Heart Attack Research Reinforces New Preventative Health Strategy

Posted on February 29, 2012 by Imogen Reed

Heart attacks are one of the leading causes of death in American men and women over 55. While men are more likely to suffer a heart attack than women, fatalities among women heart attack sufferers is far higher, and new research has discovered the possible reason for this. While symptoms of heart attack are often well publicized, with chest pain being the most obvious, research has discovered that fewer women suffer from these classic symptoms than men, making missed diagnosis far more common.

Whether under Medicare or with private surgery insurance, diagnosing and preventing heart attacks is a primary concern for all health care providers, and under the Affordable Care Act, is one of the primary preventative care strategies for Medicare. One in three Medicare patients die due to cardiovascular disease, but the risk is far greater for women than it is for men. Currently, a heart attack is fatal in around 10 percent of male Medicare patients, while for women, fatalities occur in about 14 percent of heart attacks.

New Research

Heart disease is the leading cause of death in all Americans over 55, but the research has found that the risk of death is greater for women, because they don’t always suffer chest pain, often thought of as the primary symptom of a heart attack. Because of this, researchers believe many women are not getting the right type of treatment as the heart attack is not being diagnosed.

Writing in the Journal of the American Medical Association, the researchers say their study, compiled in 1000 hospitals throughout the United States, found 42% of women who suffered a heart attack did not experience any chest pain whatsoever, compared with just 30% of men, and with younger patients, the difference was even more striking.

Despite the difference in symptoms and increase in risk of fatalities, researchers found men still suffer significantly more heart attacks in the United States than women, and cardiovascular disease tends to strike men at a younger age too; the study found that the average age of a male heart attack sufferer was 67, while for women it was 74.

Symptoms

Prompt treatment is the key to heart attack survival in all patients, regardless of sex, so it’s important that people can identify symptoms early. Without the presence of significant chest pain, identifying the symptoms of cardiovascular disease can be extremely difficult. Some patients report only breathlessness, a feeling of being unwell, and a feeling not unlike indigestion. Researchers believe this could mean than tens of thousands of American women may have suffered a heart attack and not sought any treatment, having put down the condition to indigestion, heartburn or summer other minor ailment. However, the likelihood of permanent heart damage and a repeat attack is far greater after such an episode, even if the heart attack symptoms were only mild.

Besides severe chest pain, any of the following symptoms could be indicative of a heart attack:

A dull ache, heavy feeling or mild discomfort in the chest
Pain in the back, arm or stomach
Indigestion that feels either severe or prolonged
Feelings of light headedness or dizziness

Prevention

An increasing emphasis is being placed on prevention of heart attacks and this new research suggests the importance of the preventative health measures introduced the Affordable Care Act. Medicare now covers more preventive health services aimed at helping people reduce the risk of heart attack. It is hoped, that the Million Hearts Campaign, which Medicare are helping to lead, will prevent a million heart attacks and strokes over the next five years – this could mean the saving of nearly 200,000 American lives.

Starting from American Heart Month, which began in February, Medicare will pay for an annual face-to-face visit so that Medicare beneficiaries can discuss ways to prevent cardiovascular disease with their care provider. During this visit, care providers will screen patients for high blood pressure, whilst also providing advice on healthy eating and ways to change lifestyle habits that could reduce the risk of cardiovascular disease in the future. While smokers, people with diabetes and those suffering obesity – the leading causes of cardiovascular disease in the United States – are also now entitled to claim for counseling services under Medicare since the Affordable Care Act.

Increased Audits Could Equal A Streamlined Response for Healthcare Organizations

Posted on February 23, 2012 by Kathleen Rand

Increased Audits Could Equal A Streamlined Response for Healthcare Organizations

Many Healthcare Organizations and hospital systems are moving towards a more systematized, shared response as more and more state and federal program-integrity contractors get ready to unleash their auditing power. Among the amalgam of acronyms that have emerged with the evolution of healthcare reform are: RAs, the comprehensive error rate testing (CERT) contractorderal , and zone program integrity contractors (ZPICs) and HHS Office of Inspector General (OIG) auditing machine.

It is no surprise that consequently several organizations have begun to create corporate-level regulatory response support teams. The goal is to streamline what has been taking place at individual facilities and to introduce more standardization as a means to improve the communications network, data analysis and corrective action.

Yet it is rather hard to ask senior management to spend money on something that only in theory produces revenue. The idea is that proactivity will prevent problems in the future. Systematizing across various facilities can potentially deliver better compliance, quality and efficiency. And creating committees that include case managers, RA coordinators, coders, and billers among other relevant staff to make sure that site-specific issues and requests are being addressed and responded to will help with audit issues going forward.

The corporate regulatory response team should serve as a uniting force throughout the health system, a team who can anticipate, identify and fix problems, and who can ensure nothing falls through the cracks. Consistency in the interpretation of policies and procedures and uniformity in how an issue is resolved can lead to dollars saved and a more efficient operation system-wide.

Exchange Development Could Advance As State’s Flexibility Increases

Posted on February 14, 2012 by Kathleen Rand

States given more flexibility in defining EHBs.

For states who have been putting it off, some recent clarification on how essential health benefits (EHBs) are to be defined could provide a nudge towards building an insurance exchange.

On December 16^th, CMS’s Center for Consumer Information and Insurance Oversight proposed that states use an existing health plan to define the benefits to be included in individual and small-group plans beginning in 2014. This was unexpected; many believed that a national EHB standard would be developed and issued. This bulletin may permit states to offer less inclusive coverage than is now required by state law.

Giving the states a certain level of flexibility in plan design was an important decision. Whether it will become a trend – to accept more variation by state, or to create federal-level mandates for the products and pricing available through the exchanges – remains to be determined.

It is possible that some states might have decided against launching an exchange if the Department of Health and Human Services had required all qualified health plans to include a comprehensive level of essential benefits. However, it appears that does not seem imminent at the moment, giving the states some leeway and avoiding a potential political problem.

But some states still might not act because they are hesitant to embrace reform law provisions. Consequently, the default benchmark plan (i.e., the largest plan in the state’s small-group market) will be implemented. However, ultimately states will have to choose a plan that balances costs and quality of benefit structure.

The bulletin released in December calls on states to set a ‘benchmark’ to include in the essential benefits package. To do this, states must pick an existing and popular plan. There are four benchmark plans to choose from: (1) one of the three largest small-group plans in the state; (2) one of the three largest state employee health plans; (3) one of the three largest federal employee health plan options; or (4) the largest HMO offered in the state’s commercial market.

In addition, the reform law outlines 10 broad categories — including emergency services, maternity and prescription drugs — that need to be assimilated into plan design. If states choose a benchmark plan that doesn’t include all of those 10 categories, they will likely be able to borrow from other benchmark plans to fill in the overall benefit. Hence the final benchmark plan could be a fusion of more than one plan design. Enabling states to define a benchmark based on their most popular plans will help increase acceptance and action.

If a state uses one of its own plans as the benchmark, the Affordable Care Act requires that the cost of ‘essential’ (mandated by the HHS) benefits must be paid for by the state. But the bulletin suggests that states will be allowed to define any or all existing state mandates as essential.

Further, a common benchmark being utilized by states could make it easier for state insurance exchanges to certify qualified health plans. And with input from health plan operators, state legislatures will need to study and evaluate the enrollment and cost data to help ascertain which benchmark plan will be used to define its EHB.

Hospitals May Be Pressured to Change

Posted on February 8, 2012 by Kathleen Rand

As healthcare reform rolls out, hospitals re-evaluate how they do business.

The economy may be sluggish but publicly-traded hospitals continued to be profitable in 2011. But continued low admission rates, combined with growing enrollment in low-paying government programs, could give hospitals more incentive to pressure insurers for higher reimbursements during contract negotiations. Patient volume is improving, but not enough.

In mid-2011, commercial insurance enrollment increased, while Medicaid enrollment growth declined a bit. Despite this rise in commercially insured members, there seems to be a hesitation for actual health care utilization, probably because of continued economic instability and higher cost-sharing provisions in health plans. While low patient volume is a threat to the bottom line, low Medicare and Medicaid reimbursements are the biggest incentive for hospitals to pressure the insurers at the negotiating table.

Therefore, some hospitals might want to form new relationships with insurers. Health systems seem to preparing for a world where access to doctors and diagnostics, and cost control will matter more to their overall success and financial health than having a hospital in every part of the market. Consequently having increased emphasis on improved care management and better cost control will improve dealings with health plans as well.

With healthcare reform rolling out, it is a real possibility that new state-of-the-art ambulatory care centers could supplant inpatient facilities as the preferred strategy for market access. Plus the momentum toward more coordinated and patient-focused accountable care will continue among providers.

Additionally, publicly-traded hospitals could become a more attractive option in 2012 as usage increases among commercially-insured patients. Hospitals are much more sensitive to this than health insurers. An increase in the labor force also promises to be optimistic for providers. Long-term unemployment and the number of part-time workers as a percentage of the work force are higher, which could potentially hold down utilization levels. Yet, as overall utilization improves, even slowly, hospital perception levels will decline as less critical patient procedures return to the market.

To counter pressures, including a rapidly increasing Medicare payer mix, hospital systems will need long-term cost reductions of 20% to 25%. Hospitals will apply strong cash generation to acquisitions to help counter flat organic growth. Some hospital systems have taken advantage of favorable conditions in the bond market and have renegotiated credit agreements to refinance debt and extend maturities.

But even with available cash, hospital systems might not want to target acquisitions due to uncertainty surrounding the Supreme Court’s ruling on key provisions of the reform law and the November elections. The differing agendas of politicians could lengthen due diligence and slow down deal volume. And if the court strikes down key provisions, such as the development of ACOs, the purchase of physician practices by hospitals would likely decrease. However, the primary causes for consolidation, like capturing market share, improving access to capital, and finding new efficiencies, all remain in place as viable.

Exploring Medicaid Managed Care Expansion

Posted on February 2, 2012 by Kathleen Rand

Medicaid expansion coming soon.

Medicaid managed care plans may prove their worth in containing costs in 2012 since states will seek out alternative policies and payment/delivery models to cope with a looming Medicaid expansion under the health reform law, or the Affordable Care Act.

There are plan sponsors that are focused on expanding into the Medicaid market, including larger plans like United Health Group and Coventry Health Care, Inc. This business opportunity is fueled not only by federal healthcare reform, but also by state interest in outsourcing care of both the ABD (aged, blind and disabled) populations as well as the relatively healthy mothers and children traditionally in Medicaid managed care.

The bottom line is that states will continue to need managed care plans to help both limit costs as well as make costs more predictable and consistent.

Many states are facing massive Medicaid program cuts as they head into 2012. These budget problems in part are the reason why some won’t be able to shoulder the program expansions slated for 2014. The expansion is expected to cover some 16 million to 18 million more Americans whose annual income is over 130% of the federal poverty level.

There are a few factors impacting whether states are ready for the expansion. To name a couple: states are in a budget crunch now and employment in public-sector is declining and affecting state Medicaid agencies.

Even though the federal government is initially paying for the costs of the Medicaid expansion, there will be existing state staff that have to deal with the expanding population and pretty significant changes in rules. So, states have to implement something additionally with fewer resources.

The budget situation in most of these states is both a risk and an opportunity for these Medicaid managed care organizations. Premiums may not keep up with health care costs, and plans, consequently, could face potentially lower margins. If regulators want a viable private Medicaid business, they’re going to have to allow these companies a 1% to 2% net margin or operating margin.

Budget concerns also may create a long-term opportunity for Medicaid plans. More and more states that are dealing with budget issues will turn to private companies to help them manage their Medicaid costs and to make sure their Medicaid dollars are spent efficiently. While only 20% of Medicaid spending is now in managed care, that will certainly go up over time.

The emergence of ‘accountable care organization’ models in the Medicaid space as a way to address the forthcoming expansion is a trend to watch in 2012 and beyond, insiders say.

With at least 16 million more people coming into the Medicaid system under healthcare reform

ACA Dictates Medicaid Expansion

, states are going to have to focus on very cost-effective entities to provide that care. Even in states where there already is capitated managed care, there will probably be a lot of experimentation with these ACO-type entities as well.

States can’t cut enrollees, and can only cut provider rates by a reasonable amount. So the only other place to save money is to change the way care is delivered, and the only way a managed care plan can deliver that is to partner differently with the delivery system.

For instance, Oregon has been in the process of developing “coordinated care organizations” or CCOs to coordinate care of the Medicaid and dual-eligible populations. CCOs will be community run — a structure or entity accountable to the region where it operates — integrating physical health, mental health, substance-abuse services and dental care in one organization.

The CCO initiative is going to require that all MCOs change their business model in order to meet its criteria. These entities will have to develop the ability to manage internally things like behavioral health and other social services, as well as to partner with other organizations to become a CCO entity. How MCOs like CareOrgeon fit into the broader scheme of these CCOs could dictate how others end up interfacing with the Medicaid system during the expansion.