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Bon Secours’ hospital proposal in Suffolk gets an edge over Sentara’s expansion request

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https://pilotonline.com/news/local/health/article_a058693e-d630-11e8-a732-eb28ce327e7d.html

Bon Secours Harbour View Hospital

In a race to build-out hospital services in the northern part of Suffolk, Bon Secours has received an edge over Sentara.

State health staff, who reviewed expansion requests from both health care systems this summer, recently provided a recommendation of conditional approval for Bon Secours. Its proposal seeks to add 18 in-patient beds and four operating rooms to a facility at the Harbour View campus.

The plan calls for a two-story, 76,000-square-foot facility on the northeast corner of Bon Secours Drive and Harbour Towne Parkway. Bon Secours executives say it’s an effort to better reach western Hampton Roads patients and establish a short-stay, surgically focused hospital.

Within days of each other, Bon Secours and Sentara filed letters to state health officials seeking permission to add or move beds to their respective northern Suffolk campuses.

Bon Secours filed its letter of intent first to apply for a “certificate of public need” to move hospital beds and a few surgery rooms from its Maryview Medical Center in downtown Portsmouth. Days later Sentara submitted a similar request for in-patient beds, operating rooms and a CT scanner at its Sentara Belleharbour campus on Route 17 Bridge Road.

That plan would involve moving beds from Sentara Obici Hospital. Hospital executives have said the shift would meet patients closer to where they are: About 14 patients at Obici each day are coming from Belleharbour, said Dr. Steve Julian, president of Obici, in a June interview.

But the Sentara project “duplicates” services already available in the district, according to the state’s review, and would contribute further to the hospital system’s market dominance. Staff recommended denial of the request, stating it could be “harmful to competition in the region.”

In a statement issued through a spokesman, Julian said Sentara was disappointed with the review but would consider next steps in the state’s certificate of public need process.

“We believe our application offered the most benefit for the least cost in a hospital-ready building already under construction,” Julian said in the statement.

The competing mini medical center proposals demonstrate how hospital systems vie for turf – and how the state tries to weigh those requests in the balance of keeping health care costs reasonable for patients.

The state health commissioner will render a final decision on the projects later this year.

Two letters of opposition against the Sentara project appear to have factored into the staff’s preference for the Bon Secours plan.

Dr. Joseph Verdirame, former president of the medical staff at Obici, wrote that, since acquiring Obici, Sentara has migrated many resources away from downtown Portsmouth and central Suffolk to Belleharbour and Sentara Norfolk General. He believes those shifts are detrimental to care in central Suffolk.

In another letter, Virginia Slocum, strategic operations planning manager at Chesapeake Regional Healthcare, said Sentara doesn’t have enough competition and that allowing it to spend more on expansion could drive “increases in health care costs” for consumers. 

 

 

Repeal of ACA on Republican agenda after midterms

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Repeal would end the ACA’s most popular provision, to cover those with preexisting conditions.

Republicans could try again to repeal the Affordable Care Act if they win enough seats in the midterm election this November, Senate Republican Leader Mitch McConnell said on Wednesday, according to Reuters.

WHY THIS MATTERS

Providers want to keep the ACA to minimize the cost of uncompensated care from treating individuals who have no insurance.

Insurers this year have turned around earlier losses and exits, expanding their footprint in the market and, in many cases, offering lowering premium rates for 2019.

Studies show most consumers like the ACA but remain confused about the healthcare law, with close to 80 percent unaware that open enrollment starts on November 1.

THE TREND

Republicans last year tried and failed to repeal the ACA. In another attempt to get rid of the individual and employer mandates for coverage, the GOP this summer introduced the “skinny” repeal in the Health Care Freedom Act.

On July 28, Senator John McCain cast the deciding vote when he joined two other Republican senators in voting down the skinny repeal of the ACA that the Congressional Budget Office said could result in 16 million more people becoming uninsured. Provider groups such as America’s Essential Hospitals and the American Medical Association, voiced their approval that the skinny repeal failed.

Republicans got rid of the individual and employer mandates in this year’s budget bill.

The Trump Administration also introduced a less expensive alternative to ACA plans in allowing consumers to buy short-term limited duration plans that offer coverage for up to a year and can be extended for three years. The short-term plans are not mandated by law, as are ACA plans, to cover pre-existing conditions and offer essential benefits.

THEIR TAKE

Republicans have long promised to end the ACA because they say it’s not working.

OUR TAKE

Republicans have been chipping away at Obamacare and the government has drastically cut funds to promote it, but at the same time, the Department of Health and Human Services has helped to stabilize the market. Most significantly, it has allowed insurers to silver load plans to apply full premium increases to silver plans in the ACA to make up for the loss of cost-sharing reduction payments that were eliminated by President Trump. Since nine out of 10 consumers get tax subsidies for buying plans, this move was essentially subsidized by the federal government.

Even if the GOP retains its majority this November, repeal of the ACA will be an uphill battle. It would end the ACA’s most popular provision to cover those with preexisting conditions.

President Trump tweeted on Friday his support of protecting those who have preexisting conditioins saying. “All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support. Also, Democrats will destroy your Medicare, and I will keep it healthy and well!”

 

 

 

CMS announces new waiver flexibility in ACA market

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States will have the ability to allow individuals to use ACA subsidies when buying short-term limited duration plans.

States are getting new flexibility in waivers to the Affordable Care Act, including being able to target ACA subsidies for individuals who want to buy short-term, limited duration plans, Centers for Medicare and Medicaid Services Administrator Seema Verma said today.

What is not flexible is protecting access to coverage to those with pre-existing conditions.

Verma gave no specifics on the types of waivers that will be considered, but said the agency was preparing to release a series of waiver concepts. More specifics are expected to be released in the coming weeks.

The policy goes into effect today but is expected to impact states next year, for the 2020 plan year.

IMPACT

The effect of the waivers will likely not be known until next year.

But the allowance of short-term insurance as an ACA alternative could have a more immediate effect as consumers choose plans during open enrollment starting November 1.

The Trump Administration this year extended the length of short-term plans from three months to one year, with an extension allowed for up to three years. Because these plans would not be obligated to cover the essential benefits mandated under the ACA, premiums are expected to be lower.

Opponents have said this would cause an exodus of healthy consumers from the traditional ACA market and rising prices for those left behind.

THE TREND

CMS has been taking credit for stabilizing the ACA market and lowering premiums through the use of waivers and by easing regulations.

For instance, reinsurance waivers have helped reduce premium costs, CMS said. To date, CMS has approved eight state waivers, and all but one have been a reinsurance waiver for states to develop high-risk pools to help pay the cost of high claims.

The reason for the lack of other approved waivers is due to the previous Administration limiting the types of state waiver proposals that the government would approve, CMS said.

The new Section 1332 waivers, called state relief and empowerment waivers, will allow states to “get out from under onerous rules of Obamacare,” Verma said.

WHAT ELSE YOU NEED TO KNOW

Under Section 1332 of the ACA, states can waive certain provisions of the law as long as the new state waiver plan meets specific criteria, or “guardrails,” that help guarantee people retain access to coverage that is at least as comprehensive and affordable as without the waiver; covers as many individuals; and is deficit neutral to the federal government.

The new waivers should aim to provide increased access to affordable private market coverage; encourage sustainable spending growth; foster state innovation; support and empower those in need; and promote consumer-driven healthcare, CMS said.

ON THE RECORD

“Now, states will have a clearer sense of how they can take the lead on making available more insurance options, within the bounds of the Affordable Care Act, that are fiscally sustainable, private sector-driven, and consumer-friendly,” said Health and Human Services Secretary Alex Azar.

“The Trump Administration inherited a health insurance market with skyrocketing premiums and dwindling choices,” said CMS Administrator Seema Verma. “Under the president’s leadership, the Administration recently announced average premiums will decline on the federal exchange for the first time and more insurers will return to offer increased choices.

“But our work isn’t done. Premiums are still much too high and choice is still too limited. This is a new day — this is a new approach to empower states to provide relief. States know much better than the federal government how their markets work. With today’s announcement, we are making sure that they have the ability to adopt innovative strategies to reduce costs for Americans, while providing higher quality options.”

 

Why the new ACA waivers matter

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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.”