http://www.allscripts.com/en/solutions/community-solutions/bcbsnc/faq.html
What is NC PATH?NC PATH is a collaboration among BCBSNC, Allscripts and North Carolina Health Information Exchange (NC HIE) to provide independent, primary care physicians assistance in the adoption of electronic health record (EHR) technology and meaningful information exchange. The goal of this program is to improve the health care system in North Carolina, improve the quality of care and health outcomes while helping to reduce health care spending and aid practices in becoming HIT (Health Information Technology) compliant.
Why is BCBSNC launching this program?BCBSNC is committed to improving the quality and efficiency of care while reducing costs. By providing financial support to select providers, together we can reach meaningful use requirements through certified EHR technology. This will enable the right people to have the right information at the right time to:
Facilitate coordination of care and communication between providers
Improve the quality of care and the overall patient experience
Connect patients and providers in the community
More effectively manage entire “episodes of care” across providers and care settings
Support participation in quality-of-care initiatives
What are some other benefits of this program?As part of the program, the NC HIE will coordinate with AHEC to assist practices with the Patient Centered Medical Home (PCMH) recognition process, which has been demonstrated to provide improvements to the quality of healthcare.
How does this initiative tie into National Healthcare Reform?The Obama administration believes that healthcare quality can be improved and costs can be reduced through the use of interoperable healthcare IT. An interoperable healthcare IT infrastructure enables practitioners to communicate more effectively, thereby rendering higher quality care as well as eliminating redundant testing for patients seeing multiple practitioners.
By assisting with the adoption of an EHR solution from Allscripts, BCBSNC, along with NC HIE will enable eligible physicians to obtain funding from the Federal Stimulus Program’s Healthcare Information Technology (HITECH) Act. The HITECH Act provides incentive payments via Medicare to physicians who adopt an EHR and who demonstrate that they are using it according to standards set by the federal government.
PROGRAM
How does the NC PATH program work?BCBSNC and NC HIE have endorsed an Allscripts EHR solution and negotiated special pricing for eligible physicians who wish to participate in the program.
BCBSNC is donating the cost for the implementation of an Allscripts EHR as follows:
For in-network providers, BCBSNC will cover 85% of the software cost, support and maintenance costs and the NC HIE connectivity and membership fee for a period of 5 years*. The provider is responsible for the remaining 15%.
For free clinics, BCBSNC will cover 100% of the software cost, support and maintenance costs and NC HIE connectivity and membership fee costs for a period of 5 years.**After 5 years, the practice or clinic will own the Allscripts software and will be responsible for their own product upgrades, hosting, support and maintenance, and yearly membership fees.
The NC HIE will manage the program administration and facilitation as well as support all members of the healthcare community in North Carolina regardless of their EHR technology.
AHEC and its Regional Extension Centers will assist practices with the development of workflow efficiencies, meaningful use application completion and submission, processes and procedures to achieve PCMH recognition, and BQPP participation.
Which EHR solution is being offered?Through NC PATH, the Allscripts MyWay™ EHR solution is being offered to participating providers and free clinics.
Are you dictating how clinicians should treat their patients?No. Allscripts MyWay EHR makes it easier for providers to do what they already know is best clinical practice by providing reminders, alerts, and feedback on the care they provide. All physicians want to provide world-class clinical care. This initiative will enable physicians to do this in an organized and efficient way.
What are the benefits of electronic health record technology and health information exchange to patients?An EHR has embedded ‘best-practices’, care guides, and/or decision support & alerts that can improve the clinical performance of clinicians by reminding them of necessary monitoring for patients with chronic diseases, identifying opportunities for preventive care, and preventing medical errors by checking for drug interactions or other dangerous conditions.
By connecting EHRs within various care environments across the state, all caregivers will have access to a comprehensive set of clinical information on patients, which will support better clinical decision making. As a result, patients can expect that their care will be more efficient, effective, and coordinated than ever before.
What are the benefits of electronic health record technology and health information exchange to physicians and their offices?EHRs offer a number of benefits to the physicians’ office, including immediate 24/7 access to patient information (even when outside of the office), intra-office communication tools to improve office efficiency, tracking tools for testing which has been ordered but not completed, tracking tools for results which need to be reviewed (significant source of liability risk), more accurate and timely billing capabilities and decreased administrative complexity.
ELIGIBILITY & ENROLLMENT
Who is eligible to participate in the NC PATH Program?In-network, independent (not associated with a health system), primary care providers including: pediatricians, family practitioners, internal medicine, general practitioners and OB/GYN are all eligible.
Does every provider in the office have to sign up to participate?Yes – to participate in this program, every provider in the practice must sign up.
Do I have to be PCMH recognized to participate?As part of the program, physicians are required to make a commitment of becoming PCMH recognized and commit to participating in BQPP if they are eligible. Practices with PCMH recognition are proven to experience improved care quality, reduced health care costs and additional benefits for both physicians and patients.
Do I have to participate in BQPP to be a part of the NC PATH program?Physicians are required to make a commitment of participating in BQPP if eligible. Through BQPP participation, practices can earn greater reimbursements tied to quality improvement, patient experience and administrative efficiency. Physicians who participate can earn double-digit increases in reimbursements.
INSTALLATION & SUPPORT
Who owns the data?The information is cared for the same as your paper records today. Electronic data and sharing must abide by appropriate Federal and State law including the HIPAA regulations, as well as the privacy policy and data use agreement of NC HIE. All data entered belongs to the practice at all times.
Who can access the data?Only those with certified logins can access the data. This may include multiple physicians in the office as well as specified office staff. Participants and their authorized users (includes specified office or professional staff) may access data through the HIE Network to carry out treatment, payment or health care operations to the extent permitted under federal law. For purposes of this document, the terms “treatment,” “payment” and “health care operations” have the same meaning given those terms in the corresponding federal requirements. BCBSNC will not have access to patient data, outside of normal claims information.
Are the patient records available all the time? Allscripts provides data redundancy (backup) and 99.99% uptime.
What is the maximum number of physicians that can use the EHR system?The architecture of the product is scalable. It can handle adding on as many practices as needed.
What support is provided during implementation?Those who choose to participate in the program will receive support during the initial implementation process. They will also receive software education and training, change management support, project management support and maintenance support. Data and records integration is not included.
The NC HIE will provide community programs, such as a web interface, that physicians can use to discuss medical and technology questions with other doctors.
The AHEC will provide support to practices in satisfying meaningful use guidelines, becoming PCMH recognized and participating in BQPP.
So, the practice is never without an expert assisting them along the path.
How long will it take to get up and running?EHR implementation in office typically takes 6-9 weeks although additional time will be needed to convert current paper records into electronic format, depending on the practice’s transition plan. A firm estimate will be determined during the initial assessment.
Other phases of the program take time to achieve, but through NC PATH providers are given all the support they need:
Meaningful use – approximately 3 months after implementation
PCMH recognition – approximately 12 months after implementation
Wednesday, September 28, 2011
Tuesday, September 27, 2011
US health insurers to make additional $200bn
http://www.ft.com/intl/cms/s/0/315a6e6c-abd9-11e0-945a-00144feabdc0.html#axzz1ZBWIiTvk
(Taken from Financial Times)
US health insurers stand to make $200bn in additional revenues by the end of the decade from the state insurance exchanges created by the Obama health reforms, according to a study by PwC.
(Taken from Financial Times)
US health insurers stand to make $200bn in additional revenues by the end of the decade from the state insurance exchanges created by the Obama health reforms, according to a study by PwC.
Insurers have been sceptical of the exchanges, which are due to be established in 2014, arguing that they will create additional costs and complexity for customers.
However, PwC said the insurers had warmed to the idea on the expectation of millions of new consumers and swelling premiums.
Fifty-two per cent of US insurance executives said they would participate in the exchanges and a third said they were considering it but were still undecided, PwC said. The remaining 17 per cent said they would opt out.
The state exchanges were created as part of last year’s legislation to help small businesses and individuals pool together to cut administrative costs and purchase quality and affordable coverage.
The details of the exchanges have remained hazy and states will have the option of creating their own or having them managed by the federal government.
On Monday, Kathleen Sebelius, secretary of the US Department of Health and Human Services, released guidelines setting minimum coverage standards for the exchanges.
“Insurance companies will compete for business on a transparent, level playing field, driving down costs,” Ms Sebelius said. “And exchanges will give individuals and small businesses the same purchasing power as big businesses and a choice of plans to fit their needs.”
According the PwC report, to be released on Tuesday, 12m consumers will buy insurance through the exchanges in 2014, creating about $60bn in revenue premiums for insurers. By 2019, this will swell to $200bn, when 28m consumers have purchased insurance.
“Despite concerns and unresolved legal and design questions, many insurers feel they cannot afford to opt out of health insurance exchanges,” said Jeff Gitlin, principal at PwC Health Industries. “The size of the market is difficult to ignore.”
The exchanges are at the centre of the controversial healthcare law, which continues to be embroiled in uncertainty amid legal challenges.
In May, the US House of Representatives voted to block funding for the exchanges as part of its effort to dismantle the law. The US Senate is unlikely to move the bill forward and the White House promised to veto it if necessary.
One side-effect that Michael McCallister, chief executive of Humana, is fearful about is that small and medium-sized companies will cease to offer coverage and shift workers in to exchanges.
Mr McCallister told the Financial Times last month the exchanges were a “jump ball” at this point but that if they lower distribution costs they could be a good thing.
Ana Gupte, healthcare analyst at Sanford Bernstein, said insurers were fearful of risks associated with the exchanges because they have to charge the same premiums to healthy and sick people and that young people might opt out from coverage because the penalties for doing so are relatively low.
However, most insurers still have strong incentives to participate in the programmes even if they do not like them.
“Anyone who wants to be a significant player in the insurance landscape has to participate,” Ms Gupte said. “Otherwise you would lose your current share.”Wednesday, September 21, 2011
Is the Carrot and Stick approach already working??
http://www.forbes.com/sites/rickungar/2011/01/06/more-small-businesses-offering-health-care-to-employees-thanks-to-obamacare/
Incentives of tax credit for small business leading to increases for insurability of small business employees....will the stick of $2000 for every uninsured employee be enough for employers to keep their existing plans?
Incentives of tax credit for small business leading to increases for insurability of small business employees....will the stick of $2000 for every uninsured employee be enough for employers to keep their existing plans?
Tuesday, September 20, 2011
Administration tries to sell states on health insurance exchanges
By Marilyn Werber Serafini / Kaiser Health News
Monday, September 19, 2011
WASHINGTON – Worried that the federal government could end up running new insurance marketplaces for dozens of states, the Obama administration is making a new pitch Monday for cooperation to 46 states and the District of Columbia.
Health officials from the states are meeting in Washington with the administration, which is proposing several models for ways to divide exchange duties between Washington and the states.
The exchanges, which are to open in 2014, are a key component of the health-care law, allowing individuals and small businesses to shop for coverage from a range of insurers, see if they qualify for low-income subsidies to help them buy policies, or enroll in Medicaid if they meet income requirements. The federal government will run exchanges for states that can’t – or won’t – do it themselves.
Exchange legislation had failed in 16 states – a demonstration of the widespread opposition to the law in states governed by Republicans. But the bipartisan participation in Monday’s meeting indicates a level of political pragmatism, even from states that vehemently oppose the law.
Alan Weil, executive director of the National Academy for State Health Policy, described the conundrum that Republican governors face.
"As political leaders they can say they hate the law, but as head of the executive branch, they have to be prepared," Weil said. "Some are saying they are so confident (the law is) going away that they are not going to do anything. Some are saying they hope it goes away but for now it’s the law. ... They are contingency planning."
Planning for exchanges is something the Obama administration is working to encourage.
"The notion of having many state exchanges completely federally run may not be appealing to the administration," said Linda Blumberg, senior fellow at the Urban Institute’s Health Policy Center. "The feds have been trying to be more aggressive about discussing partnership options with the states. They are looking for mechanisms for more flexibility to give states a hand in it without this being overwhelming to the states."
The partnership model helps states decide which functions they are ready to perform and which they would like to leave to the federal government, and for how long, said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the Department of Health and Human Services. "This model allows HHS and the states to be as logical and efficient with our resources as possible, while giving states the opportunity to perform the functions most important to tailoring an exchange to the unique needs of their state."
According to the Center on Budget and Policy Priorities, 10 states have passed or enacted legislation putting them on a path to state-run exchanges, and legislation is pending in seven states.
HHS on Monday is previewing for states three possible options for partnership. Instead of the federal government taking over the entire exchange operation, a state could choose to share responsibilities for managing the participation of health plans, helping consumers navigate the system, or both. The specific state responsibilities were chosen in part because states already serve some of these functions through insurance commissioners or other parts of their governments.
When it comes to health plans offered through the exchange, for example, states could oversee the selection of plans, collecting and analyzing information on rates and benefits and collecting performance data that the plans must report.
The second option would have states handle the personal component of the exchanges. For example, states would take charge of in-person assistance and manage people who will help consumers navigate the new system. States would also be responsible for consumer outreach and education.
That would leaves HHS to handle eligibility and enrollment, with the goal of achieving a seamless experience, where people can move between Medicaid and private insurance coverage on an exchange as their income situations change.
___
(Kaiser Health News is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health care policy organization that is not affiliated with Kaiser Permanente.)
http://www.bostonherald.com/news/us_politics/view/20110919administration_tries_to_sell_states_on_health_insurance_exchanges/
Health officials from the states are meeting in Washington with the administration, which is proposing several models for ways to divide exchange duties between Washington and the states.
The exchanges, which are to open in 2014, are a key component of the health-care law, allowing individuals and small businesses to shop for coverage from a range of insurers, see if they qualify for low-income subsidies to help them buy policies, or enroll in Medicaid if they meet income requirements. The federal government will run exchanges for states that can’t – or won’t – do it themselves.
Alan Weil, executive director of the National Academy for State Health Policy, described the conundrum that Republican governors face.
"As political leaders they can say they hate the law, but as head of the executive branch, they have to be prepared," Weil said. "Some are saying they are so confident (the law is) going away that they are not going to do anything. Some are saying they hope it goes away but for now it’s the law. ... They are contingency planning."
Planning for exchanges is something the Obama administration is working to encourage.
"The notion of having many state exchanges completely federally run may not be appealing to the administration," said Linda Blumberg, senior fellow at the Urban Institute’s Health Policy Center. "The feds have been trying to be more aggressive about discussing partnership options with the states. They are looking for mechanisms for more flexibility to give states a hand in it without this being overwhelming to the states."
The partnership model helps states decide which functions they are ready to perform and which they would like to leave to the federal government, and for how long, said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the Department of Health and Human Services. "This model allows HHS and the states to be as logical and efficient with our resources as possible, while giving states the opportunity to perform the functions most important to tailoring an exchange to the unique needs of their state."
According to the Center on Budget and Policy Priorities, 10 states have passed or enacted legislation putting them on a path to state-run exchanges, and legislation is pending in seven states.
HHS on Monday is previewing for states three possible options for partnership. Instead of the federal government taking over the entire exchange operation, a state could choose to share responsibilities for managing the participation of health plans, helping consumers navigate the system, or both. The specific state responsibilities were chosen in part because states already serve some of these functions through insurance commissioners or other parts of their governments.
When it comes to health plans offered through the exchange, for example, states could oversee the selection of plans, collecting and analyzing information on rates and benefits and collecting performance data that the plans must report.
The second option would have states handle the personal component of the exchanges. For example, states would take charge of in-person assistance and manage people who will help consumers navigate the new system. States would also be responsible for consumer outreach and education.
That would leaves HHS to handle eligibility and enrollment, with the goal of achieving a seamless experience, where people can move between Medicaid and private insurance coverage on an exchange as their income situations change.
___
(Kaiser Health News is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health care policy organization that is not affiliated with Kaiser Permanente.)
http://www.bostonherald.com/news/us_politics/view/20110919administration_tries_to_sell_states_on_health_insurance_exchanges/
Linguistics – Another word for “Barrier to Entry”
PPACA, HIPAA and Federal Health Benefit Mandates: Practical
The Self-Insurer August 2011
By Carolyn Smith, Esq. and John Hickman, Esq., Alston & Bird, LLP
New Claim Review Regulations Ease Compliance Burdens For Group Health Plans
On June 24, 2011, the U.S. Department of Treasury, Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly issued new interim final regulations (“Final Regulations”) and related guidance regarding the internal appeals and external claim review procedures (“Claims Review Rules”) for fully insured and self-funded group health plans and insurance policies issued in the individual market. These new requirements were added by the Affordable Care Act (ACA). The Claims Review Rules apply only to non-grandfathered group health plans otherwise subject to the health insurance reforms added by ACA. As discussed below, the Final Regulations provide significant relief from a number of the requirements that were originally included in the Claims Review Rules.
Requirements Relating to Internal Claims and Appeals
Up to 72 hours now allowed for benefit determinations relating to urgent care
The Final Regulations generally return to the pre-ACA rule in the ERISA claims regulations that determinations relating to urgent care must be made within 72 hour. However, the plan or insurer must defer to the provider’s determination as to whether a claim involves urgent care. In the preamble to the revised regulations, the Agencies emphasize that 72 hours is an outside limit and that medical exigencies may require a more rapid determination.
Diagnosis and treatment codes now only required upon request
The Final Regulations eliminate the requirement that notices of adverse benefit determinations (ABDs) automatically include diagnosis and treatment codes and their meanings. Instead, plans and insurers must provide such codes and their meanings as soon as practicable following a request from a plan participant or beneficiary. The notice of an ABD must inform participants and beneficiaries of their right to obtain such codes.
Requirements that notices be provided in a culturally and linguistically appropriate manner (“CLA requirements”)
In one of the most significant changes to the original Claims Review Rules, the CLA requirements (e.g., to provide notices in non-English languages) are completely replaced by a far simpler approach. The original plan by plan determination of whether the CLA requirements apply is replaced by a single standard based on the county to which the notice was sent. The threshold is that at least 10 percent of the population in the claimant’s county are literate only in a particular non-English language. Under the Final Regulations, Plans are not responsible for making this determination; rather, the list of counties to which the CLA requirements apply and the relevant languages are to be published by the Agencies. The preamble to the Final Regulations contains a current list of relevant counties and languages. There are 255 counties (78 of which are in Puerto Rico) that meet the threshold. In the vast majority of cases, Spanish is the relevant non-English language; however, Chinese, Tagalog, and Navajo are present in a few counties affecting just five states, Alaska, Arizona, California, New Mexico, and Utah.
The Final Regulations also eliminate the “tagging and tracking” requirement under which, once a claimant requested a notice in an applicable non-English language, all subsequent notices had to be in that language. This requirement was challenging for many current systems. In lieu of this requirement, the Final Regulations require that the English versions of all notices include a prominently displayed statement in any applicable non-English language describing how to access the language services provided by the plan. Targeted notices are not required, i.e., the statements may be included in all notices. The Agencies have published model notices that contain sample statements in each of the relevant languages. The plan or issuer must provide oral language services (such as a telephone customer assistance hotline) in any applicable non-English language and, upon request, must provide a written translation of any notice in any applicable non-English language.
The Final Regulation constrict the “strict adherence” standard for exhaustion of remedies
The original Claims Review Rules allow claimants to by-pass the internal appeals process if all of the procedural requirements are not strictly adhered to. The Final Regulations provide an exception to this strict adherence requirement for errors that are minor and meet certain other requirements. In particular, claimants may be required to exhaust internal administrative remedies despite a failure of a plan or insurer to strictly comply with the applicable rules if the failure was: de minimis; non-prejudicial to the claimant; attributable to good cause or matters beyond the control of the plan or insurer; in the context of an going good-faith exchange of information; and not reflective of a pattern or practice of noncompliance.
Effective date of changes
These changes to the internal claims process will take effect for plan years beginning on or after January 1, 2012.
Requirements Relating to External Reviews – In General
Plans and issuers must follow either a federal external review process or a state external review process. Ultimately, both the federal and state processes are to include, at a minimum the consumer protection provisions of the Uniform Health Carrier External Review Model Act promulgated by the National Association of Insurance commissioners (the “NAIC Model Act”). The process that applies depends on whether the plan is fully insured or self-insured.
Requirements Relating to External Reviews – Self-Insured Plans Subject to ERISA or the Code
Self-insured plans subject to ERISA and/or the Code are generally required to comply with a federal external review process that uses independent reviewing organizations or IROs (the “private IRO process”). DOL Technical Release 2010-01 sets forth a safe harbor process for complying with the federal external review requirements. The Final Regulations make several key changes with resepct to the federal external review process.
Scope of the federal external review process
The breadth of claims with respect to which the federal external review process applied was the subject of great concern to many employers. Under the Claims Review Rules, all benefit denials, other than questions of eligibility. In contrast, the NAIC Model Act is limited to claims relating to medical necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit.
The Final Regulations move the scope of the federal review closer to the NAIC Model Act, although it is not identical. Under the Final Regulations, the scope of the federal review includes matters that involve “medical judgment”. Medical judgment includes, but is not limited to, those factors listed in the NAIC Model Act. The actual extent of the difference as a practical matter may depend on how each plan implements its own review program. The regulations provide a couple of examples. For example, suppose a plan normally covers 30 visits to a particular specialist, but will cover more in the event of an approved treatment plan. If a claim for the 31st is denied, this involves a determination of medical judgment and would be subject to external review. On the other hand, if there is just a flat limit, with no exception, the denial of the 31st visit would not involve medical judgment and would not be subject to external review.
The preamble lists a number of other examples of situations that involve medical judgment, including (to list a few) whether a participant is entitled to a reasonable alternative standard for a reward under a wellness program; the frequency, method, treatment or setting for a required preventative service where none is specified in the recommendations; and whether a plan is complying with the nonquantitative treatment limitations under the Mental Health Parity Act. The external review process continues to apply to rescissions.
The narrowing of the scope of the federal external review is temporary, and will be revisited by the Agencies by January 1, 2014, when the remainder of the health reforms become effective. If the Agencies revert to a broader scope of review, the will provide some time for plans and issuers to adjust.
Effective date of change: The change in the scope of the federal external review is effective with respect to claims for external review initiated on or after September 20, 2011.
IRO assignment process
The original DOL safe harbor guidance on the external review process provided that, to be eligible for the safe harbor, the plan (or the plan’s TPA) must contract with at least three IROs. The purpose of this requirement was to ensure an independent and impartial review process. In subsequent Frequently Asked Questions, the Agencies clarified that failure to contract with at least three IROs would not be a per se violation of the ClaimsReview Rules and that, instead, the plan could demonstrate other steps taken to ensure that it external review process was independent and without bias.
Under revised DOL guidance, a plan must contract with at least two IROs by January 1, 2012 and rotate assignments among them. As this is a safe harbor, a plan may use an alternative process to demonstrate that reviews are independent and unbiased. However, DOL and the Treasury Department will “look closely” at any alternative means. At a minimum, these agencies expect plans to document how any alternative process constitutes random assignment, as well as how it ensures that the process is not subject to undue influence by the plan and without bias.
Requirements Relating to External Review – Fully Insured Plans
In general, in the case of a fully insured plan, the insurer is responsible for complying with the external review requirements. If the state has a compliant external review process, then the insurer must comply with that process. If the state does not have a complaint process, then a federal external review process applies. The original regulations provided a transition period to allow states to bring their laws into compliance with the NAIC Model Act. The Final Regulations end the transition rule for existing state processes on December 31, 2011, regardless of the plan year. A further transition period is provided until January 1, 2014 for state processes that are similar to the NAIC Model Act process. Beginning January 1, 2014 state process must comply with the NAIC Model Act. In states without a qualifying state process, the insurer may elect either to follow an HHS process administered through the federal Office of Personnel Management or the IRO process that applies to self-funded plans.
Sunday, September 18, 2011
How essential are essential benefits anyway?
http://www.washingtonpost.com/wp-dyn/content/article/2011/01/14/AR2011011406172.html
By N.C. Aizenman
Washington Post Staff Writer
Friday, January 14, 2011; 8:24 PM
By N.C. Aizenman
Washington Post Staff Writer
Friday, January 14, 2011; 8:24 PM
Should health insurers have to cover treatment of Lyme disease? What about speech therapy for autistic children? Or infertility treatments?
This week an independent advisory group convened by the Obama administration launched what is likely to be a long and emotional process to answer such questions.
It's hard to overstate the stakes.
Draw up a package that is too bare-bones, and millions of Americans could be deprived of meaningful health coverage when they need it most - undercutting a central goal of the health-care law. Add in too many expensive benefits and premiums could spike to unaffordable levels.
At a two-day hearing Thursday and Friday held by the Institute of Medicine ,even ardent supporters of the health-care law stressed the dangers of this second scenario: If insurance were to be become too costly, many Americans could decide it makes more sense to pay a penalty rather than comply with the law's requirement that virtually everyone obtain coverage- undermining a cornerstone of the law. Indeed, the law exempts consumers from the mandate to buy insurance if the cost exceeds 8 percent of their income.
"That must be the number one thing in your minds," Gruber said. "To understand the trade-off between our desire to make insurance generous and our desire to make it affordable."
The 18-member panel, which includes researchers and physicians as well as representatives of both consumer groups and insurers, has already received more than 300 public comments.
The committee, which aims to offer its recommendations as soon as next fall, is not charged with drawing up a comprehensive list of services to be included in the essential benefits package. Instead, Sebelius has asked it to weigh in on a number of key questions - beginning with how detailed to make the package in the first place.
Speakers representing insurers and employers argued that Sebelius should simply ensure that plans are covering the broad categories already laid out in the law. Otherwise HHS risks micro-managing in ways that interfere with insurers' ability to offer consumers choice and stifle their use of incentives to encourage consumers to control costs.
Some consumer advocates countered that unless HHS spells out the specific services to be covered in each category and prohibits insurers from placing limits on their use, patients could be denied vital care for conditions raging from obesity to kidney disease. "Access to repeated [kidney] transplants should not be limited," pleaded Troy Zimmerman, of the National Kidney Foundation.
He and advocates also urged HHS to formally define terms such as "medically necessary," which they warned insurers could otherwise interpret in ways that enable them to deny appropriate care.
"When a 40-year-old obese woman comes to my practice . . .her medical needs dictate that I provide her with obesity education and direct her to nutrition counseling . . . to help her prevent diabetes. But when billed for, these services are usually denied," said Arnold Cohen, Chairman of the Department of Obstetrics and Gynecology at the Albert Einstein Medical Center in Philadelphia.
Also at issue is language in the law directing HHS to ensure that the essential benefits package is comparable to a "typical employer plan." Did Congress mean the benefits-rich plans sponsored by large businesses? The skimpy offerings purchased by many small businesses? Something in between?
Though several current and former congressional staff involved in drafting the law testified, their answers were too varied to give a clear sense of Congress's intent.
The panel also grappled with how much consideration to give existing minimum benefits required by various states.
In some case these mandates stem from the high incidence of a particular disease in that state - lyme disease in Connecticut, for example. But James Dunnigan, a member of the Utah House of Representatives complained that in others "it's a matter of local politics and not necessarily a reflection of what's medically necessary."
States can continue to impose whatever benefits they choose above the minimum essential benefits package. But they will have to cover the extra cost for those plans sold on state-based exchanges.
Dunnigan proposed that HHS allow insurers to offer an essential benefits package that is typical of what employers offer in the given state. Jon Kingsdale, who like Gruber was instrumental in designing the Massachusetts health plan, countered that this would create an workable patchwork of mandates.
After hours of testimony, the panel's chairman John Ball, seemed to find only one point on which everyone could agree: "We have an impossible job."
It's hard to overstate the stakes.
Under the new health-care overhaul law, beginning in 2014 all new insurance plans for individuals and small businesses will have to include a package of minimum "essential benefits" falling into 10 general categories - ranging from hospitalization, to prescription drugs, to rehabilitative and habilitative services. But Congress largely left it to Secretary of Health and Human Services Kathleen Sebelius to decide how detailed to make the essential benefits package and what exactly to put in it.
At a two-day hearing Thursday and Friday held by the Institute of Medicine ,even ardent supporters of the health-care law stressed the dangers of this second scenario: If insurance were to be become too costly, many Americans could decide it makes more sense to pay a penalty rather than comply with the law's requirement that virtually everyone obtain coverage- undermining a cornerstone of the law. Indeed, the law exempts consumers from the mandate to buy insurance if the cost exceeds 8 percent of their income.
Also, while poor people would still be able to use federal subsidies to buy plans on state-run marketplaces, the impact on the federal budget could be catastrophic, ultimately dooming one of President Obama's signature legislative achievements.
Jonathan Gruber, a prominent economist who helped create the state plan in Massachusetts, told the panel he estimated that a 10 percent rise in the cost of the essential benefits package would increase the cost of government subsidies by 14.5 percent, or $67 billion, while reducing the share of the insured by 4.5 percent ,or 1.5 million, through 2019. "That must be the number one thing in your minds," Gruber said. "To understand the trade-off between our desire to make insurance generous and our desire to make it affordable."
The 18-member panel, which includes researchers and physicians as well as representatives of both consumer groups and insurers, has already received more than 300 public comments.
The committee, which aims to offer its recommendations as soon as next fall, is not charged with drawing up a comprehensive list of services to be included in the essential benefits package. Instead, Sebelius has asked it to weigh in on a number of key questions - beginning with how detailed to make the package in the first place.
Speakers representing insurers and employers argued that Sebelius should simply ensure that plans are covering the broad categories already laid out in the law. Otherwise HHS risks micro-managing in ways that interfere with insurers' ability to offer consumers choice and stifle their use of incentives to encourage consumers to control costs.
Some consumer advocates countered that unless HHS spells out the specific services to be covered in each category and prohibits insurers from placing limits on their use, patients could be denied vital care for conditions raging from obesity to kidney disease. "Access to repeated [kidney] transplants should not be limited," pleaded Troy Zimmerman, of the National Kidney Foundation.
He and advocates also urged HHS to formally define terms such as "medically necessary," which they warned insurers could otherwise interpret in ways that enable them to deny appropriate care.
"When a 40-year-old obese woman comes to my practice . . .her medical needs dictate that I provide her with obesity education and direct her to nutrition counseling . . . to help her prevent diabetes. But when billed for, these services are usually denied," said Arnold Cohen, Chairman of the Department of Obstetrics and Gynecology at the Albert Einstein Medical Center in Philadelphia.
Also at issue is language in the law directing HHS to ensure that the essential benefits package is comparable to a "typical employer plan." Did Congress mean the benefits-rich plans sponsored by large businesses? The skimpy offerings purchased by many small businesses? Something in between?
Though several current and former congressional staff involved in drafting the law testified, their answers were too varied to give a clear sense of Congress's intent.
The panel also grappled with how much consideration to give existing minimum benefits required by various states.
In some case these mandates stem from the high incidence of a particular disease in that state - lyme disease in Connecticut, for example. But James Dunnigan, a member of the Utah House of Representatives complained that in others "it's a matter of local politics and not necessarily a reflection of what's medically necessary."
States can continue to impose whatever benefits they choose above the minimum essential benefits package. But they will have to cover the extra cost for those plans sold on state-based exchanges.
Dunnigan proposed that HHS allow insurers to offer an essential benefits package that is typical of what employers offer in the given state. Jon Kingsdale, who like Gruber was instrumental in designing the Massachusetts health plan, countered that this would create an workable patchwork of mandates.
After hours of testimony, the panel's chairman John Ball, seemed to find only one point on which everyone could agree: "We have an impossible job."
Friday, September 16, 2011
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