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Monthly Archives: May 2017
Cartoon – Ideas whose time has come
Cartoon – The Question
CMS Checklist For State 1332 Waivers Focuses On High-Risk Pools, Reinsurance
On May 11, 2017, the Centers for Medicare and Medicaid Services and the Department of the Treasury released a checklist for state 1332 innovation waiver applications. Following up on Health and Human Services Secretary Price’s letter to state governors of March 13, 2017, the checklist specifically focuses on state 1332 proposals to support high-risk pools or reinsurance programs.
Indeed, the checklist begins by stating:
The Department of Health and Human Services and the Department of Treasury (the Departments) are interested in working with states on Section 1332 waivers that would lower premiums for consumers, improve market stability, and increase consumer choice. In particular we welcome the opportunity to work with states to pursue Section 1332 waivers incorporating a high-risk pool/state-operated reinsurance program. State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program.
The checklist restates the procedural requirements that states must meet under the current 1332 rules, such as posting a notice of the waiver proposal and accepting comments for at least 30 days, holding two public hearings, and consulting with Indian tribes where relevant.
Most elements in the checklist, however, describe specifically what information states must submit with applications for a 1332 waiver involving a reinsurance or high-risk pool program. While states must generally document state legislative authority to operate a 1332 waiver program, a state seeking a waiver to operate a high-risk pool or reinsurance program must establish that the legislation makes the program contingent on 1332 waiver approval or that the program will only become operational if the waiver is approved. Otherwise, the state would not be able to establish that federal 1332 waiver pass-through funding was necessary for the program.
A state must specify the provisions of the ACA it proposes to waive, which might, a footnote explains, include the ACA’s single-risk pool requirement for a reinsurance or high-risk pool proposal. State 1332 waiver proposals must include economic and actuarial data and analyses documenting the effect of the proposal on coverage and on comprehensiveness and affordability of coverage. A reinsurance/high-risk pool proposal would have to describe a baseline of premiums and coverage without the waiver and then compare this to projections of coverage and premiums under the waiver.
Proposals for 1332 waivers must explain how they would affect federal budget neutrality. A state seeking a reinsurance or high-risk pool waiver must establish a baseline of federal expenditures without the waiver and then show how federal expenditures or revenues for premium tax credits, shared responsibility payments, exchange user fees, and health insurance provider fees would change if the proposal is implemented.
States must further submit a timeline for implementation. They must describe whether they would use a condition-based list for a reinsurance program or an attachment-point-based model and the incentives they would offer providers, insurers, and enrollees to manage health care costs and utilization. They must describe how the program would affect other provisions of the Affordable Care Act and how it would provide out-of-state coverage for those who need it. States must report the actual second-lowest-cost silver benchmark plan premium annually, as well as an estimate of what it would have been without the program. The checklist further states, “For comprehensiveness, if there is no change to the provision of the ten Essential Health Benefits (EHB) identified in the benchmark plan, the state can indicate that it will report on any modifications from federal or state law on an annual basis.”
In sum, the checklist provides a roadmap for states that want to pursue high-risk pool or reinsurance 1332 waiver proposals, indicating again the priority that the Trump administration places on this approach for increasing the affordability of health insurance coverage.
Medicare’s Bundled Payment Programs Suffer From Fatal Flaws, But There Is A Logical Alternative
Several authors from the Brookings Institution recently argued in favor of making Medicare’s Bundled Payment for Care Improvement (BPCI) initiative mandatory. While the principles guiding their recommendations are sound, the recommendations themselves fail to acknowledge five fatal methodological flaws within the BPCI program. Their analysis also overlooks the most logical and reasonable alternative: a physician-focused episode-of-care payment model.
The ‘Medicaidization’ Of The Health Insurance Marketplaces: A Necessary Trend
When stripped of emotion and hyperbole, the debate about repealing and replacing the Affordable Care Act (ACA) is fundamentally about how to stretch limited funds to offer health care to two populations in need: the poor, who receive health care through Medicaid, and the “near-poor,” who were frequently without coverage prior to the ACA’s enactment. While millions of the near-poor remain uninsured today, six out of 10 limited-income individuals who purchased health care through the ACA’s health insurance Marketplaces were uninsured prior to the ACA. It is this near-poor and recently insured population, and how to cost-effectively provide health care for them, that is the focus of this post.
Many insurers have ably managed their sicker- and poorer-than-expected Marketplace membership by borrowing from the playbook of the most similar market, Medicaid. In short, we believe that the “Medicaidization” of the Marketplaces is a necessary and positive trend, and we remind policy makers that regardless of legislation or regulatory change, health plans must employ the Medicaidization playbook to well-serve a population that both parties believe needs coverage.
Health insurance Marketplaces—the centerpiece of the ACA—provide health insurance in government-refereed individual and small-group markets. However, health plans offering coverage through Marketplaces have been confronted with challenges. Enrollment is roughly 12 million, far behind original Congressional Budget Office projections of 21 million by 2016. This is largely because fewer employers than expected dropped employee coverage after the law passed and because many younger and healthier people have chosen to remain uninsured or covered by their parents’ insurance. As a whole, Marketplace enrollees are sicker and more costly than expected, and more than 80 percent receive means-tested subsidies to buy down some of their insurance costs. Furthermore, lawsuits and congressional actions have hobbled the ACA’s risk mitigation programs and threaten its subsidies. As a result, several health plans left the Marketplaces in 2017 in many states, and at least one—Humana—will exit entirely in 2018.
While the struggles of the ACA-reformed markets and the insurers that operate within those markets are well-documented, there have also been some success stories. Medicaid-focused health plans, as well as commercial plans that adopted tactics common in the Medicaid market, have performed at near break-even or better while serving the near-poor population in the Marketplaces. The relative success of Medicaid-focused plans in the Marketplaces contrasts with the struggles of national for-profit insurers and has led to the Medicaidization of the Marketplaces.
The term “Medicaidization” is not new to this post. It has been used by others, sometimes with a negative connotation. So it is helpful to define the term more precisely. Medicaidization, as used here, describes a set of practices—from sensitivity to sociocultural issues to utilization management—that have evolved to serve the Medicaid population. Because of socioeconomic disadvantage and poor health, this population responds to its health care needs very differently than other populations. However, the term “Medicaidization” belies the fact that health plans beyond those that focus on Medicaid are capable of deploying these same practices—such as several Blues and provider-owned plans—as described below.
6 Ways Leaders Should Be Like Mothers
6 Ways Leaders Should Be Like Mothers
Mother’s Day 2017
Dear Leaders,
Today is a time we set aside to celebrate our mothers. Motherhood is often a thankless and tiring endeavor. It’s easy to take for granted the hard work, sacrifice, and love that moms contribute to our lives. So today we pause to appreciate the countless ways our mothers have positively influenced us and shaped us into the people we are today.
In many ways, moms are the ultimate picture of servant leadership in action. They always have the best interests of their children in mind and will go to great lengths to help them grow, develop, and succeed in life. They are able to harmonize the polarities of unconditional love and tough love, and do so in such a way that their children always know that mom has their back. Mothers are simply amazing leaders.
Using the acronym MOTHER, here are six ways leaders can improve their effectiveness by embodying the characteristics and behaviors of great mothers:
Rival Senate healthcare group seeks to make waves
A rival group of Republican senators is seeking leverage to influence the direction of the Senate’s ObamaCare replacement bill.
The group, led by Sens. Susan Collins (R-Maine) and Bill Cassidy (R-La.), has been meeting “a couple times a week,” according to Sen. Shelly Moore Capitol (R-W.Va.).
Cassidy is a physician and Collins is a former state insurance commissioner. Both have been outspoken opponents of the House-passed American Healthcare Act, and have co-sponsored their own version of an ObamaCare repeal bill called the Patient Freedom Act.
Cassidy told The Hill he and Collins have been meeting with Senate leaders to talk about their legislation. However, he noted the politics of the Senate mean that every member’s voice matters.
“When you only have 52 senators, everybody has significant leverage. That tight vote margin means everyone is essential,” Cassidy said.
The main GOP working group on healthcare includes 13 men backed by Senate leadership who are seeking to bridge the divide between conservatives and centrists.
What ever legislation emerges from that group is likely to be the bill that comes to the Senate floor.
But if all of the Senate’s Democrats oppose the measure, Senate Majority Leader Mitch McConnell (R-Ky.) will only be able to afford two defections.
That gives the other group leverage.
“Let’s look at it practically,” Capito told The Hill. “You can only lose two votes on any one issue … so I think a bloc of four or five can be very effective.”
Health lobbyists have noted many members of the leadership-led group have been fairly measured in their criticisms of the House bill approved earlier this month.
Collins and Cassidy, in contrast, both seem keen on turning sharply from the House bill.
5 WAYS TO SUCCEED WITH AN INFLEXIBLE PIGHEADED BOSS
If you’re flexible, rigid people seem pigheaded, narrow minded, and self-centered. Why can’t everyone be flexible like you?
Rigid people drive the train:
If you have an inflexible boss or team member, they always drive the train.
- Fear of offending them controls interactions.
- Tough conversations always go one way. Everything is about winning or losing.
- Violating the “rules” is a capital offense. Throwing people under the bus may become a means of control.
Change, innovation, and progress slow to a snail’s pace when rigid people drive the train.
Stability:
Stability is the advantage of rigidity.
Organizations need rigid people even if some think they’re evil. You don’t need the dark-side of their strength. But without them, inconsistency escalates into instability.
Sure, they stress themselves and others. They complain about missed commons. But, they’re great at following procedures and delivering consistent results.
Inflexible people love systems that prevent failure.
Navigation tips:
What if your boss is inflexible?
- Adapt to them. They won’t adapt to you. No one likes to be changed – especially an inflexible boss. They’ll lash out like caged animals if you pressure them.
- Admire their strengths and say so. Say, “Your personal consistency brings stability and consistency to our organization.”
- Accept, embrace, and answer their discomforts or fears. Telling them that things will work out drives rigid people crazy.
- Prepare them for change. Don’t surprise them. Discuss problems before solutions.
- Establish rituals and routines. Don’t addd stress to their stressful lives.
What suggestions do you have for navigating an inflexible boss or teammate?
Why do CEOs get fired or leave organizations anyway?
https://interimcfo.wordpress.com/2015/01/09/why-do-ceos-get-fired-or-leave-organizations-anyway/
In my previous post, I made reference to comments written by ‘TiredofTheOverpaidFailures’ in response to a Becker Review article.
Among other things, this writer said, “As a healthcare staffer for 35 years from entry-level employee to Director, I’ve literally never seen any CFO or CEO leave our organizations for any reason other than to “spend more time with my family”. It’s true, because in every case they collected an inflated golden parachute for the next 2-3 years and indeed manage to take off time to spend with their family or most of the time do part-time consulting at some other organization where they have no idea the horrific failure they were in the previous position. For that matter, what shape they left the organization in. They usually consider them “the expert” because they are from somewhere else.”
Clearly, he or she was very bitter about what they had observed in the front office of their organization over a long period of time.
It is true that some of the folks occupying C-suite offices are not that stellar but more often than not, when they leave it is rarely because they are an idiot. The system does a pretty good job of weeding out idiots before they can reach positions of such power and influence although I have seen a number of suspects among the casts of characters I have dealt with in healthcare administration. So if the CEO is not an idiot, why let him go? I will discuss a variety of situations that I have seen that I believe explain in part why CEO turnover in healthcare is so high.
I frequently hear complaints about what a Board is and is not doing with respect to the organization and the CEO. A healthcare organization is not much different from a professional sports team. The Board is the owner and the CEO is the coach. In the end, like a sports team, the Board only has one switch or lever to use to guide the organization; hire the coach or fire the coach. As long as the Board has not decided to fire the coach (CEO), by default they are supporting or at least tolerating him. He is still their guy until the notice is delivered which can happen on the same date that an incentive award is given. If you do not like what you see the CEO doing, it is not necessarily his fault. Look to the Board for responsibility for the actions and results of their CEO.
HENRY KOTULA 