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Helping Patients Understand Insurance Benefits is Key

Helping Patients Understand Insurance Benefits is Key | Healthcare and Technology news |

Over the past several weeks, I've had the task of helping my own dad through some health issues. The biggest issue that we have run into multiple times is insurance challenges.

I know that I typically give you hints and tips to help lower your accounts receivable, get you paid on time, and manage your billing staff. But I'm going to take a different tack this week; focusing on the patient's viewpoint.

Before I get into the details of our struggle to help dad see the appropriate specialists, I feel it's most important to note that you and I are healthcare professionals. We do this job, everyday. We are immersed in professional jargon that sounds foreign to the typical patient. We understand (for the most part) that the laws are in place to protect the patient. We have to learn how to play nice with the insurance companies so that our practices get paid. Our patients don't really see this. From a patient's standpoint, they simply buy an insurance plan; they ask the practice to file a claim; and the insurance company pays what the practice is due. However, you and I know this is certainly not the case.

There is a huge gap between reality and what the patient thinks happens with their insurance plan. They do not understand that not only is it a plan they purchased, but they must also understand the nuances of that plan. Is outpatient physical therapy a covered benefit? Does the plan have a deductible? Is there a copay or coinsurance associated with some visits and not others? Is the doctor in network? The typical patient is truly not aware that this type of information is their responsibility to know.

So, that said, let me share my story. My dad has a Medicare replacement plan. He still thinks he has Medicare primary and UnitedHealthcare as a secondary insurance. So, lesson one when explaining patients' benefits prior to being seen is that they understand if they have a replacement plan, and not Medicare with a secondary.

Next, his primary physician referred him to a specialist. The specialist was 50 miles away. I'm not kidding. Dad gets to the appointment, and the office manager took him aside and said they do not accept his insurance; but he could pay the $3,000 out-of-network rate if he wanted to. No phone call, no warning about the physician's out-of-network status, nothing. Dad walked out and drove back 50 miles to his house and called me a few hours later. The next morning, Dad and I did a conference call with his medical group. I asked them why there wasn't a specialist in their group that he could see? I also said that if there isn't a physician that fits the requirements of Dad's care, they would have to provide the authorization to see an out-of-network physician, as that was not Dad's problem they didn't fill up their network. A few hours later poof! They found a doctor only 10 minutes from his house that was just credentialed that day. Shocking, I know.

So, the medical group contacted the doctor's office and set up an appointment. They called us back on another conference call and let us know everything was taken care of. I asked, "Okay, I have my pen and paper, can you please provide the authorization number for this visit?" There was silence on the other end of the line. There were four people telling us seconds ago that everything was set up and ready to go and no one could provide the authorization number. They asked for a few minutes to call us back. The phone rang, an authorization for three visits was provided, I took names, phone numbers, etc.

My dad was so frustrated and completely confused about why things are so complicated, and wondered how was he supposed to know all of this?! Technically, he is supposed to know these things, but honestly, there is no way he would ever have been able to get this figured out without my help.

I suppose my point is when you have a patient that needs an authorization, or does not understand the difference between in-network and out-of-network status, please take the time to work with them. Be patient. Be kind. They are in pain or sick, and the last thing they want to worry about is their insurance plan.

It would be ideal if the insurance company took the time to explain plan details and teach patients how best to utilize their plan benefits. We know this will never happen, as it would be very costly for the insurance company.

Take it easy on your patients and find it in your heart to spend the necessary time with your patient; remember this likely someone's dad, mom, sister, or brother.

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Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug

Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug | Healthcare and Technology news |

The Obama administration has decided that Medicare will pay for one of the newest, most expensive cancer medications, which costs about $178,000 for a standard course of treatment.

Patients, doctors, hospital executives and insurers have expressed concern about the high cost of prescription drugs, especially new cancer medicines and treatments tailored to the genetic characteristics of individual patients. Medicare officials recognized the cost and value of one such product, the anticancer drug Blincyto, by agreeing to make additional payments for it starting Oct. 1. The drug is made by Amgen for patients with a particularly aggressive form of leukemia.

The decision suggests a new willingness by Medicare to help pay for promising therapies that are still being evaluated. It is also significant because Medicare officials reversed themselves on every major scientific issue involved. After receiving pleas from Amgen and a dossier of scientific evidence, the officials agreed that the drug was a substantial improvement over existing treatments for some patients.

At issue are special “add-on payments” that Medicare makes to hospitals for new technology whose costs are not yet reflected in the standard lump-sum amounts that hospitals receive for treating patients with a particular disease or disorder.

In a preliminary decision in April, the Obama administration said it did not intend to pay extra for Blincyto because clinical studies were “not sufficient to demonstrate” that it substantially improved the treatment of Medicare patients with acute lymphoblastic leukemia, a cancer of the blood and bone marrow. Medicare officials said Amgen’s application was based on data from “a small sample group of patients whose age demographic is much younger than the age demographic of eligible Medicare beneficiaries.”

But in a final rule to be published in the Federal Register on Aug. 17, the administration says it received “additional information and input” from Amgen and other experts and now agrees with their arguments.

Blincyto “is not substantially similar” to other drugs available to leukemia patients, the administration said, and it “represents a substantial clinical improvement over existing treatment options.”

Jane E. Wirth, 59, of Reno, Nev., a former preschool teacher, said her cancer was in remission after 28 days of treatment with Blincyto, also known as blinatumomab.

“It was amazing to me that it could work so well so quickly,” Ms. Wirth said in an interview. “I had just spent a month going through standardchemotherapy, which did not make the cancer go away. It seemed so hopeless.”

The drug, engineered from two antibodies, harnesses the body’s immune system to help fight cancer. It brings certain white blood cells close to malignant cells so the blood cells can destroy the cancer cells.

Dr. Anthony S. Stein, a researcher at City of Hope National Medical Center in Duarte, Calif., who has treated more than 50 patients in clinical trials of Blincyto, said, “Its mechanism of action is totally different from that of any other approved drug.”

After the Food and Drug Administration approved Blincyto in December, Amgen said the price would be about $178,000 for the recommended two 28-day cycles of treatment, each followed by a two-week break. Medicare says it will now allow a “new technology add-on payment” to hospitals for a fraction of that amount, up to $27,000. Actual payments will vary based on the length of a patient’s hospital stays.

A cycle of treatment begins with intravenous infusions in a hospital. Patients typically continue treatments outside the hospital — at doctor’s offices, at infusion centers or at home, with the help of specially trained nurses — and Medicare will help pay for the drug at those sites, too.

The prices of new cancer drugs often exceed $100,000 a year.

Health policy experts said that President Obama had personally expressed concern in recent weeks about high drug prices and their impact on consumers and federal programs. In February, he asked Congress to authorize the secretary of health and human services to negotiate with manufacturers to determine prices for high-cost medicines taken by Medicare beneficiaries.

poll by the Kaiser Family Foundation released last month found that 94 percent of Democrats and 84 percent of Republicans support allowing the federal government to negotiate with drug makers to get lower prices on medications for those beneficiaries.

Dr. Steven M. Safyer, president of Montefiore Medical Center in the Bronx, said the Obama administration should use its influence with drug companies to restrain costs. “There are a number of very important breakthroughs with pharmaceuticals that can make a difference between life and death, and the price is too high,” he said.

More than 100 oncologists from cancer hospitals around the country recently issued a manifesto decrying the prices of new drugs.

“Effective new cancer therapies are being developed by pharmaceutical and biotechnology companies at a faster rate than ever before,” they said in a commentary in the journal Mayo Clinic Proceedings. But, they added, “the current pricing system is unsustainable and not affordable for many patients.”

Robert E. Zirkelbach, a spokesman for Pharmaceutical Research and Manufacturers of America, the lobby for drug makers, said that new spending projections issued by the government in July undercut such claims.

“Even with new treatments and cures for hepatitis C, high cholesterol and cancer,” Mr. Zirkelbach said, “spending on retail prescription medicines is projected to remain approximately 10 percent of U.S. health care spending through 2024, the same percentage as in 1960.” In the last two decades, he added, the cancer death rate has fallen 22 percent, thanks in part to new medicines.

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Young adults see cost as disadvantage of health insurance

Young adults see cost as disadvantage of health insurance | Healthcare and Technology news |

While many young adults are concerned about the cost of health insurance, they often don’t understand how out-of-pocket costs for care can add up, a small study suggests.

These adults, mostly in their 20s, see access to preventive or primary care as the biggest advantage of insurance, and the financial strain of paying for coverage as the main disadvantage, the study found.

Despite their price concerns, however, nearly half of them couldn’t define “deductible,” the amount they need to pay before insurance will pick up the bill. And 78 percent of them incorrectly defined “co-insurance,” the portion of costs they need to pay after the deductible has been met.

“Their confusion over these basic terms can have real consequences on their cost exposure down the road,” said lead researcher Dr. Charlene Wong of the Children’s Hospital of Philadelphia and the University of Pennsylvania, in an email.

From January to March 2014, Wong and colleagues observed 33 young adults aged 19 to 30 as they shopped for health insurance on, the online marketplace set up by the U.S. government as part of the Affordable Care Act, also known as Obamacare.

On average, the participants were about 26 years old. Most were white, and almost half had started or completed graduate or professional school. Most earned less than $40,000 a year.

While 60 percent of participants were uninsured at the time of the study, most were in excellent or good health and reported seeing a medical provider at least once a year.

Researchers first asked them to think aloud while browsing the insurance options available on, recording their reactions in real time. Then, they interviewed participants to assess their attitudes about insurance and their comprehension of terms related to costs.

During the period when participants were observed using, 58 percent of them considered choosing “silver” plans, which they saw as middle-of-the-road options that covered and cost more than “catastrophic” or “bronze” plans but less than the “gold” and “platinum” options.

Many young adults also considered other alternatives such as getting insurance through their employer’s plan, their parents or their school.

For the second part of the study, researchers conducted follow-up interviews in April and May with 27 participants to gauge their satisfaction with the health insurance they selected.

Eight of the 33 participants enrolled in a plan through at the time of their follow-up interview. Six of them selected silver plans, while one chose catastrophic and one opted for bronze.

They were generally satisfied with their selections, the study found.

Five participants remained uninsured at the time of the follow-up interview. All of them cited unaffordability as a reason for not purchasing insurance.

One limitation of the study is that the participants were highly educated, and may not be representative of young adults nationwide, the researchers acknowledge in the Journal of Adolescent Health.

The study’s small size and focus on a single city is another drawback; the least expensive catastrophic plan without tax credits in Philadelphia had monthly premiums of $187.

“Considering the cost of housing in a metropolitan area and other financial obligations such as student loan payments, young adults have to prioritize spending,” said Maureen Monaghan, a researcher in psychiatry and behavioral sciences at Children’s National Health System in Washington, D.C.

“Young adults, like many of us, respond to the immediate out-of-pocket cost for insurance – what the monthly premium is,” said Monaghan, who wasn’t involved in the study.

Part of the problem is that health costs aren’t transparent, she said by email.

“Presenting real world comparisons of costs for using primary care or emergency care without insurance vs. with insurance could help young adults see the value of maintaining continuous health insurance,” Monaghan said.

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Aetna to buy Humana for $37 billion in largest insurance deal

Aetna to buy Humana for $37 billion in largest insurance deal | Healthcare and Technology news |

 Health insurer Aetna Inc on Friday said it would buy smaller rival Humana Inc for about $37 billion in cash and stock, in the largest ever deal in the insurance industry.

The combination will push Aetna close to Anthem Inc's No.2 insurer spot by membership, and would nearly triple Aetna's Medicare Advantage business.

The deal will face antitrust scrutiny but if it goes through it would dwarf the previous largest insurance deal announced just this week, where Swiss property and casualty giant ACE Ltd announced it was buying Chubb Corp for $28 billion. It would also dwarf Anthem Inc's purchase of WellPoint in 2004 for $16.6 billion.

Analysts have said that M&A activity in the healthcare sector had been waiting for last week's Supreme Court ruling on Obamacare, which upheld key subsidies that underpin the reform and thus gave more certainty to healthcare insurers.

The bigger the insurer, the more power it has negotiating prices and improving its doctor networks.

Anthem has offered to buy Cigna Corp to create the largest insurer in the country, toppling UnitedHealth Group Inc .

Media reports have also said UnitedHealth could be eyeing Cigna and Aetna. On Thursday, Centene Corp said it would buy smaller rival Health Net Inc for $6.3 billion.


Antitrust authorities, who were aggressive in their review of the failed deal between Comcast and Time Warner Cable , are expected to scrutinize how the combination of insurers will affect competition for each line of insurance: Medicare, Medicaid for the poor, individual insurance, commercial insurance for small and large businesses and the large employer business.

Aetna and Humana are in nine of the same states in Medicare Advantage. Combined, they would have market share of 88 percent in Kansas, 80 percent in West Virginia, 58 percent in Iowa and 51 percent in Missouri.

Wall Street analysts and some antitrust experts have said they expect the combination will be approved, although regulators may ask for some divestitures.

Others have said it is unclear that this group of regulators will stick to the usual review playbook for such a large deal and may add other restrictions.

The Justice Department, which reviews insurance mergers, will scrutinize deals city-by-city to see if the combination would have a monopoly in any metropolitan area, said Andre Barlow, a veteran of the department who is now at Washington law firm Doyle, Barlow and Mazard PLLC.

Aetna said the combined company is projected to have over 33 million medical members, based on memberships as of March 31. Operating revenue is expected to be about $115 billion this year, with approximately 56 percent from government-sponsored programs including Medicare and Medicaid.

Last week, the U.S. Supreme Court upheld subsidies for individuals under President Barack Obama's signature healthcare law, keeping a large chunk of patients intact under the Medicare and Medicaid programs.

Insurers have said subsidies are key to bringing in new customers and the ruling has removed uncertainty for insurers looking for acquisitions. It could also spur more deal making in the health insurance sector, which has already seen a blitz of merger activity this year.

U.S. Senate Majority Leader Mitch McConnell, of Kentucky, praised Humana's presence in his home state but also noted the role of the healthcare law in the merger.

"This morning's announcement, as I predicted during the debate five years ago, is the inevitable result of Obamacare’s push toward consolidation as doctors, hospitals, and insurers merge in response to an ever-growing government," the Republican said in a statement.

The deal includes a $1 billion break-up fee payable by Aetna to Humana, should the deal fail because of antitrust concerns, an Aetna spokeswoman confirmed. The fee was first reported by the Wall Street Journal.


Hartford, Conn.-based Aetna said it would pay Humana shareholders $125 in cash and 0.8375 Aetna shares for each share held. The offer of about $230 per share is a 23 percent premium to Humana's closing price on Thursday.

Following the deal, Aetna shareholders would own about 74 percent of the combined company with Humana shareholders owning the rest. Aetna Chief Executive Mark Bertolini will serve as chairman and CEO of the combined company.

The deal is expected to close in the second half of 2016 and add to operating earnings per share from 2017.

Humana's sale has been anticipated since May when it was first reported that Cigna Corp and Aetna were interested, and multiple sources confirmed to Reuters that the company was entertaining offers.

Humana, based in Louisville, Kentucky, has been under pressure for more than a year from investors, which include activist fund Glenview Capital Management, to produce higher returns.

Last year Humana hired a CFO from investment bank Goldman Sachs and went through a strategic review that included asset sales. But it missed several quarters of earnings targets and struggled with profits in its individual business, disappointing Wall Street.

Aetna said it has received commitments from Citi and UBS Investment Bank to finance the deal.

Citi and Lazard are financial advisers for Aetna and Davis Polk & Wardwell LLP is its legal adviser. Goldman Sachs is the financial adviser to Humana, while Fried, Frank, Harris, Shriver & Jacobson LLP is its legal adviser.

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Obamacare’s Next 5 Hurdles to Clear

Obamacare’s Next 5 Hurdles to Clear | Healthcare and Technology news |

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges — including one resolved Thursday — and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles remaining:

Medicaid Expansion. About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.

Anemic Enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.

Market Stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.

Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.

Political Resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.

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The Supreme Court's Surprise Ruling Saves Obamacare

The Supreme Court's Surprise Ruling Saves Obamacare | Healthcare and Technology news |

The Affordable Care Act survived its second major challenge at the U.S. Supreme Court on Thursday. In a 6-to-3 decision, the justices ruled that the Internal Revenue Service can continue to provide health-insurance subsidies to middle-class people living in all states.

At issue in the case, King v. Burwell, was whether the subsidies should go to residents of the roughly three dozen states that use the federal health-insurance exchange, in addition to those who live in states that run their own exchanges.

It’s a highly technical difference, but had the decision gone the other way, Obamacare might have unraveled. Individuals who receive these subsidies make less than $48,000 per year, and many would struggle to afford health-insurance plans without the government’s financial help. Health-policy analysts feared that, without the subsidies in place, healthy people would withdraw from the health-insurance exchanges in large numbers. That, in turn, would cause premiums to skyrocket, making insurance unaffordable to almost anyone who does not receive insurance coverage through their jobs.

The Affordable Care Act gave states the option to either set up their own exchanges or to rely on the federal government’s marketplace through The part of the law that describes the subsidies said they should only apply to people in the exchanges “established by the state.” The plaintiffs in the King case said that clause meant the IRS was offering subsidies to residents of federal-exchange states illegally.

In the opinion of the Court, Chief Justice John Roberts dismissed the idea that the fate of the entire Obamacare law should hinge on such a technicality.

“In petitioners’ view, Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub sub-sub section of the Tax Code,” he wrote. “We doubt that is what Congress meant to do.”

Many patient advocates cheered the decision. “It means that millions of people with serious health conditions such as cancer will continue to have access to essential treatment and care, and millions of others at risk for disease will be able to afford preventive screenings and tests that could save their lives,” said Chris Hansen, president of the American Cancer Society’s advocacy arm, in a statement.

Justices Antonin Scalia, Clarence Thomas, and Samuel Alito dissented, writing, “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’”

Roberts concludes by saying that the Court is attempting to respect what Congress hoped to accomplish in passing the law: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

There are still a few, more minor, legal challenges to Obamacare remaining. But at least for now, the law lives to see another day.

Jannell Alino's curator insight, August 27, 2015 7:43 PM

Congress passed the Affordable Care Act and the Supreme Court ruled that the IRS will be able to continue to administer health insurance to middle class people to all in the United States. If this did not pull through Obamacare would have left thousands of people without insurance and helpless. Many who are on Obamacare make less than 48K a year and need assistance from the government. If this were to happen a large number of healthy people would withdraw from health insurances causing prices to go up and then no one would be able to afford health insurance! The Affordable Care Act gives states the option to set up their own exchanges or rely on the government. With the passing of this act people suffering from serious illness will be able to care and have access to treatment as well as others who are susceptible to illness. Some conclusions that can be drawn from this article are that by the passing of this act thousands of citizens are still able to have health insurance and do not have to pay with an arm and a leg. Yes this argument is logical because it would be irrational to take away a program that has aided so many Americans in getting the health care they need. This relates because if this act was to fail our health insurance prices would go up and going to get a simple checkup would cost a fortune! I think it is great that the congress passed this act because I would want everyone to be able to have the privilege to seek out help if they were ill. No there is no bias, it is objective to all citizens in the united states.!

Where are the most expensive hospitals?

Where are the most expensive hospitals? | Healthcare and Technology news |

Talk about sticker shock: Some U.S. hospitals charge patients more than 10 times the rates paid by Medicare.

Of the 50 U.S. hospitals with the highest charges, 49 are for-profit institutions, 20 operate in Florida, and half are owned by a single chain, according to a study published in the journal Health Affairs Monday.

That doesn't mean all or even most patients end up paying those charges. Private insurers are able to negotiate the sticker price down significantly. Patients paying out of pocket can often negotiate discounts or get charity care if they are low-income.

The average U.S. hospital charges a somewhat less staggering sum: 3.4 times the rates paid by Medicare, the federal health care plan for the elderly and disabled which pays fixed rates for procedures.

But for uninsured patients asked to pay full charges, insured patients who end up at an out-of-network hospital and patients whose treatment is covered by casualty or workers compensation insurance, these charges can matter a lot.

"Hopefully this is a wake-up call for people to recognize there's a problem," said Gerard Anderson, a professor of health policy at Johns Hopkins Bloomberg School of Public Health, and one of the authors of the study, which analyzed 2012 Medicare cost reports.

    "There is no justification for these outrageous rates but no one tells hospitals they can't charge them," Anderson said. "For the most part, there is no regulation of hospital rates and there are no market forces that force hospitals to lower their rates. They charge these prices simply because they can."

    Even after full expansion of coverage under the Affordable Care Act, 30 million Americans will remain uninsured and may face particularly high charges, the study said. The law requires nonprofit hospitals to offer reduced-cost or charity care to eligible patients, but the provision does not apply to for-profit hospitals.

    "Hospitals' high markups, therefore, subject many vulnerable patients to exceptionally high medical bills, which often leads to personal bankruptcy or the avoidance of needed medical services," the study said.

    Of the 50 highest chargers, half are owned by Community Health Systems, a for-profit chain with 199 hospitals. The company made $18 billion in profits in 2014 — 45 percent more than in 2013. The researchers looked at charges at nearly 4,500 Medicare-certified hospitals nationwide.

    Florida most likely had the most high-charging hospitals because it has an exceptionally high proportion of for-profit hospitals, consumer advocates said. North Okaloosa Medical Center, a CHA hospital in the Florida panhandle, had the highest charges of all: 12.6 times Medicare's rate.

    In a written statement, CHA spokesperson Tomi Galin said CHA provided more than $3.3 billion in charity care, discounts and other uncompensated care for patients in 2014, as well as "millions of dollars in taxes that help fund critically important services in every community where we operate."

    The charges examined by the study, Galin said, "are not relevant measures of what consumers, insurers or the government pay for services."

    Chip Kahn, president and CEO of the Federation of American Hospitals, a trade group representing for-profit hospitals, also argued that the charges examined by the study were not a fair assessment of hospital prices. If the study had instead examined the actual payments by patients, they would have found that hospitals on the list charge just 1.3 times what Medicare pays, compared to a national average of 1.2, he said.

    A hospital's charges can matter even for patients with private insurance, said Ge Bai, a co-author on the study and a professor at Washington and Lee University. Hospitals use those charges as leverage during negotiations with insurers, and starting from a higher price point can drive up even discounted prices.

    "Except for patients with government insurance, few consumers are immune from negative financial impacts caused by hospitals' high markups," Bai said.

    "We as consumers are paying for this when hospitals charge 10 times what they should," added Anderson. "What other industry can you think of that marks up the price of their product by 1,000 percent and remains in business?"

    The highest charging hospitals were in 13 states, mostly in the South. Besides Florida, the states included Alabama, Arkansas, Arizona, California, Kentucky, New Jersey, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia.

    The markups charged by the 50 hospitals on the list varied dramatically by procedure. Anesthesiology had the highest charges: an average of 112 times more than Medicare rates. The markup for nursery services, on the other hand, was three times the Medicare rate.

    The authors recommended that state and federal lawmakers enact policies to limit these charges. In Maryland and West Virginia, for example, state agencies set the rates that hospitals are allowed to charge for services. Requiring hospitals to disclose their charges for individual procedures could also help patients shop for the lowest-cost option, they said.

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    More Patients, Not Fewer, Turn To Health Clinics After Obamacare

    More Patients, Not Fewer, Turn To Health Clinics After Obamacare | Healthcare and Technology news |

    Nurse practitioner Martha Brinsko helps a lot of patients manage their diabetes at the Charlotte Community Health Clinic in North Carolina.

    “Most mornings when you check your sugar, what would you say kind of the average is?” Brinsko asked patient Diana Coble.

    Coble hesitated before explaining she ran out of the supplies she needs to check her blood sugar levels, and she didn’t have the gas money to get back to the clinic sooner. Brinsko helped Coble stock up again.

    “If you need to get more than one box, get more than one box,” Brinsko said. “But you need to check them every morning so that we can adjust things.”

    Coble, who is unemployed, lives with her sister and can’t afford insurance even now that the health law is in place, relies on the clinic for health care.

    “They do a great job with everything,” Coble said. “I couldn’t do without them.”

    Nancy Hudson was the clinic’s director as Obamacare rolled out and now consults for the clinic. She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of uninsured patients the clinic sees. The opposite happened, she says.

    “What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,” Hudson says.

    And now they get free or low-cost care at the clinic, which is designated by the government at an FQHC, or federally qualified health center.

    The health law was designed to cover the poorest people by expanding Medicaid, the federal-state program for low-income people. But the Supreme Court made that optional. The result in states that didn’t expand Medicaid is a gap, where some people make too much money to qualify for Medicaid but not enough to qualify for insurance subsidies. In North Carolina, about 319,000 people, like Coble, fall into the Medicaid gap.

    “Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,” says Ben Money is president of the association that represents North Carolina’s community health centers.

    North Carolina is among the 21 states, including many in the South, that are currently saying no to Medicaid expansion. Louisiana is another.

    Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. “We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,” he says.

    Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.

    “The need keeps increasing, and I think that’s reflected throughout all the states,” he says.

    Wiltz, who also heads the board of directors for the National Association of Community Health Centers, says clinics are packed even in states that expanded Medicaid. After all, most of the clinics treat Medicaid patients too.

    The Charlotte clinic’s Nancy Hudson says there’s another part of the health law helping fuel the growth: additional funding for community health centers.

    Hudson found out last week her clinic is getting about $700,000 to expand in partnership with Goodwill.

    “Many of their clients did not have any access to health care,” she says. “They can’t train and sustain a job if they don’t have the basic needs taken care of, and health care is one of them.”

    Nationwide, the federal government estimates its latest round of funding will lead to about 650,000 people getting better access to health care.

    This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.

    Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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    New Medicare data available to increase transparency on hospital and physician utilization

    New Medicare data available to increase transparency on hospital and physician utilization | Healthcare and Technology news |

    As part of the Administration’s efforts to promote better care, smarter spending, and healthier people, today CMS is posting the third annual release of the Medicare hospital utilization and payment data (both inpatient andoutpatient) and the second annual release of the physician and other supplier utilization and payment data. The announcement was made at the annual Health Datapalooza conference in Washington, DC.

    “These data releases will give patients, researchers, and providers continued access to information to transform the health care delivery system,” said acting CMS Administrator Andy Slavitt. “It’s important for consumers, their providers, researchers and other stakeholders to understand the delivery of care and spending under the Medicare program.”

    The Medicare hospital utilization and payment data consists of information for 2013 about the average amount a hospital bills for services that may be provided in an inpatient stay or outpatient visit. The hospital data includes payment and utilization information for services that may be provided in connection with the 100 most common Medicare inpatient stays and 30 selected outpatient procedures at over 3,000 hospitals in all 50 states and the District of Columbia. The top 100 inpatient stays represented in the hospital inpatient data are associated with approximately $62 billion in Medicare payments and over 7 million hospital discharges.

    The Medicare Part B physician, practitioner, and other supplier utilization and payment data consists of information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The data also shows payment and submitted charges, or bills, for those services and procedures by provider. It allows for comparisons by physician, specialty, location, types of medical services and procedures delivered, Medicare payment, and submitted charges. The new 2013 dataset has information for over 950,000 distinct health care providers who collectively received $90 billion in Medicare payments. Hospitals, physicians, and other health care providers determine what they will charge for services and procedures provided to patients and these “charges” are the amount the hospital or provider generally bills for the service or procedure, but the amount paid is determined by Medicare’s physician fee schedule or other payment methodologies. CMS protects beneficiaries’ personal information in all its data releases.

    “Data transparency facilitates a vibrant health data ecosystem, promotes innovation, and leads to better informed and more engaged health care consumers,” said Niall Brennan, CMS chief data officer and director of the Office of Enterprise and Data Analytics. “CMS will continue to release the hospital and physician data on an annual basis so we can enable smarter decision making about care that is delivered in the health care system.”

    The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. These data releases are part of a wide set of initiatives to achieve better care, smarter spending, and healthier people through our health care system. Open sharing of data securely, timely, and more broadly supports insight and innovation in health care delivery.

    Today’s data release adds to the unprecedented information recently released on Medicare Part D prescription drugs prescribed by physicians and other health care providers.

    No comment yet.!

    Health Insurance Is About Risk Management: Health Plans Need to Manage Process Risk Too

    Health Insurance Is About Risk Management: Health Plans Need to Manage Process Risk Too | Healthcare and Technology news |

    It’s ironic. Health insurance is the contractual transfer of risk from the insured to the insurer. This risk is transformed and managed by the insurer through a variety of technical, administrative. and financial means. But if you take a course in insurance underwriting, one area that’s not often addressed is process risk: Probability of loss inherent in business processes. Process risk is sometimes called operational risk, “resulting from breakdowns in internal procedures, people and systems.”

    I think this is highly ironic! Insurance is in the business of concentrating and managing risk. But it does not always use the kind of information technology that can dramatically reduce the risk of internal procedures, people, and systems breaking down. What kind of tech am I speaking of? Modern Business Process Management.

    A colleague of mine, Mike Ingrisano, wrote a great blog post titled An Application Platform Approach for Compliance and Risk Management in which he said:

    “Organizations must align strategies in order to meet regulatory guidelines to reduce operational risk. Businesses of all different types cannot afford process error and data breaches, which has led to large investments to secure data and assets.

    Now, combine the fast-paced world of digital business and access to new sources of data, and organizations find themselves investing even more in compliance management.

    Forward looking companies are using the best of enterprise IT software to adopt applications that use defined workflows, fixed business rules and process automation to establish solutions that enable the most accurate and safe compliance monitoring to mitigate risk.”

    No comment yet.!

    Ignoring the Penalty for Not Buying Health Insurance

    Ignoring the Penalty for Not Buying Health Insurance | Healthcare and Technology news |

    Obamacare’s big stick doesn’t seem to be scaring many people into buying health insurance.

    The health law includes many inducements for people to obtain health insurance — including free Medicaid coverage for many low-income Americans and subsidies for those with moderate incomes. But it also includes the notorious “individual mandate,” a fine for those who can afford insurance but don’t buy it.

    Because the law, and the fine, are new, many policy experts expected that some people would decline to sign up for insurance until they were hit with a penalty at tax time. Forecasters have estimated a big bump in marketplace enrollment next year, the first sign-up period after people have been fined. The Congressional Budget Office, for example, estimates 10 million more people will have Obamacare plans next year. The law’s structure relies on even healthy and otherwise disinclined consumers to enter insurance markets to help stabilize prices.

    Certainly, some people who might otherwise go uninsured have been persuaded by the penalty. Polls have shown that it is a well-known provision of the law. And studies of the uninsured have shown that mentioning the penalty changes some people’s thinking about health insurance. At the end of the normal enrollment period in February, about 11.7 million people had selected marketplace health plans or renewed their plans from 2014, according to the federal government.

    But the Obama administration just conducted a small experiment into how much the penalty would affect the behavior of the remaining uninsured. And the results leave some experts concerned that next year’s sign-ups will come in below expectations.

    Because of the timing of the sign-up season and tax filing deadlines, it turned out that many people would find out about the penalty only after it was too late to enroll for 2015 coverage. Consumer advocates argued that this situation would lead many people to face a needless second year of uninsurance — and penalties. So, in February, the administration and most states agreed that people who were uninsured in 2014, faced a penalty and were still uninsured for 2015 could sign up late for new health insurance. The eligible population is a small slice of the country, but precisely the sort of people whom you might expect to be most motivated by the fine, if they were going to be.

    The I.R.S. estimated that between 3 million and 6 million people faced penalties for being uninsured in 2014. On Tuesday, the federal government announced in a tweet that 147,000 people had signed up for the plans using the federal website that operates in most states during the new sign-up period. Not all of the states that run their own marketplaces and offered similar opportunities have published final numbers, but Charles Gaba, who tracks Obamacare enrollment data at his website,, estimates that total national tax-time sign-ups are around 200,000. Only three states — Colorado, Idaho and Massachusetts — declined to allow penalty-payers to sign up during a special period.

    To be clear, the number of people eligible for the special sign-up period was probably quite a bit less than 6 million. Some who paid fines for 2014 may have gotten insurance with a new job in the intervening year. And some may have signed up for Obamacare insurance during the normal sign-up period, which ran from mid-November through mid-February. The Department of Health and Human Services has provided no estimates on how many people might have been eligible for the special sign-up period.

    Some advocates have criticized the way the special period was set up, saying the low sign-ups merely reflect the last-minute nature of the decision to extend deadlines. Given more time to prepare, tax preparers might have been able to help enroll more people in health insurance, said Brian Haile, a former senior vice president at the tax preparation firm Jackson Hewitt. “H.H.S. refused to provide any information until the very last minute,” he said in an email. “As a result, the companies were not able to plan effectively.”

    But several close watchers of the law say that the special enrollments look low enough to raise more substantial questions about whether the health law’s penalty will have the intended effect of increasing sign-ups for insurance in the coming years.

    “It makes me more pessimistic,” said Caroline Pearson, a vice president at the health care consulting firm Avalere Health. When the government announced the special enrollment period, she estimated that between half a million and a million people would take advantage of it. “All the evidence is enrollment is not going to be where people thought.”

    Ms. Pearson pointed out that people earning higher incomes, who would have to pay a higher proportion of their premiums, have been less eager to sign up than those whose low incomes qualify them for substantial government help with their health premiums. She recently published an analysis describing the penalty as “too low” to move many higher earners.

    Mike Perry, a partner at the polling firm PerryUndem, says focus groups he’s held with the uninsured are consistent with Ms. Pearson’s theory. “A lot of them seem to be making calculations throughout the year what their premium would be versus this fine,” he said.

    Behavioral economists who study incentives like the mandate penalty say it may just take time for people to learn about the incentive structure set up by the penalty. It is set to increase for the next several years, so people who remain uninsured will face not just repeated but rising bills for doing so.

    Some people who learned about the fine late may not have had enough time to make room in their budgets for an insurance premium, said Brigitte Madrian, a professor at Harvard’s Kennedy School who has studied how incentives affect 401(k) plan sign-ups. Next year, uninsured people may have more time to plan ahead, and may remember the unpleasant experience of paying a fine.

    “People learn from their mistakes, and this is true in the financial domain,” Ms. Madrian said. “The learning may be more effective a few years in as they see the penalty going up.”

    No comment yet.!

    Will Obamacare Ever Be as Popular as Medicare?

    Will Obamacare Ever Be as Popular as Medicare? | Healthcare and Technology news |

    With a pen stroke, the president signed into law a health insurance expansion that had previously been deemed "socialized medicine" and had drawn fierce criticism from conservatives.

    No, the president wasn't Barack Obama, and the legislation wasn't the Affordable Care Act. Nearly 50 years ago, President Lyndon B. Johnson enacted Medicare and Medicaid amidst passionate opposition to the program that has since become widely ingrained in the fabric of society.

    But as liberals celebrate the anniversary of Medicare, it's Obamacare that comes to mind. The hope for liberals: that the shift in perspective on Medicare foreshadows a shift to eventual popularity for Obamacare.

    "Before Medicare came into law, one Republican warned that 'one of these days, you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free.' That was Ronald Reagan. And eventually, Ronald Reagan came around to Medicare and thought it was pretty good, and actually helped make it better," Obama said in a 2013 speech in Maryland. "So that's what's going to happen with the Affordable Care Act."

    But the differences between the passage and beginning stages of the two laws may be more indicative of Obamacare's future popularity than the similarities, said Jonathan Oberlander, a professor in the Department of Social Medicine at the University of North Carolina at Chapel Hill.

    "This is not 1965. American politics are extraordinary polarized by party right now. Congress is more polarized in politics and in ideology than at any point since the 1870s," Oberlander said. "This is a political environment where it's very difficult for a program like the Affordable Care Act that was adopted along partisan lines to gain traction."

    Timothy Jost, a Washington and Lee law professor, thinks "there may be some fixes," but believes the law will eventually become entrenched within society.

    "I think it already is," he said. "In fact, when people talk about repealing the Affordable Care Act, I think they really don't know what they're talking about."

    On that, both agreed: "I think it's past repeal," Oberlander said.

    Both the Social Security Amendments—creating Medicare and Medicaid—and the Affordable Care Act created political controversy, and both were passed by large majorities of Democrats in Congress after landslide elections, Jost said. And both took a long time to fully implement—Arizona was the final state to begin its Medicaid program in 1982.

    Both were even debated along party lines, although many Republicans ended up voting in favor of the final Medicare bill, viewing it as a lost cause, Oberlander said.

    On the other hand, perhaps because they were vastly outnumbered, Republicans never seriously talked about repealing Medicare. The program also had a very identifiable group of beneficiaries, while Obamacare targets diffuse populations, Oberlander said. And there were no significant court cases brought against Medicare, whereas five years after Obamacare's passage it awaits yet another Supreme Court decision on the legality of key aspects of the law.
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    Although the gap has narrowed in the past two years, more Americans—43 percent—still viewed Obamacare unfavorably in March than the 41 percent who viewed it favorably, according to a Kaiser Family Foundation poll.

    At an event hosted by the Aspen Institute Wednesday to commemorate Medicare and Medicaid's 50th anniversary, several speakers referenced today's partisan gridlock in contrast to the compromises achieved in 1965, although several also brought up the "doc fix" bill—easily passed in the Senate the day before—as a source of hope for increased bipartisanship.

    "There are a lot of people who would say this is the most polarized Congress. It doesn't look anything like '64, '65," said former Health and Human Services Secretary Kathleen Sebelius. "I think this is a changed Congress."

    Jackie Judd, a special correspondent with the PBS Newshour who served as a moderator at the Aspen Institute event, said the doc fixed served as a reminder that "passions run high around these programs, even today, 50 years later."

    But at the end of the day, a bipartisan bill was overwhelmingly passed, a reflection of the way things used to be.

    "Medicare and Medicaid were adopted, to some extent, in a bipartisan way, because the parties were much less aligned along the ideological spectrum the way they are now," Jost said.

    That meant the programs' flaws could be fixed legislatively. Today, there's little chance of that happening, and solutions instead must come administratively or from the courts, he said.

    The question of whether or not subsidies are available on federal exchanges, the largest current threat to the law, "could have easily been fixed by Congress" in 1965, he said.

    King v. Burwell, which the Supreme Court is expected to decide this summer, will heavily influence the future of Obamacare. But so will the upcoming presidential election.

    "There's a huge difference whether it's Hillary Clinton, Marco Rubio, Scott Walker, or Jeb Bush in the White House," Oberlander said. "The Court case matters greatly here, but I think regardless of what happens in the Court case, the question in 2016 will be: How will the law change?"

    No comment yet.!

    Healthcare and Health IT in 2015. What the world needs now is…….. simplicity - HealthBlog - Site Home - MSDN Blogs

    Healthcare and Health IT in 2015. What the world needs now is…….. simplicity - HealthBlog - Site Home - MSDN Blogs | Healthcare and Technology news |

    Happy New Year to my HealthBlog readers around the world. I’m back in the saddle after a 3 week hiatus for the holidays. I must say I’m feeling fully rested and looking forward to all that 2015 will deliver.

    Like you, I’m getting tired of reading prognostications about what’s hot and not for tech in the year ahead. However, I did enjoy a piece I came across today by my blogosphere colleague and Forbes contributor, Dr. John Nosta. Actually, I believe Dr. Nosta published the post not this week, but rather a full year ago. The post, Digital Heath In 2014: The Imperative of Connectivity, might as well have been written this week as it is just as true today as it was in January of 2014. In it, tech pundits from John Sculley to Steve Wozniak are quoted in musings about the tech revolution in health and healthcare and how everything you know is about to change. As has been true for the past several years, people are predicting massive disruption and transformation of health and healthcare delivery fueled by technology. And, as has been the case during the vast majority of my 14-year career at Microsoft and many years before that as a physician, tech and healthcare industry executive, I feel like I’m still waiting for the big bang.

    Now don’t get me wrong, we have certainly seen transformation (albeit slow) of healthcare, and technology is definitely driving a lot of that change. Policy is also driving change, perhaps more so than technology. And, at least in America, no policy is causing more disruption right now than that of the Affordable Care Act. However, all of this begs the question--are things getting better or worse? People are paying more than ever before for the services they receive. Many of us are seeing our health insurance premiums rise while being asked to fork over more and more of our money toward copays and high deductibles (often $5000 to $12,000 per year per family). And even though I love technology, thus far I think it is failing to deliver on its promises or potential. Let me ask you, is it getting easier or harder to pay for and manage healthcare for your family? And if you are a healthcare provider, is it getting easier or harder to take care of your patients the way you’d like to care for them?

    Technology should be making all of his easier and less expensive, but is it? Healthcare policy should be doing the same. Instead, we seem to be getting ever more complicated rules, regulations and business practices that confound both consumers and providers alike. Health insurance is more complicated than ever before, and don’t even get me started on Medicare.

    If there is a theme I’d like policy makers, tech industry leaders, insurance chiefs, healthcare executives, and clinicians to focus on more on in 2015 it would quite simply be……. simplicity. We are making everything way too complicated. Without greater focus on technology that actually makes things more simple through seamless integration of services and information exchange, improved modalities for synchronous and asynchronous communication and collaboration in clinical workflow, and business models that truly support innovation and lower costs in healthcare, all the fancy new wearable smart devices, labs on a chip and augmented reality headsets won’t do much to save us from our misery.

    I believe there are but a few global companies with the breadth, depth, and scale to really deliver on the kinds of information technology advances our health industry needs. Even then, it will take a carefully choreographed dance of enlightened public policy and innovation to deliver the goods. Otherwise, a year from now, and for many years yet to come, we’ll simply be singing more of Auld Lang Syne.

    No comment yet.!

    Health insurers working the system to pad their profits

    Health insurers working the system to pad their profits | Healthcare and Technology news |

    One of the reasons the health insurance industry worked behind the scenes in 2009 and 2010 to derail Obamacare was the fear that changes mandated by the law would cut their Medicare Advantage profits. Medicare Advantage plans are federally funded but privately run alternatives to traditional fee-for-service Medicare. 

    Although the industry’s biggest trade group, America’s Health Insurance Plans, said repeatedly that insurers supported Obamacare, the group was secretly financing the U.S. Chamber of Commerce’s TV campaign against reform. Among the companies most concerned about the law were those benefiting from overpayments the federal government had been making to their Medicare Advantage plans since George W. Bush was in the White House.  

    Bush and other Republicans saw the Medicare Advantage program as a way to incrementally privatize Medicare. To entice insurers to participate in the program, the federal government devised a payment scheme that resulted in taxpayers paying far more for people enrolled in the Medicare Advantage plans than those who remained in the traditional program. The extra cash enables insurers to offer benefits traditional Medicare doesn’t, like coverage for glasses and hearing aids, and to cap enrollees’ out-of-pocket expenses.

    When the Affordable Care Act became law in 2010, the payments to Medicare Advantage plans exceeded traditional Medicare payments by 14 percent. To end what they considered an unfair advantage for private insurers, and to reduce overall spending on Medicare, Democrats who wrote the reform law included language to gradually eliminate the over-payments.  So far, the 14 percent disparity has been reduced to 2 percent.  The final reductions are scheduled to be made next year.

    Despite that decrease, the fears by Republicans and insurance company executives that the reductions would lead to a steady decline in Medicare Advantage enrollees have proved to be completely unfounded. In fact, the plans have continued to grow at a fast clip.

    In March 2010, the month Obamacare became law, 11.1 million people were enrolled in Medicare Advantage plans—one of every four people eligible for Medicare. That was an increase from the 10.5 million Medicare Advantage enrollees in March 2009. Since then, Medicare Advantage membership has grown by more than 8 percent annually. Now 17.3 million—one in three people eligible for Medicare—are enrolled in private plans.

    As Center for Public Integrity senior reporter Fred Schulte has written over the past year, many insurers have discovered that even though the overpayments are being reduced, they can boost profits another way: by manipulating a provision of a 2003 law that allows them to get additional cash for enrollees deemed to be sicker than average.

    A risk-coding program was put in place by the government primarily because insurers were targeting their marketing efforts to attract younger and healthier—and thus cheaper— beneficiaries. Under the risk-coding program, insurers are paid more to cover patients who are older and sicker; the idea was to encourage the firms to cover those folks by offering a financial incentive. They get more money, for example, to cover someone with a history of heart disease than they do for someone with no such risk.  Last week Schulte uncovered whistleblower accusations that a medical consulting firm and more than two dozen Medicare Advantage plans have been ripping taxpayers off by conducting in-home patient exams that allegedly overstated how much the plans should be paid.

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    Do doctors really hate Obamacare?

    Do doctors really hate Obamacare? | Healthcare and Technology news |

    Anti-Obamacare critics often claim that “every” physician they know hates Obamacare. For instance, pediatric neurosurgeon and GOP Presidential candidate Dr. Ben Carsontold Fox News that “he’s spoken to hundreds of doctors throughout the country about the Affordable Care Act, and not one of them ‘liked’ President Barack Obama’s signature health care law.”

    Doctors hate Obamacare, it’s alleged, because it authorizes government to “control” the practice of medicine and impose “rationing” of care, thereby harming patients.  The conservative Examiner website quotes a New Jersey family physician, Dr. John Tedeschi as saying, “Just as a guitar string has to be tuned, so does a person’s health to get the right tone. The government has taken away, or refocused the intelligence part of the tuning, and has just about destroyed the creative, or compassion component. Now, with Obamacare, we are left with an incompetent mechanism that does not have the best interest of the patient in mind.”  An ER physician quoted in the articles said that the “storm of patients [created by Obamacare] means when they can’t get in to see a primary care physician, even more people will end up with me in the emergency room.”

    There is no question that some doctors (mainly conservatives) hate Obamacare, and if they were the only ones you talked to (like the ones who apparently talked to Dr. Carson), you might think that all doctors feel the same way. But the reality is that — surprise, surprise! — primary care physicians’ views are just like the rest of us, split by their partisan leanings.

    A new survey by the respected Kaiser Family Foundation found that 87 percent of Democratic-leaning physicians view Obamacare favorably, while the exact same percentage of GOP-leaning physicians view it unfavorably. Independent doctors split 58 percent unfavorable to 42 percent favorable.  Because there were more GOP and independent physicians among the survey respondents, the overall breakdown of primary care physicians’ views on the ACA is  52 percent unfavorable to 48 percent favorable.  Yet only 26 percent of all primary care physicians viewed the law “very unfavorably. “  So it might be said that just one out of four primary care physicians “hate” Obamacare.

    And a deeper dive into the survey results directly refutes the contention of anti-Obamacare doctors that the law is leading to poorer quality, physicians turning away patients, or longer waits for appointments:

    • Most primary care physicians say that quality has stayed the same: 59 percent said that their ability to provide high-quality care to their patients has stayed about the same, while 20 percent said it has improved, and 20 percent said it has gotten worse.
    • More primary care physicians report that Medicaid expansion has had a more positive impact on quality than a negative one: “When asked more specifically about the expansion of Medicaid under the ACA, nearly four of 10 providers (36 percent of physicians and 39 percent of nurse practitioners and physician assistants) said the expansion has had a positive impact on providers’ ability to provide quality care to their patients. About two of 10 said it has had a negative impact, and the remainder said it has not made a difference, or they are not sure.”
    • Ease of getting same-day appointments is about the same as before the ACA: “Overall, about four of 10 primary care providers said almost all their patients who request a same- or next-day appointment can get one; another quarter said most of their patients can get such appointments” which is largely unchanged from 2009 and 2012.
    • Most continue to accept new patients: “A large majority of primary care providers (83 percent of physicians, 93 percent of midlevel clinicians) said they are currently accepting new patients . . . A survey conducted in late 2011 through early 2012 found that 89 percent of primary care physicians were accepting new patients and 52 percent were accepting new Medicaid patients.  This indicates that while physicians’ rates of accepting new patients overall may have declined slightly since the ACA coverage expansions went into effect, acceptance rates for Medicaid have remained about the same.”

    When asked specifically about their views on the impact of the Affordable Care Act on five dimensions, the ACA fared well, with one exception (costs to patients).

    • Access to health care and insurance in the country overall: 48 percent positive, 12 percent no impact,  24 percent negative, and 14 percent not sure.
    • Overall impact on practice: 31 percent reported no impact, 23 percent a positive  impact, 36 percent negative  and 9 percent not sure.
    • Quality of care their patients receive: 50 percent reported no impact, 18 percent positive, 25 percent negative, and 6 percent not sure.
    • Ability of the practice to meet patient demand: 44 percent no impact, 18 percent positive, 25 percent negative, and 10 percent not sure.
    • Cost of health care for their patients: 17 percent no impact, 21 percent positive, 44 percent negative, and 16 percent not sure.

    However, “physicians’ responses to questions that mention the ACA by name are deeply divided along party lines. For example, by a three-to-one margin, physicians who identify as Democrats are more likely to say the ACA has had a positive (44 percent) rather than a negative (15 percent) impact on their medical practice overall. Republican physicians break in the opposite direction by about seven-to-one (57 percent negative, 8 percent positive).”

    The survey also does not support the contention that the ACA is contributing to primary care physician dissatisfaction with practice and burn-out:

    “Even though providers with different political affiliations do not share views about the Affordable Care Act, a large majority of primary care providers (83 percent of physicians and 93 percent of nurse practitioners and physician assistants) — both Republicans and Democrats — reported they are very or somewhat satisfied with their medical practice overall. The changing environment does not appear to be affecting overall provider satisfaction even among providers who see a larger share of Medicaid patients or work in Medicaid expansion states. Indeed, current satisfaction levels are slightly higher than what was reported by primary care physicians before the ACA. In 2012, 68 percent of primary care physicians reported they were very satisfied or satisfied with practicing medicine.”

    Interestingly, Democratic physicians (56 percent) are more likely to recommend a career in primary care than Republicans (39 percent)  or Independents (40 percent).

    I know that many conservative primary care doctors have a strong and principled objection to Obamacare, believing  passionately that it gives the government too much power and the physicians, and their patients will be hurt as a result.  I (and ACP) may not agree with them, but I respect their views, and their right to make their case to their colleagues and to the public.

    But the Kaiser Family Foundation survey shows us that the anti-Obamacare doctors do not represent the views and experience of most primary care doctors on the front lines, never mind “all” of them.  Doctors (at least those in primary care, who knows about surgeons?) clearly don’t “hate” Obamacare.  Rather, more of them see Obamacare as doing some good things, like improving access; and doing not as well on other things, like lowering costs to patients.  Much of what they do and see in their practices remains unchanged by it, for good or bad.

    And that strikes me about right, Obamacare is making many things better, but there is a lot more that needs to be done to improve quality and access, lower costs to patients, and sustain and support primary care.  Of course, such nuances do not make for as good a headline or political talking point as “Doctors Hate Obamacare.”

    No comment yet.!

    Does the Affordable Care Act Guarantee Healthcare as a Right?

    Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news |

    In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)

    It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.

    Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 

    It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:

    • 35 million uninsured, plus another similar number underinsured.
    • The first question asked of us in seeking care is "what is your insurance?"
    • 21 states have opted out of Medicaid expansion under the ACA.
    • Medicaid eligibility and coverage varies widely from one state to
    • another, in many cases falling far short of necessary care.
    • As the costs of insurance and health care continue to rise and shift
    • more to patients, a growing part of the population cannot afford either and forgo seeking care.
    • More than 40 million Americans now have an account in collection for medical debt. (4)

    This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.

    Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

    No comment yet.!

    Putting the increases in health premiums in perspective

    Putting the increases in health premiums in perspective | Healthcare and Technology news |

    Recently, health insurance companies across the nation have petitioned to increase premium rates for customers covered under the Affordable Care Act (ACA). In North Carolina, Blue Cross Blue Shield (BCBS) has proposed a 25.7 percent raise in premiums; in New Mexico, BCBS requested a 56.1 percent raise; and, in Georgia, Alliant Health Plans has submitted a proposal for a hike as high as 85 percent.

    Health care premiums are a significant burden on many American families, averaging about $1,000 a month, not counting thousands of dollars people pay in deductibles, copayments, medical supplies and medications.

    So I did some research to put the health premium issue in perspective.

    Health care premiums for private health plans are of two types. One is employer-sponsored health insurance, which 48 percent of Americans receive. Over the past few years, the premiums of these plans for individual coverage have not increased and for family coverage have slowed to a three percent annual rise. The proposed premium hikes do not impact Americans on the employer-sponsored health plans.

    The second type of private health insurance is for plans on the newly-formed health exchanges under the Affordable Care Act (or Obamacare). An exchange is essentially a one-stop marketplace where consumers can decide among categories of health insurance called platinum, gold, silver and bronze, based on benefit categories. Insurance companies such as BCBS or Cigna offer plans at varying costs. Twelve millionAmericans have purchased plans on the exchanges. The rate increase would affect this sizable group.

    I wondered, what’s motivating these changes in the ACA? Is the ACA collapsing? The answer is complicated. According to most health economists, insurers didn’t accurately predict the number of new ACA enrollees as well as the high level of health utilization by these enrollees due to their previously untreated medical conditions. At the same time, reduced government protection for insurance companies has compounded the risk of irreversible financial losses. As a result, insurers had to estimate new costs of coverage to reflect the true burden of care.

    On the bright side, there is a chance these petitions could be dismissed. Insurance companies petitioning for high rate increases are likely to be rejected by auditors in states where this authority is granted. Also, the ACA requires insurance companies to spend a minimum of 80 percent of the premiums on medical care or else give their customers rebates. In the first year of the ACA $1.1 billion was given out in rebates by insurance companies and $2.1 billion in the second year. Lastly, a good way to control premium rates is through the market. If insurers raise their rates too high, other companies will offer more competitive packages as leverage.

    Similarly, if premium hikes increase, then it’s likely subsidies would increase as well.About 80 percent of Americans enrolled in ACA receive subsidies to make health insurance affordable. This is because the subsidy depends on the cost of the premium as a percent of an individual’s income and is benchmarked to the premiums for the second-lowest silver plan.

    While the exchanges may seem chaotic and frustrating, the ACA could be life-saving for many patients. Take one of my patients who, in his 20s, contracted HIV. For years, he had good employer-sponsored health insurance, working at a university as an office administrator. He followed-up regularly for his appointments and took his medications.

    But then he was laid off and lost his health insurance. He stopped coming to my office, stopped taking his retroviral medicine and ultimately his HIV flared and progressed to AIDS. He was repeatedly admitted to the hospital until he signed up for the exchanges. Now he has health insurance as well as money for his prescriptions and health care. One day, sitting on the examining table, he confided, “I think these exchanges saved my life.”

    Even with this proposed premium hike, the exchanges are not collapsing. Rather, they are going through a market correction. The exchanges are an innovative, market-driven strategy, which foster competition, cost-savings, and quality among insurers. They are an example of managed competition as its best, an idea originally proposed by a conservative think tank, the Heritage Foundation.

    The most important question we must ask is, who ultimately controls the rise and fall in our premium rates? While doctors, hospitals and insurance companies play a large role, we consumers can collectively help to lower our health premiums by changing many of our behaviors. For example, avoiding unnecessary ER visits can save $38 billion. Smoking costs the nation nearly $170 billion dollars in direct medical care. Roughly 11 percent of our aggregated health care expenditure is associated with inadequate exercise, and healthier diets may prevent $71 billion dollars in medical costs associated with diseases like diabetes.

    All of this trickles down to affect our health care premiums.

    Finally, another way to lower our premiums is to convince more people, our friends and neighbors, to sign up for health insurance, because on average a family or their employer pays $1,017 extra in premiums for those who are uninsured. It’s time we all do our part.

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    Obamacare's next 5 hurdles to clear

    Obamacare's next 5 hurdles to clear | Healthcare and Technology news |

    In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges –including one resolved Thursday – and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles left for the law:

    • Medicaid expansion. About 4 million more Americans would gain coverage if all states expand the state-federalMedicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.
    • Anemic enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.
    • Market stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.
    • Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.
    • Political resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.
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    Obama Is Optimistic Justices Will Let Health Care Law Stand

    Obama Is Optimistic Justices Will Let Health Care Law Stand | Healthcare and Technology news |

    There has been a lot of discussion and focus on the "triple aim" of good patient care which translates to access, cost, and quality. Which factor is most important? It depends upon who is talking, but more importantly it depends upon who your customer is.

    In a medical practice there are many customers, with patients coming first and foremost, followed by referring providers, staff members, and other business partners. In order to meet the needs of the customer, I believe that quality is the most important factor, or as some may remember from the Ford Motor Company, "Quality is job one!"

    One way to achieve quality is to create a quality management system (QMS). A QMS focuses on the quality of the desired outcome, as applied to patient care. The premise here is that quality outcomes will ensure good patient access and also control costs — therefore the focus for any business must be on the quality of services provided.

    Creating a quality system

    Here are four basic requirements to create a system:

    • A system is a coordinated approach to deliver services to meet the needs of the customer — patients, referring physicians, staff members.

    • A system does not succeed without a focus, so your practice's purpose (mission statement) stated simply could be: provide quality patient care, efficiently and effectively, to meet customers' needs.

    • A system requires resources, machines, processes, supplies/equipment, and people.

    • A system requires the efficient use of these resources — the role of management is to coordinate activities, ensure there is not waste, and ensure the practice is achieving its goal of quality patient care.

    The patients come to your practice with a set of expectations. The question that should be asked every day is, "Did we meet our patients' expectations?" The best way to answer "yes" to that question is using a coordinated approach to all aspects of your practice's operations. One that will lead to long-term survival and success.

    Barriers to quality

    Too often we find ourselves creating "silos," where staff members say, "My job is to do only this, and I don't care what others do." Physicians may say, "I want to do things my way, because that works for me, and that is what I think is best for the practice."

    A systematic and coordinated approach to patient care, on the other hand, suggests that these silos be removed. For example: Look at the basic patient flow in your office. The five steps are: check in, triage, the physician/patient encounter, follow up, and check out. If the medical assistant does not consider the role of the receptionist and only focuses on what she does, there will be problems at some point in the patient visit. Focusing on a single role will lead to delays, barriers, and inefficiency in the delivery of patient care.

    A systematic approach also takes advantage of the strengths of the physicians as a whole, standardizing operations as much as possible. This is the tough one, as physician training involves independent thinking and decision making. The idea of having to change "my" approach to care to meet some administrator's idea of making things better is foreign and difficult to achieve.

    This is where the discussion must occur about the effective use of resources by physicians. Reviewing what works best to achieve the practice's overall mission is a good start. Comparing physician metrics through appropriate reporting and positive peer pressure will assist in changing behavior to a more systematic approach.

    What's the key point of all of this? Your practice should focus on the quality of care it provides and the quality of relationships it has with customers, in a systematic fashion. If this is accomplished, your practice will flourish and meet the expectations of each of its customers.

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    One Quarter Of Insured Still Can’t Afford Care

    One Quarter Of Insured Still Can’t Afford Care | Healthcare and Technology news |

    One in four of those with health insurance coverage still can’t afford to utilize their health insurance plans due to high deductiblesaccording to a Families USA studydespite the fact the Affordable Care Act has increased access to health insurance. But just because people have insurance, it does not mean that they can actually afford the health care that it promises.

    In fact, high deductibles mean it’s still often cheaper for people to go to the ER than to arrange a visit with a physician. The group’s report points toward plans with deductibles of $1,500 or more as the most likely leading cause for patients skipping medical tests, treatments, and follow-up care.

    The advocacy group argues simply having health insurance does not guarantee that enrollees can actually utilize their plan to obtain healthcare, and the report suggests that silver plans should be reconfigured to include lower deductibles, making the plans actually effective for member use. Most commonly skipped categories of care included medical tests, treatments and follow-up care, according to the report, Non-Group Health Insurance: Many Insured Americans with High Out-of-Pocket Costs Forgo Needed Health Care.

    “It is critically important that consumers be able to afford all of these types of care,” the report said. “Not getting follow up care to treat an illness or not taking needed medications can result in people facing avoidable, more serious health problems and more expensive health care costs down the road.”

    The gap in care was most common among lower- to middle-income adults, with almost one out of three (32.3 percent) reporting they skipped needed health care because they couldn’t afford it. “Our findings show that too many lower- and middle-income consumers face deductibles that are likely unaffordable relative to their incomes and that could create barriers to them getting the care they need.”

    “State policymakers could require that every insurer in their state offer at least one silver plan that covers basic outpatient services and prescription drugs before the deductible is paid. Federal policymakers could take a similar step and require insurers in all states to offer a plan like this,” report co-author Lydia Mitts told Northeast Public Radio.

    Mitts explained that such plans would not automatically mean higher premiums, and pointed to the examples of state marketplaces in New York, Connecticut, and California, where there are standardized plans that exempt routine care from the deductible.

    “Connecticut’s marketplace is a really good example of this,” Mitts says. “They’ve created a standard silver plan that covers doctor’s visits, including primary care visits and specialty care visits, tests and lab work, generic prescription drugs and a number of other outpatient services before the deductible is paid.”

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    Despite Obamacare, gap health insurance market explodes

    Despite Obamacare, gap health insurance market explodes | Healthcare and Technology news |

    Despite the promise of coverage through the U.S. Affordable Care Act (ACA), the number of people applying for non-compliant, short-term health insurance policies was up more than 100 percent in 2014, according to new data available from companies who broker these policies.

    This type of health insurance is exactly the kind that the ACA, known commonly as Obamacare, was supposed to upgrade. Short-term plans provide low-cost coverage for major medical events like hospital stays, with high deductibles and out-of-pocket costs, and are subject to denial if applicants have pre-existing conditions. They do not offer the protections of Obamacare for preventive care or maternity coverage, for example.

    The government does not count these gap plans as qualifying health insurance, so people who have them are subject to penalties for being uninsured.

    Sign-ups at eHealth Inc to the short-term plans it offers through its website were up to 140,000 in 2014 from 60,000 in 2013, an increase of 134 percent, according to the company.

    At another short-term carrier, Agile Health Insurance, a subsidiary of Health Insurance Innovations Inc, new policies were up 100 percent last year over the previous year, and are up again so far in 2015, according to Scott Lingle, the company's senior vice president of business development.

    Accounting for much of the jump are individuals who somehow missed the open enrollment period for an Obamacare plan. More than 11.7 million consumers signed up for Obamacare coverage through Feb. 22, according to the government.

    People missed out mostly because of poor communication between consumers, the government and insurance companies, says Nate Purpura, eHealth's director of PR and Content. Those who missed the opportunity to sign up and did not have a qualifying event now have to wait until the next open enrollment period to try again, so they need an insurance plan to bridge the gap.

    Both eHealth and Agile are also seeing new signups from retirees who are looking for a low-cost plan to tide them over until Medicare kicks in at 65. At eHealth, the 55 to 64 age group is now 9 percent of the market.

    "If you shop for a 50-year-old on, it is very expensive," says Agile's Lingle. "There are people who have looked at the prices and it makes more sense to buy short term."

    The largest constituency is young, healthy people seeking low-cost catastrophic coverage. Those aged 18 to 34 account for 57 percent of eHealth's buyers. A typical policy could cost around $100 a month, depending on the state of residency and the features of the plan.

    These customers include 19-year-old college student Kelly Thomas-Cutshaw, who had no insurance through family and her school did not offer group coverage. Thomas-Cutshaw did not qualify for a subsidy under the ACA because she did not have enough income, yet she could not get Medicaid in Oklahoma, where she goes to school, because she made too much and was not a permanent resident there.

    Over the winter, Thomas-Cutshaw became ill, and now has a medical bill she says will take her four years to pay off. She decided she needed some plan in place in case she fell ill again.

    When her short-term plan runs out in the fall, she is prepared to sign up for an ACA-compliant major medical plan.

    "I can mostly afford to live, so that's nice," Thomas-Cutshaw said, thanks to a summer job she just landed. "It been a ridiculous and frustrating experience. I don't wish this on other people."

    No comment yet.!

    Medicare paid doctors $90 billion in 2013, up 17 percent: officials

    Medicare paid doctors $90 billion in 2013, up 17 percent: officials | Healthcare and Technology news |

    Medicare, the government-run health insurance program for elderly and disabled Americans, paid physicians $90 billion in 2013, up 17 percent from $77 billion in 2012, U.S. healthcare officials reported on Monday.

    Physician payments accounted for less than one-fifth of Medicare's 2013 net outlays of $492 billion, which rose from $466 billion in 2012. Payments to hospitals for the top 100 inpatient stays cost Medicare $62 billion in 2013, while the rest went for drugs, privately run Medicare Advantage plans and other program costs.

    The payments went to about 950,000 doctors, nurse practitioners and other individual healthcare providers who participate in the program. That was up from 880,000 providers in 2012.

    The hospital data offer a glimpse of what ails America's elderly - and the quality shortfalls in U.S. healthcare.

    The single-greatest hospital expense was to replace knees, hips and other joints in 446,148 operations, with $6.6 billion paid to hospitals.

    The second-greatest hospital payment, $5.6 billion, went for 398,004 cases of septicemia, or blood poisoning, often a sign of poor in-patient care.

    In a significant change from the data released last year, the Center for Medicare and Medicaid Services differentiated between what it paid physicians for their services and what it paid to cover the costs of drugs they administered. Some physicians had complained that they were portrayed as exorbitant billers because the cost of drugs was included in what Medicare paid them.

    Among physicians, the highest-paid specialists were radiation oncologists, who received an average of $403,512 from Medicare for their services. That was closely followed by dermatologists ($331,108), vascular surgeons ($329,874), and ophthalmologists ($326,621).

    In contrast, medical oncologists, who treat cancer patients with chemotherapy and generally coordinate their care, received an average of $181,747. The previous year's data portrayed them as some of the top Medicare billers, but that largely reflected reimbursements for the cost of drugs - an average $473,926 in 2013.

    The data showed that patients who lament how little time they get with their physicians are not imagining it. Dermatologists billed for the most office visits lasting only five or 10 minutes (nearly 30 percent of total visits), whereas oncologists had almost no visits that short.

    Medicare patients averaged six physician visits in 2013, but that varied significantly by state. Patients in New York, New Jersey, Florida, and Tennessee saw their doctors nearly seven times that year; those in northern New England, the Dakotas, Idaho, Montana, and New Mexico averaged fewer than four visits.

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    Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare

    Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare | Healthcare and Technology news |

    As Healthcare Informatics reported last month, the Office of the National Coordinator for Health Information Technology (ONC) released a report in early April that highlighted what the federal healthcare IT agency referred to as “information-blocking.” As Senior Editor Gabriel Perna noted in his April 10 report immediately following the release of the ONC document, “The report’s authors and researchers detailed several examples of electronic health record (EHR) developers and health systems blocking health information sharing between each other. The act of information blocking occurs when an entity or person knowingly and unreasonably interferes with the exchange of electronic health information. Examples of this,” he noted, “are charging prices and fees for data exchange; creating terms of a contract that restrict individuals access to their health information; developing health IT in a non-standard way that dissuades information sharing; and developing health IT in a way that locks in information.”

    The ONC cited examples in its report of anecdotal evidence suggesting that “EHR application developers are breaking several of the rules in this regard,” Perna’s report noted. “Using interviews with people at regional extension centers (RECs), the authors detailed complaints from industry sources on how developers are charging fees that make it cost-prohibitive to send, receive, or export electronic health information stored in EHRs. Some EHR developers even charge a substantial transaction fee any time a user sends, receives, or queries a patient’s electronic health information, the report says. The variation in prices reported to ONC suggests that some are taking advantage of the situation.”

    In announcing the availability of the report, National Coordinator for Health IT Karen DeSalvo, M.D. noted in a blog on the agency’s website that it is difficult to pinpoint concrete evidence of information-blocking. “The full extent of the information blocking problem is difficult to assess, primarily because health IT developers impose contractual restrictions that prohibit customers from reporting or even discussing costs, restrictions, and other relevant details,” she noted. “Still, from the evidence available, it is readily apparent that some providers and developers are engaging in information blocking,” she said.

    Given all this, I read with interest a May 20 blog in Health Affairs online by Julia Adler-Milstein on this subject, because of the clear way in which she frames the dynamic tension taking place right now in the industry between the forces that would restrict information for profit or proprietary gain, and those that would advance it for the common good. AsAdler-Milstein, who is an assistant professor of information in the School of Information and an assistant professor of health management and policy at the School of Public Health at the University of Michigan, states very bluntly in her blog, “When it comes to sharing electronic patient health information, public good should trump private gain. While it may seem like an obvious statement, it represents a tectonic shift in the narrative surrounding health information exchange,” or HIE.

    As Adler-Milstein notes, “For more than a decade, our federal strategy has largely left HIE to the market under the assumption that, if there is benefit to be created (and estimates suggest that there is), we should see the emergence of ways to capture that benefit. In practice, this means that HIE efforts have sprung up in various health care markets across the country, and where public money has been spent on HIE (largely at state and community levels), it has come in the form of one-time start-up funding, not a commitment of ongoing support or regulatory mandates for HIE participation.”

    Here’s where Adler-Milstein really scores a home run on this, in my view: “What has been substantially underappreciated, however,” she writes, “is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not doing so. And as a result, these actors may behave in ways that interfere with the free-flow of patient information that is needed to improve health and health care.”

    Instead, she says, “With the release of the information blocking report, which was produced in response to a 2015 Omnibus bill request that introduced the term ‘information blocking,’ ONC makes plain that this behavior will no longer be tolerated. This enormously exciting development means we might see real progress after decades of investment that has failed to convert into sustainable approaches to robust HIE. The key to such progress, however,” she warns, “lies in how well we can identify when information blocking is occurring. This will not be easy.”

    And in those short paragraphs, we can see some of the core opportunities and challenges moving forward in this critical area. In this arena as in so many others in healthcare, we see a dynamic tension based on conflicting incentives within the U.S. healthcare system. On the one hand, there is broad consensus that data- and information-sharing will be essential to accountable care organization (ACO) development, population health management, bundled payment-facilitated care delivery, patient-centered medical home work, and indeed, every iteration of the new healthcare. Yet at the same time, there are many elements embedded even in those concepts that speak to at least short-term—and certainly arguably, medium-term as well—market advantages that can be gained through data- and information-hoarding.

    It is this clash of incentives that we are collectively burdened with at this early stage of the trajectory towards the new healthcare. The rhetoric around healthcare policy right now is all about sharing for common gain, and yet the incentives in the moment are far from purely conducive to—well, purity.

    That’s why it’s good to be reminded at times like this by elegantly concise writings like those of Julia Adler-Milstein. Adler-Milsteiin’s blog reminds us what the ultimate prize is, on which we should at least theoretically all be setting our eyes. This is not to engage in the laying of blame on those working for specific market advantage, but rather to affirm the need to continue to push forward collectively as an industry and indeed as a society, towards a more mature healthcare system—one in which all the incentives really all will be aligned. In other words, keep watching this space.

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    5 Reasons The Affordable Care Act Will Be Good For Americans

    5 Reasons The Affordable Care Act Will Be Good For Americans | Healthcare and Technology news |

    In October, 2013, at the launch of the Affordable Care Act, I predicted that the health insurance exchanges about to go into effect would grow in popularity and  improve the health insurance marketplace, then so imperfect.

    Twenty months later, the exchanges are proving effective in reducing the number of uninsured and are beginning to provide the information people need to make an informed selection about which plan is best for their needs. As a result, I’m even more convinced than I was that they will bring about major improvements – improvements not only in how health coverage is purchased, but also in lowering cost and increasing quality outcomes.

    Although concerns still exist, I predict that many of the latest headlines – about the technical challenges faced in the rollout of the law, the pending Supreme Court decision on whether subsidies are being made available consistent with the letter of the law, and the continued bipartisan bickering – will be largely forgotten a decade from now.

    Already, with second-year enrollment complete, the results of the exchanges are nothing short of impressive. According to Gallup, the rate of uninsured Americans has dropped from 16% to 12%.  And some 14.1 million Americans already have signed up for the public exchanges.

    Here, then, are the top five improvements to American healthcare that will come directly from the exchanges.

    1. They Will Transform The Health Insurance Market

    The rules of engagement in the marketplace are shifting dramatically. Individuals who sign up for insurance through the exchanges are guaranteed coverage. They also gain advantages from standardized benefit design, cost transparency, and increasingly – at least in some states – data on quality.

    With our limited experience on utilization and risk among enrollees, pricing has yet to settle. But in the future, as competition grows, the plans that sell insurance products through both private and public exchanges will be forced, if they want to attract new members, to lower prices and increase the value delivered.

    Previously, insurance plans in the individual and small group market competed with each other mainly through product design and risk selection.

    The most successful insurance companies figured out how to “slice and dice the risk pool” – selectively trying to enroll the youngest and healthiest in the individual market and thereby minimize the amount they had to pay to physicians and hospitals.

    In the individual market, insurers did this by denying coverage to individuals with pre-existing conditions and creating “skinny” plans with limited benefits.

    Such tactics are no longer legal under the ACA.

    In addition, because competing plans in most communities used essentially the same physicians and hospitals, insurance companies had difficulty differentiating themselves from each other based on quality.

    And as a result, they only invested minimally in improving the effectiveness and efficiency of care delivery.

    Now we can predict that going forward, individuals will have a broader set of options with added information. And the winners will be those plans that provide high quality medical care at the lowest cost, rather than those who are best able to attract the healthiest patients or design coverage with the narrowest benefits.

    2. They Will Enable Companies To Move From a Defined Benefit to a Defined Contribution  

    The exchanges extend to employers the opportunity to get out from being a “middle man.” Rather than being responsible for selecting the company’s insurance plan, negotiating the coverage provided and determining the size of the deductibles required, they can provide employees a set amount of money for health insurance – a defined contribution – and increase it in subsequent years at a rate consistent with their ability to fund this benefit.

    Employees can then pick among the numerous options on an exchange based on personal preference. If they select a less expensive plan, they can take home the difference. Or they can enroll in a more expensive option and contribute their own money.

    Previously, to control costs, some employers forced employees to switch insurance companies and, as a result, change doctors. Others required employees to pay more out of pocket. Both of these means of controlling costs made employees unhappy with their employers.

    Now employers can avoid being put in the middle, while ensuring that their company’s cost of healthcare coverage increases at a rate the company can afford.

    3. They Will Help Individuals To Comparison Shop Among the Different  Plans  

    With costs now transparent, and increasingly quality information being made available, enrollees will be better equipped to make informed choices about the best plan for themselves and their families.

    The public exchanges offer standardized benefits and comparable pricing. Each plan, from platinum and gold to silver and bronze, varies in monthly premiums and patient cost-sharing requirements.

    Previously, healthcare pricing and benefits constituted nothing less than a “black box.” Plans varied widely in what was covered and how much an individual or family needed to pay out of pocket. It took an actuary to figure out which plan had the most value.

    No more.

    4. They Will Motivate Changes In Behavior That Drive Down HealthCare Costs

    Enrollees through the exchanges will be more active participants in controlling their healthcare costs.

    The government-funded subsidies are designed to make the Silver tier the most desirable. By law, this level of coverage requires on an actuarial basis that 30% of the cost be borne by an enrollee. As a result, all include deductibles for which enrollees must pay first dollar out of pocket payments.

    Knowing they will be personally responsible each year to pay for a significant amount of their care, they will be more likely to take advantage of the free preventive services offered  and deepen their personal commitment to life style changes that could minimize major medical problems in the future.

    And having to pay out of pocket will fuel individuals to be financially motivated to make more cost effective choices — for example, to take time to shop to find the lowest priced CT scan and request generic rather than brand name medications.

    But one risk is that higher levels of cost sharing will lead individuals to forgo needed care, and end up with increased medical problems and long-term cost. This bears watching.

    5. They Will Increase Health Insurance Options And Competition Over Price

    We can expect increased competition to lead to lower pricing.

    The number of programs available through most public exchanges today, already quite large, is projected to increase significantly in the future.

    And thanks to the pooling of risk and reduced transactional costs, participating plans should be able to further restrain their prices.

    Previously, many individuals working for a small business were given only one choice. Offering more options was too expensive.

    The Small Business Health Options Program (SHOP) in the ACA is an important step forward, especially the provision that enables employees to choose coverage among competing plans. Unfortunately, SHOP is being implemented slowly.

    But with momentum, more businesses will move to exchanges, individuals will have more choice and plans will be forced to provide higher value if they want to attract new enrollees.”

    Kiara J Stonestreet's curator insight, April 23, 1:56 AM
    The affordable health care act has changed our health care system.!

    U.S. deciding whether to extend Obamacare enrollment

    U.S. deciding whether to extend Obamacare enrollment | Healthcare and Technology news |

    Americans who have started enrolling for health insurance under the Affordable Care Act can still sign up, and the U.S. government is weighing whether to open a special enrollment period for those who missed Sunday's deadline, the health secretary said on Wednesday.

    So far, 11.4 million Americans have enrolled in private health insurance through the health reform law known as Obamacare during the open enrollment period that ended on Sunday, according to the White House.

    The Affordable Care Act requires most Americans to have health insurance or face a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns in coming weeks.


    HHS will decide within the next two weeks whether to allow another special enrollment period for consumers, Health and Human Services Secretary Sylvia Burwell told reporters in response to a question about those consumers amid the looming April 15 tax-filing deadline.

    “We’re going to analyze it, we’re going to think about it, and we’ll be back. And we will be back quickly on it," she said at a news conference.

    Separately, Burwell said fewer than 150,000 people were "in line" as of Sunday to get health insurance coverage through the marketplace set up by the Affordable Care Act. They will have until Feb. 22 to complete their application, she said.

    Those applicants were in communication with the telephone call center for the federal exchange marketplace but could not complete their application before Sunday's deadline, according to HHS. They do not include people who had technical issues with the website that prevented them from completing their enrollment, the department said.

    Kiara J Stonestreet's curator insight, April 23, 1:59 AM
    It's 2020 and I am still not updated about that, but I'm pretty sure it ended.