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Senate leaves town with no Obamacare fix

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State Department: China, Russia want to ‘break the West’

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The Senate left town on Thursday for more than a week without reaching a deal to stabilize Obamacare’s marketplaces.

Talks between Democrats and Republicans started up again in earnest late last month after the GOP’s latest attempt at Obamacare repeal collapsed. However, the Senate left town Thursday without finalizing any deal, although negotiators pledged to continue talks.

Meanwhile, the Senate is in recess all of next week and won’t return until Oct. 16, just a few weeks before 2018 open enrollment starts on Nov. 1. A Senate aide said there is “no question a sense of urgency if you want to have impact on 2018.”

Sen. Lamar Alexander, R-Tenn., leading the Republican side of the talks, said Thursday that Democrats and Republicans remain in good faith negotiations.

When asked if it was too late to reach an agreement to affect the 2018 coverage year, Alexander quickly responded “no.”

Sen. Patty Murray, D-Wash., did not give a timeline for when to finish a deal.

“We are absolutely working on this. No one should think this is easy,” she said.

Some senators were perturbed they are leaving for a week without any bipartisan plan.

“I had hoped that we would pass before leaving town a bill that would help stabilize the insurance markets and lower premiums,” said Sen. Susan Collins, R-Maine, a major proponent of an agreement.

The basic framework of the agreement is funding insurer subsidies in exchange for giving more flexibility to states for waivers.

The subsidies reimburse insurers for lowering copays and deductibles for low-income Obamacare customers. The Trump administration has been making the payments month to month but has not made a commitment to the payments for 2018, which insurers have been pleading with them to do.

Republicans want in exchange for the subsidies greater flexibility and a quicker approval process for states to waive Obamacare regulations for insurers. States have complained the current process for approving waivers by the federal government is slow and burdensome and they want fewer constraints on what regulations they can waive.

Alexander said earlier this week the two sides have “differences in opinion on what amounts to giving states meaningful flexibility in exchange for two years of cost-reduction payments.”

Insurers are already finalizing rates for next year and some could charge higher rates without the subsidies.

For instance, Highmark Blue Cross Blue Shield in Delaware announced Thursday it will raise Obamacare rates by 25 percent next year, according to Delaware Online. The insurer said the rate request was based on the uncertainty surrounding the payments and questions around whether the federal government will enforce the individual mandate that forces people to have insurance.

The nonpartisan Kaiser Family Foundation has estimated that rates for silver plans, the most popular of Obamacare’s three metal tier plans, will go up 19 percent without the payments.

Medicare Advantage will have more enrollment, lower premiums in 2018

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http://www.healthcaredive.com/news/medicare-advantage-will-have-more-enrollment-lower-premiums-in-2018/506293/

Dive Brief:

  •  The CMS says Medicare Advantage (MA) members will have more choices and lower premiums in 2018. Medicare open enrollment starts on Oct. 15.
  • The average MA monthly premium is expected to decrease by about 6% from $31.91 in 2017 to $30 in 2018. The CMS said 77% of MA enrollees who stay with their current plan will have the same or lower premiums in 2018.
  • MA’s enrollment is expected to increase by 9% to 20.4 million in 2018. The CMS expects that slightly more than one-third of Medicare enrollees will have an MA plan next year.

Dive Insight:

While the CMS has talked negatively about the Affordable Care Act (ACA), CMS Administrator Seema Verma is a big fan of MA. Verma (a candidate for HHS secretary in the wake of Tom Price’s departure) said MA and Medicare Part D “demonstrate what a strong and transparent health market can do — increase quality while lowering costs.”

Payers are enjoying positive financial numbers in the MA market. UnitedHealth Group said recently that it believes eventually half of all Medicare beneficiaries will have an MA plan. Payers are looking at the MA market for growth opportunities. In some cases, payers, such as Humana, are cutting back on ACA plans and investing more in MA.

Despite the CMS’ overall support of MA, the agency still sees one way to improve the program. The CMS wants MA payers to provide current and accurate information about their providers. The CMS found that 45% of MA provider directories had incorrect information, such as listing which providers are taking new patients, or providing the wrong phone numbers and addresses.

Currently, the CMS can only review MA plans’ provider networks when there is a triggering event. This can include when the insurance company starts in MA or extends its coverage, or the CMS receives a complaint about provider network issues. The CMS wants to have more oversight over provider network information, so that it can ensure the information is up to date.

While MA plans have been popular with the CMS, members and payers, there is a concern about a small number of payers monopolizing the market. The Kaiser Family Foundation said UnitedHealth controls nearly one-quarter of the MA market and is a major MA player in 42 states and the District of Columbia. KFF found UnitedHealth, Humana and Blue Cross Blue Shield affiliates make up 57% of MA enrollment and the top eight MA payers comprise three-quarters of the market.

Another issue for MA payers is that federal investigators are concerned about how much MA is paying insurers. The Department of Justice (DOJ) is investigating payments to insurance companies involved with MA.

Two of the bigger cases involve UnitedHealth. The payer is involved in two whistleblower lawsuits that allege MA overpaid the insurer by billions. The DOJ joined the lawsuits, which allege that UnitedHealth changed diagnosis codes to make patients seem sicker, which resulted in higher reimbursements to the insurer.

The CMS estimated that it overpaid $14.1 billion in 2013 to MA organizations. Medicare Advantage payers received about $160 billion in 2014. The CMS estimated about 9.5% of those payments were improper.

Congress misses deadline to reauthorize CHIP

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http://www.healthcaredive.com/news/congress-misses-deadline-to-reauthorize-chip/506252/

Dive Brief:

  • The Children’s Health Insurance Program (CHIP), which provides coverage to 9 million children, expired this weekend after Congress failed to reauthorize the program before the Sept. 30 deadline.
  • There is still hope that Congress will approve a reauthorization quickly, but state leaders are concerned if Congress doesn’t act soon they will run out of money for the program, which is mostly paid for with federal funds. House and Senate lawmakers have said they will pursue CHIP legislation this week.
  • The Medicaid and CHIP Payment and Access Commission (MACPAC) estimated that if CHIP isn’t reauthorized three states and the District of Columbia will run out of program funding by the end of the year and another 27 states will run dry in the first quarter of 2018.

Dive Insight:

MACPAC warned that stopping CHIP funding will impact state budgets and force states to decide whether to continue coverage on their own dime. If states limit or stop CHIP coverage, hospitals and providers could feel the brunt of fewer insured children and more bad debt. This is especially true for children’s hospitals.

Jim Kaufman, vice president of public policy at Children’s Hospital Association (CHA), recently told Healthcare Dive that CHIP is important for children’s hospitals. “CHIP is good for kids, and that makes it good for children’s hospitals and children’s providers,” Kaufman said.

Not reauthorizing CHIP quickly could especially be an issue for the three states (Arizona, Minnesota and North Carolina) and the District of Columbia, which are expected to run out of CHIP money by the end of the year.

There was hope last month that Congress might be able to reauthorize the program in time. A bipartisan group of senator agreed on a reauthorization bill in September that would have extended CHIP for another five years. However, momentum for that bill stalled when Capitol Hill turned its attention to the Graham-Cassidy ACA repeal legislation. Graham-Cassidy died without a floor vote, and Congress didn’t take up CHIP reauthorization before the deadline.

CHIP, which costs about $14 billion annually, was created in 1997 as a way to provide more health insurance coverage to children of families with low and moderate incomes. The federal government sends CHIP money to states annually, based on previous spending of the funds and populations factors. The states must spend the federal money within two years. Money that isn’t used goes back to the federal government to reallocate to states with CHIP funding shortfalls.

Congress has reauthorized the program periodically since its creation. CHIP has wide support and studies have shown the program helps reduce hospitalizations and child mortality and increase quality of care. When the program was created, 15% of children were uninsured. That number is now about 5% because of CHIP, the Affordable Care Act and Medicaid expansion.

Why for-profit hospitals in Chicago are losing

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http://www.modernhealthcare.com/article/20171002/NEWS/171009998?utm_source=Sailthru&utm_medium=email&utm_campaign=Newsletter%20Weekly%20Roundup:%20Healthcare%20Dive%2010-07-2017&utm_term=Healthcare%20Dive%20Weekender#

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The Chicago-area hospital market is notoriously fragmented, competitive and dominated by not-for-profits. The few for-profit players there, notably national hospital chains Quorum Health and Tenet Healthcare Corp., have failed to gain share while their charitable rivals bulk up and expand. Tenet and Quorum each accounted for roughly 2% of the market in 2015, according to an analysis by independent Minneapolis-based consultant Allan Baumgarten.

Now the for-profits might be skipping town. Quorum, which owns Vista Health System in north suburban Waukegan, has already inked a deal to sell one of Vista’s two hospitals to a for-profit behavioral health company. Tenet is apparently entertaining offers from potential suitors for its four Chicago-area hospitals. In fact, the entire company might be for sale, according to the Wall Street Journal.

So why is it so hard for investor-run health systems to succeed in the Chicago area?

For one, for-profit health systems have shareholders to answer to, so they aren’t inclined to balance services that generate revenue like orthopedics and cancer treatments with ones that don’t. Plus, Chicago’s population isn’t growing. Actually, it’s shrinking. And unlike in some other states, Illinois regulators control the fate of big-ticket items, like a new hospital wing or a pricey outpatient building.

“If you think about the amount of capital a for-profit has, where are they going to place their bets?” asks Elyse Forkosh Cutler, president of Chicago-based Sage Health Strategy. “If they’re looking for low regulatory barriers and population growth, Chicago is not going to be where they come.”

There’s also this: The hospital industry in the Chicago metro area is one of the most fragmented in the nation, with 95 medical centers in the six-county area. Of those, 16 are defined as for-profit, and nearly half are general hospitals. The rest are specialty, according to 2015 state records, the most recent available.

The competition for patients and doctors is fierce. Add margin pressures for for-profits, and it’s even tougher.

“Each (hospital) fights in its own little niche for something,” says Brian Sanderson, Chicago-based national managing partner for healthcare at tax and advisory firm Crowe Horwath. “If you can’t differentiate, and there’s a number of ways to do that, then you can’t really position yourself any better to garner more market share.”

Representatives for Dallas-based Tenet, Quorum in Brentwood, Tenn., and some of its hospitals in the Chicago area didn’t return phone calls or declined to comment.

Large local not-for-profits, such as Advocate Health Care (the biggest hospital network in the state), UChicago Medicine, Northwestern Medicine and Rush are either scooping up community hospitals, forging less formal affiliations with them or investing heavily in outpatient facilities to feed back patients to their main campuses. “They’re leveraging themselves to create volume and expand the breadth of services,” says Dan Marino, a Chicago-based executive vice president at consultancy GE Healthcare Camden Group. “I don’t see the for-profits doing that. Historically, it’s a very traditional old-school model.”

To be sure, Vista has tried. With fewer dollars (about $203.2 million in 2015 net patient revenue) and a higher share of low-income patients than billionaire rivals such as Advocate and Northwestern, the system in recent years has expanded its intensive-care unit at its main general hospital, Vista Medical Center East in Waukegan, and opened a free-standing emergency center in wealthier Lindenhurst.

The system won state regulators’ approval to make all patient rooms at Vista East private, too, a move many hospitals have already made. But in June, Quorum put that project on hold, according to a letter interim Vista CEO Norman Stephens sent to state regulators. Perhaps the biggest blow was regulators rejecting Vista’s pitch to build a hospital in Lindenhurst, which the system argued would have been a lifeline to support its Waukegan facilities.

Quorum also owns MetroSouth Medical Center, a community hospital in south suburban Blue Island.

Some winners, more losers

Tenet arrived in the Chicago area in 2013, paying a premium for Vanguard Health Systems, which had four local hospitals. They are Weiss Memorial Hospital in Chicago’s Uptown neighborhood and three hospitals in the western suburbs: Westlake Hospital in Melrose Park, West Suburban Medical Center in Oak Park and MacNeal Hospital in Berwyn.

MacNeal was the most profitable of its sister hospitals by far, with $48.2 million in net income in 2015, according to Baumgarten’s analysis. Weiss and Westlake were money-losers, with losses of $2.8 million and $4.3 million, respectively, he said.

Weiss in particular is in one of the most competitive pockets of the Chicago area. Located along Lake Shore Drive, Weiss sits within a few miles of several hospitals with stronger branding power and cachet, including Advocate, and big Catholic provider Presence Health. Doctors and patients alike have plenty of options in terms of employment and care.

The Tenet hospitals in recent years have focused on smaller investments, too. Instead of glitzy new towers, improvements include renovations to an operating room waiting area, building a food pantry and buying software, state records show.

It’s not clear what the fate of Tenet’s investment is in the Chicago market. The company has been hustling to sell off weak hospitals in markets across the country that aren’t core to the brand. That could include Chicago: Piper Jaffray research analyst Sarah James says the market isn’t considered a major one for Tenet.

With a potential sale of the entire company, not-for-profit hospitals in the Chicago area would continue to dominate.

Analysis: Nurse force to grow 36% by 2030, thanks to millennials

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http://www.healthcaredive.com/news/analysis-nurse-force-to-grow-36-by-2030-thanks-to-millennials/506539/

Dive Brief:

  • Millennials are becoming registered nurses at nearly twice the rate of baby boomers, but that still won’t necessarily prevent a nursing shortage as boomers retire, a new analysis in Health Affairs concludes.
  • The number of younger RNs nearly doubled to 834,000 in 2015, after dropping to 440,000 in 2000 when Generation Xers were joining the workforce.
  • The number of millennials entering the space has leveled off recently, however, suggesting only modest growth over the next decade. Still, millennials will dominate the nurse workforce in the 2020s, the article says.

Dive Insight:

The average age of the nursing workforce in 2005 was 44, spurring widespread predictions of a nursing shortage as baby boomers retired from the field, according to the authors.

They attribute millennials’ embrace of nursing to several factors. The profession offers stable lifetime earnings and low unemployment as well as opportunities for advancement and relocation. And it can be parlayed in myriad ways across the healthcare industry.

“Considering the acceleration in retirement of the baby boomers and the stabilization of the entering cohort sizes among millennials, we expect the nurse workforce to grow 36%, to just over four million RNs, between 2015 and 2030, a rate of 1.3% annual per capita growth,” the authors write. “This is a rate of per capita growth similar to that observed from 1979 to 2000, but half the rate observed in the rapid-growth years of 2000-15.”

Whether that growth rate is enough to meet demand as baby boomer nurses retire is hard to gauge.

While nursing may be enjoying a surge in popularity, as professions go, retention is a growing problem. In a recent Medscape poll, about one in five nurses said they would not make the same career choice again. Nurses with more than 21 years in the profession were more likely to be dissatisfied than those who were new to the practice.

To retain nurses, hospitals need to provide opportunities for upward mobility and changing roles. They also need to address clinician burnout associated with increasing regulatory and administrative tasks. Allowing nurses to practice at the top of their licenses can also increase workplace satisfaction — not to mention helping address the problem of physician burnout.

Critics see Trump sabotage on ObamaCare

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http://thehill.com/policy/healthcare/354308-trump-sabotage-seen-on-obamacare

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The Trump administration is taking a hatchet to ObamaCare after failing to pass legislation through Congress repealing President Obama’s signature law.

The administration has cut funding for advertising and outreach by 90 percent, raising the odds that fewer people will join the health-care exchanges during the fall enrollment period.

It has slashed funds by 41 percent for outside groups that help reach and enroll likely ObamaCare consumers.

The enrollment period has also been chopped in half, and the administration announced plans to take down the Healthcare.gov website for maintenance for hours at a time on several days during the sign-up period, two other steps likely to cut into enrollment.

All of these steps could lead fewer people to sign up for the law, which in turn might lead to higher premiums that could force others off the exchanges.

Healthy people are the most likely to drop coverage because of a lack of outreach, leaving a sicker group of enrollees that drives up costs for everyone else.

“One has to assume at this point that enrollment will be lower as a result of the administration’s actions and that will lead to fewer healthier people signing up,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation.

The Trump attacks go beyond enrollment, too.

President Trump has threatened to cut off key ObamaCare payments to insurers in a bid to make the law “implode.”

And on Friday, his administration took a new step to roll back the law, limiting the requirement for employers and insurance plans to cover birth control.

Andy Slavitt, a former top health-care official in the Obama administration, warned on Twitter Thursday that the administration’s “sabotage” of the law added up to what he called “synthetic repeal,” meaning a range of small steps that add up to repealing ObamaCare even if Congress doesn’t act.

The administration counters that ObamaCare is a failing law that should not be propped up.

“Obamacare has never lived up to enrollment expectations despite the previous administration’s best efforts,” a Department of Health and Human Services spokesperson wrote in an emailed statement. “The American people know a bad deal when they see one and many won’t be convinced to sign up for ‘Washington-knows-best’ health coverage that they can’t afford.”

The cuts are having real world consequences already.

Reducing the outreach budget has forced local organizations known as navigators to dramatically scale back their operations.

Shelli Quenga, director of programs at the Palmetto Project, a navigator group in South Carolina, said her organization has had to cut staff from 62 people to 30 after its funding was reduced by around 50 percent.

“You want to talk about designed to fail?” she said. “This is the playbook for how to build something to make sure it fails.”

Quenga said that she only found out about the cut to her organization’s funding after the administration publicly made an announcement about the navigator cuts and she was called by a reporter for reaction.

She said the career officials she works with at the Centers for Medicare and Medicaid Services (CMS) were not aware of or involved in the decision to cut the funding, saying the decision was made at higher levels of the administration.

Navigators across the country had to scramble to craft new plans ahead of the open enrollment period beginning on Nov. 1.

“I’m just feeling very anxious about the fact that we have a whole lot less time to gear up then we should have had,” said Jodi Ray, director of Florida Covering Kids and Families, which is affiliated with the University of South Florida.

“We had a very well thought out plan, and we definitely had to go back and revise that plan, except we didn’t plan on having 3.5 weeks to put it together,” said Ray, whose group will receive $900,000 less, a 15 percent reduction.

A group of former Obama administration officials this week announced plans to launch their own enrollment effort, called Get America Covered, to try to fill the gap left by the cuts.

Insurers and ObamaCare supporters are also on edge about an executive order from Trump that could come as soon as next week loosening rules to allow businesses and other groups to band together to purchase health insurance. The problem is that these special insurance plans are not subject to the same ObamaCare rules and pre-existing condition protections, which could suck the healthy enrollees out of ObamaCare plans and damage the market.

The administration has also resisted efforts by some states, even conservative ones, to make changes aimed at stabilizing ObamaCare.

Iowa submitted an innovation waiver, which lets states alter ObamaCare as long as the law’s basic protections are retained. Part of the proposal included conservative reforms to the Affordable Care Act, yet President Trump reportedly wasn’t on board.

Trump saw a story about the waiver in The Wall Street Journal, and asked CMS to deny it, according to The Washington Post.

The application has not been formally rejected, at least not yet. It is in the midst of a 30-day public comment period, and is still pending, an Iowa Insurance Division spokesman confirmed to The Hill.

But without it, Iowa’s Insurance Commissioner Doug Ommen has warned the impact “on many Iowa families would be catastrophic.”

The deep-red state of Oklahoma had sought a waiver to help stabilize its markets, but withdrew it at the end of September because it hadn’t received approval from the administration in time.

The withdrawal came even after “months of development, negotiation and near daily communication over the past six weeks” between the state and the administration, Oklahoma wrote in a letter complaining to the administration about the lack of action.

“While we appreciate the work of your staff, the lack of timely waiver approval will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums in 2018,” wrote Terry Cline, Oklahoma’s Commissioner of Health.

 

Grassley Pressing to Include Drug Pricing Measures in CHIP Reauthorization

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https://morningconsult.com/2017/10/03/grassley-pressing-include-drug-pricing-measures-chip-reauthorization/

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  • The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition.
  • The Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay the market entry of competing drugs.

Sen. Chuck Grassley, a senior member and former chairman of the powerful Senate Finance Committee, is pressing GOP leaders to tackle high drug prices in a critical bill to renew funding for the Children’s Health Insurance Program.

Grassley (R-Iowa), who has tried for years to advance legislation targeting rising prescription drug costs to little avail, is pushing two bills as potential offsets for CHIP funding.

Both measures have some bipartisan support, but neither has advanced in previous congressional sessions amid fierce pushback from the pharmaceutical industry. But with urgency on Capitol Hill to renew CHIP, which expired last week, Grassley is taking a shot at getting the bills — the CREATES Act and the Preserve Access to Affordable Generics Act — included in the reauthorization as partial offsets.

The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition, while the Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay competing drugs from entering the market.

Experts on Grassley’s staff have talked with staff on the Senate Finance Committee and in leadership about the proposals ahead of a committee markup of the CHIP legislation on Wednesday, according to a senior GOP aide.

Supporters from the health sector, which include health insurers, providers and patient organizations, say their chances have never been better, given public outrage at exorbitant drug prices, bipartisan desire to address the issue in Congress and interest in drug prices from within the Trump administration. The proposals have even united progressive advocacy group Public Citizen and the conservative FreedomWorks.

Still, despite unprecedented momentum to tackle rising prescription costs, it is still far from certain whether Grassley will be successful. Senate Finance Committee Chairman Orrin Hatch (R-Utah) has not endorsed either measure and has sometimes sided with brand-name drugmakers on divisive pricing issues. Hatch’s office did not respond to a request for comment on Tuesday.

“It is a delicate conversation between two chairmen who’ve been here for more than a cup of coffee,” Rodney Whitlock, Grassley’s former health policy expert, said in an interview Tuesday. Whitlock is now vice president of health policy at the consulting firm ML Strategies LLC.

Political procedure also complicates Grassley’s effort. Both drug pricing measures have been referred to the Senate Judiciary Committee, which Grassley chairs, while the Senate Finance Committee has jurisdiction over CHIP.

A spokesman for Senate Majority Leader Mitch McConnell (R-Ky.) directed a request for comment to Grassley’s office.