What the Hill? The Latest in Healthcare News from Capitol Hill

Posted on May 16, 2012 by Linda Ringquist

Here are some of the latest stories from Capitol Hill according to The Hill. The original stories may be found by accessing http://thehill.com/blogs/healthwatch/.

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Obama administration announces plan to fight Alzheimer’s Released from the Health and Human Services Department (HHS), there is a plan for the prevention and treatment of Alzheimer’s which will encompass clinical trials and training for doctors. The release date is 2025. “This is a national plan, not a federal one, because reducing the burden of Alzheimer’s will require the active engagement of both the public and private sectors”, according to HHS Secretary Kathleen Sebelius.

Sequestered cuts keep K Street on high alert According to lobbying disclosure records, several interests lobbied on the budget sequestration last quarter. Defense contractors as well as healthcare groups were closely monitoring the budget cuts proposed for next year. The proposed budget cuts include a reduction of $123 billion in payments to Medicare providers. According to Ken Raske, president and CEO of the Greater New York Hospital Association, “the budget cuts will add to the financial burden on the healthcare system. This could be a compounded horror show for the hospitals The spending cuts could hinder hospitals providing care to patients.

Nurse practitioners push for bigger role as coverage expands Nurse practitioners are pushing to expand their role in healthcare. The American Academy of Nurse Practitioners (AANP) states their role should become more important as Obama’s healthcare law pushes through. The new law will provide coverage to millions of people which will increase the importance of nurse practitioners.

Senator Leahy hopeful that John Roberts will vote to uphold health law Before the court heard arguments in the healthcare case, Supreme Court Chief Justice John Roberts was mentioned as a potential swing vote. “I thought I saw a chief justice who understands the importance of this case to all Americans, including those millions who would otherwise continue without health care insurance and access to affordable health care”, Senate Judiciary Committee Chairman Patrick Leahy said in a floor speech. The court is supposed to make a decision next month whether the healthcare law, which requires everyone to purchase insurance, is constitutional or not. If the mandate is nixed, the court will have to decide whether the entire law will be nixed or if the rest will pass.

Study: Insurers to lose $1 trillion if health law struck down According to the Bloomberg Government, at stake in the Supreme Court’s decision on healthcare reform is nearly $1 trillion of the insurance industry’s total revenue through 2020. “It’s a confirmation of, one, how much money we’re spending as a nation on healthcare, and two, how much is riding on this court case and the Supreme Court’s decision”, according to Matt Barry. “You’re talking about an amount of money here that can affect the economy, not just an industry. The revenue would come from both the expansion of Medicaid and from additional subsidies to individuals purchasing insurance. The Supreme Court is expected to issue a decision by the end of June 2012.

The financial management of health care and healthcare financial analysis are important topics of discussion. If you don’t want to see the same things happen to your company as are proposed for our nation, please review BHM Healthcare Solution’s financial improvement page and/or contact BHM Healthcare Solutions at 1-888-831-1171. Following are a few of our many financial improvement services offered: healthcare financial analysis, revenue cycle, cost variance analysis, and consolidations and mergers. BHM is a one of the top healthcare management consulting firms with a large array of services provided.

Consumer-Driven Health Plans – What Should You Consider When Choosing?

Posted on May 15, 2012 by Linda Ringquist

According to the Bureau of Labor Statistics, the combination of a pretax payment account with a high-deductible health plan is what is commonly referred to as a consumer-driven health plan (CDHP).⁷ In terms of payment methods, CDHPs are composed of a three tier payment system

A savings account
BHM Healthcare Solutions
Out-of-pocket payments
Insurance plan.

The first tier is a pretax account that allows employees to pay for services using pretax dollars. The account may be funded by the employer or the employee, depending on the type of account. The funds from this account can be used to satisfy the insurance plan deductible. The second tier is the difference, or the “coverage gap,” between the amount of money in the individual’s pretax account and the deductible. The amount that is not covered by the pretax account must be covered by the insured. If health care expenses exceed the deductible amount, then the third tier, the high-deductible health insurance plan, kicks in.

In an article from the URAC website, there are ten things to be considered when evaluating and choosing consumer-driven health plans and products.

Is the information regarding the consumer health driven plan available in a variety of formats and media? Is the information available in different languages as applicable? Is the information written in such a way that it can be understood easily, including to those who may have mental or physical impairments or disabilities?
Are all of the costs laid out in a manner in which deductibles, out-of pocket expenses, tax consequences and benefits are clear?
Does the information indicate clearly the details of the plan, including benefits and coverage, customer satisfaction results, and a directory of providers?
Is wellness and prevention data readily available and easily accessible?
Do you have access to a Health Risk Assessment which is evidence-based, reviewed by the organization’s top clinical staff, and provide feedback as to the health status and any recommendations to improve the current health status?
Does the plan provide data explaining the enrollees role and responsibility for making their own decisions for health care? Are there additional expert resources available to the enrollee to help answer any additional questions.
Are there specific instructions as to how to access assistance on a 24/7 basis through different media such as phone, email, and in person?
Is there a method for requesting a detail of the cost and quality for each provider?
Does the health plan provide assistance in making financial decisions about coverage gaps, managed care or review processes necessary for coverage and how to seek care once the personal health account has been exhausted?
Does the health plan reach out to those with chronic diseases to educate them about how to most effectively manage their health care?

BHM Healthcare Solutions specializes in URAC accreditation and URAC consulting. For more information regarding URAC accreditation assistance, please visit the URAC page of our website or call for a fee consultation call BHM at 1-888-831-1171 today!

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.

Building State Exchanges – And the Challenges

Posted on October 17, 2011 by Kathleen Rand

Commonwealth Fund Image for Insurance Exchange

One of the challenges in building the new state insurance exchanges under the Affordable Healthcare Act for state insurance commissioners and stakeholders will be to guard against unplanned consequences. The possibility that the exchanges could end up with a lopsided share of high need enrollees, while the young and healthy are able to find less costly coverage outside these exchanges is a significant threat to overall success.

The following are the major obstacles state regulators and other stakeholders must overcome to ensure the success of insurance exchanges:

(1) Adverse selection: Coverage options available within the exchanges must be attractive to and affordable for individuals and small employers in order for them to be economically worthwhile. Regulation of insurers — both on and off the exchanges —will be the deciding factor for every state in determining whether their exchange becomes a viable entity. If an exchange is left with too many potentially expensive enrollees, then two parallel, unrelated markets will spring up.

(2) Eligibility: Most states will need to develop and implement an eligibility system for not only their exchanges but for their Medicaid program as well. It would be rather easy to simply determine eligibility for exchange enrollees but Medicaid users cannot be ignored. This translates into coordination with older, legacy systems that are not all that flexible, or put another way a lot of discipline and planning to encompass Medicaid eligibility.

(3) Legacy Medicaid systems: Technology developed for the exchanges will have to allow members to easily switch between Medicaid and subsidized coverage as eligibility status changes. Also, it will need to transmit and receive data from HHS regarding subsidies and citizenship status as well as collect and remit premiums. The IT for the exchanges will need to incorporate the ability to determine eligibility and administer health benefits beyond Medicaid. Safeguards will be necessary to keep enrollees in a medical home and not have them moving from plan to plan because of income eligibility changes.

(4) Federal deadlines: While the exchanges must be operational by January 1, 2014, set up and testing must be completed before that. The federal timeline is rather aggressive, and it will be a challenge for every state. Even by compressing preliminary stages, there is little time for pilot implementations to test exchange rules and functionality. The need to meet timelines established by the Affordable Care Act has created a “monumental task” for states. Further, political unanimity must be established among all stakeholders, but sometimes people work better under tight deadlines.

(5) Momentum: Some states’ legislatures meet only every other year, so it’s crucial that legislation is enacted this session to illustrate to the federal government that they are serious about moving forward. Maintaining forward momentum is necessary to ensure eligibility for the next round of federal grants that will be used to build out the exchange.

(6) State mandates: The basic benefit package needs to be consistent across states. Once the mandatory package is clearly defined, then decisions about additional state-mandated benefits can be possible. It will be important to keep in mind that everything added will increase the cost of the premiums, and that anything not included in the federal requirements will have to be paid for by the state or the consumers.

(7) Business model: Before the framework can be developed, states must first recognize the needs among individuals and small employers and then decide how the exchange can meet those needs. Planning funds are being utilized to develop and test business models as well as corroborated planning between Medicaid and states. Further a public stakeholder process will assess ideas.

(8) Brokers: Enrollees and small employers will need assistance traversing the exchanges. In the end it will be the brokers who will serve a vital role in the development of the exchanges, and they will need to be compenated for their services so they will be willing to help consumers and employers.”

(10) Care delivery: The exchanges must do more than just enroll members in coverage. States cannot just deliver insurance but rather offer an adequate provider work force who can address people’s health needs. States should not forget the public health and prevention factor of healthcare reform, and hence focus on an integrated approach in order to make the delivery of care more efficient.

The Affordable Care Act – The Communication Obstacle

Posted on October 6, 2011 by Kathleen Rand

Over the next three years, as part of the ongoing healthcare reform initiative the Affordable Care Act (ACA) will be rolled out. As this

Communication Obstacles in healthcare reform

Affordable Care Act- Obstacles

unfolds, America’s state and local officials will then be charged with responsibility of reaching out to more than 30 million individuals in order to enroll them in publicly funded or subsidized health plans. These plans will be offered through state insurance exchanges.

Unfortunately, the majority of those individuals have very little knowledge of health coverage and will have difficulty finding, understanding, and using the insurance information that is necessary to getting properly enrolled.

Failure to meet the enrollment goals, however, will undermine the success of the new health law, and, more importantly, will not increase health insurance coverage. Steps need to be taken to clear up the language and procedures surrounding the enrollment process. Otherwise individuals will more than likely not enroll. A roadblock which will amount to a significant waste of time, energy, and taxpayer dollars.

Properly enrolling in a health insurance plan, particularly a government funded or subsidized plan (such as Medicare or Medicaid), is a complicated undertaking. Individuals must find their way through a maze filled with eligibility guidelines, forms to complete, and lists of mandatory citizenship and financial documentation required for enrollment. Needless to say, if the information is not clear and usable, people will get lost and stalemated.

Additionally, they need to understand concepts such as premiums, co-pays, and benefits, and then apply this comprehension to their existing health situation so that they can choose the most appropriate plan. In short, they must figure out which services are covered and which are not, and complete additional paperwork to enroll in a plan they select.

My head’s spinning just thinking about it. And research proves an even larger issue: Fourteen percent of US adults have trouble finding the date of a physician’s visit on an appointment slip. According to the National Assessment of Adult Literacy, only 12 percent can successfully compute their contribution toward health insurance costs, even when a table is included to facilitate the analysis.

Clear communication is the only hope for the success of the Affordable Care Act to enroll those newly eligible in an appropriate insurance plan. We cannot rely upon a website and assistance from insurance exchange counselors alone. These insurance counselors themselves have to be fully articulate in the language and literacy barriers facing many of those individuals now able to obtain coverage. Even now, state Medicaid programs do not successfully enroll all eligible populations. 88 percent state enrollment is considered highly successful, while the least successful states enroll just 44 percent of those who qualify for services.

The Affordable Care Act does require health plans that are seeking certification in state exchanges to provide information in plain language. This means, according to the ACA, using “language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices.”

But is this a reality? One obvious obstacle is the up-front expense of creating insurance information and enrollment processes that use clear, accessible language. However, not making the enrollment process understandable to people of all literacy levels will be even more costly.

A system that is difficult to figure out equals delays in enrollment or failure to enroll at all in any health plan, particularly individuals who are healthy and feel less pressure to have insurance coverage. If these individuals remain un-enrolled, the majority of the individuals participating in the exchange market will be sicker (or higher risk), resulting in higher costs for health care overall.

Proactive measures need to be taken to support individuals through the enrollment process. Assistance with completing the application can be provided by community-based organizations and health providers as well as by the exchange counselors. Low health literacy has to be considered a factor in healthcare reform and actions to eradicate it have to be in place for the Affordable Care Act not to fall short of expectations.

Are You Ready For The Sweeping Mental Health Parity Rules

Posted on February 23, 2010 by Mark Rosenberg

The Paul Wellstone Mental Health and Addiction Equity Act went into effect on or before Oct. 3, 2009. For more detailed information please see the BHM white paper “Mental Health Parity Preparedness: opportunity for managed care organizations”.

Below is a timeline for Federal Mental Health Parity:

1.?The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act (WDA) was passed on Oct. 3, 2008 ?This act was passed as a component of the Troubled Asset Relief Program (TARP) signed by President George W. Bush ? .

2. The law was initially slated to go into effect on Oct. 3, 2009.

3. Congress deferred the effective date to Jan. 2010 for plans which would have otherwise been covered in 2009 .

4. On Jan. 29th 2009 the IRS (Treasury), Labor, and Health & Human Services, released the interim final guidelines for this act. ?The new “rules” go into effect on July 1st 2010.

The law was 13 pages but the rules are 154 pages. There are going to be many very significant changes when these rules go int effect. This will create both challenges as well as opportunities for both healthcare providers as well as healthcare insurers. BHM’s Mike Forrester will be presenting a number of target webinars to assist organizations in reducing the risk and maximizing the potential of this new legislation.

Until you are able to join Mike Forrester at one of his webinars below are a few tips to begin the preparation:

Keys for Parity Preparation • Review organization history of health care coverage patterns

• Evaluate integration of physical and behavioral health within your current organization • Procure relationships with outside vendors if in-house care is not possible

• Carefully reevaluate your plans provider network • Evaluate potential changes in the following areas:

Removal of limits
Change in co-payments
Change in insurance
Covered diagnosis
Pharmacy Benefits

The Wellpoint Mugging by WSJ 1 18 10

Posted on February 18, 2010 by Mark Rosenberg

The Wall Street Journal reported today about the very controversal Wellpoint rate hike in CA. It appears that everyone is jumping on the evil health insurance band wagon. We have discussed that even if health status and health cost per person in america was stable that the current recession will drive up healthcare costs. As employees loss their jobs, they and their family do some quick math. What are my monthly known medical expenses and what is the current cost of COBRA. Families that have high health care cost in relation to the premiums they will be charged for COBRA keep their insurance where as those that have low or no real healthcare cost ( ie the healthy population) chose to take the risk of a major medical event while uninsured. This has a double impact on health insurers, decreased revenue due to lost members( layed off employees) and increased expense ( health insurance companies biggest expense is their members health care cost). In response to this I suspect we will see large increases in health insurance premiums over the next few years. The WSJ went on to say that the recently proposed health insurance reform will led to very similar rate hikes. Any type of healthcare reform has to take very seriously the unintended consequences.