Tag Archives: Health Policy

Value-Based Drug Pricing: Watch Out for Side Effects

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http://www.commonwealthfund.org/publications/blog/2016/jul/value-based-drug-pricing?omnicid=EALERT1068913&mid=henrykotula@yahoo.com

What would penicillin cost under value-based pricing, a system in which drug makers set prices based on the benefits of their products to consumers and the larger society, rather than drugs’ costs of production? Penicillin has saved millions of lives since its first use in 1942, and it still works for many patients despite growing bacterial resistance to the drug. (Fortunately, many fewer patients get infections with pneumococcus now because we have a good vaccine for it.) Surely, under value-based pricing, penicillin would sell for thousands or tens of thousands of dollars a dose.

Nondiscrimination And Chronic Conditions — The Final Section 1557 Regulation

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http://healthaffairs.org/blog/2016/07/20/nondiscrimination-and-chronic-conditions-the-final-section-1557-regulation/

Blog_Burwell2

Before the Affordable Care Act (ACA), those with serious or chronic health conditions were often denied health insurance coverage or paid high prices for substandard plans with coverage exclusions. Many went uninsured and untreated. For them, the ACA’s new coverage opportunities and protections against discriminatory practices by health insurers serve as an essential lifeline.

Under the ACA, insurers can no longer charge higher premiums or deny coverage for people with pre-existing conditions. However, some insurers have tried to circumvent ACA protections by designing benefits that discourage enrollment by persons with significant health needs.

NHeLP and The AIDS Institute filed a landmark complaint with the Department of Health and Human Services’ Office for Civil Rights after four Florida insurers placed all HIV medicines, including generic drugs, on the highest cost sharing tiers. Researchers found that this practice—called “adverse tiering”—is widespread. A New England Journal of Medicine study found that one-in-four insurers placed all drugs to treat HIV in the highest tiers. Another study in Journal of the American Medical Association found that up to 15 percent of plans in the federal marketplace lack in-network physicians for at least one specialty, making access to care significantly more expensive for those with specialized care needs.

The Department of Health and Human Services (HHS) recently finalized regulations for the cornerstone non-discrimination provision of the ACA — Section 1557. For the first time, the provision applies civil rights protections against discrimination on the basis of race, ethnicity, national origin, sex, age, and disability specifically to health programs and activities administered by or receiving federal funding.

Health advocates and patient advocacy organizations lauded the final regulations for Section 1557, which expressly prohibit insurers from employing plan benefit designs or marketing practices that discriminate.

20 things to know about balance billing

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http://www.beckershospitalreview.com/finance/20-things-to-know-about-balance-billing.html

Medicine and Dollars

As payers and providers wage war over reimbursement rates for medical services, patients have been increasingly strapped with unanticipated healthcare bills that can have detrimental financial effects.

The practice of balance billing refers to a physician’s ability to bill the patient for an outstanding balance after the insurance company submits its portion of the bill. Out-of-network physicians, not bound by contractual, in-network rate agreements, have the ability to bill patients for the entire remaining balance.

Balance billing may occur when a patient receives a bill for an episode of care previously believed to be in-network and therefore covered by the insurance company, or when an insurance company contributes less money for a medical service than a patient expected.

In recent years, the rise in out-of-network payer-provider reimbursement clashes have spawned a growing number of balance billing cases. Last October, Aetna discouraged members from seeking emergency medical care at in-network Allegheny Health Network hospitals in Pittsburgh after out-of-network emergency physicians began ‘aggressively’ balance billing policy holders. In a more drastic move, UnitedHealthcare announced last year the insurer would no longer cover medical bills for members who unknowingly received out-of-network treatment by physicians at in-network hospitals.

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

10 states with the costliest employer-sponsored health insurance

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http://www.beckershospitalreview.com/payer-issues/10-states-with-the-costliest-employer-sponsored-health-insurance.html

Money Roll

The Agency for Healthcare Research and Quality recently released data from its Medical Expenditure Panel Survey, a large-scale study of families, individuals, providers and employers in the U.S. concerning the cost and use of healthcare and health insurance.

Here are the 10 states with the costliest employer-sponsored health insurance in 2015, listed with the average single premium per enrolled employee at private-sector organizations:

Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries

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http://www.commonwealthfund.org/publications/in-the-literature/2016/june/association-between-medicare-accountable-care-organization?omnicid=CFC1066901&mid=henrykotula@yahoo.com

“Medicare ACO programs are associated with modest savings on average across all beneficiaries, with savings concentrated in clinically vulnerable beneficiaries and use of institutional settings.”

Anthem-Cigna Deal: Seeking Merger Approval, Anthem Makes Major Donations To State Political Groups

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http://www.ibtimes.com/political-capital/anthem-cigna-deal-seeking-merger-approval-anthem-makes-major-donations-state

Money in Sky

Seeking regulatory approval for a controversial merger proposal, health insurer Anthem recently pumped $460,000 into groups supporting the election campaigns of governors and state attorneys general. The money was disclosed in second-quarter campaign finance reports reviewed by International Business Times.

Those federal filings, which were released by the Internal Revenue Service late Friday, show Anthem gave $210,000 to the Republican Governors Association, $200,000 to the Democratic Governors Association in the last three months. In many states, the insurance commissioners reviewing the proposed Anthem-Cigna mega-merger are appointed by governors. The cash to state officials is on top of $50,000 Anthem gave to a Democratic-affiliated political group called “Unity Convention 2016.”

The money to the DGA is particularly notable because the group is headed by Connecticut Gov. Dannel Malloy, whose insurance commissioner, Katharine Wade, runs the agency leading the national multistate review of the deal. Anthem money flowed to the DGA in June amid an ethics probe prompted by IBT’s investigative series documenting Wade’s personal and familial ties to Cigna.

Malloy has refused to force Wade to recuse herself from the merger review, at a time when Anthem and Cigna have increased their donations to the DGA, which backed his campaigns and which he has chaired since late 2015. In all, the DGA has raised a total of $1.1 million from Anthem and Cigna since Malloy began the process of nominating Wade to the insurance post in 2015. That sum is 37 percent more than the group raised in the entire 2014 election cycle, and almost half of the total campaign contributions the companies have given the group in the last decade.

iFHP cost report highlights cause for concern over lack of provider competition

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http://www.healthcaredive.com/news/ifhp-cost-report-highlights-cause-for-concern-over-lack-of-provider-competi/422860/

The International Federation of Health Plans (iFHP) today released its2015 Comparative Price Report, detailing its annual survey of medical prices per unit. Designed to showcase the variation in healthcare prices around the world, the report examines the price of medical procedures, tests, scans and treatments in seven countries.

The report undercuts the idea of what’s being played out in the recent Sutter Health case which alleges the health system is overcharging insurers causing medical costs to be pushed downstream to patients. Last Friday, the suit was allowed to seek class-action status. Matthew Cantor, partner and attorney at Constantine Cannon and lead lawyer for the plaintiffs, told Healthcare Dive the plaintiffs allege to have contracts which require health plans to purchase all the hospital services that Sutter provides in Northern California.

Sutter is “leveraging its larger power in those markets to say to these health plans that they have to also purchase Sutter Health hospital services elsewhere and not only do they have to purchase them but they have to purchase those Sutter services at higher, super competitive prices,” Cantor said, adding that this, in turn, raises the costs of medical services to health plans. These higher costs, Cantor said, are then sent downstream to insurance policyholders.

“Competition is not working,” Sackville told Healthcare Dive. “The market’s not working because if it was, no one would get away with charging $17,000 [for a day of hospital care].”

The report put a focus on the lack of provider competition and consolidation. There’s been a fair amount of consolidation in various states and more systems are pursuing the idea of mergers or partnerships. Such activity, in theory, could bring down competition in an area and tick up costs for consumers as hospitals’ market power grows. “Powerful hospital systems have the ability to raise the prices of medical care. Health plans have no alternative but to take these forced, higher costs upon them because [if they refused] then no one would buy their insurance,” Cantor told Healthcare Dive.

Where’s the value in accountable care?

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Where’s the value in accountable care?

From left: Stephanie Baum of MedCity News, Christina Miles of Aon Hewitt, David Van Houtte of Aetna, Dr. Katherine Schneider of Delaware Valley ACO and Dr. Greg Carroll of GOHealth Urgent Care

Accountable care is supposed to be about paying for value. But six years after passage of the Affordable Care Act heralded the shift away from fee-for-service, Dr. Greg Carroll, corporate clinical leader of GOHealth Urgent Care, has an important question: “Where’s the value?”

Hospitals oppose potential rebirth of ‘public option’ coverage

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http://www.fiercehealthcare.com/finance/hospitals-chafe-against-potential-rebirth-public-option-coverage?mkt_tok=eyJpIjoiTXpVMk1HRm1NRE5pWW1JMSIsInQiOiIrM3BwTVBRRXorTzl3NjQxOWNPOUh1UUxUT0ZcL2xNTGdleWQzKzRFRzIwZzhHYTg2T0c3TWlZV1BjUEsxd0JBRmNJaGk0WU9NMTRvWmFyZndPVit2SzZmUDFxM1dWSm1OV2l4Rnd1YlBMWTQ9In0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

Pillar of building etched with the word insurance

Under pressure from onetime rival Bernie Sanders and the liberal wing of her party, Hillary Clinton has pushed for a “public option” form of coverage in the state and federal health insurance exchanges.

The decision is considered to be a middle ground option away from Sanders’ primary campaign push for single-payer coverage. The proposal was recently endorsed by President Barack Obama.

However, the public option has drawn fire from the hospital sector, which fears it would depress the payments it receives to provide care. As a result, the American Hospital Association and the Federation of American Hospitals reached out last week to the Democratic Platform Drafting Committee.

Physician group: High cost-sharing undermines insurance protections

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http://www.fiercehealthcare.com/payer/physician-group-high-cost-sharing-undermines-insurance-protections?mkt_tok=eyJpIjoiTXpVMk1HRm1NRE5pWW1JMSIsInQiOiIrM3BwTVBRRXorTzl3NjQxOWNPOUh1UUxUT0ZcL2xNTGdleWQzKzRFRzIwZzhHYTg2T0c3TWlZV1BjUEsxd0JBRmNJaGk0WU9NMTRvWmFyZndPVit2SzZmUDFxM1dWSm1OV2l4Rnd1YlBMWTQ9In0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

closeup of a person holding a credit card

Increased cost-sharing, particularly high deductibles, lead patients to neglect necessary healthcare, according to a position paper from the American College of Physicians (ACP).

“The effects are particularly pronounced among those with low incomes and the very sick,” said Nitin S. Damle, M.D., president of the ACP in an announcement that accompanied the paper.

By exposing individuals to the full cost of certain expenses, cost-sharing undermines the primary function of insurance, says the ACP, noting that underinsurance may be a more challenging problem than lack of insurance.

More than 40 percent of marketplace plan enrollees and more than 20 percent of those insured through employers who report being in fair or poor health or having a chronic condition express confidence that they can afford necessary care, the paper says. But those with high-deductible plans have less confidence in their ability to afford a serious illness than those with low-deductible plans.

The ACP notes that rising premiums have led many employers to shift costs to employees in the form of higher average deductibles, which more than doubled between 2005 and 2015, even as wages remained largely flat.