Category Archives: Uncategorized

Five tough decisions for the GOP on healthcare

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Five tough decisions for the GOP on healthcare

Image result for Five tough decisions for the GOP on healthcare

 

Republicans have left Washington for the August recess with healthcare decisions hanging overhead, many of which must be addressed by the end of September.

Here are five decisions looming for the GOP.

  1. Should there be one more effort at ObamaCare repeal?

While the GOP attempt at repealing ObamaCare has stalled for now, some in the party are not giving up.

“This ain’t over by a long shot … we won’t rest until we end the ObamaCare nightmare once and for all,” Vice President Pence said at the Tennessee GOP 2017 Statesmen’s Dinner Thursday, according to a pool report.

Yet Republicans are running out of time to take action, as the legislative vehicle they were using to gut the health law and avoid a Democratic filibuster expires at the end of September.

Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) are pushing a new plan to redirect money currently spent on providing coverage through ObamaCare and instead give it to states to spend as they choose.

They have been meeting with White House officials, who are also pushing Congress not to give up on repeal.

“I hope that our leadership will pay attention to this effort because the idea of leaving ObamaCare without a replacement is pretty naive,” Graham said this week.

Still, Senate GOP leadership has largely signaled they are moving on from repeal for now, with the legislative session in September likely to be dominated by work on funding the government and raising the debt ceiling.

And there are so far no signs that any of the three GOP “no” votes who sunk repeal, Sens. Lisa Murkowski (Alaska), Susan Collins (Maine), or John McCain (Ariz.), are changing their minds.

However, Graham said he is working with conservative Sens. Mike Lee (R-Utah) and Ted Cruz (R-Texas) to try to incorporate their ideas on repealing ObamaCare regulations into the plan.

And Majority Leader Mitch McConnell (R-Ky.) left the door open to bringing repeal back in some form, noting the fast-track procedure being used to avoid a filibuster had not expired.

“There’s still an opportunity to do that,” he said.

  1. Should we work with Democrats?

Lawmakers are ramping up bipartisan talks on the next steps for healthcare legislation, some more enthusiastically than others.

Sen. Mike Rounds (R-S.D.) said that following the failure of the Senate GOP’s ObamaCare repeal vote, Democrats have been more willing to talk with Republicans about ways to fix the law.

“Both sides are moving a little bit more to the middle,” Rounds said. “The discussions I’m having have been positive with Democrats, saying ‘look we are open to these changes, we will listen, we will work with you.’”

Sen. Roy Blunt (R-Mo.), a member of the GOP leadership, told The Hill he still wants to repeal ObamaCare “and start over, but that doesn’t mean an effort to hold up the collapsing structure in the short term isn’t the right thing to do.”

Both the Senate’s Health and Finance committees plan to hold bipartisan hearings in September when lawmakers return from recess.

Sen. Lamar Alexander (R-Tenn.) — the chairman of the Health, Education, Labor and Pensions Committee — said the goal is for the panel to craft a bipartisan, short-term proposal by mid-September, as insurers must sign contracts saying they’ll sell plans on the federal exchange by the end of that month.

Finance Committee Chairman Orrin Hatch (R-Utah) did not suggest the panel would produce legislation, but said there was bipartisan interest in a hearing.

“We’ve also heard a lot of demands from members of the committee for a healthcare hearing. I intend to do that as well shortly after the recess,” Hatch said Thursday.

But it’s not clear that the renewed interest in bipartisanship will yield legislation.

Alexander’s committee runs the ideological gamut from conservative Sen. Rand Paul (R-Ky) to progressive Sens. Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.).

Getting everyone behind a bill could prove a tall order, especially as some Republicans like Paul are committed to repealing ObamaCare, not repairing it.

  1. Should we back legislation to make key payments to insurers?

Insurers are desperate to know whether they’re going to continue to receive critical ObamaCare payments from the federal government.

President Trump has threatened to halt the payments, which compensate insurers for subsidizing out-of-pockets costs for certain healthcare consumers.

But Congress could take the matter out of his hands by authorizing the payments the administration has been making on a monthly basis, which total about $7 billion for fiscal 2017.

Even if Trump doesn’t halt the cost-sharing reduction payments, a yearlong appropriation from Congress would give insurers certainty that they’ll continue to receive the funds.

Republicans are divided on what to do.

Many say the ObamaCare marketplaces need to be stabilized and are open to funding the payments. Alexander took the first concrete step forward to do so, saying that any stabilization package his committee produces should fund the payments.

But conservatives are vehemently opposed.

“I think it is a mistake to simply go forward with bailouts for big insurance companies,” Cruz said. “For whatever reason, the Democrats’ central priority seems to be providing billions of dollars in subsidies and bailouts to giant insurance companies.”

  1. What’s to be done with CHIP?

Time is of the essence for Congress to reauthorize the Children’s Health Insurance Program (CHIP). Funding is set to expire Sept. 30.

CHIP has historically had bipartisan support, and the Senate Finance Committee announced on Thursday it would hold a post-recess hearing on CHIP.

Congress last reauthorized the CHIP program in 2015 as part of a broader health package.

However, for Republicans still searching for a way to pass provisions of their failed ObamaCare repeal legislation, the authorizing legislation may be a tempting vehicle.

If CHIP funding expires, states will be forced to make difficult decisions about coverage. Millions of families would have to find other sources of insurance for their children at a time of uncertainty around the stability, availability and affordability of other types of coverage.

  1. What’s to be done with ‘bare’ counties?

Insurance commissioners have a big fear: That the ObamaCare health marketplaces will open for business, but people in some areas won’t have any plans to choose from.

This scenario has never happened before, but as of Friday, 17 counties have zero insurers committed to their exchange, according to Kaiser Family Foundation.

The deadline to participate is looming. Insurers sign contracts with the federal government at the end of September, saying they’ll offer plans on the ObamaCare exchanges.

If the Senate Health Committee is able to meet its goal — hammering out a bipartisan short-term stabilization bill by mid-September — then that could help prevent more insurers from fleeing the marketplaces.

And behind the scenes, insurance commissioners have been offeringinsurers previously unheard of flexibilities to keep or entice them into the marketplaces.

Congress is aware of the situation, and has proposed several other solutions.

One bill from Tennessee’s Republican senators, Bob Corker and Alexander, would let people use their ObamaCare subsidies to purchase plans off the exchange — that is, if they live in a “bare county” without any ObamaCare plans to buy.

A counter bill from Sen. Claire McCaskill (D-Mo.) would allow those in bare counties to buy coverage on Washington, D.C.’s exchange, where Congress members and their staff purchase insurance.

Florida insurance regulators ask payers to file backup rates in case Trump administration withholds CSRs

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://www.fiercehealthcare.com/aca/florida-insurance-regulators-ask-payers-to-file-back-up-rates-case-trump-administration?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWkRKbFpUZzBZVFl6TkdGaSIsInQiOiJwMDRSM0NHYzQ1MFdOVlJuUFMxUEpQbGpYM0tHZUZzNjZXaFJ5eDNEMTVsOTV2WDRHOWxEYWZpeml0eEpjTW4zSitjZGdrWE1kSzI5RGI2QnVZSDNSZVJIbHhycWRZWHFKU1N3cjdrbXhOS0lxQURRWW5cL1llanZ6UXpLVXI2MzQifQ%3D%3D

Health insurance, pen and stethoscope

Uncertainty over the Trump administration’s plans for cost-sharing reduction payments has payers on edge as they file their individual market rates for 2018. And in one state, regulators have asked insurers to file back-up plans.

The Florida Office of Insurance Regulation asked the nine payers that participate in the state exchanges to file rates in case the CSR payments don’t come through, the agency told FierceHealthcare. The average rate increase was already 17.8% for 2018, according to reported (PDF) from FOIR. With CSR payments out of the picture, rates are more than likely to jump.

Blue Cross Blue Shield of Florida, the state’s largest insurer, is projecting increases of about 20% if the Trump White House does not fund CSRs, according to its filings. Darnell Smith, the payer’s market president for North Florida, said in a July interview with the Jacksonville Daily Record that it would likely make insurance unaffordable for some of its members.

“If those go away, the coverage that we provide could become unaffordable for quite a few folks,” Smith said.

The fate of the CSR payments rests at least in part in President Donald Trump’s hands. Experts have named continued funding for those payments as key to stabilizing the individual insurance markets.

A court ruling earlier this week, though, may have made a notable dent in Trump’s power to use CSRs as a health reform bargaining chip. A U.S. appeals court ruled that states can intervene in Congress’ ongoing suit against the payments.

The uncertainty about CSRs is reflected in rate filings beyond Florida as well. Median premiums in New Hampshire could rise 43% based on state filings (PDF) and significant increases are also expected in states like Wyoming (PDF). Molina Healthcare, which posted significant losses in its second quarter, could hike its Affordable Care Act plan rates by as much as 55%.

America’s Health Insurance Plans spokeswoman Kristine Grow told FierceHealthcare that payers are in desperate need of certainty when planning for 2018 and beyond.

“As plans make decisions for 2018, they do so with a view of wanting to serve consumers in the market for the full year,” she said. “That’s why it’s so important to know what will happen with CSRs long term.”

 

GOP states move to cut Medicaid

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

GOP states move to cut Medicaid

GOP states move to cut Medicaid

Republican governors are working with the Trump administration to do something Congress couldn’t accomplish: fundamentally alter their state Medicaid programs.

At least six states with GOP governors— Arkansas, Kentucky, Arizona, Maine, Wisconsin and Indiana — have already drafted plans meant to introduce new rules people would have to meet to be eligible for Medicaid, which provides healthcare to low-income Americans and those with certain disabilities.

Some want to add work requirements or introduce drug testing for recipients. Others want to raise premium prices.

The Trump administration has to approve the plans. Some approvals could come in weeks.

Critics say the proposed changes will leave fewer people on Medicaid and hurt the poor and vulnerable.

“There are limits on what’s allowable, and tying eligibility to work or drug testing or some of these other things is not consistent with what should be allowed,” said Judith Solomon, vice president for health policy at the liberal-leaning Centers on Budget and Policy Priorities.

“That said, we know we now have an administration that likely thinks differently, and we could see some changes in that regard,” she said.

Proponents argue the changes, which would waive federal requirements under Medicaid, are an important tool in trimming the fast-rising costs of the program.

They say Medicaid recipients should have some “skin in the game” — an incentive to transition from government support to full-time employment.

“Medicaid is Pac-Manning state budgets right now. It’s taking money away from education, transportation, in expansion and non-expansion states alike. It is eating their budgets,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

In the past, waivers have been granted to test new ways of delivering care and expanding Medicaid coverage. The only real requirements are that the waivers be budget neutral and promote the objectives of the Medicaid program.

Health and Human Services Secretary Tom Price, a former Republican congressman from Georgia and a vocal ObamaCare critic, has enormous flexibility in deciding what that means.

In March, Price and Seema Verma, who helms the Centers for Medicare and Medicaid Services, sent a letter to governors saying the administration would allow work requirements, larger premiums and other waiver provisions.

It was a dramatic departure from the Obama administration and “an open invitation” for states, said Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured.

“By and large, Obama let states use waivers to expand the number of people in the Medicaid program,” Archambault said.

The Trump administration seems poised to do the opposite.

Critics say the proposed requirements go beyond the authority of the executive branch, but Archambault said the statute on what’s allowed is extremely broad, meaning the administration has the authority to approve most, if not all of the proposals.

Republicans in Congress have been deeply divided over Medicaid, with conservatives seeking to cut spending on the program but centrists from states where it was expanded under ObamaCare pushing back.

The House and Senate’s ObamaCare repeal bills sought to drastically cut back Medicaid spending by capping federal financing and ending ObamaCare’s enhanced federal funding for coverage expansion. The bills also would have given states the option of imposing work requirements.

Medicaid waivers can’t change the program’s financing the way a federal law could, but several state waivers filed months ago include a work requirement as a way to trim spending.

Work requirements “will have the result of cutting state Medicaid costs because fewer people will be on Medicaid,” said Deborah Bachrach, a partner at Manatt Health and former Medicaid director of New York.

To date, no state has received an approval for a waiver requiring people to work to be eligible for Medicaid. If the Trump administration approves of one, most experts think other states will get similar requirements approved quickly.

“If and when Kentucky and Arizona get approval … you’ll see a bunch of other Republican states copycat,” Archambault said.

Other changes, if approved, include lowering the eligibility levels for coverage and a time limit for being on Medicaid.

Arkansas recently filed a waiver request to lower the Medicaid eligibility level while still receiving extra federal money as a Medicaid expansion state. It’s the first state to make such a request of the Trump administration; some states tried similar requests during the Obama administration and were denied.

Wisconsin would like to screen all and test some applicants for drugs. Those who test positive for drugs would be required to receive treatment; those who refuse to be screened or take a test would be ineligible for Medicaid benefits.

The state also wants to impose a 48-month limit on Medicaid eligibility, unless the person is working.

“My biggest concern is that the state is going to create a lot of new red tape and expense that is going to suppress Medicaid participation and increase total healthcare costs by putting greater reliance on hospital and emergency departments,” Jon Peacock, research director for Wisconsin-based Kids Forward, said.

Experts warn certain controversial provisions, if implemented, could be targets for lawsuits.

“Some of these waivers are pushing the boundaries of what has been approved before, and that could lead to potential litigation,” Rudowitz said.

The financial barrier to developing antibiotics? No big payday for drug companies

Posted on by • Posted in Uncategorized • Tagged , , , , • Leave a comment

http://www.pbs.org/newshour/bb/financial-barrier-developing-antibiotics-no-big-payday-drug-companies/

Image result for dollars

 

The New Metrics

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

http://www.healthleadersmedia.com/leadership/new-metrics?spMailingID=11626424&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1220355864&spReportId=MTIyMDM1NTg2NAS2

Image result for critical metrics

The business and clinical intelligence that are necessary for healthcare leaders to better manage their organizations are changing rapidly. Returns may be greatest for organizations that are able to measure outcomes and show value.

An old saying from Six Sigma and other process improvement regimes is that “what gets measured gets done.” That’s important for senior healthcare executives to remember. But that truth leaves out the critical question of what should be measured.

The options are literally endless, but determining the most important metrics to measure in an era in which healthcare is transforming is no trivial decision.

The move toward reimbursement based on the value the healthcare organization provides to the patient and the payer, which is happening at vastly different rates in some geographical areas compared to others, means that asking and answering that question at regular intervals is crucial.

If that’s the case, what are the metrics that leaders need to watch to ensure clinical, financial, and strategic success?

This special issue of HealthLeaders examines how high-performing organizations are instilling and adapting to new performance measures that healthcare leaders need to track to “get value done.”

Our editorial team talked with more than a dozen organizations in a variety of sectors, from leaders of hospital inpatient organizations to payer leaders, from leaders of postacute care organizations to information technology, nursing, and finance leaders; all have measurements they find useful to achieve value in a rapidly transforming healthcare business environment.

Some metrics may be familiar, such as admissions or readmissions per thousand patients. Other metrics may be unfamiliar, such as a “user resource metric,” part of which incorporates the speed with which patient calls are answered at a call center.

Many more important metrics are clinical in nature, but are often monitored and reported by the financial arms of the organization, as they provide a proxy for customer satisfaction, a growing component of the value equation.

Also critical is the latency of such measurements. For example, it’s less valuable to learn about line infection rates and sepsis diagnoses after the patient has been discharged, because little can be done to influence the statistics by that time.

Whistleblowers: United Healthcare Hid Complaints About Medicare Advantage

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , • Leave a comment

http://www.healthleadersmedia.com/leadership/whistleblowers-united-healthcare-hid-complaints-about-medicare-advantage?spMailingID=11626431&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1220355933&spReportId=MTIyMDM1NTkzMwS2#

Die Whistleblower

 

The suit, filed by United Healthcare sales agents accuses the giant insurer of keeping a “dual set of books” to hide serious complaints about its services

United Healthcare Services Inc., which runs the nation’s largest private Medicare Advantage insurance plan, concealed hundreds of complaints of enrollment fraud and other misconduct from federal officials as part of a scheme to collect bonus payments it didn’t deserve, a newly unsealed whistleblower lawsuit alleges.

The suit, filed by United Healthcare sales agents in Wisconsin, accuses the giant insurer of keeping a “dual set of books” to hide serious complaints about its services and of being “intentionally ineffective” at investigating misconduct by its sales staff. A federal judge unsealed the lawsuit, first filed in October 2016, on Tuesday.

The company knew of accusations that at least one sales agent forged signatures on enrollment forms and had been the subject of dozens of other misconduct complaints, according to the suit. In another case, a sales agent allegedly engaged in a “brazen kickback scheme” in which she promised iPads to people who agreed to sign up and stay with the health plan for six months, according to the suit.

Though it fired the female sales agent, United Healthcare concluded the kickback allegations against her were “inconclusive” and did not report the incident to the Centers for Medicare & Medicaid Services, according to the suit.

Asked for comment on the allegations in the suit, United Healthcare spokesman Matt Burns said: “We reject them.”

Medicare serves about 56 million people, both people with disabilities and those 65 and older. About 19 million have chosen to enroll in Medicare Advantage plans as an alternative to standard Medicare. United Healthcare is the nation’s biggest operator, covering about 3.6 million patients last year.

The whistleblowers accuse United Healthcare of hiding misconduct complaints from federal officials to avoid jeopardizing its high rankings on government quality scales. These rankings are used both as a marketing tool to entice members and as a way for the government to pay bonuses to high-quality plans.

Medicare paid United Healthcare $1.4 billion in bonuses in fiscal 2016 based upon their high quality ratings, compared with $564 million in 2015, according to the suit. CMS relies on the health plans to report problems and does not verify the accuracy of these reports before issuing any bonus payments.

The suit alleges the bonuses were “fraudulently obtained” because the company concealed the true extent of complaints. In March 2016, for instance, the company advised CMS only of 257 serious complaints, or about a third of the 771 actually logged, according to the suit.

The suit was filed by James Mlaker, of Milwaukee, a sales agent with the insurance plan in Wisconsin, and David Jurczyk, a resident of Waterford, Wis., a sales manager with the company.

The suit says Jurczyk had access to “dual” complaint databases, described as “the accurate one with a complete list of complaints and more details of the offenses and the fraudulent, truncated one provided to CMS.”

Jurczyk “has direct, personal knowledge of dozens of cases in Wisconsin alone in which customer complaints raising serious issues were routinely determined and falsely documented as either “inconclusive” or “unsubstantiated” by the company, according to the suit. Overall, about 84 percent of complaints alleging major infractions, such as forging signatures on enrollment forms, were determined to be inconclusive or unsubstantiated, according to the suit.

According to Mlaker, one sales agent faced little disciplinary action even after allegedly forging a customer’s signature on an enrollment form. The customer was “shocked” to learn that the agent had enrolled him because he had told the agent he was “not interested and did not want to enroll,” according to the complaint.

As a result, according to the suit, CMS officials never learned of these customer complaints.

The two men said that in early 2013 they began noticing that investigations of serious customer complaints that previously would have been completed “swiftly” instead “were drawn out; little actual inquiry was made, or even worse, known facts were ignored and discounted to falsify findings,” according to the suit.

Complaints also brought “much fewer and less serious corrective or disciplinary actions,” according to the suit. According to the suit, United Healthcare took steps to encourage any members with complaints to report them directly to the company rather than to complain to CMS.

The unsealing of the Wisconsin cases comes as United Healthcare and other Medicare Advantage plans are facing numerous cases brought under the Federal False Claims Act. At least a half-dozen of the whistleblower suits have surfaced since 2014.

The law allows private citizens to bring actions to recover damages on behalf of the federal government and retain a share. The Justice Department elected not to take over the Wisconsin case, which could limit the amount of money, if any, recovered. United Healthcare spokesman Burns said the company agreed with that decision.

In May, the Justice Department accused United Healthcare of overcharging the federal government by more than $1 billion by improperly jacking up risk scores over the course of a decade.