referrals to law enforcement based on proactive analysis and initiated 182 proactive investigations that are open and being developed for referral to law enforcement. The provisions of the proposed rule would provide CMS the additional ability to take administrative action when a pattern or practice of abusive prescribing is identified through data analysis and confirmed through subsequent investigation. Accurate Prescriber Identifiers Used to Confirm Prescribing Authority: Through rulemaking finalized in 2012, CMS required Part D sponsors to submit Prescription Drug Events (PDEs—Part D claims data) with active and valid individual prescriber National Provider Identifiers (NPIs) beginning January 1, 2013. CMS began to apply edits to any PDE without an active and valid individual NPI on May 6, 2013. Of the 2013 PDEs submitted through the end of June, only about 0.02 percent (approximately 148,000 of the 611.3 million PDEs) were rejected by CMS either because the prescriber identifier reported was not an NPI or the NPI submitted by the provider was inactive or invalid. CMS will continue to monitor sponsor performance regarding the use of valid and active NPIs. CMS examined the taxonomy codes for 2013 PDEs, which are self-reported by the providers to identify their specialty in the National Plan and Provider Enumeration System (NPPES). Of the 2013 PDEs (submitted through July 1, 2013) with a valid NPI, only about 0.5 percent were for drugs prescribed by providers with a taxonomy code that would be inappropriate for a prescriber (such as, adult companion). Based on a review of the PDEs reporting these apparently inappropriate taxonomy codes, CMS determined that about 10.6 percent were for controlled substances. We further determined that, for all but 16.5 percent of these PDEs for controlled substances, the prescriber in fact did have a valid DEA number. Thus, despite the inappropriate taxonomy code, the vast majority of these prescribers were found to be authorized to prescribe. CMS is conducting ongoing analysis to identify other possible sources of these errors, such as incorrect selection of an NPI when the prescriber has multiple identifiers. # [1] 77 FR 54664: [2]

More than 15% of patients are at high risk for leaving their current physician and medical practice, according to a recent study .

Source: "Press Ganey Identifies Key Drivers of Patient Loyalty in Medical Practices ," Press Ganey Press Release, December 10, 2013,

According to a recent survey of 1,000 American adults and 363 opinion leaders:

• 72% prefer to see a physician for their medical care • 7% prefer to see a nurse practitioner • 21% either have no preference (16%) or don’t know (5%) • 73% of adults and 84% of opinion leaders prefer to take a loved one to a physician over a nurse practitioner Source: "Americans Prefer Physicians for their Medical Care," Ipsos Press Release, December 18, 2103,

Medicare Advantage enrollment tops 15 million

BY KATHRYN MAYER January 7, 2014 Enrollment in Medicare Advantage plans is on the rise. Aggregated enrollment in Medicare Advantage plans hit 15.1 million in December, up nearly 1.3 million members since December 2012, according to a new report by Mark Farrah Associates. Membership surpassed 15 million members in October. The growth comes despite “conservative growth strategies, pricing concerns, reductions in service areas and the loss of 25 carriers servicing this market,” the research group said in a brief. Nationwide, nine organizations insure more than 250,000 MA members each and cover more than 65 percent of the MA market, according to the report. UnitedHealth and Humana together control nearly 38 percent of the market, up 0.9 percent from a year ago. “In Georgia and Texas, UnitedHealthcare gained more than 50,000 members in each state. Humana, with an aggressive MA growth strategy in many areas of the country, experienced mixed results in many states,” the report said. “However, Humana did add 50,254 MA members in Kentucky, 30 percent of its overall gain year-over-year.” The report found that Aetna saw significant gains in part due to its acquisition of Coventry Health Care. WellCare also acquired many smaller Medicare Advantage and Medicaid plans in 2003. Enrollment in MA plans is drawn primarily from two sources, direct purchase by individuals or an employer group retiree plan. More than 17 percent of total Medicare Advantage enrollment comes through EGHPs. Kaiser Foundation Health Plans has the largest MA enrollment from group plans, the report found. Mark Farrah Associate’s report is based on analysis of enrollment data for Medicare Advantage plans released by The Centers for Medicare and Medicaid Services.

SNP ‘Models of Care’ Changes Could Mean Mounds of New Paperwork

By James Gutman - January 3, 2014 Sometimes it’s not good to be “Special.” That seems to be one of the takeaways from the proposed National Committee for Quality Assurance (NCQA) changes, as disseminated by CMS, in the Models of Care (MOC) requirements covering Medical Advantage Special Needs Plans (SNPs). The well-intentioned draft document would do some things the SNP Alliance trade group likes, such as reorganizing the requirements into fewer “domains” than currently mandated and having all the care management-related functions put under a single domain. But the changes also would dramatically increase documentation and reporting requirements for both SNPs and their providers, and that has already financially squeezed SNPs very worried. The MOC requirements stem from an Affordable Care Act provision mandating that all new and existing SNPs be approved by NCQA beginning Jan. 1, 2013. NCQA does all the reviewing and scoring of plans on the MOC based on guidelines developed by CMS, which did not make changes to the requirements for 2013. But CMS is proposing a plethora of changes for 2014 that would become part of SNPs’ applications for 2015 due next month. Among other things, those changes seemingly would create the need to develop complex care plans for every SNP beneficiary, even though 85% of SNP enrollees are Medicare-Medicaid dual eligibles, who are impoverished but often don’t need more health care than “periodic assessments,” says SNP Alliance Co-Chair Valerie Wilbur. The changes also would impose major new training requirements for SNPs’ provider networks, she says, that could drive providers away from participation in SNPs, especially since the providers’ compensation for SNP patients isn’t high to begin with. And there would be a host of new quality measurement and administrative reporting requirements, some of which involve “a lot of duplication” and one of which is “just additional busywork,” she asserts. Neither Wilbur nor other SNP experts queried by AIS take issue with the need for strict standards to ensure SNPs meet the needs of their beneficiaries, all of whom are substantially disadvantaged in some way. But they are hoping that the final new MOC requirements, which they expect to be unveiled at a joint NCQA-CMS conference in Baltimore Jan. 13, will back off new mandates that they fear will drain more of their already-sparse resources and time. What do you think will happen? Where do you draw the line between making sure SNP beneficiaries get the extra attention they need and imposing so many requirements that it may not be feasible to provide that care? What would be the impact of these changes on SNP star ratings? How can SNPs avoid being so “Special” that they are loved to death?

Quote of the Day

“The majority of the lowest-cost products [on public insurance exchanges] have ultra-narrow networks, but the majority of ultra-narrow networks are not the lowest priced. What we have concluded is that ultra-narrow networks are neither completely necessary nor sufficient to get to the lowest price point in a market.” — Paul Mango, director of health care systems and services at McKinsey & Co., previewing his firm’s new research paper at a Dec. 12 AHIP conference in Washington, D.C.

Tuesday, January 7, 2014

National Health Spending Growth Remains Low for 4th Consecutive Year

WASHINGTON — Overall national health expenditures grew at an annual rate of 3.7 percent in 2012, marking the fourth consecutive year of low growth, the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary reported today. Health spending as a share of gross domestic product fell slightly from 17.3 percent in 2011 to 17.2 percent in 2012. “For the second straight year, we have seen overall health care costs grow slower than the economy as a whole. This is good news,” said CMS Administrator Marilyn Tavenner. “We will continue to work with tools given to us by the Affordable Care Act that will both help us control costs for taxpayers and consumers while increasing the quality of care.” An article summarizing the study is being published in the January issue of the journal Health Affairs. The entire report is being published on the CMS National Health Expenditures website. The report found that the continued low growth in 2012 was driven by slower growth in prescription drug, nursing home, private health insurance, and Medicare expenditures. The report from CMS’ Office of the Actuary also found that the Affordable Care Act (ACA) contributed to the slow growth for the Medicare program in 2012, but had a limited impact on overall spending as reforms were still being implemented in 2012. The report’s findings include: Private health insurance spending growth remained low. Private health insurance spending continued to grow at a low rate, increasing 3.2 percent in 2012 compared to 3.4 percent growth in 2011. Medicare spending growth continued to be low. Despite a large uptick in Medicare enrollment, Medicare spending growth slowed slightly in 2012, increasing by 4.8 percent compared to 5.0 percent growth in 2011. Total Medicare spending per enrollee grew by only 0.7 percent in 2012. Prescription drug spending growth was low. Retail prescription drug spending slowed in 2012, growing only 0.4 percent as the result of numerous drugs losing their patent protection, leading to increased sales of lower-cost generics. Nursing home spending growth slowed. Spending for freestanding nursing care facilities and continuing care retirement communities increased by only 1.6 percent in 2012, down from 4.3 percent growth in 2011, due to a one-time Medicare rate adjustment for skilled nursing facilities. Medicaid spending continued to grow at a historically low rate. Total Medicaid spending grew 3.3 percent in 2012. While an increase over 2011, this increase still represents historically low overall growth rates tied to improved economic conditions, as well as efforts by states to control costs. The report also found accelerated growth in hospital and physician and clinical services spending, and slightly faster growth in out-of-pocket spending, 3.8 percent in 2012 compared to 3.5 percent in 2011. The full report can be found at: Read an article about the report from the CMS Office of Actuary at

CDHPs Impact on Health and Healthcare Costs

Over the last nine years, Aetna has studied the impact CDHPs have on health and health care costs. Aetna's studies show that employees who switch from a PPO to a CDHP can save, on average, $350 per year. Employers can see cost savings as well. CDHP participants are also more engaged in their own health care - they are twice as likely as PPO members to complete a health assessment and 30 percent more likely to participate in a disease management program. Source: Aetna

ACA Reactions from Midsized Business Owners and Executives

Definitely will not cap part-time hours so workers remain below regulatory requirements for an offer of coverage. - 23% Considering capping part-time hours so workers remain bellow regulatory requirements for an offer of coverage. - 31% Definitely will not suspend hiring - 37% Considering Suspending hiring. - 26% Definitely will not downsize the number of employees as a result of the ACA. - 50% Considering downsizing the number of employees as a result of the ACA. - 25% Data Source: ADP Research Institute Publication Source: Employee Benefit News, December 2013

Monday, January 6, 2014

Analysts expects slower Medicare Advantage growth

By The Associated Press January 03, 2014 ________________________________________ Enrollment in Medicare Advantage plans will grow more slowly in 2014 than it did the past couple years, predicted a Citi analyst who follows health insurers. Insurers have cut benefits and scaled back coverage, which may make it harder for them attract new customers, said Citi's Carl McDonald in a research note Thursday. Medicare Advantage plans are privately run versions of the government's Medicare program for the elderly and disabled people. Insurers offer hundreds of versions of this subsidized coverage, and the plans often come with extras like vision and dental benefits that are not available with standard Medicare. UnitedHealth Group Inc., Humana Inc., and WellCare Health Plans Inc. are among the biggest providers of this coverage, which has been pressured in recent years by reduced funding. The government has been cutting funding in part to help pay for the health care overhaul, the federal law that aims to cover millions of uninsured people. Insurers have responded by trimming the benefits their Medicare Advantage plans offer, dropping doctors from their coverage networks or, in some cases, pulling out of markets where they feel they can no longer make a profit. Medicare Advantage customers will have about 18 plans to choose from, on average, in 2014, down from 20 last year, according to the Kaiser Family Foundation, a nonprofit that studies health care issues. Enrollment in these plans grew about 9 percent last year to 15.1 million people. McDonald said he expects that growth to slow to about 5 percent in 2014. That works out to about 750,000 new customers. "Since most plans increased premiums and reduced benefits this year, it will be more difficult to attract seniors out of traditional Medicare," he said. But he expects most existing Medicare Advantage members to stay on the plans. Shares of UnitedHealth climbed 71 cents to $75.28 in Friday afternoon, while Humana fell 57 cents to $102.27 and WellCare dropped 58 cents to $69.67. The Standard & Poor's 500 index was almost unchanged.

Today's Datapoint

3 … troubled state-run health insurance exchanges are now without an executive director with the departure of Maryland’s Rebecca Pearce, Hawaii’s Coral Andrews, and Oregon’s Rocky King.

Quote of the Day

“I think Medicare Shared Savings Program ACOs will not convert to two-sided risk in large numbers. The majority of [current] ACOs would not be eligible for value-based payment.” — Clif Gaus, CEO of the National Assn. of ACOs, told AIS’s ACO Business News.

Friday, January 3, 2014

According to a recent survey,

respondents considered the following to be the most important characteristics in the healthcare professional who they see for their main medical needs: • ‘knowledgeable’ (37%) • ‘up to date when it comes to the latest medical advances and treatments’ (29%) • ‘experienced’ (27%) • ‘someone you can trust ( 27%) Source: "Americans Prefer Physicians for their Medical Care," Ipsos Press Release, December 18, 2103,

2014 Outlook: Could Bad Enrollment Numbers Prompt ACA Changes?

By Neal Learner - December 30, 2013 Most health reform observers expect to see little legislative action on the Affordable Care Act (ACA) in 2014. But that could change quickly if the early enrollment numbers look particularly bad, says one former Capitol Hill staffer. A key development to watch in January is whether the number of uninsured in the country actually increases as a result of the ACA, says Chris Condeluci, an attorney at the law firm Venable LLP, who served as tax counsel for the Senate Finance Committee during the crafting of the reform law. “It’s a likely possibility,” Condeluci says, pointing to the millions of people who had their policies canceled in light of the new ACA minimum benefit requirements. “And that won’t play well for those Senate Democrats who are up for election in 2014,” he adds. “But the question is, how widespread is that going to be, and how big is that number going to be?” If the number is significant, then Condeluci says he could see Democrats in the Senate becoming active enough to force changes in the law, including extending the open-enrollment period and, at the most extreme, delaying the individual mandate to purchase health insurance. Still, Condeluci isn’t convinced the figure will be large enough to prompt action. In fact, he says, Senate Democrats started down that path in the early days of the website launch fiasco, but pulled back after the Obama administration was able to get operating better by Nov. 30. “That has quelled the rebellion,” he says of any legislative action. Question: How do you think the enrollment numbers will play out in early 2014? And could they be bad enough that the Democratic-controlled Senate will push for extending the open enrollment period or delaying the individual mandate?

Millions visit before enrollment deadline managed heavy traffic Tuesday as Americans in 36 states rushed to meet the new enrollment deadline for health plans effective Jan.1: there were 2 million website visits, the call center fielded more than 250,000 inquiries and the queuing system handled approximately 129,000 emails, government spokeswoman Julie Bataille told Forbes. But while extending the sign-up deadline another day helped consumers, the extension caused reform-related headaches for payers. "Insurers would like to have two to three weeks to process applications," consultant Robert Laszewski told the Associated Press. "Now they're going to have a week, less one more day." Open enrollment ends in March for coverage effective after February. By then, the Obama Administration expects to see 7 million newly-insured customers, Forbes noted. Among them is the president himself: though he doesn't need it and won't use it. President Barack Obama last weekend joined with other Americans who purchased a bronze-level plan through the D.C. exchange, The Washington Post reported. The White House called this a "symbolic" gesture of solidarity with insurance buyers and a show of support for the marketplaces, the Post noted.

Quote of the Day

“[Shortly after the Medicare Part D program launched, some people didn’t show up as being registered.] We essentially said to pharmacists, ‘give them their drugs and we will work it out later.’ And [it] took more than a year to sort through. The alternative was to have people turned away, which would have been a failure and potentially a catastrophic failure. I don’t think there’s any question that on Jan. 1 there are going to be people showing up for care…human beings, who made every effort [to enroll].” — Michael Leavitt, Founder and Chairman of Leavitt Partners, who served as HHS Secretary under George W. Bush between 2005 and 2009.

Today's Datapoint

$87.1 billion…was spent on specialty drugs in 2012 by CVS Caremark clients, $39.2 billion of which fell under the medical benefit, according to the company’s recently released 2013 Specialty Trend Management Insight Report.

Quote of the Day

“There is more focus now on the unwillingness of providers to reduce the charges and the prices that were being offered in the old market to adjust to the new market. We are at the bleeding edge of bringing affordable benefit packages home to consumers to meet the needs of their budgets. And now the discussion needs to be enlarged to make sure that our provider partners are willing to do that….” — Karen Ignagni, AHIP President and CEO, told the audience at AHIP’s Dec. 12 conference on insurance exchanges.

Quote of the Day

“There is more focus now on the unwillingness of providers to reduce the charges and the prices that were being offered in the old market to adjust to the new market. We are at the bleeding edge of bringing affordable benefit packages home to consumers to meet the needs of their budgets. And now the discussion needs to be enlarged to make sure that our provider partners are willing to do that….” — Karen Ignagni, AHIP President and CEO, told the audience at AHIP’s Dec. 12 conference on insurance exchanges.

Today's Datapoint

78% … of Medicare Advantage beneficiaries did not know when open-enrollment season ended, and many mistakenly thought they had until Dec. 31 to make changes to their plans, according to a survey by