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Last Build Date: Mon, 24 Oct 2016 18:06:28 +0000


Making Marketplaces Work: California’s Ingredients For Success

Mon, 24 Oct 2016 15:45:00 +0000

For the first time in our country’s history, more than 91 percent of Americans have health care coverage. More than nine out of every 10 people you see have access to quality health care and are protected from the high cost of medical bills if they get sick or injured. In the face of clear indications that the Affordable Care Act is making a huge difference in the lives of millions of Americans there is a drumbeat (once again) by some observers that the sky is falling and the reform embarked on six years ago is not “sustainable.” While there has been very inconsistent “success” across states, this does not mean that the Affordable Care Act isn’t working. Instead, it is an opportunity to make a diagnosis of why it is working so well in some areas and not working in others. There are both state-based and federal marketplace states that have health plans that are delivering good value, keeping risk pools balanced, and building a foundation for success. California is one of those places where it is working — and our lessons can be instructive as we move to the next phase of the building on, refining, and improving the Affordable Care Act. Lessons from California, other states, and those health plans that have shown they can make markets work for consumers can inform the future of health care in America. Indicators of Success In California—the largest and most diverse state in the nation—the launch of this new era of health care has been largely successful though certainly not without challenges and bumps along the way. Here are some of the indicators of that success: The U.S. Census Bureau says California’s uninsured rate has been cut in half to 8.6 percent from 2013 to 2015. In raw numbers, California decreased the number of uninsured by 3.2 million people, which is the biggest decrease in the nation and more than the next three states combined. In addition, we have continued to make progress in many areas in 2016. The Centers for Medicaid and Medicare Services found that Covered California had the healthiest risk mix in the nation in 2015, about 19 percent lower than the national average. This marked the second consecutive year that California had the best risk mix in the country. Health plans in the California market have succeeded financially, generally meeting or exceeding their (low) profit targets and not forcing consumers’ to experience big swings in premiums. For the individual market, not only were initial rates in 2014 lower than many predicted, over the past three years the average rate increase has been about 7 percent — lower than the frequently seen double-digit increases that consumers faced prior to the Affordable Care Act. Covered California is on solid ground. We are sustainable without federal or state support, with substantial reserves and funding from an assessment on plans that averages 2 percent of the combined premium both on and off the exchange. The low assessment helps carriers lower their cost to bring in new enrollees compared to the prior market — meaning more dollars are available for health care. California’s success is anchored in the fact that our state expanded its Medicaid program (known as Medi-Cal) and launched its own state-based marketplace. Other states have also leaned-in and used all of the tools of the Affordable Care Act, such as Washington, Rhode Island, and Massachusetts. Not only have they been able to keep rates under control, but they also offer a meaningful choice of plans with meaningful coverage. However, the broad enrollment and success in the individual marketplace has not been without challenges. Like many states, California’s rate change for 2017 at 13.2 percent is higher than what we saw in 2015 and 2016, when we posted changes of 4.2 percent and 4 percent respectively. The reason for this is simple and one we have long known would be happening. This is not a sign of any impending crisis. Rather it is an expected transition year due mostly to the end of the temporary federal reinsurance program. Key Policies Behind [...]

The Off-Exchange Individual Market And Small Group Market: New HIX Compare Data

Mon, 24 Oct 2016 04:29:41 +0000

Lately there has been increased interest in better understanding the individual insurance market as a whole. While much is known about the products available on the ACA Marketplaces, the off-exchange segment is fairly large; it is estimated to comprise roughly forty percent of enrollment in the overall individual market. To be clear, “off exchange” describes a group of insurance products, rather than a distribution channel. Off-exchange products are ACA-compliant individual market plans that are only sold off the exchange, meaning that they are not made available to customers who are eligible for tax credits. They must be purchased from brokers or directly from carriers. “Off exchange” denotes a “what” rather than a “where”. This is significant because the vast majority of products sold on the exchange are also available off the exchange, so unsubsidized customers can purchase most exchange plans from a carrier or broker, without visiting an exchange website. There is a small group of products, including Cost Sharing Reduction (CSR) plans and some others, which are only available on the exchange. Off-exchange customers are unsubsidized. However, family members or other third parties may purchase an off-exchange product for an individual who may be eligible for a subsidy or even for Medicaid. Other off-exchange customers may be eligible but unaware of the existence of subsidies. While off-exchange and on-exchange products are part of the same risk pool, there are some important differences. The sales of off-exchange products do not generate fee payments to exchanges in most states. Further, there is more flexibility with respect to commissions. Recent carrier exits have differentially involved the on- and off-exchange segments of the market, although premium increases have been fairly even-handed.  Exposure to premium increases in the unsubsidized off-exchange market is higher, due to the absence of subsidies. In fact, HHS recently issued a brief aimed at off-exchange purchasers, noting that approximately half may qualify for subsidies and encouraging these consumers to consider exchange products during open enrollment. It has even been suggested that in response to carrier exits and lack of insurer competition for exchange products in some rating areas, customers should be permitted to use tax credits to purchase products sold on or off the exchange. Thus far, little has been known about the products that are sold off exchange. While they must be ACA-compliant, they may differ in important ways from exchange products. Since they are not included in exchange websites or federal or state data sets, it has been very difficult to analyze these products comprehensively. The newly revised version of HIX Compare includes, for the first time, complete information about ACA-compliant off-exchange products, as well as small group products, sold in 2016. The data set is available in machine readable format. Comparable data for 2017 will be available in several months. Significant Differences In Metal Distribution Over twenty-five percent of the more than 13,488 unique ACA-compliant individual market products sold in 2016 were sold exclusively off the exchange. Additionally, there were nearly 30,000 unique ACA-compliant small group plans on the market in 2016, of which nearly 90 percent were “off exchange,” meaning not available on the SHOP exchange. On- and off-exchange small group plans are combined in this analysis, resulting in three buckets: on-exchange (individual market) plans, off-exchange (individual market) plans, and small group plans. Multiple instances of plans across rating areas are collapsed so that the unit of analysis is the unique plan. The metal distribution of these market segments was strikingly different; on-exchange products were approximately 65 percent silver, with symmetrical distribution of both higher and lower metals. Relative to this, off-exchange products were only half as likely to be silver and twice as likely to be either lower or higher metal value.[...]

Social Science Insights To Advance A Culture Of Health

Fri, 21 Oct 2016 16:00:30 +0000

Editor’s note: This is part of a periodic series of Health Affairs Blog posts discussing the Culture of Health. In 2014 the Robert Wood Johnson Foundation announced its Culture of Health initiative, which promotes health, well-being, and equity. The initiative identifies roles for individuals, communities, commercial entities, and public policy that extend beyond the reach of medical care into sectors not traditionally associated with health. Health Affairs is planning a theme issue in November 2016 that will explore various aspects of the Culture of Health. The Robert Wood Johnson Foundation’s culture of health initiative aims to start a movement to improve the health and well-being of everyone in America. The US continues to lag its global peers in overall health and in health equity. A dynamic movement focused on a culture of health could help address the societal inertia that has for decades stymied efforts to close these gaps. But the pivot to culture also introduces perils. Culture is a tricky concept that both reflects and emerges from social inequalities. Historically, even well-meaning cultural analyses of social problems have drifted into victim blaming. In policy debates, “culture” is too often careless shorthand for “minority group.” In medicine and public health, cultural analyses may struggle to distinguish the biological or behavioral bases of behavior from their social context or structural causes. In short, when used injudiciously, culture can become a simplistic code word for group pathology or a means to stigmatize the vulnerable. We are concerned that the culture of health initiative has left itself unnecessarily vulnerable to some of these perils because of how it defines culture. The initiative boasts a groundbreaking action framework, but that framework is built upon an anachronistic definition of culture. A better definition that acknowledges recent advances in the social sciences can provide a firmer conceptual and scientific foundation for building a culture of health. Since the Foundation undoubtedly wants the idea of a culture of health to guide productive research, advocacy, and action, it makes sense to put some work into defining what is cultural about the culture of health. Done right, this definitional work can be more than an academic exercise and actually help make the culture of health a more powerful lever for change. What is the Culture of Health? The culture of health initiative encompasses four action areas that together constitute a framework for health improvement. Make health a value Foster inter-sector collaboration Create equitable communities Improve health-system integration This is a dynamic recipe for fostering culture-driven change. However, this thoughtful framework rests upon a classic and antiquated definition of culture: “sharing and alignment of beliefs, attitudes, values, and actions.” Over the last four decades, this shared belief model of culture has been criticized and largely abandoned by researchers who study the science of culture. It proved too vague to guide scientific inquiry; it erroneously cast people as passive consumers of culture rather than culture-creators; and it stressed how culture is shared, coherent, and aligned when in reality culture is typically messy—contradictory, convoluted, and often inarticulable. Perhaps most crucially for the culture of health initiative, shared-belief models fail to tie culture to social inequality and remain mute about the link between culture and individual-level cognitive processes and behavior. Contemporary, inter-disciplinary definitions of culture can correct these shortcomings. They do so through a three-part definition of culture. Culture includes the personal and group-historical experiences that shape how people experience the world and what they want from it. Over time, people assemble a “cultural toolkit” that includes practical strategies for how to get things done in the world. Culture’s shared symbols and u[...]

Examining The HHS Projections For 2017 Marketplace Enrollment (Updated)

Wed, 19 Oct 2016 21:33:18 +0000

October 22 Update: Employer Payment Plans In The Context Of Student Health Plans On October 21, the Departments of Health and Human Services, Labor and Treasury jointly issued a frequently asked question (FAQ) regarding student college and university payment reduction arrangements for student health coverage. The three departments have previously issued a series of guidances clarifying that attempts by employers to use employer payment plans (EPPs) or health reimbursement arrangements (HRAs) to help employees purchase individual health insurance coverage violates the ACA. The Departments consider EPPs and HRAs that are not integrated with an ACA-compliant group health plan to be group health plans that violate the ACA because they have maximum dollar limits and do not independently offer preventive services without cost sharing. Universities often, however, offer their students (typically graduate students) coverage through student health plans without charge or at a reduced rate. Student health insurance plans are a form of individual coverage. Where students are also employed by the school to do research or teaching the school may effectively be offering their student employees an EPP for individual coverage, which is prohibited by the 2013 tri-agency guidance. The ACA specifically provides for special treatment for student health plans. In February of 2016, the departments issued a joint guidance providing that they would not assert that a school’s premium reduction arrangement violated the ACA for a transition period including plan or policy years beginning before January 1, 2017. The October 21, 2016, extends that enforcement moratorium until further notice. As long as the guidance is in effect, an institution of higher learning that offers a premium reduction arrangement to a student in connection with an insured or self-insured student health plan will not be considered to violate the dollar limit or preventive services requirements. October 20 Update Children’s Coverage A series of government reports over recent months have repeatedly noted that the percentage of adults aged 18 to 64 who are uninsured has fallen precipitously since the enactment of the ACA. On October 20, the White House released a blog post noting that the uninsured rate among children has also dramatically decreased, from 9.5 percent in 2008 to 5.3 percent in the first quarter of 2016, resulting in 3.1 million more children under the age of 18 having coverage. This gain in enrollment is in part attributable to the ACA, but also to the Children’s Health Insurance Program Reauthorization Act (CHIPRA), enacted in 2008, which extended CHIP funding through 2017 and provided states with flexibility and incentives to simplify enrollment, improve outreach, and expand eligibility. Enrollment gains were greatest among the lowest-income families and people of color. The blog post cites research documenting that the expansion of coverage has improved access to care and is likely to have long-term effects in improved health and labor market outcomes. New Health Plan Selection Data On October 19, 2016, CMS also released public data sets reporting by health plan and insurer and by state and county the total number of health plan selections for the 36 states served by marketplaces that used the platform for individual market enrollments during 2014. (methodology) The tables include plan- and insurer-level data. The insurer data is organized by age (four categories), household income as a percentage of the Federal Poverty Level (FPL), (five categories), gender (two categories), and tobacco status. The plan data includes information on cumulative disenrollments. Original Post The fourth marketplace open enrollment period begins on November 1, 2016. On October 19, the Department of Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) released projections of 2017 marketplace enrollment. CMS also released an effectuated enrollment snaps[...]

An Urgent Call For A National Surveillance System For Inpatient Psychiatric Facilities

Wed, 19 Oct 2016 17:15:30 +0000

The Helping Families in Mental Health Crisis Act (H.R. 2646), which passed the House in early July of this year, purports to address a cause of mass shootings by easing commitment processes for inpatient psychiatric treatment, among other provisions focused on expanding access to care for the most seriously distressed. Framing the need to improve the mental health system as a solution to violence is both stigmatizing and misinformed, as individuals with psychiatric diagnoses are more likely to be the victims of violence than the perpetrators. Nonetheless, while the motivation is the wrong one, the passage of H.R. 2646 suggests there may be a window of opportunity for mental health policy reform. Such reforms should focus at least as much attention on the quality of inpatient psychiatric care, about which there is little systematic information, as they do on access. In what follows, we describe the scant data available on the quality of inpatient psychiatric care and propose policy mechanisms that have been adopted in other parts of the health care system to promote improved quality of inpatient psychiatric care, monitor harm, and inform the development of best practices. Value-Based Purchasing Outside of inpatient psychiatric care, value-based purchasing has been implemented for acute general hospitals, physicians, and long-term care facilities. These measurement and incentive systems are now well established and cover process and outcomes of care domains, including patient experience as well as cost. But only recently did psychiatric inpatient facilities start to become subject to a similar kind of scrutiny and much work remains. While the Centers for Medicare and Medicaid Services (CMS) has begun a pay-for-reporting program where hospitals are incentivized to report on a small number of core quality measures for inpatient psychiatric care, they are not yet incentivized to perform on these measures. Moreover, the indicators lack meaningful assessment of patient experience and outcomes. Indeed, not only do psychiatric institutions lack the ability to track patient diverse outcomes at or after discharge, but also they lack a system to consistently and reliably track adverse events that arise during inpatient treatment. This is a particularly critical gap in light of evidence of injury and death to inpatient psychiatric consumers. Recent Known Harms Within Inpatient Psychiatric Facilities The largest supplier of inpatient psychiatric beds in the country, Universal Health Services (UHS), has been under continuous federal investigation regarding abuse, death, and fraud at many of their hospitals across the country. One UHS case was recently heard in the Supreme Court and involved the death of a teenage girl at a Massachusetts psychiatric hospital due to effects of medication that were administered by unsupervised and unlicensed staff. Such reports are not confined to privately-owned facilities. For example, Tomah Veterans Affairs Medical Center, All-Saints Inpatient Mental Health Unit (a non-profit facility operated by Wheaton Franciscan Healthcare), and Rusk State Hospital have recently been subject to Federal investigations into unsafe clinical environments that resulted in significant patient harm. Common themes of media reports of harm toward consumers of psychiatric facilities include suicide, lack of attention towards other medical conditions, inappropriate use of restraints, medication toxicity, physical and sexual assault, and lack of coordination at discharge. Youth and older adults have added layers of vulnerability and staff are also at risk for harm due to workplace violence. Moreover, mainstream media accounts rarely touch on non-physical harm, such as emotional trauma, and are likely a small window into a much larger problem (Table 1). The facilities highlighted in Table 1 underwent local/federal investigation or civil litigation and were compiled to reflect the diversity in patient demographics, facil[...]

Capping Enrollment To Save Minnesota’s Individual Market

Tue, 18 Oct 2016 17:35:51 +0000

The Minnesota Department of Commerce struck a deal with five health plans in the state’s individual market to prevent a market collapse. In June, Blue Cross Blue Shield announced that it was leaving the individual market, with 103,000 individuals left to find a new plan when open enrollment starts on November 1. It was feared that other plans would quickly follow suit. Given that BCBS had a broad network and notably higher risk profile, the remaining plans were not eager to take on new enrollees in a guaranteed issue environment. The agreement reached included caps on health plan enrollment and significant rate increases between 50-66.8 percent. Only one of the five plans, BCBS’s narrow-network HMO plan, Blue Plus, agreed to offer plans without an enrollment cap. The aggregate cap of 153,700 represents two-thirds of the 250,000 in Minnesota’s individual market. The caps included each plan’s’ current (2016) enrollment plus a very limited number of “slots” for new enrollees. The number of new slots is just 27,100, or 24 percent of the 112,100 dropped from existing plans for 2017 (103,000 from BCBS and 9,100 from a closed HealthPartners product). Figure 1 provides an overview of the capacity limits. Figure 1: Minnesota Individual Market Caps  2016 EnrollmentPublished CapNew Enrollment Cap Blue Plus13,000No CapNo Cap PreferredOne1,8001,7000 UCare16,00030,00014,000 Medica43,00050,0007,000 HealthPartners65,90072,0006,100 Total139,700153,70027,100 Notes: Enrollment numbers are rounded. PreferredOne agreed to take no new members. HealthPartners 2016 enrollment excludes the 9,100 individuals that will be dropped for 2017. The capacity caps guarantee an influx of enrollment to the narrow-network Blue Plus, which is offered in all but five counties (see page 14) across the state. The five remaining counties will have no plan option once the state-wide caps are met. They include a total population of 290,000 and an estimated 18,000 uninsured. Note that the caps are aggregated across the state and not allocated by geographic region or county. There is also no “hardship” exemption or explicit provision for those without a plan option, although the Commerce Commissioner has stated that no one will be without an offer of coverage. Policy Implications of Enrollment Caps Access to Affordable Coverage One of the core principles of the ACA, guaranteed issue, will not apply to everyone wishing to purchase coverage. The rate increases for the remaining plans are likely to make coverage unaffordable for many. For counties where health plans are available, many can be directed to MNsure for the tax credits that are available and others can apply for “hardship” exemptions from the individual mandate. Once the statewide caps are met it is likely that there will be five counties with no health plan option. This issue came up recently when Pinal County, Arizona was close to no individual market health plan offers. Because of the lack of clarity in the ACA on a tax exemption for this particular circumstance, i.e. no health plan offerings, Senator John McCain introduced legislation to provide a tax exemption to individuals living in areas with one or fewer health plan offers. Minnesota’s Commerce Commissioner has stated, “Everyone who needs coverage in the individual market will be able to get coverage; no individual will be without a coverage option.” Clearly, this issue—lack of health plan offers in the individual market—was not anticipated. In addition to the people dropped by BCBSM, the remaining uninsured will also be looking for affordable coverage. Minnesota has a very low uninsurance rate of 4.3 percent, or 234,000 people. There are an estimated 70,000 uninsured people that lack access to ESI and are eligible to purchase in the individual market. For the 18,000 uninsured in the five counties (Benton, Morrison, Crow Wing[...]

MACRA Final Rule: CMS Strikes A Balance; Will Docs Hang On?

Mon, 17 Oct 2016 18:29:48 +0000

On Friday, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—aka the “SGR” repeal bill, aka Medicare physician payment 3.0. The central theme of the MACRA Final Rule is its softening of key program parameters in an effort to allay provider concerns, rally participation, and avoid adverse consequences out of the gate. While the rule concludes—for now—the crescendo that started with passage of MACRA in 2015 and gained steam with the Proposed Rule CMS issued in April, the song is far from over. What seems clear is that CMS has called the tune for the first few years of the program; what’s less clear is whether physicians and related providers will play along. Background The rule finalizes parameters of the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs), collectively referred to as the Quality Payment Program (QPP). (You can’t break this stuff down without a healthy dose of alphabet soup). The rule softens several parameters of the MACRA regime, changes that have been hinted at, for example, during Acting Administrator Andy Slavitt’s appearance before the Senate Finance Committee on July 13 and the Agency’s September 8 announcement that physicians would be able to “pick their pace” for satisfying MIPS criteria in 2017. More on that in a bit. Highlights of the rule include, first, formalization of the “transition year” during calendar year (CY) 2017 that significantly modifies the reporting requirements of the QPP for that year. Second, CMS took steps to weaken the thresholds by which providers may participate. Third, CMS reduced the amount of measures required for reporting under the Advancing Care Information and other MIPS categories. Finally, the Agency softened the degree of risk providers must accept in Advanced APMs, though it preserved the requirement that such entities face downside risk (i.e., the possibility of losing money due to poor performance). We’ll catch a few additional changes along the way. As part of the fanfare accompanying this sweeping regulation, demonstrating their optimism for (or faith in) the MACRA regime, CMS and White House officials held a press conference in the morning and Acting Administrator Slavitt posted an open letter to physicians on the CMS Blog. For additional background, please refer to my recent Health Affairs blog posts on MACRA, MIPS, and APMs, as well as the comprehensive Health Affairs Health Policy Brief on MACRA. CMS provides its own summary of the rule in a handy executive summary here. The policies begin taking effect in CY 2017. Provider performance during that year will yield payment consequences to them in CY 2019. Despite being final for 2017, the Rule has a sixty day comment period. MIPS Think of MIPS as the “base” program for MACRA—if providers don’t participate in it or gain an exemption from it, they receive a payment cut (even in the first year). The Final Rule establishes the manner in which eligible clinicians and groups will participate in MIPS, which consolidates components of three existing programs: the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and the Electronic Health Record (EHR) Incentive Program. It also adds a fourth performance measurement component, clinical practice improvement activities. Eligible clinicians may see positive, neutral, or negative adjustments of up to four percent to payments in 2019 based on their 2017 performance, with an additional $500 million allotted annually between 2019 and 2024 for “exceptional” performance. The final rule simplifies CMS’ proposals in several of the statutorily specified quality domains. Domain scoring weights for CY 2017 are noted parenthetically: Quality Activities (60 percent). In the final rule, CMS e[...]

The Culture Of Health Action Framework And Systems Science: Opportunities And Challenges

Mon, 17 Oct 2016 16:00:50 +0000

Editor’s note: This is part of a periodic series of Health Affairs Blog posts discussing the Culture of Health. In 2014 the Robert Wood Johnson Foundation announced its Culture of Health initiative, which promotes health, well-being, and equity. The initiative identifies roles for individuals, communities, commercial entities, and public policy that extend beyond the reach of medical care into sectors not traditionally associated with health. Health Affairs is planning a theme issue in November 2016 that will explore various aspects of the Culture of Health. The Culture of Health Action Framework, developed recently by the Robert Wood Johnson Foundation (RWJF), focuses on improving the health and wellbeing of all Americans by supporting mobilization for collective change. The framework specifically focuses on four areas: Making health a shared value, Fostering cross-sector collaboration to improve well-being, Creating healthier, more equitable communities, and Strengthening the integration of health services and systems. Moving forward in any of these areas—and their integration—to improve health requires new conceptual ideas as well as novel ways of organizing knowledge, combining insights, and developing solutions. The main challenge to realizing this vision is determining how best to address the complexity of making all the moving parts work together in tractable ways. In creating a Culture of Health, we need to be able to know, in a timely fashion, what works and what does not work to improve health, why a given strategy succeeded or failed, and what changes are necessary to make meaningful progress. Can Systems Science Help Advance The Culture Of Health Action Framework? Systems science is an interdisciplinary field focused on the study of complex systems that are usually characterized by dynamic interdependencies and interactions among system components and outcomes. By combining systems thinking with advanced computational modeling techniques such as system dynamics, agent-based modeling, discrete-event simulation, and network analysis, systems science has the potential to provide insights about the complex connections and interaction among multiple determinants of health; thus, as evidenced by examples described in this post, systems science can play an important role in shaping and informing the implementation of the Culture of Health Action Framework. Systems science emphasizes a holistic approach toward solving the complex population health challenges that are typically addressed by scientists, policymakers, and practitioners in fragmented ways. For example, it is clear that being physically active is an effective way to prevent obesity; however, an intervention that aims to increase physical activity may not be fully effective if factors such as the walkability or safety of a neighborhood are not considered in its design and implementation. In addition, systems science represents a promising approach to conducting counterfactual studies to assess the intended (or unintended) consequences of an intervention (or a set of alternative interventions) on population health outcomes. For example, interventions that promote healthy eating may include incentivizing the retail sale of fresh produce, levying taxes on less healthy foods, offering nutrition education courses, or implementing mass media nutritional campaigns; a systems science approach can be useful to evaluate the likely impact of these interventions while taking into account factors such as the socioeconomic and cultural characteristics of a given community and the level of collaboration across sectors. This knowledge can in turn be used in innovative ways to create an environment that fosters collective action to improve health. Examples Of How Systems Science Can Support A Culture Of Health We believe that systems science has the potenti[...]

CMS Details Open Enrollment Strategy (With Risk Corridor Litigation Update)

Thu, 13 Oct 2016 20:40:16 +0000

October 17 Update: House Seeks To File Amicus Brief In Risk Corridor Case On October 13, 2016, the United States House of Representatives requested permission of the Court of Claims to file an amicus brief in Health Republic v. United States. Health Republic was the first of at least eight cases that have now been filed by insurers challenging the failure of the government to pay the full amount they claimed under the risk corridor formula contained in the ACA. The risk corridor program is one of the three premium stabilization programs created by the ACA. It collects contributions from participating insurers that make profits that exceed certain statutory “risk corridors” and make payments to insurers whose losses fall outside those risk corridors. Although the risk corridor statute seems to require payments to insurers with excessive losses regardless of the amount actually collected under the program from profitable insurers, Congress adopted appropriations riders in 2015 and 2016 making the program budget neutral—that is, limiting the administration to paying out only as much as it collected under the program. In fact, HHS paid out only 12.6 cents on the dollar for claims for 2014 and has announced that all 2015 collections will go to 2014 claims. The administration moved to dismiss the Health Republic case in June, but argued only that the case was premature because the risk corridor program was still ongoing and more money might be paid later. In guidance released in September, HHS suggested that the full amount due insurers under the program would have to be paid and that it was open to settling the cases against it. This provoked a furious outcry from Republicans in Congress, who accused the administration of trying to make an end run around the appropriations rider. In late September, the administration filed motions and briefs in other risk corridor cases arguing that in fact the appropriations rider cut off any further risk corridor funding for 2014. In its proposed amicus brief, the House of Representatives maintains that the same arguments that were made in the other cases apply to and should have been made in Health Republic. It contends that the appropriations riders cut off any sources of additional funding to cover claims under the risk corridor program, and therefore Health Republic should be dismissed. It pointedly rejects the earlier assertion of HHS that full payment under the program is owing to the insurers. It is not wholly clear at this time whether or not the administration is pursuing settlement talks with the insurers in the risk corridor cases. What is clear is that if the administration does try to settle the cases for additional risk corridor payments, congressional Republicans will be very angry. Original Post The marketplaces (and indeed the entire individual market) opens for the fourth open enrollment (OE4) period on November 1, 2016. A recent Commonwealth Fund survey found that nearly 40 percent of the uninsured did not know about the marketplaces and nearly 50 percent did not know about the financial assistance they offer. The Department of Health and Human Services (HHS) believes that 10.7 million uninsured individuals are eligible for marketplace coverage, and 9 million of them for tax credits. Given the extensive coverage the media has been giving to premium increases in the individual market for 2017, it is important that consumers understand that affordable alternatives remain available, particularly for those who qualify for financial assistance. It is important to get this message out not just to get the uninsured covered, but also because HHS believes that the population that remains uninsured is younger and healthier than the population currently insured through the marketplace, and thus enrolling more of the uninsured could contribute to marketplace stab[...]

Mega Teaching Health Centers: A New Model To Power CHCs

Thu, 13 Oct 2016 15:00:33 +0000

Community Health Centers (CHCs) have assumed an important role in bridging coverage and access gaps for some of the most vulnerable Americans. Nevertheless, prominent gaps in coverage and access (discussed in more detail below) persist. Millions of lower-income Americans are still uninsured, and even for those with coverage, substantial barriers remain to accessing affordable, high-quality care. We believe that major CHC expansion could go a long way toward addressing the remaining access to care barriers for lower-income Americans. However, CHC expansion is limited by the critical shortage of Primary Care Professionals (PCPs) necessary to accommodate a projected major increase in patients. Teaching Health Centers (THCs) provide graduate education for primary care physicians and dentists who aspire to be based in CHCs and other community settings. However, in spite of successful achievement of their mission to date, THCs are currently underfunded and undergoing potential atrophy. We describe the unique aspects of a proposed modified and greatly expanded THC model—Mega THCs—and suggest a program funded by the Center for Medicare and Medicaid Innovation (CMMI) to demonstrate this new paradigm. We conclude by describing in some detail the aforementioned coverage and access gaps which could be addressed by expanded CHCs. We believe that the Mega THC is essential in developing the workforce pipeline essential to enable CHC expansion to serve lower-income Americans. Current Status of CHCs and THCs Since the 1965 demonstration projects that launched them, CHCs have served to link clinical services and community health. After a half century of the program, 1,375 CHCs, located in every state, provide a wide range of services to over 24.3 million previously underserved Americans. In 2010, federal CHC funding was expanded through an $11 billion, five-year Affordable Care Act (ACA) growth fund, which was extended for an additional two years under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These funds support services that many insurers do not cover. They also reduce patient cost sharing to affordable levels through the use of sliding fee schedules tied to family income. The recently updated Clinton health care proposal includes a doubling of current CHC funding, with support of $40 billion over 10 years. THCs began development and evaluation in 2011, but are now jeopardized by inadequate federal funding. THCs are essential to train PCPs necessary for major expansion of CHCs. As of 2014, 60 THC programs in 24 states were training over 550 residents in primary care, dentistry, and psychiatry, with a projected expansion to 800 trainees in future years. The program was initially supported under the ACA by $230 million over five years, which expired at the end of FY 2015. THC programs are located in community-based ambulatory care settings and serve a large number of Medicaid patients. Those who train in these underserved areas are likely to remain in practice in the same or similar settings, with location of residency training often predicting practice style regarding quality and cost. Congress recently provided $60 million per year of continued support for THCs in FY 2016 and 2017. However, a greater level of funding is required to sustain THCs. While the demand for THC training is strong, existing programs have faced problems determining whether they would be able to continue their operations in view of limited funding. Development Of The Mega THC Mega THCs would greatly increase PCP production, enabling the further expansion of CHCs needed to accommodate an influx of patients due to addressing access barriers. The Mega THC would be a multi-specialty primary care group practice augmented by increased utilization of non-physician PCPs and dentists in central [...]