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Senate debate day 2: A resounding no for Affordable Care Act ‘repeal and delay’

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Congress

During the second day of debate over plans to replace the Affordable Care Act, the Senate voted down a motion to repeal President Barack Obama’s signature legislation in two years while lawmakers worked on a replacement plan.

The 45-55 vote, originally scheduled for 11:30 a.m., was delayed to 3:30 p.m. following approximately six hours of debate Wednesday on the Senate floor. A majority vote was needed to move forward with the plan.

The repeal-and-delay plan, sponsored by Sen. Rand Paul, R-Ky., was modeled after legislation that both the House and Senate approved in 2015 before it was vetoed by President Obama. It would have kept the ACA in place for two years, after which time it would have removed Medicaid expansion, the individual and employer mandates, marketplace subsidies and the marketplace exchanges, as well as taxes on the wealthy and the healthcare industry, but it kept pre-existing conditions protections. It also included an amendment (PDF) by Sen. Mike Enzi, R-Wyo., which would have banned people from using subsidies to buy insurance plans that cover abortions.

Other amendments up for consideration

The Senate has approximately 12 hours left to debate proposals over the next two days. Shortly after the repeal-and-delay motion failed, they took up a vote on an amendment sponsored by Democrats to send the bill back to committee so that both parties would be able to work together on a replacement plan. That motion failed on a 48-52 vote. The Washington Post reports that senators will likely next take up bills for a “skinny” repeal and the Graham-Cassidy amendment. Hundreds of other amendments could be presented to stall a vote, Business Insider reports.

The “skinny” repeal would roll back the ACA’s individual mandate, the employer mandate and a tax on medical devices. Although they are among the healthcare reform law’s least popular mandates, the American Academy of Actuaries warns that repeal would lead to increased premiums, increased federal government costs for premium subsidies and insurance losses and solvency issues.

The Graham-Cassidy amendment proposes to repeal the individual and employer mandates and medical devices taxes under the ACA and keep requirements for pre-existing conditions. It would also keep the ACA’s taxes on the wealthy but give those funds in the form of block grants to states to administer their own health insurance programs.

Democratic senators, including Senate Minority Leader Chuck Schumer, D-N.Y., warned during the debate Wednesday that the skinny or scaled-back version of repeal is the Republican senators’ attempt to pass some sort of legislation that would lead to a full repeal. “Make no mistake about it,” Schumer said, “the skinny repeal is equal to a full repeal. It’s a Trojan horse designed to get the House and Senate into conference where the hard-right flank of the Republican caucus, the Freedom Caucus, will demand full repeal or something very close to it.”

He likened the idea for a conference with the House to a game of “hot potato” where the Republican leader in the Senate would pass the potato to the House, and the House leader would hand it back to the senate leader. “Neither wants to be responsible for what is inevitable, the demise of TrumpCare,” Schumer said.

But at the beginning of the debate on Wednesday, Senate Majority Leader Mitch McConnell said he expects the Senate to consider many different proposals and ultimately agree on legislation that will effectively end the ACA. “This certainly won’t be easy,” he said; “hardly anything in this process has been. But we know that moving beyond the failures of Obamacare is the right thing to do.”

Why There’s No Substitute for the Individual Mandate

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http://www.commonwealthfund.org/publications/blog/2017/jul/no-substitute-for-the-individual-mandate?omnicid=EALERT1248041&mid=henrykotula@yahoo.com

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Republicans seeking to replace the Affordable Care Act (ACA) are finding it difficult to eliminate its individual mandate while maintaining protections for people with preexisting conditions. The mandate has succeeded in keeping young, healthy people in the insurance market. The alternatives under consideration won’t accomplish that and would cause some people harm.

Protections for people with preexisting health conditions can destabilize health insurance markets because these protections encourage people to sign up for coverage only when they need care. The ACA addresses this by requiring those who can afford it to buy insurance even if they’re not sick and imposing a penalty on those who fail to make timely coverage purchases. The mandate has been quite effective because people may or may not believe they will need health insurance, but they can be sure they will have to pay a penalty at tax time if they don’t purchase it.

The ACA’s mandate worked. Although some have argued the law’s penalties are insufficient, the evidence indicates that they did lead young, healthy people who could afford coverage to buy insurance. In 2013, just before implementation of the ACA reforms, the uninsured rate among college-educated men ages 26 to 34—the group most likely to be able to afford coverage but not see it as a priority—was 6.9 percent. By 2015, during the first full year of the mandate, that rate had dropped to 3.8 percent, a decline of 45 percent (Exhibit 1).

Republican proposals would replace the individual mandate with provisions that penalize people who don’t maintain continuous coverage, either by forcing them to pay a premium surcharge when they do sign up for coverage (House plan), or forcing them to wait six months for coverage (Senate plan). These proposals would therefore replace the ACA’s modest but predictable assessment with larger but far-off, uncertain penalties for not buying coverage.

Studies over more than half a century consistently show that in most situations people are more responsive to immediate and certain consequences than they are to far-off, uncertain ones.1 That result is even stronger in the context of our fragmented health care system. For the Republican penalties to encourage continuous coverage, people must believe there’s a good chance they’ll face consequences if they delay purchasing insurance. But in our health care system, they know they probably won’t.

In the individual insurance market, prior to the ACA’s reforms, penalties for delaying insurance were large, far-off, and uncertain—as in the current Republican proposals. Just as in the current Republican proposals, coverage in the nongroup market before the ACA was guaranteed renewable, meaning that once in the market, people could continue to obtain coverage at prices that did not reflect changes in their health status. But before the ACA, when people first entered the nongroup market after being uninsured, insurers could lock out those with health conditions, exclude preexisting conditions, or charge any level of premiums they wanted. Those very costly consequences ought to have provided a strong inducement to avoid breaks in coverage. But the reality is that very few people actually faced those consequences. Over a seven-year period, just 15 percent of those who lost their health insurance coverage ultimately made their way to the individual market (Exhibit 2). Instead, most people who switched coverage eventually moved to employer plans (as policyholders or dependents) or to Medicaid or Medicare, which have few penalties for delaying the purchase of insurance.

This is especially true for young people. Not only are these “young invincibles” less likely to believe they need health coverage, they assume that if they do eventually want it, they will be able to get it outside of the individual market. From 2003 to 2009, about 23 percent of those ages 55 to 63 with a change in coverage eventually entered the individual market. Just 12 percent of those ages 25 to 34 did so. Most young adults who had been uninsured eventually gained coverage through an employer plan. That’s a big reason why the large, but far-off and uncertain, penalties in the pre-ACA market were never enough to encourage many young, healthy people to sign up for individual coverage—and why the ACA mandate, by contrast, prompted so many of them to sign up.

The Republican penalties are not just likely to be ineffective in encouraging people to make timely insurance purchases. As with any arbitrary penalty, their burden would disproportionately fall on some people. Before the ACA, some unlucky people who lost coverage assumed they’d regain it through a job or public program, but guessed wrong. While uninsured, they became ill or got injured. Some may then have paid exceptionally high premiums for individual coverage, many went without care, and still others paid their health care costs out of pocket. In that last group were nearly 150,000 people who became uninsured each year and incurred more than $20,000 in out-of-pocket medical expenses; 20,000 of them incurred over $50,000 in expenses. That’s a hefty price to pay for an unlucky choice.

The Republican proposals to replace the individual mandate with large but uncertain penalties would leave us in the worst of both worlds: high prices for those who do participate in the market and hefty punishments for those who are unlucky. The proposals won’t persuade young, healthy people to enter, and help to stabilize, the individual market. And they will leave some unlucky people who gambled wrong, held off buying coverage, and got sick to face exorbitant costs.

 

Geisinger Lowers Turnover for Healthcare Revenue Cycle Success

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Geisinger earned a healthcare revenue cycle excellence award after reducing staff turnover rates and engaging employees

Geisinger Health System’s VP of revenue management attributed healthcare revenue cycle excellence to lower staff turnover rates and an engaged workforce.

A MAP Award for High Performance in Revenue Cycle from the Healthcare Financial Management Association (HFMA) indicates that a health system achieved outstanding healthcare revenue cycle performance on metrics such as net days in accounts receivable and cost to collect.

However, the award also signifies healthcare employment improvements for Pennsylvania-based Geisinger Health System, one of four winning integrated delivery systems.

Barbara Tapscott, CHFP, CPAM, Geisinger’s Vice President of Revenue Management, attributed the system’s healthcare revenue cycle performance to staff and physician engagement strategies as well as the system’s collaborative workflows.

“It’s more the cohesiveness of the team that brings Geisinger the good performance,” she recently shared with RevCycleIntelligence.com. “We have a very engaged executive senior executive team here with CFOs and our System CFO. We have great employees and they’re all engaged. Geisinger provides professional development opportunities. We do additional education. We do executive coaching. We have certification for all to promote careers at Geisinger so that we get to retain our talent.”

But establishing an engaged healthcare workforce at the physician-led system of about 30,000 employees, 12 hospital campuses, and two research centers did not happen overnight. Geisinger Health System recently struggled to retain staff like many other healthcare organizations across the country.

Average turnover rates among healthcare employers reached 19.2 percent in 2015, representing a 1.5 percent increase from the previous year, a Compdata survey revealed.

Healthcare organizations also faced greater turnover rates for a wide range of positions. The Missouri Hospital Association found that the roles with the highest turnover rates in 2016 included housekeeper (29.6 percent), registered behavioral health nurse (29.2 percent), unlicensed assistive personnel (25.9 percent), licensed practice nurse (21.8 percent), certified occupational therapy assistant (20.8 percent), and registered staff nurse (17.9 percent).

High turnover rates can put significant financial strain on hospitals and health systems and negatively impact healthcare revenue cycle performance. An NSI Nursing Solutions report stated that the average cost of a turnover for a bedside registered nurse can be up to $58,400, which could result in average losses of $5.2 million to $8.1 million annually.

“It’s difficult when we have high turnover…That does take a lot of time and diminishes results.”

In light of healthcare employment challenges, Geisinger Health System targeted rising turnover rates to achieve excellent healthcare revenue cycle performance. The most recent HFMA recognition represented the system’s success with lowering turnover rates, Tapscott explained.

“One of the key performance indicators where we improved this year was in our turnover rate,” she said. “It’s difficult when we have high turnover and have to engage recruitment to get people onboard. That does take a lot of time and diminishes results.”

The integrated delivery system aimed to boost employee and physician engagement to reduce turnover rates by investing in health IT systems to support employees.

“We have significant investment in technology to manage administrative costs and routine transactions,” she stated. “We want people to be engaged and not necessarily be doing transactions that are routine. We can engage technology for that. These best practices and this focus on providing education and retention strategies for our staff have paid off.”

A major technological investment Geisinger recently made was in Fast Healthcare Interoperability Resources, or FHIR. The health IT innovation is a standard for electronic health information exchange.

Geisinger worked with Cerner Corporation in 2016 to implement FHIR to move beyond the EHR system for workflow improvements. By linking an application to the EHR system, the healthcare data standard resource stopped providers and other staff from going to multiple health IT systems to gather information on the same patient.

In addition to health IT support, a centralized business office also helped the large integrated delivery system improve its workforce engagement across several hospitals and two states.

“We are here to take care of people. That culture permeates through all of our employees regardless of where they sit.”

“Even when I have employees at different hospitals and they’re in different teams, there is centralized management so that we have standardization in our processes,” Tapscott pointed out. “We work very closely with our leadership at the various facilities to make sure that we’re still there to take care of our patients.”

“At the base of what we do is our mission. We are here to take care of people. That culture permeates through all of our employees regardless of where they sit,” she added.

With an engaged healthcare workforce, Geisinger realized healthcare revenue cycle performance improvements.

“We keep extreme focus on the cycle itself, such as how long does it take for us to gather the right information for billing once a patient has received care and then making sure that we have an environment that is free of billing errors,” she said.

“Once we have that, we can point to the metric that everyone loves, which is how much of your accounts receivable is older than let’s say 60 days or 90 days,” she continued. “If it’s that old it wasn’t collected quickly. We look at making improvements in those areas. We always look at using lean techniques. What’s my root cause? How can I fix it?”

An example of how Geisinger’s healthcare workforce demonstrates cohesiveness from patient access members to clinical teams and the patient starts with the pre-service unit.

“They are the first stop for engaging a clinical team to ensure that what the clinical team has ordered is verified according to insurance coverage,” Tapscott remarked. “If the insurance requires an authorization or it requires a referral, all those administrative transactions are handled before the patient arrives. There’s a lot of coordination with the clinical team to make sure that our clinicians and our patients and then the administrative part are all on the same page.”

The coordinated workflows for pre-service units and clinical teams also earned the integrated delivery system recognition from HFMA MAP for its patient financial responsibilityinitiatives, she added. HFMA awards hospitals, health systems, and physician practices the High Performance in Revenue Cycle award partly based on the organization’s use of best practices for patient financial communications.

“At the same time, we use the tools available to us before a service is rendered,” she said. “We provide financial estimates to our patients. We’ve verified their insurance.”

With a patient financial responsibility workflow in place, Geisinger staff notify patients of the portion their insurance is expected to pay and the estimated out-of-pocket expenses they can anticipate owing.

“Then, we go into the discussion as to what options are there for our patients, from paying in full to making monthly payments,” she stated. “We offer interest-free installment payments to our patients. For those patients that don’t qualify, we have a very generous financial assistance policy.”

“All of that is done in conjunction with communicating with our clinicians and with our patients,” she continued. “We want the patient experience when that patient arrives for care to be totally 100 percent focused on clinical care.”

To evaluate patient experience, the integrated delivery system implemented the ProvenExperience program. Under the program, patients provide feedback on a mobile application and if the patient experience was positive, system leaders recognize providers and staff involved in the experience, increasing employee engagement.

“Your definition of value and my definition of value is probably not the same.”

However, if the patient reports a negative experience, he can request a refund.

“Simply, they didn’t feel that the encounter was as valuable as it should have been,” Tapscott elaborated. “That ProvenExperience program has been in place now for the better part of two years. It’s been very successful. People would think that it would cost any company a lot of money. In actuality, it has not.”

“We have learned a lot about what we could do differently for our patients,” she continued. “Your definition of value and my definition of value is probably not the same. Again, it’s treating people with kindness at a time when they may be overwhelmed by an unexpected event or a bad diagnosis or just the uncertainty of medical care.”

As in other areas within the integrated delivery system, the ProvenExperience team charged with improving patient experience draws on experts from a range of departments to ensure cohesiveness and engagement from all aspects of the patient experience. The team consists of physicians, nurses, and administrative staff.

While Geisinger’s recent HFMA MAP award shows how system leaders effectively reduced days in accounts receivable and implemented patient financial communication best practices, it also speaks to the system’s dedicated workforce.

“It’s all about hiring the right people with the right skills,” Tapscott stated. “At the end of the day, it’s people with the right training that are helping us look for the root cause of a problem so that we can then engage to find a solution.”

Which health-care plans the Senate is voting on (and who to watch) – The Devils in the Details

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Senate Republicans opened debate on their health-care bill on Tuesday, but the devil’s in the details.

The Senate is considering a series of amendments to the House’s health-care bill. But don’t let the name fool you; many of these amendments would actually replace the entire House bill with an alternative plan. If the amended bill does pass, it will either be reconciled with the House bill in a conference committee or return to the House for an up-or-down vote.

Here are some of the most significant amendments we expect to come up:

‘Skinny repeal’ could be the Senate’s health-care bill of last resort

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https://www.washingtonpost.com/news/powerpost/wp/2017/07/25/skinny-repeal-could-be-the-senates-health-care-bill-of-last-resort/?tid=hybrid_collaborative_1_na&utm_term=.0d728e0d1595

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As the Senate prepared Tuesday to take a first-step vote on ill-defined Republican plans to go after the Affordable Care Act, a new phrase entered the lexicon of the debate: “skinny repeal.”

In substance, this plan would repeal just three parts of the ACA, according to several sources familiar with the approach. It would eliminate the requirement that most Americans carry health insurance as well as the requirement that employers with at least 50 full-time employees offer coverage to their workers. Both are central elements of the 2010 health-care law and its least popular aspects with the public.

The “skinny” plan also would rescind the tax on medical devices, one of several taxes the ACA created to help pay for other elements of the law.

A close variant of this surfaced two years ago in the House, as part of the GOP’s strategy back then to lower federal deficits. Congressional budget analysts estimated at the time that 15 million fewer Americans would have insurance coverage “most years” as a result.

For Republicans now in the Senate, the purpose is as much tactics as policy: A slimmed-down repeal plan would essentially be a placeholder bill. The idea would likely surface on the Senate floor as an amendment later this week if the chamber has been unable to pass a fuller demolition of the law. It would buy the Senate’s GOP leaders more time because any bill they successfully push through their chamber would lead to a conference committee with the House, which this spring passed its own anti-ACA legislation.

Negotiations between lawmakers of the two chambers could then continue past Congress’s August recess, preserving the ability of Senate Majority Leader Mitch McConnell (R-Ky.) and other GOP leaders to continue searching for a health-policy formulation that could garner the support of enough members of their caucus.

Key ACA Insurer Urges Gov’t to Keep Customer Subsidies

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https://www.nytimes.com/aponline/2017/07/25/business/ap-us-aca-exchange-future.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54638652&_hsenc=p2ANqtz–eAN-_JrsPxvnowpY3QX9kVEamYR1GA2aSVSqWWmEKE0DlaDC9kqZ9Mwg5FWysQGaGA358Th4IOMGqfHw–p1v5lHXeA&_hsmi=54638652

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One of the biggest insurers in the Affordable Care Act’s marketplaces is warning the federal government that it must preserve cost-sharing payments for low-income customers to avoid hurting millions of people.

Centene Corp. said Tuesday that a better-than-expected performance in those individual insurance markets prompted it to beat Wall Street expectations in the second quarter and raise its forecast for 2017.

But Chairman and CEO Michael Neidorff, like other insurance executives, is worried about the fate of cost-sharing reduction payments that ease expenses like deductibles for people with low incomes. Money for those payments has made it into Congressional bills that aim to dismantle the Obama-era law, but the fate of that legislation is uncertain.

Republicans have challenged those payments in court, and President Donald Trump has offered no guarantees that they will continue beyond this month.

Neidorff said those payments and some other government support will be crucial to stabilize the exchanges, which have been marred by dwindling choices and soaring prices.

“Any intentional act to stop these … payments does not advance the debate on how to fix our health care delivery system,” he said. “It only hurts the millions of Americans who currently have affordable health care insurance in the marketplace.

“The leadership in Washington bears the responsibility to ensure that is not happening.”

Centene covers more than 1 million people through the law’s state-based health insurance exchanges, which let people shop for coverage and then buy a plan with help from an income-based tax credit. While big national carriers like UnitedHealth and Aetna have retreated from this market, Centene has switched to growth mode.

The St. Louis-based insurer plans to expand next year into exchanges in Nevada, Kansas and Missouri, with growth in its home state filling a void in 25 counties that had no exchange choices for shoppers.

Analysts have said Centene does well on the exchanges because it sticks with customers it knows. The insurer specializes in managing the state and federally funded Medicaid program for the poor. On the exchanges, it markets to low-income customers in areas where it has a Medicaid presence.

“They came at the exchanges from a core Medicaid business and built (care) networks around largely the same providers,” said Jefferies analyst David Windley.

People with low incomes are eligible for large tax credits that help keep their premiums affordable and shield them from big tax hikes. That makes it more likely they keep up with their insurance payments and renew their coverage.

Neidorff didn’t spell out on Tuesday what his company would do if the cost-sharing reduction payments end. But other insurers have said premiums will soar in many markets.

Leerink analyst Ana Gupte said in recent note that she expects more insurers to leave the markets if the future of payments isn’t clarified by September, and that could include Centene reducing its presence. But both she and Neidorff think the funding ultimately will be preserved.

Neidorff said that he thinks congressional leaders won’t have the appetite to leave the “most vulnerable populations” without coverage.

“I am personally, and I think corporately we are, convinced that when all the dust settles there will be subsidies in some form,” he said.

Senator McCain Delivers a Key Health Care Vote, Scolding Message

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The maverick stood with his party on Tuesday, casting a crucial vote in the Republican drive to repeal “Obamacare.” But then, like an angry prophet, Sen. John McCain condemned the tribal politics besetting the nation.

Confronting an aggressive brain cancer, the 80-year-old Arizonan served notice he would not vote for the GOP legislation as it stands now. McCain’s impassioned speech held the rapt attention of his colleagues in the Senate chamber.

“Stop listening to the bombastic loudmouths on the radio, television and the internet,” he intoned. “To hell with them! They don’t want anything done for the public good. Our incapacity is their livelihood.”

A few minutes earlier, McCain dramatically entered the chamber for the pivotal vote, his first since surgery and his cancer diagnosis in Arizona. Unified for once, Republicans and Democrats applauded and whooped for the six-term lawmaker. “Aye,” he said, thumbs up with both hands, for the GOP vote to move ahead on debate.

After he voted, McCain stood at his seat and accepted hugs and handshakes from senators in both parties, drawing laughter from the spectators’ gallery when he and Vermont Sen. Bernie Sanders exchanged an awkward embrace.

McCain then spoke his mind. His face was pale, cheek bruised, a red scar and stitches above his left eye where doctors had removed a blood clot. But his voice was strong. He offered a bit of self-deprecation, saying he was “looking a little worse for wear.”

He bemoaned the lack of legislative accomplishments in the current Congress and the GOP’s secretive process in working on repealing Obamacare. He issued a plea for Democrats and Republicans to work together.

Obama and the Democrats shouldn’t have pushed the Affordable Care Act through on party-line votes when they controlled Washington back in 2010, McCain said, “and we shouldn’t do the same with ours. Why don’t we try the old way of legislating in the Senate?”

That would involve committee hearings and testimony from experts and interested parties, an incremental process that could take months.

He blasted the path taken by Republican leaders “coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them that it was better than nothing.

“I don’t think that’s going to work in the end, and it probably shouldn’t,” he said.

Debates in the Senate have become “more partisan, more tribal, more of the time than at any time I can remember,” he lamented.

With President Donald Trump threatening electoral retribution for Republicans who don’t toe the line, McCain urged senators to stand up for their own constitutional status.

“Whether or not we are of the same party, we are not the president’s subordinates,” he said. “We are his equal!”

People with health care problems had speculated on social media how McCain would vote, and his decision disappointed many. Addressing concerns that tens of millions will lose coverage if the Republican bill becomes law, McCain said the process is far from over.

“I voted for the motion to proceed to allow debate to continue,” he said. “I will not vote for this bill as it is today. It’s a shell of a bill right now.”

Arizona is one of 31 states that expanded Medicaid under President Barack Obama’s health care law, and Republican Gov. Doug Ducey is worried about tens of thousands losing their health insurance. That has to be addressed, said McCain.

The Arizona senator has emerged as one of Trump’s most outspoken GOP critics. During the presidential campaign Trump had mocked McCain for his capture by the Vietnamese.

The speech Tuesday received a standing ovation.

“He’s tough as a boot,” said Republican Sen. John Kennedy of Louisiana. “Many people understandably would be curled up in bed in the fetal position.”

McCain’s return was reminiscent of a similar scenario involving McCain’s good friend, the late Democratic Sen. Ted Kennedy of Massachusetts, who returned to the Senate in July 2008 while battling brain cancer to vote on Medicare legislation, his dramatic entry in the chamber eliciting cheers and applause. Kennedy died in August 2009. (The current Sen. Kennedy is no relation.)

McCain himself campaigned heavily on the “Obamacare” repeal issue last year as he won re-election to a sixth and almost certainly final Senate term. But he has not been a booster of the GOP health bill.

His best friend in the Senate, Lindsey Graham of South Carolina, said he’s been impatient to get back to work.

“Is it surprising that he would get out of a hospital bed and go to work? No,” Graham said. “It’s surprising he’s been in the hospital this long.”