http://www.commonwealthfund.org/publications/case-studies/2016/oct/hennepin-health
This case study is one in an ongoing series examining programs that aim to improve outcomes and reduce costs of care for patients with complex needs, who account for a large share of U.S. health care spending.
What Would A Public Insurance Option Look Like In California?
The “public option,” which stoked fierce debate in the run-up to the Affordable Care Act, is making a comeback — at least among Democratic politicians.
The proposal to create a government-funded health plan, one that might look like Medicare or Medicaid but would be open to everyone, is being reconsidered at both the federal and state levels.
Amid news that two major insurers were pulling out of Affordable Care Act exchanges, 33 U.S. Senators recently renewed the call for a public option. The idea was first floated, then rejected, during the drafting of the federal health reform law, which took effect in 2010.
Democratic presidential candidate Hillary Clinton includes a public option in her campaign platform, and President Barack Obama urged Congress to revisit the idea in a JAMA article published in August.
Dave Jones, the elected regulator of California’s private insurance industry, endorsed the idea of a state-specific public option in an interview last month with California Healthline, though he did not specify how it might work.
“It would look just like an insurance plan,” except that the state would pay for medical care, potentially set up the network of doctors and hospitals, and make rules about paying providers, Kominski said. Private industry could be involved in these or other aspects of running the health plan, much as they do in Medicare Advantage and managed care Medi-Cal.California may be uniquely poised for a public plan — but the state may not need one, according to Gerald Kominski, Director of the UCLA Center for Health Policy Research.
Creating a public option in California may not be necessary at present, since the state currently has sufficient competition in the private insurance market, Kominski said. But he said policymakers could choose to implement a public option now as a backstop against a potential future scenario in which private insurers scaled back their California plan offerings.
Click to access barrierstocare-full.pdf
Anti-kickback and anti-fraud regulations, such as the Stark Law, have the unintended consequence of major barriers to care coordination, according to a new report from the American Hospital Association (AHA).
The passage last year of the Medicare Access and CHIP Reauthorization Act (MACRA) removed one regulatory barrier to care but called on legislative groups to make recommendations for removing other similar obstacles. The AHA report identifies seven barriers created by the Anti-Kickback Statute and Stark Law. These barriers, according to the report, obstruct:
The report also calls for numerous legislative solutions to these obstacles. For example, Congress should develop “safe harbors” under the Anti-Kickback law, both to protect shared savings and incentive programs and to develop the assistance patients need to recover. Current rules on safe harbors and exceptions, the report states, “are not in sync with the collaborative models that reward value and outcomes.” Legislators should also refocus the Stark Law to align it with its original purpose of regulating compensation agreements, report authors write.
The report comes around the same time as a report from the Senate Finance Committee on ways to improve the Stark Law. The suggestions range from establishing new exceptions and waivers for risk revenue to loosening current restrictions on waivers. Others consulted for the report, however, argued that expanding exceptions would only further complicate the regulatory framework and repealing the law entirely would be a better option.
The Internal Revenue Service (IRS) is ratcheting up surveillance of non-profit hospitals regarding their levels of community benefits and patient financial assistance.
The IRS reviewed 692 hospitals in fiscal 2016, which ended late last month, Bloomberg BNA has reported. Of those, 166 were referred for a closer “field examination.” The increased scrutiny is specific to 501(r) requirements under the Affordable Care Act, which mandate that hospitals formulate clear written financial assistance policies for patients and make reasonable efforts to determine if patients are eligible for assistance prior to taking any collection actions. The IRS is supposed to review each hospital every three years.
The U.S. Treasury Department issued regulations as to how the rules are to be enforced in 2014. Penalties for non-compliance include being subject to an excise tax or even losing a tax exemption entirely.
“We’ve entered into the enforcement phase now,” Donald B. Stuart, a partner with the law firm Waller Lansden Dortch & Davis LLP told Bloomberg BNA. “We’ve just moved into this new phase and new stage of 501(r), which is going to be a little bit of a wake-up call for a lot of people.”
The hospital sector has pushed back on enforcement, saying that some of the requirements were too burdensome.
Red flags included a hospital’s lack of a community health needs assessment or financial assistance guidelines. Hospitals that are out of compliance risk being audited, which can lead to other issues, such as scrutiny of unrelated business income.
The Joint Commission workplace violence resource was established in response to growing rates of violence in healthcare settings. Outside of law enforcement, healthcare is the most violent industry in the nation and healthcare workers face more non-lethal violence than employees in any other industry.
Workplace violence in healthcare settings could be even worse than statistics show. A study published in the New England Journal of Medicine found incidents of violence against providers are under reported. Providers often excuse violent behavior when they are under the influence of drugs and alcohol or who are otherwise in an altered state of mind.
Hospitals in particular face various challenges when it comes to preventing workplace violence. Several physicians working in hospitals told Healthcare Dive in the past about the difficulty of gauging a patient’s capacity for violence during triage and to screen for weapons.
There are seven states with laws requiring employers to run workplace violence prevention programs and 26 states with laws covering assaults on nurses, but no federal laws that specifically address workplace violence in healthcare settings. Establishing an online resource center is a small first step by the Joint Commission.
http://www.healthcaredive.com/news/the-case-of-the-disappearing-hospital-beds/427211/
Click to access 2016chartbook.pdf
Healthcare is leaving the traditional four walls of hospitals. As patients, payers, and providers seek to reduce costs and improve quality, they are relying less on inpatient stays and more on outpatient services. A growing reliance on outpatient services could drive healthcare costs down as costly inpatient services are increasingly reserved for patients who truly need them.
http://www.gallup.com/poll/196193/uninsured-rate-new-low-third-quarter.aspx
In the third quarter of 2016, 10.9% of U.S. adults were without health insurance, representing a new low in Gallup’s and Healthways’ nearly nine years of trending the rate of uninsured. This is down from 11.9% in the fourth quarter of 2015, before the 2016 open enrollment period that allowed U.S. adults to obtain insurance through the government health insurance exchanges.
The uninsured rate has declined 6.2 percentage points from 17.1% in the fourth quarter of 2013, right before the Affordable Care Act’s requirement that Americans carry health insurance took effect in early 2014.
Results for the third quarter are based on approximately 44,000 interviews with U.S. adults aged 18 and older from July 1- Sept. 30, 2016, conducted as part of the Gallup-Healthways Well-Being Index. Gallup asks 500 U.S. adults each day whether they have health insurance, which, on an aggregated basis, allows for precise and ongoing measurement of the percentage of Americans with and without health insurance.
Have you ever worked with a colleague who diverted drugs to feed an addiction?
Chances are you have, though you may not have known it, since drug diversion and addiction are often very secretive issues. Most estimates put nurses’ drug and alcohol misuse at around 6% to 10%, or about one in 10 nurses.
This makes it highly likely that at some point in your career you’ll encounter a colleague or staff member who is, or will, divert and misuse drugs.
Yet, diversion and addiction are still misunderstood, says Laura Wright, PhD, CRNA, associate professor in the Department of Acute, Chronic, and Continuing Care at The University of Alabama at Birmingham, School of Nursing.
“Addiction is a disease, it’s not a moral defect,” she says. “But, when I talk about addiction, I still get people asking me, ‘Why would they ever do that? That’s an awful thing. How could they do that to their children?'”
Here are five things Wright, who is a member of the American Association of Nurse Anesthetists Peer Assistance Advisors Committee, (AANA) wants nurses to know about drug diversion and addiction.
http://www.scpr.org/news/2016/10/07/65331/transgender-man-s-suit-is-latest-clash-over-cathol/
Josef Robinson was born a woman; he started the process of becoming a man about two and a half years ago. He began hormone therapy and planned to undergo a bilateral mastectomy as well.
But Robinson, a registered nurse at a Dignity Health facility in Arizona, got some surprising news: His San Francisco-based employer, which describes itself as being “rooted in the Catholic tradition,” refused to cover any of his transition-related care under its employee health insurance plan. His policy excludes all coverage related to sex transformation surgery.
That “was totally shocking to me,” said Robinson. “I never would have thought in a million years that that would happen.”
Robinson sued Dignity, alleging that its refusal to cover transition-related care qualifies as sex discrimination under Title VII of the Civil Rights Act of 1964 and the Affordable Care Act.
Title VII forbids discrimination on the basis of sex. The Affordable Care Act prohibits discrimination based on sex in health insurance and health care. Section 1557 of the law, which the U.S. Department of Health and Human Services finalized in May, says categorical exclusions related to gender transitions are discriminatory.
“I work for a hospital who treats all kinds of people – doesn’t matter race, religion, whatever – yet they have an insurance policy that has an exclusion for transgender individuals,” Robinson said. “It just doesn’t add up for me.”
Everything You Wanted To Know About Your Health Plan (But Were Afraid To Ask)
It can be well worth the effort to go up against your health plan if it denies you treatment you think you need.
That’s just one of the many lessons consumers can glean by using a new online tool unveiled today by the Department of Managed Health Care.
It shows that last year, nearly two-thirds of Anthem Blue Cross enrollees who filed an appeal with the department to challenge a denial of-care ended up getting the medical services they requested. The same was true in well over half of the appeals filed by people with Blue Shield of California coverage and 45 percent of cases involving members of Kaiser Permanente, the state’s largest insurer. In some of those cases, the insurer itself decided to reverse its decision.
The department’s “health plan dashboard,” which can be found on its website, contains information pertaining only to the plans it regulates. But those plans cover 25 million Californians — nearly three-quarters of the state’s insured population.
There are many other sources consumers can use to educate themselves about insurance plans, but the Department of Managed Health Care has a wealth of data that probably exceeds any other organization’s, said Betsy Imholz, director of special projects at Consumers Union, an advocacy group.
Imholz noted that many consumers are unaware of all the information available, and it is often difficult to understand. Reporting on quality and other aspects of health care is still in a developmental stage, she said. “But our hope is that data will become better and more accessible. “This [dashboard] is a good step.”
HENRY KOTULA 