Category Archives: Uncategorized

Why the new ACA waivers matter

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https://www.axios.com/newsletters/axios-vitals-0c7471b2-4434-433d-95c2-929297dedf3c.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

 

As in-the-weeds as a revised waiver process sounds, the practical effects of what the Trump administration announced yesterday could add up to one of its most substantive blows yet against the Affordable Care Act.

The big picture: These changes will likely cause more separation of healthy and sick people, but only in states that avail themselves of these new options — creating another level of segmentation between red and blue states.

How it works: Under the Obama administration, states seeking a waiver from the ACA’s rules had to show that their alternatives would cover just as many people as the ACA, with insurance that’s just as robust, for the same cost. That’s why only 8 waivers have ever been granted.

  • But under the Trump administration’s approach, if the same number of people have access to ACA-level coverage, that’ll count — even if few of them actually choose it.
  • Likewise, “a waiver that makes coverage much more affordable for some people and only slightly more costly for a larger number of people would likely meet” the new standards, the formal policy guidance says.
  • States could, for example, seek a waiver that would let their residents apply the ACA’s premium subsidies to “short-term” insurance plans, even though those plans don’t meet the ACA’s requirements, including the mandate to cover people with pre-existing conditions.

Between the lines: The Trump administration has often treated the ACA’s exchanges as a de facto high-risk pool. And that’s the best prism through which to understand these latest changes.

  • These waivers will let states lean even further into new, non-ACA options for healthy people. That will likely increase premiums for ACA coverage. But because the vast majority of ACA enrollees are subsidized, they’ll be insulated from those costs.

There are limits to how far that dynamic can go, because states’ waivers still can’t add too much to the federal government’s costs. But that’s the basic dynamic at play here — and it’s one that will continue to move the larger individual market further and further away from the ACA.

 

Anthem ER policy could deny 1 in 6 visits if universally adopted, JAMA study warns

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https://www.healthcaredive.com/news/anthem-er-policy-could-deny-1-in-6-visits-if-universally-adopted-jama-stud/540241/

Dive Brief:

  • Anthem Blue Cross Blue Shield’s controversial policy that denies emergency coverage based on a patient’s diagnosis after a visit to the ER, would affect as many as one in six (15.7%) ER visits if adopted universally by commercial insurers, according to a new study from JAMA Network.  
  • Anthem’s policy is currently active in six states. In July, the American College of Emergency Physicians and the Medical Association of Georgia filed a federal lawsuit asserting that Anthem BCBS of Georgia is violating federal law requiring insurers to cover the costs of emergency care based on a patient’s symptoms rather than their final diagnosis.
  • “Our results demonstrate the inaccuracy of such a policy in identifying unnecessary emergency department visits,” Shih-Chuan Chou, lead author of the JAMA study, wrote. “This policy could place many patients who reasonably seek emergency care at risk of coverage denial.” 

Dive Insight:

As healthcare costs rise, insurers continue to seek ways to stem payments for emergency care, which hit their pockets the hardest. Anthem’s approach, taken in the summer of 2017, is to disincentivize what it deems to be unnecessary ER visits by denying coverage for patients with non-emergent ER discharge diagnoses. 

Earlier this year, UnitedHealth Group began reviewing ER claims with the most serious conditions in an effort to reduce or deny claims with improper evaluation and management codes. While similar in that they both crack down on ER visits, Anthem’s policy looks to move patients away from ERs and into less expensive urgent care centers and retail clinics, while UnitedHealth’s policy change is about making sure hospitals are billing properly.

The backlash has been much harsher for Anthem. According to a report issued this past July by Sen. Claire McCaskill, D-Mo., Anthem denied roughly 12,200, or 5.8%, of all emergency room claims in Missouri, Kentucky and Georgia from July 2017 to Dec. 2017 through this policy. Missouri’s hospital association was one of many health organizations to publicly oppose the policy.

In a statement to Healthcare Dive, Anthem defended its ER policy as a way to “ensure access to high quality, affordable healthcare” by encouraging consumers to receive care in “the most appropriate setting.” 

“If a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED,” the statement reads. “But for non-emergency health care needs, EDs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care.” 

 

 

3 Shifts that Expand Influence

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3 Shifts that Expand Influence

The way you treat others is the chief culture building influence in your organization.

Lousy leaders act like individual contributors. Incompetent leaders can’t see the impact of their attitudes, words, and actions.

Newton said, “For every action there is an equal and opposite reaction.” The relationships you enjoy, for example, begin with you.

When you focus on weaknesses and ignore strengths, others build protective walls.

Adversarial leaders invite conflict.

Passive leaders create anxiety.

Teams don’t practice accountability until leaders follow-up and follow-through.

When you confront tough issues with kindness, others have tough conversations with greater confidence.

3 shifts that expand influence:

#1 Shift from who is right to what is right.

In one sense, leadership isn’t personal. The issue is the issue. It doesn’t matter who comes up with solutions. The person who screwed up last week might be this week’s genius.

#2. Shift from talking-at to talking-with.

Engagement requires “with.” The more you talk “at” the more you lose “with.” Talking-with requires humility, honesty, curiosity, openness, and forgiveness.

  1. Humility acknowledges the perspective and strengths of others.
  2. Honesty explains issues without hidden agendas.
  3. Curiosity asks, “What do you think?”
  4. Openness listens and explores. Defensiveness is the end of innovation.
  5. Forgiveness gives second chances after responsible failure. Honor sincere effort. Don’t punish ignorance.

#3. Shift from right and wrong to better.

Most issues are solved with progress. It’s about next steps, not moral imperatives. Stop judging so much. Start cheering more.

Complex issues have more than one answer. Their answer is better than yours, even if it’s not quite as good, because they own it.

Bonus: Shift from punishing to learning.

Treat responsible failure as a learning opportunity and risk is easier. But treat people like tools and you propagate self-serving attitudes.

Carol Dweck says the #1 quality of a growth mindset is learning from failure.

What shifts expand a leader’s influence?

What behaviors short-circuit a leader’s influence?

 

DOJ Indicts 4 Florida Men in $1B Telemedicine Fraud Conspiracy

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https://www.healthleadersmedia.com/doj-indicts-4-florida-men-1b-telemedicine-fraud-conspiracy

Private payers, including Blue Cross Blue Shield of Tennessee, were bilked out of about $174 million in the compounding pharmacy scam, which inflated prices for invalidly prescribed pain creams and other drugs.

KEY TAKEAWAYS

Seven compounding pharmacies were indicted along with their owners in the scheme.

The scam affected tens of thousands of patients around the country.

The alleged scammers billed private payers for about $931 million in fraudulent claims.

Four Florida men were charged in a multistate telemedicine scheme that billed at least $931 million in fraudulent claims to private insurance companies, the Department of Justice said Monday.

According to a 32-count indictment filed in U.S. District Court in Greeneville, Tennessee, the four defendants, owners of seven compounding pharmacies in Florida and Texas, set up an elaborate telemedicine scheme that solicited insurance and prescription drug information from consumers across the country.

Physicians unwittingly approved the prescriptions for pain creams and other drugs without knowing that the defendants were jacking up the prices of the invalidly prescribed drugs, which were billed to private payers.

Tens of thousands of patients and more than 100 physicians in East Tennessee bore the brunt of the scam, which ran from mid-2015 through April 2018. Private payers in the region, including Blue Cross Blue Shield of Tennessee, were bilked out of about $174 million, prosecutors said.  

BCBS Tennessee issued a statement on Tuesday noting that it was “only one of hundreds of insurers impacted by this case.”

“We remain committed to partnering with our customers, providers and law enforcement to fight fraud, waste, and abuse in the healthcare system,” BCBST said.

All totaled, the indictment alleges that the defendants submitted not less than $931 million in fraudulent claims for payment. It’s not clear how much was paid out.

The four Florida defendants were identified as Andrew Assad, 33, of Palm Harbor, Peter Bolos, 41, of Lutz, and Michael Palso, 44, of Odessa, and Larry Everett Smith, 48, of Pinellas Park.

The companies were identified as: Germaine Pharmacy in Tampa; Synergy Pharmacy Services, in Palm Harbor; Precision Pharmacy Management, Tanith Enterprises, ULD Wholesale Group, and Alpha-Omega Pharmacy, all in Clearwater; and Zoetic Pharmacy in Houston, Texas.

The four defendants were each charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce.

If convicted, the four men face prison terms of up to 20 years for each mail fraud charge, up to 10 years for conspiracy, and up to three years in prison for introducing misbranded drugs into interstate commerce.

The indictment also seeks forfeiture of approximately $154 million.

The indictments come on the heels of the related Sept. 26 guilty plea by Scott Roix, 52, the CEO of HealthRight LLC, a telemedicine company in Pennsylvania and Florida, for his role in the scheme. Roix and HealthRight also pleaded guilty to wire fraud charges in a separate scheme that fraudulently telemarketed dietary supplements, skin creams, and testosterone.