A Blueprint for Consumer Engagement in Dual Eligible Demonstrations

May 23rd, 2013

Building anything new is tough. That’s why we turn to blueprints and experts.

The same principle applies to the federal demonstration projects for people eligible for Medicaid and Medicare (dual eligibles) that are under construction in more than 20 states across the country. These projects are building complex new systems of care for millions of the most vulnerable people in the nation that are supposed to combine services paid for by both Medicaid and Medicare into a coherent, coordinated program. Fortunately, the federal government is supplying sketches for the states to work from, and requiring states to consult the experts – in this case, the consumers who will be served.

But to help these projects succeed, the states and the delivery systems that will operate these projects need a detailed blueprint for how best to engage those consumer experts. Today, Community Catalyst is supplying that blueprint, A Seat at the Table: Consumer Engagement Strategies Essential to the Success of State Dual Eligible Demonstration Projects, drawing on engagement that’s working elsewhere.

The blueprint starts with the federal requirement already in place that each state establish a plan for meaningful consumer input in the demonstrations. Then, it adds structures at the federal, state, delivery system and community levels to ensure consumers and their family members are at the decision-making tables, shaping the projects, and helping to fix flaws before they can undermine the whole enterprise.

Key elements of the blueprint:

  • • Detailed state plan for consumer engagement in formal oversight, planning and monitoring of everything from enrollment practices to provider networks to quality improvement. This includes broad consumer membership on statewide oversight councils and workgroups, requirements for managed care companies (MCOs) and managed fee-for-service delivery systems to implement engagement strategies, and established timetables and mechanisms for collecting feedback from individual consumers
  • • MCO and delivery system inclusion of consumers on their governing boards or establishment of consumer advisory committees
  • • State measurement of the effectiveness of consumer engagement as part of quality assurance and adjustment of both the engagement plan and implementation as needed. Measures might include program changes resulting from consumer engagement, the number of consumers engaged at each stage and each level, and the degree to which those involved reflect the diversity of the demonstration population
  • • Federal funds made available to states for consumer engagement activities
  • • Training for consumers to help them be effective in these roles
  • • Stipends for consumer time and travel to participate
  • • All consumer engagement conducted in a manner fully accessible to those with disabilities, and linguistically and culturally competent
  • • Consumer membership on oversight or advisory committees that reflects the diversity of participants in the demonstration projects
  • • CMS oversight to ensure follow-through

More details and examples are included in the full blueprint. In addition, other resources on consumer engagement in delivery systems are available in a separate Community Catalyst report. To fully build this out will require federal and state policymakers, MCOs, delivery systems and consumers working together. Advocates can help by urging full adoption of the blueprint.

– Alice Dembner, Project Director

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New Polling Shows Strong Support for Expanding Medicaid in the Deep South

May 22nd, 2013

This week advocates in the South received yet another good reason to push for expanding Medicaid in their states. A new poll from the Joint Center for Political and Economic Studies found that residents in five of the most conservative states in the nation strongly support expanding Medicaid and implementing the core pieces of the Affordable Care Act. Residents in the deep Southern states of Alabama, Georgia, Louisiana, Mississippi, and South Carolina not only support expansion overall, but the support spans across racial lines.  This evidence of strong support among the very people they serve should be a clarion call for Southern state lawmakers to expand Medicaid.

The Joint Center conducted a poll of 2,500 Southern residents between March and April of this year to examine how the public in conservative states view key parts of the Affordable Care Act generally and the Medicaid expansion specifically. Among the findings:

  • • 62 percent support Medicaid expansion
  • • 75 percent support the creation of health insurance Exchanges
  • • Nearly 69 percent support financial help (premium subsidies) for low-income individuals
  • • Expansion draws support across all ethnic groups

There are nearly 15 million uninsured people in the South – the highest number and proportion of any region of the country. Expanding state Medicaid programs will provide insurance coverage to 7 million people, greatly improving the health and productivity of Southern residents. This dramatic increase in health care coverage through Medicaid will also address health disparities in reducing death and disease among nonelderly adults, racial and ethnic minorities, and residents of low-income areas. With the federal government covering the full cost of expansion for the first three years, expanding Medicaid will also be a great economic benefit to states. This should be a no brainer for the South.

But even with these clear cut health and economic benefits, nine Southern governors stand in opposition to accepting federal funding for expansion – with only, Arkansas, Kentucky, and Florida in favor. And even in Southern states with a supportive governor, challenges remain, especially when it comes to persuading state legislators.

The voices of their constituents should serve as a powerful motivator for policymakers who say they are representing the will of the people. The case for expanding Medicaid is clear. And advocates in the South will add this strong evidence of support to their efforts to mobilize and engage key constituencies. State policymakers have a responsibility to not just speak into their own megaphones but to listen to the voices in the crowd. These poll findings clearly show that the will of the people is to expand Medicaid in states across the Deep South.

Ongoing debates during the 2013 legislative sessions showed signs that even within the most conservative states expanding Medicaid was not completely off the table. Statements from Governor Bentley (AL) that Medicaid will not be expanded “as it exists under the current structure,” suggest that expansion remains possible. In addition, a number of governors and legislators are considering alternative models such as Arkansas’ premium assistance model to expand Medicaid.

As these poll results show, and to borrow from Mark Twain, reports of the demise of Medicaid expansion in the South have been greatly exaggerated. For economic, political, and moral reasons, expanding Medicaid is a top priority for advocates in the Southern states. At Community Catalyst, we will continue to lift up and promote all the reasons why Southern states should move forward with expanding Medicaid and implementing the Affordable Care Act. Advocates will discuss their Medicaid expansion campaign strategies at the 6th Annual Southern Health Partners convening in Atlanta, Georgia this July. There is no doubt the findings of this report will be an integral part of the conversation.

– Dara Taylor, Project Director
Southern Health Partners

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New Resources to Find Affordable Medications

May 16th, 2013

As patients and consumers, we face more and more choices about our health care each year.

We all support consumer empowerment in decisions about their care, but consumers don’t always have all the information they need to choose between different prescription drugs.

And the billions of dollars that the drug industry spends on advertising to patients and doctors is designed to make things worse. Industry advertises expensive new drugs, but not equally effective and lower-cost alternatives.

But trends are changing. State laws promoting the use of generic medications have saved consumers hundreds of billions of dollars. Employers are educating their employees to emphasize value — getting an equally effective drug that costs one-tenth as much as a brand-name option. For example, skipping the $200-a-month Nexium, and choosing Prilosec — made by the same manufacturer with the same active ingredient — for just $27.

Whether you or your organization’s members are uninsured, have high copays, or just want to be sure to get the best value for their health care dollar, these resources can help advocates, doctors, and patients make better choices for their health – and their wallets.

The Truth About Generics – safe and affordable

Generics are as safe and effective as their brand-name counterparts, but can cost 90 percent less. Go here to see why generic drugs are an affordable option used by nearly all patients.

New Generic Drugs Coming this year, and next!

Is your drug going generic soon? Dozens of expensive brand-name drugs like Cipro and Provigil have become generic, and their prices are dropping… Generic Plavix costs less than $15 even without insurance. See this year and next year’s newest generic drugs.

Uninsured? Here are some ultra-low cost options

Go here to see why, and see how you can find hundreds of drugs for $4 or $5 — many of the same drugs that you may be taking now, available at a lower cost. And learn why drug costs can vary so much from pharmacy to pharmacy.

If an expensive brand name drug is your only option, and you meet other insurance and income qualifications, a local hospital or community health center may be able to help you find low cost medicines. Find out more here.

Is that drug coupon a good thing? Maybe not!

Did you find a coupon by a drug manufacturer online? You should think twice about using it to make Nexium or some other drug more affordable. Read this to see how these coupons can actually turn over your personal private health information to the drug company, and cost you more in the long run. If you have drug coverage through Medicare or Medicaid, using a manufacturer coupon is prohibited by federal law.

Please help us share these resources!

These consumer resources were created through the generous support of the California HealthCare Foundation, and are intended to be shared freely with the public, including on other organization’s websites.

Please contact us at wwilkinson(at)communitycatalyst.org if we can help you share these resources with your members, assist you posting them on your website, or if you want to host a guest blog on ways to find affordable medications.

– Wells Wilkinson,  Project Director
Prescription Access Litigation

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Did Issuers Get a Free Pass on the Inclusion of Essential Community Provider Requirements?

May 6th, 2013

The Affordable Care Act requires qualified health plans participating in health insurance marketplaces (aka Exchanges) to maintain a sufficient number of Essential Community Providers (ECP) in their provider network. ECPs are safety-net providers within the following categories: federally qualified health centers, family planning clinics, Ryan White HIV/AIDS centers, American Indian health providers, public or non-profit hospitals, and others such as mental health and substance abuse providers and STD Clinics. They are the ‘essential’ and trusted source of primary care for poor and low-income communities with the greatest health needs. Many of them work to reduce health disparities as well as provide culturally and linguistically competent services.

“A remarkably generous policy”

Earlier this month, the Department of Health and Human Services (HHS) released its final Letter to Issuers on Federally-Facilitated and State Partnership Exchanges. This letter provides directions to insurers that want to participate in the Federally-Facilitated Exchanges. Compared to the draft version published for comments on March 1, this letter establishes much weaker standards for the inclusion of ECPs—essentially giving a free pass for insurers to sidestep building a robust network of providers for populations at risk.

According to the final letter, there are two levels of standards issuers need to meet. The ‘safe harbor’ standard is granted to participating health plans that contract with at least 20 percent of all ECPs in each county in the area the plans serve, meaning all available American Indian health providers and at least one ECP in each category mentioned above. In cases where a health plan fails to meet the safe harbor standard, an even less demanding option exists. In this instance, at the minimum the plan needs only to contract with 10 percent of these providers as long as it can present a justification as to how low-income and underserved communities can access needed care under its approach.

In addition, despite the low bar, HHS continues to offer further flexibility. While the draft letter suggested that health plans would not likely be certified if they did not meet the minimum expectation, the final letter suggests otherwise. Instead, HHS promises to “take into account factors and circumstances” in evaluating compliance. This suggests health plans are allowed to go below the 10 percent minimum expectation.

What can advocates do?

Advocate for a higher minimum standard to at least 50 percent

The safe harbor standard and the minimum expectation plainly fail to ensure reasonable and timely access to a broad range of providers for low-income, medically underserved individuals, and could prevent vulnerable individuals from getting adequate care. In a geographically large rural county, one health center located in one corner of the county may not be accessible for those who reside in the other side of the county. Therefore, a more rigorous minimum standard of at least 50 percent is needed. The Connecticut Health Insurance Exchange requires qualified health plans to contract with at least 75 percent of the essential community providers in any county and at least 90 percent of the federally qualified health centers or “look-alike” health centers in the state. In addition to the 50 percent rule, it is important to include specific criteria on enrollee to provider ratios, travel time and distance to providers.

Help safety-net providers build relationships and start the negotiation process with issuers

Safety-net providers are not automatically included in qualified health plans’ provider networks. Recently, the Center for Consumer Information and Insurance Oversight (CCIIO) published a list of essential community providers. As stated in the notification letter, the list does not include all eligible providers and will not be updated prior to 2014. A starting point is to review the list to identify any missing qualified ECPs. The next is to work with state insurance commissioners and other state officials to help build relationships and begin the negotiation process between safety net providers and qualified health plans. In Maryland, the Maryland Health Benefit Exchange, along with the Maryland Community Health Resource Commission and the Maryland Department of Health and Mental Hygiene will host several regional “Meet and Greet” sessions to help safety-net providers and qualified health plans begin discussions on contracting.

 – Quynh Chi Nguyen, Program and Policy Associate

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New Study Builds Case for Expanding Medicaid

May 3rd, 2013

A new study in the New England Journal of Medicine confirms what consumer health advocates have known for decades: Medicaid is essential for keeping low-income households on stable financial footing. This should come as no surprise, since protecting families from unexpected and devastating medical costs is exactly what health insurance is meant to do. The study also proves that Medicaid coverage significantly improves beneficiaries’ mental health.

But opponents of Medicaid have distorted the study’s results; they claim it supports their agenda to block millions of low-income, uninsured families from accessing this vital coverage program. Their arguments are misinformed at best. The new study only strengthens the case for expanding Medicaid.

What the study tells us: Medicaid Works!

The researchers looked at the health and finances of low-income, uninsured Oregon residents who were given the opportunity to enroll in Medicaid through a one-time lottery, and compared it to their peers who remained uninsured.

The study shows that Medicaid virtually eliminated all catastrophic medical expenditures (medical expenses exceeding 30 percent of household income) for its beneficiaries. It also indicates that people with Medicaid coverage are significantly less likely to face any medical debt, borrow money to pay bills, or skip payments.

These results are extremely promising, especially in light of the fact that medical bills currently prompt more than 60 percent of U.S. bankruptcies. If we want to reduce the drag bankruptcies create on our economy and the ruin they leave behind in our communities, providing low-income families with Medicaid coverage is a good place to start.

The study also found that Medicaid is a powerful tool in combating mental illness. Medicaid beneficiaries in the study were 30 percent less likely to suffer from depression than those who remained uninsured. Given that suicide takes more lives in the US than any other form of injury and that depression accounts for more than $83 billion in the US between lost productivity and medical expenses, the impact of Medicaid on depression deserves attention and celebration.

File Under: Non sequitur

Instead of celebrating, opponents of Medicaid are arguing this study makes the case for withholding Medicaid coverage from millions of low-income, uninsured families. They base this on the study’s failure to detect statistically significant improvements in a handful chronic disease measures — blood pressure, cholesterol, or hemoglobin levels — in those with Medicaid compared to those without coverage.

That’s like saying because your blood pressure didn’t go down, we are going to prevent you from getting coverage for cancer treatment or a pap smear.

It’s certainly true that the U.S. health care system needs to be better at managing chronic conditions. We routinely lag behind other industrialized nations on measures of chronic care management, such as following medical guidelines for treating hypertension and diabetes. Plus, this study only looks at the impact of two years of coverage; significant improvements in these persistent chronic illnesses may take much longer to materialize.

This is hardly a reason to block millions of low-income families from gaining health coverage they need and deserve. We have no evidence that people with private insurance or Medicare fare any better than Medicaid beneficiaries on these measures, yet no one is suggesting we should all drop our health insurance.

Getting people covered is the first step in creating an effective health care system that works for everyone, but it is not the only step. The ACA contains numerous initiatives to improve the quality of health care.

File under: extremely relevant

Meanwhile, dozens of states are still trying to decide whether or not to take up the option to extend Medicaid coverage to millions of low-income, uninsured adults. This study confirms Medicaid can give beneficiaries peace of mind that they won’t go bankrupt when they experience that unexpected illness, and make staggering improvements in their mental health. It adds to the growing list of reasons why this decision should be a no-brainer for all 50 states.

–Katherine Howitt, Senior Policy Analyst

 

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White House: Ending Pay-for-Delay Pharma Deals Would Save Americans $11 Billion

April 29th, 2013

Earlier this month, the White House released its proposed budget for Fiscal Year 2014. While the White House’s budget plan includes some Medicare benefit cuts, such as raising premiums for Part B and Part D, it includes some policy proposals to help lower drug costs for consumers and the government that we at Community Catalyst support, including a ban on “pay-for-delay” deals between brand-name and generic pharmaceutical companies. Obama’s April 10 proposal, “Reducing the Deficit in a Smart and Balanced Way”, reasons that restricting pay-for-delay agreements would “increase the availability of generic drugs and biologics” and deliver $11 billion in savings to federal health programs over the next 10 years.

Pay-for-delay settlements are agreements in which the brand name drugmaker pays a generic company to delay bringing a generic drug to market. A ban on these agreements would improve patient access to affordable, generic versions of necessary pharmaceuticals while lowering health care costs. Federal Trade Commission Chairman Jon Leibowitz praises proposals to ban pay-for-delay deals, noting they would “reduce the deficit by billions of dollars without raising taxes or cutting critical programs.”

Despite this fiscal wisdom, all of the House and Senate bills proposed to stop this anticompetitive behavior have failed. If Obama’s 2014 budget proposal is enacted, it will bolster the FTC’s ability to investigate and intervene in these companies’ shady back-room dealings. We hope that would inspire Congress to finally pass the Preserve Access to Affordable Generics Act, putting a stop to these deals, once and for all.

While the White House budget doesn’t address how to reimburse the billions of dollars that have already been unfairly taken from consumers and taxpayers, it serves as a symbolic victory highlighting the Administration’s awareness that pay-for-delay deals cost us all, whether as consumers or as tax payers. A case about the legality of pay-for-delay is pending before the Supreme Court (as we have discussed here), with a decision expected by June. Whether Congress, the Administration or the Supreme Court does it, it’s now abundantly clear that our government must take action to stop these deals. As Arthur and Zachary Kaplan explain in their CNN opinion post, “the right prescription for making medicines cheaper and better is to encourage competition, not stifle it with backroom deals where everyone gets a great deal except for the patients.”

Additionally, the Administration recommends reforms to save another $3 billion, by preventing companies from making small changes in a biologic drug and using them to delay competing versions (often called ‘evergreening’) and by making it possible for companies to begin making “biosimilar” (generic) versions of these very expensive biologic drugs five years earlier.

Overall the Administration’s prescription drug recommendations emphasize the importance of ensuring prescription are more affordable for consumers. We at Community Catalyst are glad to see these vital proposals recommended and are hopeful they will be enacted to benefit consumers.

– Khadijah M. Britton, Program and Policy Associate
Prescription Access and Quality Project

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The “Rate Shock” Myth

April 26th, 2013

As Affordable Care Act opponents continue grasping at straws to find fault with the law, an assertion perpetuated by the insurance industry that the ACA’s coverage expansions will significantly increase premiums has gained prominence. Lately, many insurance industry-funded studies and the resulting news coverage of them have focused on the potential for “rate shock” for the young and healthy, fear mongering young adults and others into thinking their rates will skyrocket come 2014. None of these reports address all of the protections written into the bill to prevent steep rate changes and many fail to accurately represent the true scope of benefits and costs. Community Catalyst has prepared this fact sheet to help cut through some of the confusing arguments swirling around.

Very few people will be affected by significant rate changes. To give a sense of how small this number is, more than half of employed 19-44 year-olds were covered through their employers. Of those who are not offered insurance through an employer, 92 percent of young adults expected to enroll in individual plans with subsidies through the Exchanges would not be subject to premium increases. This is not to say that nobody will experience rate changes, but it is important to understand the relative impact of increases and the small number of people affected.

Rate changes will primarily impact young men between the ages of 19-27, who have incomes higher than 400 percent of the federal poverty level (more than $45 thousand per year) and are not covered through their employers. And even these individuals will only experience moderate changes – on average an increase of 10-13 percent compared to current non-group rates, according to the Congressional Budget Office.

Most importantly, the ACA means everyone will gain increased value per health care dollar through better benefit packages and limits on how much patients can pay out-of-pocket. New plans will be required to meet certain standards of benefits, including covering maternity, mental health, prescription drug coverage, and charging no co-pay or deductible for preventive services including cancer screenings and contraception. These new standard benefits ensure that consumers will get greater value and better protections than many plans currently provide. Young adults will also have the option of enrolling in a catastrophic coverage plan that covers the same benefits but offers lower premiums with a higher deductible.

The law also makes the system fairer across gender and age groups. Currently, insurers commonly charge women more than men, simply because they have the potential to incur more costs through maternity care. This unfair practice costs women in the private market approximately $1 billion per year, but is outlawed under the ACA starting in 2014. Similarly, insurers are allowed to charge older adults significantly higher rates. The ACA places limits on this practice so older adults can only be charged a maximum of three times as much as younger adults. This change reflects a more accurate approximation of the health cost differences between young and old, correcting years of overcharging adults for their health care services. Finally, the ACA ends discrimination against those who have preexisting conditions. This is not irrelevant for young adults, since 16 percent of 16-24 year olds have preexisting conditions and either are unable to gain coverage or are pay higher rates because of their medical history.

When it all shakes out, the benefits of the ACA for young adults far outweigh any costs. The impact of premium changes will be limited, will help make the health insurance system fairer, and will ensure consumers get more bang for their buck.

– Sarah Gordon, Private Insurance Team Intern

 

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Cross Post: Potential Costs and Challenges in Boston

April 24th, 2013

This blog was originally posted on CHIRblog.

With much of the country still reeling from the Boston marathon bombings, many of the victims – as well as their families and friends – have already begun the long road to recovery. With estimates that total medical costs could be as high as $9 million, there have been widespread reports of funds being established for individuals (here, here, and here, to name a few). And Governor Deval Patrick and Boston Mayor Thomas Menino established The One Fund Boston to help cover medical and other costs that raised more than $7 million in 24 hours, with contributions from the Boston Celtics, the Boston Red Sox, and Bain Capital, among others. (For ways to help, USA Today published this helpful guide.) With this outpouring of support from family, friends, and strangers, we’ve begun to consider some of the costs and challenges that the victims might face in obtaining the care they need to recover.

What kind of costs are we talking about? Given that Massachusetts has the highest insured rate in the country, many local victims are likely to have private or public coverage. For those that are covered, many will turn to this coverage for their medical expenses. However, even with private coverage in Massachusetts or another state, victims could face significant costs for their care. Although coverage may vary (and individuals should review their policies to understand the extent of their coverage), here are some of the potential costs worth considering:

Coverage Limits. Some plans have limits on the amount or type of coverage you can receive. Although the Affordable Care Act prohibited lifetime dollar limits on essential health benefits (such as ambulatory patient services, emergency services, hospitalization, prescription drugs, mental health, and rehabilitative services and devices), consumers might face costs because plans can 1) impose other restrictions, such as a limit on the number of visits for physical and occupational therapy; or 2) vary in the ways they define these categories so that a benefit that seems to fall within one category might not be clearly covered. Further, while the Affordable Care Act prohibited annual dollar limits on essential health benefits in 2010, some insurers received a waiver to maintain an annual dollar limit (currently, $2 million annually) until 2014. If a victim has this type of coverage, they could face high out-of-pocket costs depending on their medical condition.

In addition, some plans might not cover certain benefits at all, which places the burden on the consumer to pay for the service or benefit. Health insurance policies may, for example, exclude coverage for making changes to a victim’s home, such as installing a wheelchair ramp or safety grab bars. What’s more, health insurance policies may specifically exclude coverage for “acts of war” or “terrorism,” which – depending on how these terms are interpreted – raises the possibility that victims might not be covered. (In response to the attacks on September 11, 2001, the National Association of Insurance Commissioners (NAIC) considered whether it was appropriate to allow exclusionary language for acts of terrorism in health insurance policies (in addition to other lines of insurance) and adopted a policy statement concluding that “terrorism exclusions are not necessary for individual life and health products, and are generally not necessary to maintain a competitive market for group life and health products.” Many states, such as Kansas and North Carolina, issued subsequent guidance to insurers stating that they would disapprove exclusions for terrorism unless an insurer could show that it would face insolvency without the exclusion. It is unclear how many states currently prohibit exclusions for terrorism. For more on the coverage of terrorism-related events, see this GAO report and this NAIC resource list.)

Finally, those without comprehensive medical care – such as a limited benefit policy or drug discount plan – could find that they face significant out-of-pocket costs because their plan covers less than expected. Such policies are not regulated in the same way as comprehensive health insurance coverage and include far fewer protections to ensure that consumer needs are adequately met in the event of catastrophic need.

Cost-sharing Limits. Depending on the type of plan that a victim has, they may face out-of-pocket costs associated with their care. Most types of comprehensive health coverage include a deductible, an out-of-pocket maximum, and coinsurance requirements. If a consumer’s costs exceed the deductible and the out-of-pocket maximum for covered benefits and services, the insurer will typically pay for the remaining services. However, not all benefits or services may apply towards a deductible or out-of-pocket maximum; some plans might exclude mental health or prescription drug coverage from this amount, leaving the consumer to pay these additional costs. Other plans may place cost-sharing requirements on durable medical equipment, such as artificial limbs, that require the consumer to pay 20 percent of the cost of the equipment even after a deductible is met. Still others might be enrolled in high-deductible plans, which have become popular among employers in recent years, and require a consumer to pay out thousands of dollars before the insurer covers the costs.

Out-of-Network Care. Victims, particularly those from outside of Massachusetts, may face additional costs because they are receiving care outside of their typical provider network. If, for example, an individual lives in a different state and has coverage through an HMO or PPO, her insurer is likely to have a provider network based in her state that contracts with the insurer to provide services. But, outside of this established network of providers, most states allow consumers to be penalized – in the form of higher cost-sharing – by using an out-of-network provider, such as perhaps Brigham and Women’s Hospital in Boston. Even where state law requires an insurer to help cover the costs of coverage for out-of-network care, very few restrict the practice of balance billing (where a provider, such as a physician or hospital, seeks to collect from the patient any difference between the charges billed for a service and the amount that the insurer paid on that claim).

What could help? Given the outpouring of support for the victims, one would hope that at least their initial medical costs – such as hospitalization, prosthetic limbs, and out-of-pocket costs for other immediate needs – will be taken care of. Victims or their families should check with their insurer to understand what services are covered, how much the individual will face in out-of-pocket costs, and whether there are certain coverage exclusions. And, for the uninsured, hospitals might provide free or discounted services to those injured. Beyond these initial costs, however, there will be a critical need to ensure that the victim’s continuing needs – such as rehabilitative services and mental health treatment – are met.

One thing is certain – we will continue to reflect on the Boston Marathon bombing and what it means for our society to be faced with senseless violence perpetrated by others. As health policy professionals, we naturally turn to assessing our health care system’s ability to respond to the needs of the victims, including the level of public health preparedness and access to life-saving care and rehabilitative services. While we do not yet know all of the costs that the victims will face on the road to full recovery, it will be important to understand whether they have access to the services they need without significant financial hardship.

– Katie Keith, Assistance Research Professor and Project Director
The Center on Health Insurance Reforms
Georgetown University Health Policy Institute

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From the Feds Down to the States: Using Navigators to Promote Health Equity

April 23rd, 2013

HHS recently released the cooperative agreement funding opportunity for organizations interested in serving as Navigators in states with a Partnership or Federally Facilitated Exchange. Navigators, designed to assist individuals and families by identifying and explaining the insurance coverage options in the Exchange, can be social service organizations, consumer health advocates, community-based organizations, as well as a host of other entities that undergo specific training.

HHS requires at least one Navigator in each state to be a community and consumer-focused non-profit, opening up the possibility of advancing some of the key elements of the ACA that aim to reduce health disparities. Navigators will be on the ground in communities enrolling people in coverage and educating community members about their health insurance options. This role gives Navigators the ability to advance health equity as they are on the ground recognizing and responding to the economic and social barriers many face in accessing quality health care.

We’re heartened to see that the cooperative agreement proposal includes several elements that make health equity a clear priority. These include the requirements that those applying to serve as Navigators must be capable of:

  • • addressing the needs of underserved and vulnerable populations, such as rural populations and individuals with limited English proficiency
  • • conducting public education activities to raise awareness about Exchanges
  • • providing information and services in a fair, accurate, and impartial manner
  • • providing referrals to any consumer assistance or ombudsman program to address consumer grievances, complaints, or questions about their health plan, coverage, or a determination
  • • providing information in a manner that is culturally and linguistically appropriate to diverse communities and accessible to individuals with disabilities

Additionally, HHS recently issued a proposed rule that would establish standards to provide culturally and linguistically appropriate services and help that is meaningfully accessible to persons with disabilities, for all Navigators serving consumers in Federally Facilitated and Partnership Exchanges.

While we know that enrollment will be an ongoing process, requiring a true “all hands on deck” approach, these guidelines are an encouraging start. Moreover, while $54 million is not enough to execute a comprehensive education, outreach, and enrollment strategy in the 34 states eligible to apply for the funding, it’s a good starting point. This funding provides a strong opportunity for state advocates to leverage federal dollars with local and regional funders committed to reducing health disparities.

The amounts available to each Partnership and Federally Facilitated Exchange state for the Navigator program can be found here, but it is worth noting that those states with higher numbers of uninsured people, and many states with higher total populations of low-income communities and people of color, have been allocated higher funding levels. While the minimum amount any state may receive from the funding is $600,000, those states with greater uninsured populations can receive more funding, helping ensure that those with greater systemic disadvantages have more support to enroll in health insurance. We checked out these breakdowns according to 2010 Census data and matched against Kaiser’s tracking of a state’s total uninsured.

Given that these proposals are due by June 1, now is the time for consumer health advocates and smaller community-based organizations to coordinate. Organizations that work with targeted groups are more trusted and better able to engage with particular constituencies, making this proposal an opportunity for collaboration and true impact. For those consumer health advocates looking to partner with other groups on the proposal, consider regional or even local organizations outside of the health world that already provide social services. For smaller community-based organizations, identify your region’s or state’s consumer health advocacy organization and plug into their efforts to assist in outreach, education, and enrollment. Even if you haven’t yet been involved, uninsured people in your community need your help now!

Finally, if you and your organization are interested in learning the basics of federal grants and federal grant writing, join The Office of Minority Health Resource Center (OMHRC) on April 25, 2013 for a Capacity Building Webinar, Technical Assistance: Foundations of Grant Writing. RSVP online to ensure you can join the webinar.

– Emily Polak, State Advocacy Manager

 

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The Fine Print

April 16th, 2013

Building new ways of delivering care to the millions of older adults and people with disabilities who are eligible for both Medicare and Medicaid (dual eligibles) is a daunting task. There is much work to be done – from building appropriate provider networks, to assessing the needs of enrollees, to creating a robust set of appeals and grievances procedures. To facilitate the development of new delivery systems the Centers for Medicare and Medicaid Services (CMS) designed its “Financial Alignment Demonstrations,” which offer states two options for financing demonstration projects aimed at better integrating care for dual eligibles. Most of the 20-plus states participating in the demonstration chose the “fully capitated” option that would turn over responsibility for care to managed care plans. Under capitation, a health plan receives a flat fee for each person in exchange for providing all the medical and support services the person needs. However, the learning curve may be steep for plans with little to no experience in creating integrated systems of care around members with very high needs. Having a good payment system will be critical to ensuring high quality care for beneficiaries.

To date, four states—Illinois, Massachusetts, Ohio and California—have signed agreements with CMS to use this financing option. While the financing proposals differ in each state, there’s one big problem: the financing structures are weak across the board. We recently explored how the weak structures in Massachusetts, Ohio and Illinois could spell trouble for plan members, especially those with the most complex needs. The method for setting Medicaid rates does not account for members’ varied needs for non-medical supportive services like personal care attendants and home health care. Overall capitated financing unwisely puts health plans at too much financial risk, which increases the danger of beneficiaries not getting the care and support they need. Other provisions that reduce the capitation rates only increase this risk.

The newest agreement with California perpetuates the problematic financing. California’s intricate financing structure appears to offer an improvement over those in the other three states. However, a closer read of the complicated fine print shows similar weaknesses in the overall approach. The financing proposal does not adequately take into account the needs of the most complex beneficiaries, and savings expectations are unreasonably high. Risk sharing between the plans and Medicare and Medicaid is insufficient, effectively not protecting enrollees from the potential affect losses would have on plans and their obligation to provide essential medical and support services.

Advocates in California point out that these expectations do not bode well for members, coming on the heels of recent cuts to Medicaid provider rates and consumer-directed services. The agreement between California and CMS fails to shelter plans from serious losses, raising the risk of underservice. On the other hand, there are almost no limits on the profits plans could make.

We have a simple solution for the federal and the state government: require that every financial alignment demonstration that uses the capitated model incorporate “the three R’s”—risk adjustment, reinsurance and risk sharing, described in more detail below.

Risk Adjustment: It’s important the needs of the most complex and high cost beneficiaries are taken into account in setting plan reimbursement rates. Until plans and the federal and state government have more data on beneficiaries’ functional status, states should use individual prior cost information to risk adjust payments for dual eligibles enrolled in the demonstrations, especially those with a high need for long-term services and supports.

Reinsurance: Plans should be shielded from large losses for individuals whose annual costs exceed an appropriate threshold, e.g. $100,000.

Risk corridors: Limiting the windfall profits or catastrophic losses of plans will reduce the incentives to avoid or undertreat high-need beneficiaries. During the life of the demonstration, we recommend total risk to each health plan should be limited, so that none will lose or profit by more than 3 percent.

These simple, straightforward approaches—which every plan sold in an Exchange must have—will provide a solid foundation on which to build truly innovative approaches for improving the lives of the millions of dual eligibles enrolled in the demonstrations. And, with the first demonstration slated to launch in less than three months, the time to get the financing fine print right is rapidly running out.

– Renée Markus Hodin, Director, Integrated Care Advocacy Project

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