As a key July 1 implementation milestone approaches, most Massachusetts residents support a new state law to provide health coverage to almost all residents, including the individual mandate that requires residents to obtain coverage or pay a penalty, according to a new June poll of 1,003 Massachusetts residents.
The poll, conducted by the Kaiser Family Foundation, the Harvard School of Public Health, and the Blue Cross Blue Shield of Massachusetts Foundation, finds support for the new health insurance law has increased. In this recent poll, 67% of state residents who have heard of the new health insurance law support it, compared with 16% who oppose it. In a poll conducted last September, 61% who had heard of the law said they supported it.
In addition, more than half (57%, compared with 52% in September) say they support the law’s individual mandate requirements, compared with 36% who oppose it.
“Given reports of sticker shock and ongoing debate about the law, we might have expected overall support to fall, but in fact, support is widespread and has gone up,” said Kaiser president and CEO Drew E. Altman, PhD. “If Massachusetts succeeds, it will have a big impact on the momentum for national health reform.” Access the report.
The Kaiser Family Foundation’s latest Health Security Watch tracking poll shows that minorities are significantly more worried about healthcare access and costs than whites (56% versus 29%), and people with low incomes are more worried than those with high incomes (59% versus 25%)--disparities that are at or near record highs.
Since Kaiser began tracking in February 2004, nonwhites have expressed higher levels of concern about their health care than whites. However, the March and June 2007 surveys showed record high levels of worry among nonwhites, with nearly six in 10 saying they are very worried about their health care, compared with fewer than three in 10 whites. The gaps between whites and nonwhites were 29 percentage points and 27 percentage points in March and June 2007, which are the largest gaps ever recorded in the survey. Read the report.
According to a new report issued June 25 by the Centers for Disease Control and Prevention National Center for Health Statistics, the number of uninsured Americans increased by 2 million from 2005 to 2006. That increase was almost entirely in the nonelderly adult (younger than age 65) group.
The report, Early Release of Health Insurance Estimates Based on Data from the 2006 National Health Interview Survey, examines data collected from interviews in more than 100,000 households nationwide. Some of the highlights include:• In 2006, there were 43.6 million Americans of all ages who did not have health insurance (at the time of the interview), or 14.8% of the population.• Among working-age Americans (those ages 18-64), 19.8% did not have health insurance in 2006, an increase from 18.9% in 2005.• Approximately 9.3% of children under age 18 did not have health insurance in 2006, an increase from 8.9% in 2005.• In 2006, the percentage of uninsured at the time of interview among the 20 largest states ranged from 7.7% in Michigan to 23.8% in Texas. Read the report.
All hospital transplant programs, approved for Medicare participation as of June 28, 2007 (approved either under end-stage renal disease [ESRD] conditions of coverage or national coverage decisions), must submit a request for new approval under the conditions of participation established by new regulations to the Centers for Medicare and Medicaid Services (CMS) by Dec. 26, 2007.
On March 30, 2007, the Department of Health and Human Services issued regulations authorizing the survey and certification of transplant programs. Prior to this new regulation, organ transplant programs were approved for Medicare participation either through ESRD conditions of coverage (renal programs) or national coverage decisions (nonrenal). The new regulation established conditions of participation for all covered organ transplant programs.
CMS will not launch the approval process until the program has entered a formal request for approval under new the Conditions of Participation and the necessary information concerning the program(s) has been received. If a program does not submit a request for approval under the new conditions of participation by Dec. 28, 2007, CMS will conclude that the program no longer desires Medicare participation and will begin the process to withdraw Medicare approval.
Direct any questions to Sherry Clark in the Survey and Certification Group at CMS at (410) 786-8476.
The American Medical Association (AMA) announced on Monday that the nation’s physicians voted to approve a set of strategies for containing healthcare costs and achieving even greater value for health spending. Physicians at the AMA annual meeting asserted that successful cost containment must focus on balancing costs and benefits.
To manage healthcare costs and improve value, the AMA will advocate for the following four broad strategies:• Reduce the burden of preventable disease.• Make healthcare delivery more efficient.• Reduce nonclinical health system costs that do not contribute to patient care.• Promote “value-based decision-making” at all levels.
From these broad strategies follow a number of specific policy interventions to improve the cost-effectiveness of the U.S. healthcare system. Among the interventions identified by the AMA are promotion of patient lifestyle counseling, comparative cost-effectiveness research, continued development of health IT, use of clinical performance measures that promote efficient use of services, targeted insurance benefit design, and investigation of opportunities to reduce nonclinical activities that do not add value to patient care. Read the report.
Pay for performance can work in a Medicaid managed care setting, but only if plans place enough dollars at stake and communicate well with providers, researchers from Mathematica Policy Research say in a Health Affairs web exclusive.
In work supported by the California HealthCare Foundation (CHCF), the Mathematica authors describe the results of a 2003-05 pay-for-performance demonstration aimed at improving the timeliness of well-baby care. The demonstration involved seven California Medicaid managed care plans operating in different regions.
Five of the plans implemented various new incentives for physicians and other primary care providers, while two did not. The specific goal of all five incentive programs was to ensure that providers saw infants for six well-baby checkups in the infants’ first 15 months of life. The plans varied greatly in size; the smallest had 72 primary care providers serving infants, while the largest had more than 2,000 such providers.
The overall results of the demonstration were mixed at best: Provider incentives appear to have yielded significant results in only one plan. That plan conducted good communications with providers, and provided “stair-step” well-baby incentives, meaning that providers achieved bonuses for each additional well-baby visit, with a maximum award to each provider of $470 per baby on top of the provider’s regular capitated payment.
The WEDI ROI Task Group is asking you to again take a brief survey regarding implementation of the Health Insurance Portability and Accountability Act (HIPAA) X12 5010 version of the 837 healthcare claim transactions. The original survey had a poor response rate, attributed to the lack of clarity in several of the questions and to flaws in the possible answers. As a result, the group has reissued an improved survey.
If you have implemented, or plan to implement, the HIPAA-adopted X12 837 healthcare claims transactions, please complete the reissued survey. WEDI and the designated standard maintenance organizations need this information to provide the federal government with an industrywide cost-benefit analysis for adopting version 5010 of the X12 837. To ensure that your responses are included, please complete the survey by July 2, 2007. Access the survey.
The Centers for Medicare and Medicaid Services (CMS) announced in mid-June that in response to concerns about marketing practices, seven healthcare sponsors have signed an agreement to suspend voluntarily the marketing of private fee-for-service (PFFS) plans. This suspension will be lifted only when CMS certifies that the plan has the systems and management controls in place to meet all the conditions specified by CMS. The signatories include United Healthcare, Humana, Wellcare, Universal American Financial Corporation (Pyramid), Coventry, Sterling, and Blue Cross/Blue Shield of Tennessee.
“While we note that most health insurance agents are helpful and responsible in describing and explaining choices to beneficiaries, there are a few bad actors that need to be removed from the system for good,” said Leslie V. Norwalk, acting administrator of CMS. “This voluntary agreement demonstrates that CMS and the plans are stepping up to ensure that deceptive marketing practices end immediately, and that beneficiaries understand what they are purchasing.”
CMS had logged 2,700 agent complaints between December 2006 and April 2007. Although the complaints represent less than one half of one percent of the 1.3 million members enrolled in individual PFFS plans, “we can always do better,” said Norwalk.
Plans signing the agreement will be actively monitored to ensure they do not engage in marketing while the voluntary suspension is in place. To have the suspension lifted, the plans must meet several provisions, including passing a written test that demonstrates their thorough familiarity with both the Medicare program and the product they are selling, and putting in place a provider outreach and education program to ensure that providers have reasonable access to the plan terms and conditions of payment.
The Centers for Medicare and Medicaid Services (CMS) announced on June 20 a new pilot program to enable certain beneficiaries to access and use a personal health record (PHR) provided through participating health plans. The data that will be made available to the beneficiaries include name, address, and policy number as well as lists of their medications and medical conditions.
The PHR tools will allow beneficiaries to look up information about their own medications and medical conditions to help them manage their health care. Beneficiaries are in charge of their own PHR and will control who is able to see the information it contains.
CMS will launch the program this month in conjunction with four health plans to test the use of their PHRs--HIP USA, Humana, Kaiser Permanente, and the University of Pittsburgh Medical Center. The pilot is expected to run for 18 months, during which CMS will collect both quantitative and qualitative data to assess the use, usefulness, usability, and feature preferences of the tools. The goals of the project are to determine the features that are most attractive to Medicare beneficiaries, identify the minimum content and functionality for the PHRs tools, and assess the best methods for outreach and education to encourage adoption and ongoing use.
Health care remains the top domestic issue that the public wants presidential candidates to address, trailing only Iraq on the public’s overall priority list, according to the latest Kaiser Family Foundation Health Tracking Poll: Election 2008.
The June poll finds that 43% of adults cite Iraq as one of the most important issues for presidential candidates to talk about, followed by health care (21%). Iraq ranks first among Democrats, Republicans, and independents alike. Health care ranks second among Democrats and independents, while Republicans rank immigration slightly ahead of health (20% versus 18%).
When asked what concerns them about rising healthcare costs, the poll found people are twice as likely to cite having to pay higher premiums and increased out-of-pocket costs (38%) as they are to say increases in spending on government health insurance programs like Medicare and Medicaid (18%) or increases in what the nation as a whole spends on health (18%). A smaller share (13%) cite increases in the health insurance premiums that employers pay to cover their workers. These views vary little based on party identification.
“Health is not yet back at the level it was in the early ’90s as a national issue, but it is rising,” said Foundation president and CEO Drew E. Altman, PhD. “The decisive factor that will determine whether we again have a big national debate will be the degree to which the presidential candidates really take on the issue in the campaign.”
The Centers for Medicare and Medicaid Services (CMS) has announced new information about healthcare value available to the public: updated pricing and volume information on certain elective hospital procedures, as well information about new outcomes such as mortality outcome measures that reflect care of patients with heart attacks and heart failure on the Hospital Compare web site. In 2008, CMS will add patient satisfaction information to the site. Access the updated pricing and volume information. Visit the Hospital Compare web site.
CMS has released a toolkit for the 2007 Physician Quality Reporting Initiative (PQRI) designed to assist professionals with quality reporting. The toolkit consists of some existing educational resources plus new measure-specific worksheets with step-by-step instructions for reporting for each measure. The toolkit is available on the. To access the toolkit, go to the CMS PQRI web page and scroll down to the “PQRI Tool Kit” tab.
The health industry is in a period of decelerating growth, which is expected to mean a return to single-digit increases in benefit expenses for employers and employees in 2008, according to a new PricewaterhouseCoopers Health Research Institute report, Behind the Numbers: Healthcare Cost Trends for 2008. Based on discussions with private insurers, researchers forecast that medical costs will rise by 9.9% for preferred provider organizations, 9.9% for health maintenance organizations/point of service plans/exclusive provider organizations, and 7.4% for consumer-directed health plans. This compares with estimates of 11.9%, 11.8% and 10.7%, respectively, in the prior year. While the increase in healthcare costs continues to warrant concern as healthcare trends continue to outpace inflation, the trend is declining, reinforcing a longer trend pattern of deceleration, according to the report.
The deceleration in the medical cost trend is influenced by a number of short- and long-term factors. For 2008, the report identified those factors as:
This week, the Service Employees International Union (SEIU) will announce the formation of SEIU Healthcare, a new national healthcare union with more than one million members. “The creation of a national healthcare union will enable us to pool our resources, coordinate our strategies, and unite our strength like never before,” said Dennis Rivera, chair of SEIU Healthcare. SEIU Healthcare’s goals include increasing membership in the union, raising standards for workers, and creating a healthcare system that “puts patients and quality care first” and “provides affordable care to every man, woman, and child in America.” An early step in this effort will be a joint campaign of the United American Nurses and the Nurse Alliance of SEIU for safe staffing to improve the quality of care in hospitals.
The Catholic Health Association of the United States has released a draft document, Our Vision for U.S. Health Care, which includes principles against which reform proposals can be assessed.
Included are principles stating that the healthcare system should “provide a basic health benefit package to everyone” and “never limit access to health care coverage based on one’s age, health status, employment status or financial means.”
The principles are being made available for comments from Catholic health care leaders, caregivers, administrators, and other professionals, whose input will shape the final document to be released later this year. Download Our Vision for U.S. Health Care.
A shortfall in filling cardiothoracic (CT) surgery training vacancies signals a forthcoming shortage in CT surgeons, while an aging population will bring increasing demand for their services, according to the Society of Thoracic Surgeons (STS).
On June 13, the National Residency Match Program announced that only 87 of the 130 CT surgery training positions were filled, leaving 33% of the training positions vacant and 36 of the 92 training programs unfilled, the third straight year of similar shortfalls, said STS. Compounding this problem is research indicating that the average age of the approximately 3,700 practicing CT surgeons is 55, and more than 50% plan to retire within the next 10 to 13 years.
STS is seeking collaborative efforts with the government to make changes to attract more applicants to the specialty’s training programs.
The Department of Health and Human Services Office of Inspector General (OIG) announced yesterday it would not move forward with a final rule to define excessive charges. The OIG stated that it could not identify a “single, fixed numerical benchmark” that would apply across the industry. In addition, the OIG expressed concern that the rule might increase healthcare costs. The OIG stated it would “continue to evaluate billing patterns of individuals and entities on a case-by-case basis.” Individuals or entities found to charge “substantially in excess” of “usual charges” can be excluded from the Medicare program, but the OIG's long-standing position is that "when calculating their ‘usual charges’ for purposes of Section 1128(b)(6)(A) [pertaining to exclusion for excessive charges] individuals and entities do not need to consider free or substantially reduced charges to (i) uninsured patients or (ii) underinsured patients who are self-pay patients for the items or services furnished.”
Download the notice of withdrawal from the Federal Register. Download the OIG addendum explaining the withdrawal and the OIG enforcement policy.
The Medicare Payment Advisory Commission’s (MedPAC’s) June 2007 report to Congress examines several approaches to promoting greater efficiency in the Medicare program, including a more accurate approach for computing the hospital wage index, which is used to adjust payments for differences in labor costs across geographic areas.
MedPAC recommends that Congress repeal the existing hospital wage index statute and give the Secretary of HHS authority to establish new wage index systems. MedPAC further suggests that HHS establish a hospital compensation index that:
Download the full report (297 pages).
The Medicare Payment Advisory Commission (MedPAC) offered its support for proposed changes to the inpatient prospective payment system for FY08, but suggested several refinements to ease the transition and improve payment accuracy.
In a June 11 letter to Centers for Medicare and Medicaid Services (CMS) Acting Administrator Leslie Norwalk, MedPAC encouraged CMS to adopt Medicare severity DRGs as proposed, but to improve the transition process through steps including a –1.6% to –1.8% per year adjustment for two years to “offset the expected impact of improvements in documentation and reporting of diagnoses.” MedPAC also suggested several steps to improve payment accuracy, including adopting cost-based, hospital-specific relative value weights.
The Pennsylvania Health Care Cost Containment Council has released hospital-specific quality and payment data for coronary artery bypass graft (CABG) and other cardiac surgery performed in the state that shows a declining mortality rate but higher readmission rates.
Cardiac Surgery in Pennsylvania 2005 includes information on 17,331 CABG and/or valve surgeries performed in Pennsylvania hospitals in 2005. The report noted that in-hospital patient mortality following CABG surgery in Pennsylvania continued to decline, dropping from 1.98 percent in 2004 to 1.90 percent in 2005. However, both 7-day and 30-day readmission rates for CABG patients increased slightly during this same time period.
For a CABG-only procedure, commercial insurance payments averaged $30,247 and Medicare payments averaged $29,175. For a valve-only procedure, commercial payments averaged $41,651 and Medicare payments averaged $42,433. Costs were significantly higher for patients with hospital-acquired infections.
The IRS yesterday released for comment and discussion a draft Form 990, including a new portion designed to quantify community benefit of tax-exempt hospitals. Form 990 is the annual return required to be filed by tax-exempt organizations to report information about their operations. The IRS hopes to have the form ready for use for the 2008 filing year (returns filed in 2009).
Of special interest to hospitals is a new form, Schedule H, that attempts to quantify the community benefit standard applicable to tax-exempt hospitals. The IRS used the Catholic Health Association's community benefit reporting model for Schedule H, which includes sections on:
The redesign of Form 990 is based on three guiding principles:
In releasing this redesigned form, the IRS said it is soliciting comments, especially in connection with the goals of increased transparency of information and use as a compliance tool. The comment period lasts until Sept. 14, 2007.
Questions and comments should be e-mailed to the IRS at Form990Revision@irs.gov. Read an overview and highlights from the IRS.
On June 13, the ERISA Industry Committee (ERIC), an association representing America’s largest employers, introduced New Benefit Platform for Life Security, which presents a new approach to complement the current voluntary employee benefit system.
The platform recognizes that a secure retirement must include healthcare coverage and provides an opportunity for post-employment coverage. It proposes a new structure for providing benefits through independent benefit administrators who would compete with each other based on quality, use of IT, plan design, and cost. Each benefit administrator would be required to offer plans for a core set of “lifetime security” benefits--health, retirement, and short-term savings.
Employers would have the option of keeping the benefit structure they currently maintain, or participating in the new system by selecting one or more benefit administrators for their employees and dependents.
There are large gaps in quality of care, access to care, avoidable hospitalizations and costs, equity, and healthy lives among states, according to a new state scorecard issued by The Commonwealth Fund Commission on a High Performance Health System. Aiming Higher: Results from a State Scorecard on Health System Performance is the first report to assess how the U.S. health system is performing across these five dimensions on a state-by-state basis.
The report ranks states on 32 indicators grouped in categories that include access, quality, avoidable hospital use and costs, equity, and healthy lives, and compares each state to benchmarks that have already been achieved in states across the country. Although no single state performed at the top across all categories, some states far surpassed others. States in the Northeast and Upper Midwest often rank high in multiple areas. In contrast, states with the lowest rankings tend to be concentrated in the South.
“The differences we found between the top and bottom states were shocking, often a two- to three-fold variation or greater,” said co-author and Commonwealth Fund Senior Vice President Cathy Schoen. “Where you live clearly matters: for access to care when you need it, the quality of care you receive, and opportunities to live healthier lives.”
Across the country, the scorecard found that states that do well on access to care—particularly health insurance coverage—were also more likely to do better on quality of care. Notably, the five top-ranked states overall (Hawaii, Iowa, New Hampshire, Vermont, and Maine) all have high rates of insurance coverage, with nearly 90 percent of working-age adults insured. In contrast, in the five lowest-ranked states (Nevada, Arkansas, Texas, Mississippi, and Oklahoma), the share of adults insured ranges only between 70 and 78 percent. Download the report.
Health coverage is becoming less affordable for Californians in both the small-group and individual insurance markets, but affordability problems are showing up in very different ways in the two markets, according to a paper published yesterday on the Health Affairs web site.
Premiums paid by employees for small-group coverage in California increased 53 percent between 2003 and 2006, from $250 in 2003 to $382 in 2006. Premiums for individual coverage rose only 23 percent between 2002 and 2006, from $211 in 2002 to $259 in 2006.
However, the average actuarial value of individual coverage declined dramatically: Individual-market policies paid 75 percent of medical costs on average in 2003 but only 55 percent in 2006. In contrast, small-group policies retained their actuarial value, paying for roughly 83 percent of medical expenses across the period. Read the abstract.
The Kaiser Family Foundation has released a study that compares out-of-pocket costs of maternity care under 12 consumer-directed health plans (CDHPs) from the group and individual markets with a traditional health insurance plan. The study, Maternity Care and Consumer-Driven Health Plans, prepared by researchers at the Georgetown Health Policy Institute and Kaiser, found great variation among CDHPs compared with traditional health plans in the amount of potential out-of-pocket expenses a family could face. Because the cost of maternity care varies by the type and nature of the delivery, cost estimates were developed for three different birth scenarios based on recommended clinical practice guidelines. These were used to analyze the differences in out-of-pocket costs that families with CDHPs might experience compared with a more traditional health plan. For example, for an uncomplicated pregnancy with a vaginal delivery, the total allowable costs were estimated to run $9,660 and out-of-pocket costs under a traditional health insurance policy would total $1,455, compared with $3,000 to $7,884 for CDHPs.
The study also explored other factors that affect family costs, including coverage for prenatal care, transparency and limits in healthcare coverage, and predictability of costs. Read the report.
Sen. Chuck Grassley, R-Iowa, ranking member of the Committee on Finance, had harsh words following the issuance of a new report last Friday by the Inspector General for the Department of Health and Human Services, titled Quality Concerns Identified Through Quality Improvement Organization Medical Record Reviews. “These findings are yet another indication that the QIO program needs a major overhaul,” said Grassley, who had requested the analysis last December.
The evaluation examined the role of quality improvement organizations (QIOs) in overseeing and enhancing the quality of care within Medicare by identifying quality-of-care concerns through medical record reviews. According to the report, QIOs selected 318,018 cases for reviews between Feb. 1, 2003, and Jan. 31, 2006. They completed full quality-of-care reviews on 34,768 of these cases, and confirmed one or more quality concerns in 19 percent of them. QIOs assigned the two least serious classifications to more than 80 percent of the cases with a confirmed quality concern, recommended one or more corrective actions in 4,645 cases with a confirmed quality concern, and imposed no corrective actions in 1,794 cases with a confirmed quality concern. In 70 percent of the cases with corrective actions, QIOs recommended the least severe corrective action available. The Inspector General’s report said this raises questions about the effectiveness of the QIO case reviews.
“A major purpose of the QIOs is to review the care provided to Medicare beneficiaries and recommend corrective actions to improve poor quality care,” said Grassley in a statement. “Instead, we’re getting a soft approach that too often accepts poor quality or turns a blind eye. This approach doesn’t get the job done for either taxpayers or Medicare beneficiaries.” Download the report.
Several philanthropic healthcare organizations in 18 states and two Canadian provinces have become part of a new fundraising system designed to better meet corporate compliance and transparency requirements, and to ensure that donations are accounted for and spent effectively.
The Association for Healthcare Philanthropy (AHP) announced last week that 41 of its member organizations now subscribe to the AHP Performance Benchmarking Service, a database of business practices and performance metrics for raising philanthropic healthcare fundraising to new levels of performance. Participating organizations are in Alabama, Arizona, California, Florida, Georgia, Illinois, Maryland, Michigan, Minnesota, Nebraska, New Jersey, New York, Oklahoma, Pennsylvania, Tennessee, Virginia, Washington, Wisconsin, and the Canadian provinces of Ontario and Saskatchewan.
With the AHP benchmarking program, participating not-for-profit hospitals, clinics, and healthcare systems can compare their fundraising efforts with those of other facilities across the country. Systematic data-gathering techniques and standard definitions eliminate “apples-versus-oranges” problems that can arise when gauging one system’s practices against another’s. Read the press release.
Although states experienced stable finances in 2007, somewhat tighter fiscal conditions are expected in 2008, according to a report released last week by the National Governors Association (NGA) and the National Association of State Budget Officers (NASBO). The report cites healthcare costs as a large contributor to increased state spending.
The report, The Fiscal Survey of States, indicates that although most states expect reasonable revenue growth during FY08, some states already are seeing significant slowing of their fiscal conditions. States expect continued expenditure pressures in areas such as health care, education, corrections, employee pensions systems, and infrastructure.
“The steady rise in healthcare costs continues to be a dominant force of increased state spending,” said NGA executive director Raymond C. Scheppach. “Governors realize that meeting these ever-increasing expenditure expectations with limited revenues will be problematic in the future.”
Medicaid is approximately 22 percent of total state spending, while all health care accounts for 32 percent--the single largest spending area. Thirty-four governors introduced proposals to reduce the number of uninsured residents in their states during FY08. These include expanding the State Children’s Health Insurance Program, increasing individuals’ access to private insurance, and using traditional Medicaid expansion and flexibilities offered under the Deficit Reduction Act, along with various other state programs. Proposed FY08 funding for these programs totals nearly $18.4 billion.
Business Roundtable, an association of CEOs whose companies represent more than 10 million employees and provide healthcare coverage for more than 35 million Americans, last week unveiled Health Care Costs in America: A Call to Action for Covering the Uninsured, which includes the organization’s principles for healthcare reform. Business Roundtable is also a founding member of Divided We Fail, a national effort with AARP and SEIU designed to engage healthcare consumers, elected officials, and the business community to find broad-based, bipartisan solutions to healthcare and long-term financial security issues.
Calling for a combination of private market reforms and changes in government programs, the Business Roundtable’s principles assert, among other things, that all Americans must have access to affordable coverage, that they have a responsibility to obtain coverage (catastrophic coverage at a minimum), and that safety nets play an important role and low-income individuals may need subsidies.
“These principles are based on the premise that the employer-based healthcare system is valuable, and the CEOs of Business Roundtable are committed to maintaining and improving it,” said Mike McCallister, CEO of Humana and chairman of the Business Roundtable’s healthcare task force. Read the principles.
Employer-sponsored coverage for substance abuse treatment continues to have annual limits and lifetime caps on treatment visits and inpatient days and also requires higher cost sharing than coverage for general medical care, according to a new analysis published as a Health Affairs web exclusive.
In 2006, 88 percent of insured workers had some coverage for substance abuse services, but only 19 percent were enrolled in a plan without limits on the number of office visits or hospital stays. Such limitations are virtually unknown in general medical care, where nearly all covered workers had unlimited medical-surgical hospital days and office visits, according to Jon Gabel, a senior fellow at NORC, and coauthors.
A second Health Affairs web exclusive reports that many workers are exempt from state mental health “parity” laws aimed at bringing private-sector mental health benefits more in line with coverage for other types of disorders. As a result, as of 2003, only one-fifth of U.S. workers with employer-sponsored health insurance were covered by “strong” parity laws that mandate mental health benefits, prohibit limits on outpatient visits and inpatient days, and limit the extent to which enrollees can face higher cost sharing for mental health services.
Researchers say that nearly every state has enacted mental health parity laws since the passage of the federal Mental Health Parity Act (MHPA) in 1996. However, the MHPA is limited in scope; for instance, it does not mandate mental health benefits, it exempts small firms, and it allows caps on outpatient visits and inpatient days. Many state initiatives are stronger, but their impact has been blunted by exemptions. Most notably, the federal Employee Retirement Income Security Act exempts self-insured firms from state regulation.
David J. Brailer, MD, PhD, announced on Tuesday the launch of Health Evolution Partners, a private equity fund that will invest up to $700 million in solutions intended to advance the quality, efficiency, and consumer orientation of health care.
As an investor and strategic advisor dedicated to realizing value in health care, Health Evolution Partners will support promising healthcare ventures that challenge traditional models of delivering clinical services, including the way they are organized, financed, and oriented toward patients. Among its targets will be companies working in disease management, chronic care improvement, pharmaceutical management, telemedicine, remote and in-home patient monitoring, and predictive genomics. The firm’s goal is to commercialize those innovations.
“Health Evolution Partners will accelerate inevitable change that is under way in health care,” said Brailer, who served as the nation’s first National Coordinator of Health Information Technology. “We will build a team of leading healthcare investors and entrepreneurs who want to see real and positive change.”
The California Public Employees’ Retirement System, the fund’s inaugural investor, will commit $500 million to the Health Evolution Partners Fund for direct investments, health care-focused private equity investments, and strategic joint ventures, as well as up to $200 million for investments in other healthcare initiatives. Read the press release.
The Centers for Medicare and Medicaid Services has announced that the list of 2007 Physician Quality Reporting Initiative measure specifications, originally posted on April 1, 2007, have been updated. The measure specifications are available in the “Downloads” section of the PQRI web site. The details of the changes are described in the document entitled “June 1, 2007 Release Notes, Version 1.0,” which is available as a separate download.
CMS does not anticipate additional measure changes; however, consistent with the statute, the measures are subject to modification until July 1, 2007.
The PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to Dec. 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.
A pay-for-performance program at hospitals was not associated with significant improvement in processes of care or outcomes for heart attack patients, according to a study reported in the June 6 issue of JAMA.
Researchers examined whether hospitals participating in the pay-for-performance program showed improvement in certain process measures and outcomes for treatment of heart attack beyond that in hospitals not participating in the quality improvement program. The study included an analysis of data for 105,383 patients with a certain type of myocardial infarction. Patients were treated between July 2003 and June 2006 at 54 hospitals in the CMS program and 446 control hospitals.
The researchers found no significant difference in the rate of improvement in the composite score between the two hospital groups. Two of the six CMS measures, aspirin prescription at discharge and smoking cessation counseling, had slightly higher rates of improvement at pay-for-performance hospitals than control hospitals. For composite measures of heart attack treatments not subject to incentives, rates of improvement were not significantly different. There was a slight reduction in the rate of deaths over time at both pay-for-performance and control hospitals, although the difference in the rate of the reductions between the groups was not statistically significant. Read the abstract.
The Divided We Fail group, made up of AARP, Business Roundtable, and the Service Employees International Union, on Wednesday endorsed legislation intended to help improve healthcare quality and efficiency and bring patients the performance data necessary to make educated decisions about their care.
The Medicare Quality Enhancement Act was introduced by Sens. Judd Gregg, R-NH, and Hillary Clinton, D-NY, and would provide Medicare enrollment, claims, and survey and assessment data to private organizations to develop reports that measure healthcare quality for public use. The reports could include physician-specific data that are essential for identifying high-quality and efficient practice patterns and promoting cost control strategies that improve quality.
Under the act, the private organizations that would mine the Medicare data, known as Medicare quality reporting organizations (MQROs), would be required to follow strict privacy guidelines. For instance, they would be required to allow the Centers for Medicare and Medicaid Services to review their reports to ensure that personal and identifiable data are not divulged. Read the press release.
The House today passed H.R.1467, a bill to authorize the National Science Foundation to award grants to institutions of higher education to develop and offer education and training programs in healthcare IT. Known as the “10,000 Trained by 2010 Act,” the bill authorizes $99.6 million through FY11 for four health IT grants administered through the foundation for basic research on innovative approaches to improve information systems. The goal is to train 10,000 new health IT professionals by 2010.
Rep. David Wu, D-Ore., sponsored the bill, citing the fact that “no systematic plan exists for designing and implementing systems and information tools and for ensuring that the healthcare workforce can make the transition to the information age.”
The bill now goes to the Senate. Read H.R.1467.
In related health IT news, former Rep. Nancy Johnson, former Sen. John Breaux, and National Association of Manufacturers president John Engler yesterday announced the formation of Health IT Now! Healthy Patients for Health Technology, a coalition to promote the rapid deployment of health IT. The coalition, chaired by Johnson and Breaux, unites patients, practitioners, and employers to push for federal legislation this year to promote a connected healthcare IT system. The coalition’s initiatives include educating Congress and the public on the benefits of health IT. Read the press release.
The Centers for Medicare and Medicaid Services wants to hear from you. At least that’s the reported response of CMS to complaints that it published a rule May 29 that was put on hold (until May 2008) by the supplemental funding legislation passed by Congress and signed by President Bush on May 25. According to various reports, CMS wanted to publish the rule to “solicit comments from the public on issues related to the definition of the Unit of Government.” The definition is key to future implementation of the rule.
The rule would have curtailed states’ financing of Medicaid through the use of certified public expenditures, and removed federal funding of graduate medical education as Medicaid expenditures, both vigorously opposed by the hospital industry.
According to CMS, the final rule would clarify, among other things, that entities involved in the financing of the nonfederal share of Medicaid payments must be a unit of government, and would limit Medicaid reimbursement for healthcare providers that are operated by units of government to an amount that does not exceed the healthcare provider’s cost of providing services to Medicaid individuals. Download the rule.
Credit rating implications for not-for-profit hospitals are likely to vary widely as institutions face the challenge of developing healthcare delivery systems to operate in a more dynamic and challenging environment in the future, according to a new report by Moody’s Investors Service.
In addition to the numerous short-term operating and financial challenges, Designing the Healthcare Delivery System of the Future: Credit Rating Implications for Not-for-Profit Hospitals Vary According to Strategy and Investments outlines how future healthcare delivery systems will be shaped by several long-term, macro issues that challenge the healthcare industry, including growing consumerism, increasing demand as the U.S. population ages, further shortages of healthcare workers and physicians, rising influence of insurers, and more uninsured patients.
“With each of these challenges and strategic responses, a long-term commitment to change is needed to create a healthcare delivery system that is successful,” said Moody’s senior vice president Lisa Goldstein, author of the report. “This includes willingness and an ability to assess performance versus plan at various midpoints in the strategic process and change course, if needed.”
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As increasing numbers of states debate ways to expand health insurance coverage, the question of how to determine whether coverage is affordable is front and center. In a Health Affairs web exclusive published yesterday, Urban Institute researchers propose basing the affordability benchmark on the amounts now devoted to health spending by privately insured individuals.
The researchers emphasize that affordability thresholds should consider all health spending, not just premiums. “Because of the highly skewed distribution of healthcare spending and the large potential variation in plans’ actuarial values,” write the researchers, “affordability must take out-of-pocket liability into account in addition to premiums.”
Using data from the three most recent Medical Expenditure Panel Surveys, the researchers found that across all income levels, the median total health spending for individuals and families with nongroup coverage was 16.9 percent and 14.7 percent of income, respectively.
For those with employer-sponsored coverage, the median direct employee spending for individuals and families across all income groups was considerably lower: 3.1 percent and 5.5 percent of income across all income levels, respectively. However, if one assumes, as most economists do, that employees ultimately pay the employer’s share of coverage costs as well--through decreases in wages and other forms of compensation--then median total health spending rises considerably, to 12.3 percent of income for individuals and 15.1 percent of income for families. Read the abstract.
The Agency for Healthcare Research and Quality has requested input on a proposed public-private national healthcare data stewardship entity, which would have oversight of the various uses of healthcare data and be responsible for setting rules and standards for sharing and using healthcare quality measurement data.
The AHRQ asks for public input by way of responses to a number of questions in its Federal Register notice of June 4, such as:• Whether or not there is a need for such an entity and the reasons, including the value such an entity might bring and issues it might solve• Desirable governmental and private sector roles in such an organization, or in health data stewardship more generally• The risks of creating such an entity• Key challenges to creating and maintaining a data stewardship entity
Responses are requested by July 27, 2007.
A notice was published in the Federal Register on May 25, 2007, announcing the start of a second public comment period for the revised version of the advance beneficiary notice (CMS-R-131). The notice requests public comments on a revised ABN package that reflects changes made after the first round of public comments. Formerly, the Centers for Medicare and Medicaid Services maintained two versions of the ABN--a general version and one that is laboratory specific. CMS is now proposing to combine these two versions of the ABN into a single notice meeting both needs. Other proposed changes are described in the web site posting.
The ABN is used to inform beneficiaries of potential financial liability, except for certain institutional benefits such as home health and inpatient hospital. Physicians, practitioners, providers, and suppliers already required to use ABNs should continue using the currently approved ABNs until the revised notice is approved. Comments are due by June 24, 2007. Read the notice.
CMS announced last week that it will discontinue assigning Unique Physician Identification Numbers on June 29, 2007, and will disable the CMS UPIN registry and its “look up” functionality on Sept. 30, 2007.
This decision by CMS could lead to claim payment disruptions for providers and health plans that currently use the UPIN as a legacy number for claim adjudication and payment. Many entities rely on the UPIN as a way to identify themselves or other providers in their claims.
CMS recently announced a contingency plan that allows for use of legacy numbers for some period of time beyond May 23, 2007. Under the Medicare fee-for-service contingency plan, UPINs and surrogate UPINs may still be used to identify ordering and referring providers and suppliers until further notice. Nevertheless, this contingency plan does not affect CMS plans to discontinue assigning UPINs or to disable the UPIN look-up functionality.
Seeking greater transparency into the workings of tax-exempt organizations including charities, Sens. Chuck Grassley, R-Iowa, and Max Baucus, D-Mont., of the Senate Committee on Finance are urging the Treasury Secretary to update the IRS tax form used by the not-for-profit sector.
The senators made their request in a letter sent May 29. They urged the Treasury Department to make gathering more and better information a top priority and to pay particular attention to the operational complexities of not-for-profit hospitals and universities.
“While we always hear that sunshine is the best disinfectant, sunshine can’t do its work unless we open the blinds,” Grassley and Baucus wrote. “The sooner we open those blinds, the better.”
Their particular concern centers on Form 990 and Form 990PF, which charities file with the IRS--specifically, that Form 990 has not kept up with modern practices in the charitable sector and needs significant updating. The senators said they “view it as vital” that the IRS include supplemental information requests for major subsectors of the charitable field, because large, complex institutions, such as hospitals and universities, require more detailed questions tailored to the specifics of their fields if transparency and openness are to have real value.
Particular issues that Baucus and Grassley believe are in critical need of greater reporting and transparency are executive compensation, endowments, related organizations, joint ventures, governance, dollars raised versus dollars for charity, and hospitals. Read the letter.
The latest proposal to provide health coverage for all Americans has come from Sen. Barack Obama, D-Ill., who spoke on Tuesday at the University of Iowa.
Key points of Obama’s proposal for reform include:* Allowing individuals and small businesses to buy health care similar to that available to federal employees, without being turned away for preexisting conditions* Providing subsidies for premiums for those who cannot afford insurance* Making available a National Health Insurance Exchange to reform the private insurance market* Ensuring that all 9 million currently uninsured children have affordable, high-quality health coverage* Expanding Medicaid and SCHIP* Requiring employers to make a meaningful contribution to employee health coverage* Reforming market structure to increase competition in the insurance and drug markets
“We often hear the statistic that there are 45 million uninsured Americans,” said Obama. “But the biggest reason why they don’t have insurance is the same reason why those who do have it are struggling to pay their medical bills--it’s just too expensive.”
Obama would help finance his plan by allowing President Bush’s temporary tax cuts for the wealthiest taxpayers to expire. Obama’s campaign estimated that the plan would cost $50 billion to $65 billion a year when fully phased in. Read the plan.
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