Kaiser Health News provides a fresh take on health policy developments with "Going Viral?" by John Cole.
And here's today's health policy haiku:
GILEAD TO BOOST PRICE OF NEW HEPATITS C DRUG
The new Hep-C drug?
Gilead, not Galahad
Son of Cost-a-Lot
If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.
The following is a guest post by Janice Hyde, director of the Global Legal Collection Directorate at the Law Library of Congress.
The Law Library of Congress has always relied on primary sources of law wherever possible to respond to requests from the U.S. Congress and its other patrons. For foreign countries, the fundamental source of law is generally the official gazette and the Law Library has amassed a voluminous collection of gazettes since acquiring its first one, from Mexico, in the mid-nineteenth century. Although many countries now make their official gazettes available online, making use of these sources over the years has proved challenging since many of them lack indexes. To solve this problem, beginning in the 1950s in what was then the Hispanic Law Division of the Law Library, foreign law specialists began to create their own indexes to the content of the gazettes for twenty Spanish-and Portuguese-speaking countries of Latin America and the Caribbean. (One French-speaking Caribbean nation, Haiti, was also included.) Attorneys created brief descriptive summaries of the legal instruments that were typed up on 3″ X 5″ index cards along with basic information about the publication source. To access this information quickly, the indexers also included subject terms on the cards which were then filed alphabetically by subject.
The cards were accumulated into folios that were published in eight volumes as the Index to Latin American Legislation, covering the period of 1950-1975. For nearly three decades, these “red books” served as the primary means for locating pre-1976 laws from the twenty Latin American and Caribbean countries. From 2004-2007, the Law Library undertook a project to enter data from the index into an online system known as GLIN and to digitize the corresponding texts of legal instruments. This effort created a rich resource of primary source historical legal material from Latin America and the Caribbean. Recognizing the value of such information to legal researchers, the Law Library is now providing access through the Law Library’s Guide to Law Online to many of these older legal materials as well as additional laws from gazettes provided by other countries that are in the public domain. The archived information includes English language summaries of laws, regulations, and related legal instruments that in turn link to the full-text PDFs that are in the official language(s) of the country. Legal items from the gazettes of the following countries are now available under the “Legislative” sources list for each jurisdiction: Brazil, Canada, Democratic Republic of Congo, Costa Rica, El Salvador, Guatemala, Honduras, Haiti, Republic of Korea, Kuwait, Mexico, Mauritania, Nicaragua, Panama, Paraguay, Peru, Philippines, Portugal, Romania, Spain, Taiwan, Tunisia, and United States.
The archived data makes accessible a small fraction of foreign law materials that may be found in the Law Library’s vast collection. Readers are invited to explore the “Global Legal Collection Highlights” series of blog posts prepared by my colleagues for information on the incomparable range of legal materials found in the Law Library’s collection for various countries.
Today's headlines include reports about the number of people who will lose their new Obamacare insurance because they failed to prove they were U.S. citizens or legal immigrants who were eligible for coverage.
Kaiser Health News: Insuring Your Health: Health Law Tempers New State Coverage Mandates
Kaiser Health News consumer columnist Michelle Andrews reports: “For decades, states have set rules for health coverage through mandates, laws that require insurers to cover specific types of medical care or services. The health law contains provisions aimed at curbing this piecemeal approach to coverage. States, however, continue to pass new mandates, but with a twist: Now they’re adding language to sidestep the health law, making it tougher than ever for consumers to know whether they’re covered or not” (Andrews, 9/16). Read the column.
The New York Times: U.S. To End Coverage Under Health Care Law For Tens Of Thousands
The Obama administration said on Monday that it planned to terminate health insurance for 115,000 people on Oct. 1 because they had failed to prove that they were United States citizens or legal immigrants eligible for coverage under the Affordable Care Act. It also told 363,000 people that they could lose financial aid because their incomes could not be verified (Pear, 9/15).
Los Angeles Times: Many May Lose Obamacare Coverage Because Of Missing Paperwork
Some 115,000 people are poised to be cut from insurance rolls at the end of the month because they haven't verified their citizenship or immigration status. Another 363,000 people haven't sent in the necessary forms proving their income, a key requirement for calculating the size of government subsidies some consumers are eligible to receive under the law. Together, that represents about 10% of those who signed up for coverage on new federal marketplaces created by the law (Levey, 9/15).
The Wall Street Journal: Tens Of Thousands Likely To Lose Health Insurance At End Of September
The government is now set to inform insurers to terminate at the end of the month the coverage those people bought through HealthCare.gov. A provision in the Affordable Care Act bars people living in the U.S. without authorization from obtaining coverage through the site. Federal officials also said they would send notices to about 279,000 people whose income can't be verified, giving them until Sept. 30 to submit further documentation. Those people won't lose their coverage if they don't respond, but the tax credits that offset the cost of their premiums could be suspended (Radnofsky, 9/15).
The Washington Post: 115,000 Immigrants To Lose Health Coverage By Sept. 30 Because Of Lack Of Status Data
Those individuals can still send in the needed information to the federal exchange and if they are found eligible, they will be able to regain coverage, officials said. They will be considered under a special category reserved for people who have experienced a major life change, such as having a baby or getting divorced or losing a job with health insurance. Separately, about 363,000 consumers who have coverage could lose financial subsidies for their insurance premiums unless they clear up information about their incomes that differs from that on federal tax records. If those individuals don’t provide updated income information by Sept. 30, federal health officials will adjust their premiums to “reflect what we have in our records,” said Andy Slavitt, principal deputy administrator at the Centers for Medicare and Medicaid Services, which manages HealthCare.gov, the federal exchange (Sun, 9/15).
USA Today: Feds Give Immigrants More Time On Health Care
About 115,000 of 966,000 people who bought plans on HealthCare.gov and owed more information about their immigration status have unresolved issues, Andy Slavitt, principal deputy administrator at the Centers for Medicare and Medicaid Services, said. These people were given a deadline of Sept. 5 to submit information — they now have until Sept. 30 to provide proof of their citizenship, or they will lose coverage. After that date, those people can reapply if they can prove citizenship even though the open enrollment period is closed. The other 851,000 people either have had their cases resolved, or the cases are in the process of being resolved. Slavitt would not comment on how the resolved cases were decided. "The good news is they have been able to resolve one way or another most of the problem applications where federal databases could not verify income or legal status," says health care consultant Kip Piper, a former state and federal Medicare official (O’Donnell, 9/15).
The New York Times: Number of Americans Without Health Insurance Falls, Survey Shows
Federal researchers reported on Tuesday that the number of Americans without health insurance had declined substantially in the first quarter of this year, the first federal measure of the number of uninsured Americans since the Affordable Care Act extended coverage to millions of people in January. The number of uninsured Americans fell by about 8 percent to 41 million people in the first quarter of this year, compared with 2013, a drop that represented about 3.8 million people and that roughly matched what experts were expecting based on polling by private groups, like Gallup. The survey also measured physical health but found little evidence of change (Tavernise, 9/16).
The Wall Street Journal: Tally Of Uninsured Fell By 3.8 Million In Early 2014
Shortcomings in the data are likely to limit the conclusions that either supporters or critics of the law can draw from it. The survey, based on interview responses for 27,627 people, was carried out from the beginning of January through the end of March, which is when enrollment ended for most consumers. Responses from earlier in the period wouldn't reflect the late surge in enrollment under the law, potentially making the tally of people who gained coverage artificially low (Radnofsky, 9/15).
Politico: Fewer Uninsured, CDC Finds
But the survey does not capture the tidal wave of last minute sign-ups who flooded into the new health insurance exchanges in March. They had signed up — but their coverage didn’t begin until April at the earliest, so their new health insurance won’t show up until the second quarter survey (Norman, 9/16).
The Associated Press: New Questions Over Abortion Coverage In Health Law
A nonpartisan congressional agency is raising new questions about compliance with a key compromise on abortion that allowed the federal health care law to pass in 2010. The Government Accountability Office said in a report released late Monday that only 1 of 18 insurers it reviewed was separately itemizing a charge for coverage of elective abortions on enrollees’ bills (9/15).
Politico: GAO: Obamacare Abortion Rules Widely Ignored
There are widespread instances of Obamacare insurance plans violating the rigid rules surrounding whether customers can use federal health care subsidies on insurance policies that cover abortion procedures, according to a Government Accountability Office investigation. The report, commissioned by House Republican leadership and obtained by POLITICO on Monday night, found that 15 insurers in a sample of 18 are selling Obamacare plans that do not segregate funds to cover abortion (except in cases of rape, incest or the mother’s life) from their Obamacare subsidies (Haberkorn and Everett, 9/15).
Los Angeles Times: California Health Insurance Exchange Unveils Ad Campaign And Outreach
Preparing for the second year of Obamacare enrollment, California unveiled new television ads and handed out $14.6 million to community groups for consumer outreach. The state-run insurance exchange, Covered California, said the new grant funds are in addition to $33.4 million that has already been given to clinics, unions, schools and nonprofit groups helping with enrollment (Terhune, 9/15).
The Wall Street Journal: Humana Unveils $2 Billion Buyback Program
The new plan is slated to run through the end of 2016. About $782 million was remaining under the company's prior authorization after making $118 million in buybacks so far during the third quarter. The move comes after the board initiated a $1 billion buyback plan about five months ago, when it had $569 million left on its previous repurchase program. Humana is considered a key health insurer to watch, as its results are closely tied to Medicare Advantage plans. While membership has grown in the plans--the private-sector version of government insurance for elderly and disabled people--the government has scaled back funding for them, prompting margin concerns for Humana (Calia, 9/16).
The Wall Street Journal: Doctors: Skeptical About Health Law, Optimistic About Future Of Medicine
Doctors are overextended, skeptical of changes wrought by the federal health law, but more optimistic about the future of medicine than they were two years ago, according to a new survey of 20,000 U.S. physicians. Despite many specific complaints, 71% of those polled said they would choose to become doctors again if they were making the choice today, up from 66% two years ago. And 50% would recommend it to their children, compared with 42% in 2012 and 40% in 2008 (Beck, 9/16).
The Wall Street Journal: AMA Urges Overhaul Of Electronic Medical Records
It's no secret that many physicians hate the electronic-medical-records systems they use, saying they are cumbersome, poorly designed and detract from patient care. Amplifying those concerns, the American Medical Association on Tuesday is calling for a major overhaul of EMR systems to make usability and high-quality patient care a higher priority (Beck, 9/16).
The Associated Press: Fla.’s ‘Gray Belt’ A Glimpse At Nation’s Future
In Citrus County, about 70 miles north of Tampa, health care dominates the labor force. Residents prefer to get their news from a newspaper. Strip malls have an unusually high number of hearing aid businesses. The library offers Medicaid planning seminars. Voters turn out in large numbers, albeit often by absentee ballot. Having such a high concentration of elderly citizens has its trade-offs. You get an engaged citizenry with high voter turnout and volunteerism, but also an economy based on low-skill jobs such as health-care aides, retail clerks and food service workers (9/15).
Politico: House GOP: VA Interfered With IG’s Report
Congressional Republicans are accusing the Department of Veterans Affairs of influencing an independent review of whether delayed health care resulted in the deaths of nearly three dozen patients. The VA’s inspector general released a report last month that said investigators could not “conclusively” link the deaths of 40 veterans to long wait times plaguing the agency. That shocked many Republican lawmakers, who say there’s no question that the two issues are connected (French, 9/15).
The New York Times: New York Files An Antitrust Suit Against The Maker Of An Alzheimer’s Drug
New York State’s attorney general filed an antitrust lawsuit on Monday seeking to stop a pharmaceutical company from forcing patients with Alzheimer’s disease to switch to a new version of a widely used drug. The lawsuit contends that the switch is designed to blunt competition from low-priced generic versions of the medication (Pollack, 9/15).
The Associated Press: NY Bid To Halt Alzheimer’s Drug Swap
Attorney General Eric Schneiderman (SHNEYE’-dur-muhn) alleges both anti-trust and state law violations in the federal suit filed Monday in Manhattan against Dublin-based Actavis PLC and New York subsidiary Forest Laboratories (9/15).
Los Angeles Times: California Broadens Autism Therapy Coverage For Children On Medi-Cal
California children enrolled in public healthcare will regain access to an expensive form of autism therapy after the state Monday became the first in the country to comply with new federal guidelines. The therapy, called applied behavior analysis, was at the center of controversy last year when state officials phased out the Healthy Families program, which covered the treatment, and shifted poor children into Medi-Cal, which did not (Megerian, 9/15).
The New York Times: Arizona Republican Official Resigns After Remarks About Medicaid Recipients
The former Arizona lawmaker who sponsored the state’s stringent anti-immigration law resigned as a top state Republican official late Sunday amid criticism for remarks he made supporting mandatory birth control or sterilization for Medicaid recipients (Medina, 9/15).
Politico: Russell Pearce Resigns After Birth Control Remarks
Former Arizona state Sen. Russell Pearce resigned from his post as vice chairman of the state’s Republican Party following recent controversial remarks about Medicaid, suggesting women be required to use birth control. However he pointed blame at media. “Recently on my radio show there was a discussion about the abuses to our welfare system. I shared comments written by someone else and failed to attribute them to the author. This was a mistake. This mistake has been taken by the media and the left and used to hurt our Republican candidates,” Pearce said in a statement in which he announced his resignation, published by the Arizona GOP on Sunday (McCalmont, 9/15).
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Recently, domestic violence has been in the news because of the release of a video showing Ray Rice, former running back for the Ravens, assaulting his fiancée in an elevator. A national debate on the subject of intimate partner violence has ensued. David Kocieniewski has made an attempt to put the case in perspective regarding how the criminal justice system treats the crime in his New York Times article, “Ray Rice Case Draws Attention to a Crime Often Obscured.”
The Mass. Trial Court Law Libraries webpage, “MassachusettsLaw About Domestic Violence” is a rich source of links to both information about the law itself and help for victims and survivors of domestic violence.
For decades, states have set rules for health coverage through mandates, laws that require insurers to cover specific types of medical care or services. The health law contains provisions aimed at curbing this piecemeal approach to coverage. States, however, continue to pass new mandates, but with a twist: Now they’re adding language to sidestep the health law, making it tougher than ever for consumers to know whether they’re covered or not.
State coverage mandates vary widely. They may require coverage of broad categories of benefits, such as emergency services or maternity care, or of very specific benefits such as autism services, infertility treatment or cleft palate care. Some mandates require that certain types of providers’ services be covered, such as chiropractors. They may apply to all individual and group plans regulated by the state, or they may be more limited.
While patient advocates view state mandates as a crucial tool in their efforts to address coverage shortcomings, the insurance industry generally opposes mandates, saying they drive up the cost of insurance.
Since the health law established a comprehensive set of “essential health benefits” that individual and small group plans must cover (unless they existed prior to passage of the law in 2010), it was hoped that mandates would no longer be much in demand, says Sabrina Corlette, project director at Georgetown University's Center On Health Insurance Reforms.
Mandates are “not the most rational way to build a benefit package,” says Corlette.
To discourage states from passing mandates that go beyond essential health benefits requirements, the law requires states, not insurers, to cover the cost of mandates passed after 2011 that apply to individual and small group plans sold on or off the state health insurance marketplaces. If a mandate increases a plan’s premium, states will be on the hook for the additional premium cost that’s attributable to the mandate.
The payment requirement is waived until 2016, says Kelly Brantley, a senior manager at Avalere Health who’s looked at mandates related to infertility coverage, and regulations describing how the process will work haven’t yet been issued.More From This Series Insuring Your Health
Rather than forgoing mandates altogether, some states are simply excluding from the mandates plans that the states would have to pay for. The result: Consumers who buy individual or small group plans may not get the mandated benefits that are required in large group plans. (Self-funded plans, used by many large employers to pay employee claims directly rather than buying insurance for that purpose, aren’t bound by state mandates.)
That’s what’s happening with state mandates related to autism coverage, says Lorri Unumb, vice president of state government affairs at Autism Speaks, an advocacy group.
By the group’s count, 37 states and the District of Columbia have mandates requiring autism coverage. In 26 states, autism coverage is part of the essential health benefits, typically because coverage was mandated before 2012 and so was included in that state’s “benchmark” plan that sets the standard for coverage there.
New mandates are different. “For the most part, the states that have passed autism mandates post Dec. 31, 2011, have excluded ACA-compliant plans from the mandate,” Unumb says.
States have taken different approaches to structuring new mandates so they don’t have to pay for them, says Justin Giovannelli, a research associate at Georgetown’s Center on Health Insurance Reforms, who has examined state laws in this area. The law may say that the mandate only applies to large group plans, for example, or that it doesn’t apply to any plans that are required to provide the essential health benefits. A state may say that if the mandate increases premiums by a certain percentage the provision doesn't apply.
Confused? Policy experts fear consumers will be too.
“Your state has passed a law but everything is so market specific it’s hard to know what coverage you’re getting,” says Katie Keith, research director at the Trimpa Group, a consultant for autism and other advocacy groups.
Although some states are trying to sidestep having to pay for new mandates by limiting which plans are included, advocates say uncertainty about who is going to have to foot the bill is having a chilling effect overall.
Last year, the California legislature sent a bill to Gov. Jerry Brown that would have mandated that large group plans cover fertility preservation services such as freezing eggs or sperm for cancer patients and others who are facing medical treatments that might cause infertility.
The governor vetoed the mandate, even though the state would not have been required to pay for it because it didn’t apply to small group or individual plans. In his veto message, the governor said that “we should not consider mandating additional benefits until we implement the comprehensive package of reforms that are required by the federal Affordable Care Act.”
“It’s bad for consumers in many respects,” says Barbara Collura, president and CEO of Resolve, an infertility advocacy group. “Because of the uncertainty [about state payment obligations for mandated benefits], no one really knows how this will work, and uncertainty causes people not to want to do anything.”
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.
When Bill Lorimer’s doctor diagnosed him with a kidney stone in May, the Minnesota retiree and part-time resident of Marathon in the Florida Keys went to his local hospital for diagnostic scans of his pelvis and abdomen.
A few weeks later, Lorimer received a bill in the mail from Fishermen’s Community Hospital, showing the charge for the CT scan: $9,165.21.
“I was kind of blindsided by this,’’ said Lorimer, 67. “I thought the charge was a mistake.’’
Lorimer didn’t have to pay Fishermen’s full charge, though. Because he’s on Medicare, Lorimer was responsible for only a portion of the bill, and his share came to $1,456.36, which the hospital recently recalculated to $1,817.55 after adding a physician’s fee.
“Had I been a better health care buyer,’’ Lorimer said from his other home in St. Paul, Minn., “I would have probably checked around. But I was in a lot of pain. So I went over to the hospital.’’
Lorimer, like many health care consumers, didn’t give much thought to the cost of his medical service before receiving it, nor was he inclined to research it while in pain.
But that may have to change. Increasingly, individual consumers with health insurance are feeling financial pressure to be more careful shoppers as employers and insurers pass along a greater burden of costs through higher deductibles, co-payments and co-insurance rates.
Placing more financial responsibility on patients for their health care also may change costly behaviors left over from the days when generous health insurance plans shielded consumers from the true cost of medical care, health care experts say.
“There’s more interest in what folks are paying,’’ said Bruce Rueben, president of the Florida Hospital Association, which has launched a committee to study healthcare price transparency and the ways hospitals can communicate costs to consumers.
“The very fact that people were insulated from the cost of care because it was the insurance company paying for it … gave people less incentive to be asking those questions,’’ Rueben said. “Now that they are, we’re certainly trying to respond.’’
Health care prices can be hard to find, though, and the contracted rates between insurers and hospitals or physicians are considered proprietary.
Yet the price a consumer pays for a medical procedure can vary significantly from one hospital or doctor to the next — often with little difference in quality. And those price differences can add up, especially for so-called “consumer-directed” plans with co-insurance, which requires consumers to pay a percentage of medical costs.
If a CT scan costs $9,000 at one medical facility but much less at another, a consumer could save on out-of-pocket costs by knowing which provider has the lower price.
Consumers trying to lower their healthcare costs do have some help in the marketplace — but most aren’t using the tools available.
Cigna, the health insurance company, offers an Internet-based transparency tool that shows plan members price information on the 200 most common procedures, which make up about 70 percent of the company’s medical claims, said Mark Slitt, a spokesman.
“People really like cost transparency,’’ Slitt said, “and having quality information as part of their choice.’’
But some studies show that only a very small percentage of consumers use these tools, which are offered by a number of insurance companies, when planning a medical service, said Joe Smith, a physician and engineer who chairs the board of West Health Policy Center, a Washington, D.C.-based nonprofit that studies healthcare reform.
“Maybe 98 percent of those who are covered have access to some sort of price transparency tool, which appear to be used about 2 percent of the time,’’ Smith said.Power of Price: A glossary of healthcare terms
- All-payer claims database: A state-run database that tracks what insurers and other payers actually shell out for health care services from different hospitals and providers. Florida’s Agency for Health Care Administration was denied a budget request of $5 million to develop a database last spring.
- Charge: The price a health care provider says it is owed for a service; not necessarily what it expects to receive. Insurance companies negotiate with providers for cheaper rates than the listed charge. People who are uninsured may be billed for the whole charge — but even then, the amount is frequently negotiable. Appears as the amount billed column on an explanation of benefits.
- Chargemaster: A hospital’s list of charges for common procedures. These lists are different from the list of rates negotiated by each insurer. Starting in October, the Affordable Care Act requires hospitals make charges available to the public. Many hospitals plan to satisfy this requirement with the chargemaster.
- Contracted rate: The price an insurer and provider have agreed upon for a particular service — usually lower than the charge. This is also known as the reimbursement or negotiated rate. On an explanation of benefits, it appears as the amount paid by the insurer.
- Copay: The standard price paid by an insured patient for a covered service or medication. This is in addition to what the insurance company will pay on behalf of the patient.
- Cost adjustment: The difference between the charge and the contracted rate. It’s sometimes presented to health insurance customers as savings.
- Deductible: The amount a patient must pay for covered health care before the insurance company picks up the rest of the tab.
- Explanation of benefits (EOB): A statement from an insurance provider detailing how it covered a patient’s health care. EOBs typically include details like a description of the service and its billing code, the amount the provider charged, the amount the insurer paid (the contracted rate), and what the patient owes. It looks so much like a bill that some insurance companies write, “this is not a bill,” on the statement.
- Premium: The monthly price you pay for health insurance. It is separate from the deductible and copay.
- Medicaid: Health insurance for people with disabilities and low-income individuals and families. It’s managed at a state level with federal oversight and it’s funded with federal and state money.
- Medicare: Federally run health insurance, mostly for people over 65.
- Self-Insured: When an employer takes on the risk of insuring its employees and pays their health care claims. Self-insured employers, like Miami-Dade County, frequently hire an insurance company to manage the claims process and negotiate rates with providers on the employer’s behalf.
As if health care pricing wasn’t complex enough, try talking about it without running into some conversation-stopping jargon. Words that mean one thing to the rest of the English-speaking world can mean something completely different in health care — like a “charge” that isn’t the same as the price.
To help clarify, here’s a glossary of common terms in the world of health care finance:
Compiled by Sammy Mack
Cigna’s transparency tool allows plan members to search by medical service and provides them with a range of providers and an estimate of their prices. But Cigna does not reveal the underlying rates that the insurance company has negotiated with those providers, nor does the insurer’s tool show the rates that other insurers have negotiated with the same providers — the sort of insight that would empower consumers to comparison shop.
“They all want you to be informed,’’ Linda Quick, president of the South Florida Hospital and Healthcare Association, said about insurer transparency tools. “They just only want you to have their information.’’
Lorimer, the part-time resident of the Florida Keys, would not have had to look far for information that may have saved him more than $1,000 on his share of the CT scan from Fishermen’s.
He intends to pay the bill, “but I will pay it under protest,” Lorimer said. “The whole system is very opaque. There’s no question about that. But there are prices available.”
About a mile away from the hospital, an independent imaging center named Homestead Diagnostic Center advertises a CT scan starting at $275 and topping out at about $350 when a contrasting dye is included.
Tomas Gonzalez, the owner of Homestead Diagnostic, said he makes “a nice profit” with his rates. And he’s well aware that hospitals charge higher prices for the same services.
“Running a hospital is a lot more expensive than me running a diagnostic center,’’ he said.
But Gonzalez was taken aback by the charge from Fishermen’s — even after acknowledging that the hospital has the only CT scanner in Marathon. At his facility, patients who need x-rays, ultrasounds and digital mammograms are seen on site. Those who need CT scans and MRIs are bused for free to the company’s main facility in Homestead, an 80-mile trip that might not be worth it for someone in pain.
Still, Gonzalez said, “$9,000 for a CT scan? Come on. It’s outrageous. It really is. I’m in business to make money, but not like that.’’
Hal Leftwich, chief executive of Fishermen’s, said part of the reason for the hospital’s high charge is that the facility is certified by Medicare as a so-called “critical access hospital,’’ a designation typically assigned to rural hospitals that are far from other medical facilities.
The designation requires around-the-clock emergency care capability, and care for the uninsured, adding considerable costs for Fishermen’s, Leftwich said.
Medicare reimburses critical access hospitals on a cost basis, instead of a fixed rate like most urban hospitals receive. For Lorimer’s CT scan, Medicare paid $673.85, after adjusting the charge.
Leftwich declined to discuss Lorimer’s hospital visit or his bill, citing patient privacy laws. But he said he had “some knowledge” of the charge, and that the amount represented two CT scans — one performed with a contrast dye, and one without the dye.
“There’s basically two CTs being done there,’’ Leftwich said.
He explained that Fishermen’s compares its prices with other hospitals in South Florida for similar services, and that their prices “are very similar,” for the services involved.
“What we’ve tried to do,’’ Leftwich said, “is keep our pricing to be below the market leaders. But because we’re in such a rural-type area with low [patient] volumes, of course, we can’t be the lowest price, either.’’
Maintaining a CT scanner can be expensive. Leftwich said the hospital pays for a $90,000 annual service contract, among other costs.
“That $90,000 will get amortized over fewer studies here because there are fewer people,’’ Leftwich said.
Advocates for health care pricing reform call the practice of factoring operating costs into the price of a particular service “cross-subsidizing,’’ and some say it’s disingenuous of hospital administrators and unfair to the community that has to foot the bill.
Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, a Connecticut-based nonprofit, said hospitals blend their costs precisely because healthcare prices are shrouded in secrecy.
“The reality is today people can do this because there is no price transparency,’’ he said. “So you have all this cross-subsidization that goes on at hospitals that leads to high prices. They say it’s high because of all these additional expenses that we have to cover. Yes you do, but those ought to be covered in an open forum about the explicit need to subsidize them.
“It’s either done by taxpayer money so everyone pays a price,’’ de Brantes said, “or you close it down. But that’s your community’s decision. It shouldn’t be up to the hospital administrator.’’
Leftwich said Fishermen’s has developed ways to reduce costs, particularly for those patients who are willing to pay their own way.
“We may not match $350,’’ he said, referring to Homestead Diagnostic, “but we’ll come pretty close if they’re willing to pull out the credit card and pay right there.’’
That's how one Hollywood resident who asked the Herald not to use his name because of privacy concerns, paid for his hernia operation at Imperial Point Hospital in Fort Lauderdale this summer.
The 52-year old, self-employed man has not carried health insurance since about 2012, saying he got fed up with the confusion and complexity of the cost for his healthcare.
“I found dealing with insurance and the bills and trying to obtain a clear itemized bill from the guy who is sending us the bill was very difficult,’’ he said.
Prior to his surgery, the marine industry worker contacted friends who work as insurance claims adjusters, and they helped him to identify national averages for a hernia operation, and negotiated on his behalf with the physicians and hospital.
The negotiated prices for the outpatient surgery: $125 for the initial doctor’s visit, $1,000 for the surgeon, $1,000 for the anesthetist and $2,753 in hospital fees.
“I was expecting something in the region of $15,000 to $20,000,’’ he said.
Instead, he paid around $5,000 total for his surgery — in advance, on his credit card.
That’s about the same amount as his deductible when he had health insurance, he said, minus the paperwork and confusion.
“What’s the point of having insurance,’’ he said, “if at the end of the day I’m going to pay more? I would far prefer to accept my own risk and pay for it than to have insurance and have them turn everything around and turn it into a deductible.’’
There was a small drawback: The physician prescribed a narcotic pain killer that cost $245 without health insurance. He stuck with ibuprofen to relieve the pain.
Overall, Smith said, he was satisfied with the quality of care he received and the price tag.
“It’s been much easier,’’ he said, “because I knew what I was going to pay.’’
Could the U.S. save $700 billion in health care spending waste and inefficiency if high-cost states were to emulate the practices of low-cost states? "The conventional wisdom," says Louise Sheiner, "is: We'd save a lot of money if we would just adopt the practices of the low-cost states. If we could, for example, turn Mississippi into Minnesota, we'd save a lot of money." Yet, according to Sheiner, a Brookings senior fellow and policy director of the Hutchins Center on Fiscal and Monetary Policy, "geographic variation in health spending does not provide a useful way to examine the inefficiencies of our health system."
In her new paper for the Brookings Panel on Economic Activity, Sheiner contradicts the widely-held view from the Dartmouth Atlas of Health Care that the variance in health care spending across states is due to "practice styles"—the extent and intensity of medical interventions in a given area. Instead, she finds that the variation is linked to socioeconomic and demographic factors connected to population characteristics.
Unlike in the Dartmouth approach, which takes an individual-level view, Sheiner's research focuses on the state-level. For example, she writes: "A comparison of health spending in Mississippi with health spending in Minnesota is not likely to provide a useful metric of the 'inefficiencies' of the health system in isolation; rather, the difference in spending likely mirrors broader societal problems unrelated to the health system per se." Relative to Minnesota, Mississippi is a high-health spending, less-healthy state.
Justin Wolfers, co-editor of the Brookings Papers on Economic Activity, explains the paper in this video:
Learn more about the paper, "Why the Geographic Variation in Health Care Spending Can’t Tell Us Much About the Efficiency or Quality of Our Health Care System," and read more about what she had to say about the paper and research to the Washington Post.
Also, visit this interactive chart, showing the relationship between Medicare spending and health for each state (using the proportion of the state's population with diabetes as a proxy for general health).Authors
- Fred Dews
By Alvin Tran
One out of every three American adults has high blood pressure. And, whether you’re a man or a woman, your blood pressure naturally increases with age, raising your risk of health problems from stroke to heart disease and diabetes.
But there is a silver lining – at least for men with higher fitness levels, a new study finds.
The study, published in the Journal of the American College of Cardiology, found that men who maintained higher levels of fitness tended to develop high blood pressure significantly later than less-fit men.
“We think improving fitness can slow the natural increased trend of systolic blood pressure with aging,” says Dr. Xuemei Sui, an assistant professor at the Arnold School of Public Health at the University of South Carolina and one of the study’s coauthors.
Sui and her colleagues’ data suggest the systolic blood pressure (the top number) of men with higher fitness levels reaches prehypertension – the level between normal and high blood pressure – at a much later age, on average: at 54, compared to an average of 46 in less fit men.
The research team analyzed medical exam records of nearly 14,000 men, ranging in age from 20 to 90, who were followed over a 36-year period. The research team divided the men into three equal groups of fitness: low (the bottom one-third), moderate, and high (the upper one-third).
Aside from the delay in the development of high blood pressure, the study also found that men in the higher fitness category had other more favorable health outcomes compared to those in the lower groups, including lower body mass index scores, percent of body fat, and cholesterol. These findings, Sui says, aren’t surprising. What was surprising, she says, was the significant delay in hypertension.
So, what should the men out there do?
“Physical activity is the primary determinant of fitness level,” Sui says.
At a hearing to discuss the rising costs of healthcare benefits for Miami-Dade County employees this year, a labor union consultant raised his hand to ask what seemed like a basic question.
Could the committee charged with reducing Miami-Dade labor’s healthcare expenses look at the spreadsheet showing the rates that the county pays local hospitals and doctors for medical services to employees?Healthcare Prices: Many Moving Parts Veiled By Confidentiality Agreements
“We really need to understand where the money is being spent in order to be insightful about benefit design changes,’’ said Duane Fitch, a healthcare consultant for SEIU Local 1991, which represents physicians and nurses at the county-owned Jackson Health System.
But the answer to Fitch’s question at that inaugural meeting of the Miami-Dade Labor Healthcare Committee last March was the same response he would receive every time he repeated the question during the panel’s next six meetings through July.
“Contracts are proprietary,” said Patricia Nelson, regional head of strategic accounts for AvMed Health Plans, the county’s health benefits administrator that negotiated the payment rates for medical services for county employees. She noted that both the insurance company and the healthcare providers agree to keep such payment rates confidential.
Fitch and others who asked for the information never got to see precisely how Miami-Dade spends more than $400 million a year to pay healthcare claims for nearly 60,000 employees, retirees and dependents in the health plan.
That’s because Miami-Dade — like many employers across the country — isn’t allowed to know the prices their own insurance plan administrators negotiate with healthcare providers, even when they’re self-insured, like Miami-Dade County, and the claims are paid with taxpayer dollars.
And that means that the mayor’s healthcare committee has no more insight than the average Florida consumer on how to lower costs for their employees or themselves — frustrating everyone from union leaders to county commissioners who are trying to push down prices.
Because when county officials claim they are doing everything they can to reduce employee healthcare costs, they actually don’t know how and where the public’s money is being spent.
“You need the data in order to do the proper plan design that drives your outcomes,’’ said Miami-Dade Commissioner Juan C. Zapata, whose requests for AvMed’s contracted rates also have been rejected. “Without that, you’re just shooting in the dark, basically.’’
The lack of disclosure of a most basic fact — how much does it cost? — has prompted a movement around the country toward greater price transparency, even as insurance companies and hospitals say revealing those rates will put them at a financial disadvantage with competitors.
A local hospital CEO, Steve Sonenreich of Mount Sinai Medical Center on Miami Beach, even made a public pledge on WLRN-91.3 FM radio last year that he would reveal the contractual rates the hospital charges private insurers — only to learn that he was barred under the non-disclosure agreement in the contract.
Sonenreich said in a written statement this week that he believes one of the problems with pricing secrecy is that it allows large hospital systems to leverage their “geographic dominance” to run up rates on insurers, who pass on the increases to employers and consumers through higher premiums, deductibles and other costs.
“If we make healthcare pricing information available to consumers, particularly employers,’’ he said, “they will be able to make better decisions.’’
But the push for price transparency has had an uneven impact across the country.
Some states, such as Colorado, New Hampshire and Massachusetts, have adopted legislation that requires insurance companies and healthcare providers to report reimbursement rates and payments for use in what they call an “all-payer claims database” — a repository of comprehensive information on healthcare use and payments for all medical services by Medicaid, Medicare and commercial insurers, among others.
Florida has enacted or amended statutes and regulations more than a dozen times since 1985 requiring some level of transparency and disclosure from hospitals and physicians, but not insurers.
A state-mandated website managed by the Agency for Healthcare Administration at floridahealthfinder.gov gives consumers average and total charges for a variety of medical services by hospitals — but not specific reimbursement rates.
In the bewildering world of healthcare pricing, charges are not the same as prices — because almost every payer gets a discount on hospital charges, and usually by double-digit percentages.
While Florida’s price transparency efforts are not as robust as other states, AHCA officials did request about $5 million in annual funding this year to build and maintain an all-payer claims database. The request was ignored by state lawmakers.
By keeping prices secret, healthcare providers and insurers leave employers with little choice for managing their benefits costs as they go up. Most choose to shift more financial burden onto employees, said Francois de Brantes, executive director of Health Care Incentives Improvement Institute, a Connecticut nonprofit that advocates for payment reform.
“If you’re an employer,’’ de Brantes said, “and you don’t have access to your underlying claims data, even though you’re self-insured, there’s absolutely no way for you to make decisions on benefit design — other than using the brute force of across-the-board premium increases.’’
And that’s what the county’s healthcare committee recommended in its final report: Require a biweekly premium for employees who currently pay none for single coverage in the county’s HMO plan, and increase existing premiums for those in the POS plan. Employees also will be offered a new plan with no premiums for individual coverage, but a limited choice of hospitals and doctors.
Need For Transparency
For most people with employer-provided health insurance, rising premiums are not unusual. Insured consumers across the country are shouldering more financial responsibility for their medical care through high deductibles, co-insurance rates and health savings accounts — fueling momentum for price transparency.
“The consumer is going to basically have to take responsibility for their own healthcare,’’ said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network in South Broward County, “and look not only at costs but quality outcomes, the safety metrics. All of that has to be transparent, and then they’ll have to make informed decisions.”
But translating healthcare pricing to into useful information for consumers is complicated because every patient’s experience can be different, even for similar procedures, said Linda Quick, president of the South Florida Hospital and Healthcare Association, a trade group for regional providers.
Then there’s the variety of payers, from government programs such as Medicaid and Medicare, to private commercial insurers — all paying a different rate.
Adding to the complexity: a procedure such as a knee replacement may require that an insurer pay a number of different providers, from the lab and physician to the hospital and home health agency.
“So if the hospital told you that their cost is $27,000,’’ Quick said, “it’s still not a true representation of the cost of knee surgery, because the surgeon’s bill is going to be separate, and the anesthesiologist is going to bill separately.
“It’s very hard,’’ she said, “to make it totally transparent.”
AvMed, the county’s health insurance administrator, declined to discuss healthcare pricing with the Herald and WLRN, canceling two interviews with Jim Repp, vice president of marketing. The company also declined to discuss its management of Miami-Dade’s employee health plan while the county’s labor unions and administrators negotiate new collective bargaining agreements in the coming months.
But when Repp addressed the mayor’s healthcare committee in June, he said AvMed had secured average discounts of 65 percent with South Florida hospitals and physicians, helping to save the county what he estimated was about $56 million on expected claims from 2010 through 2013.
For employers, having access to data on actual payments would be much more useful than knowing the average discount negotiated by a plan administrator, de Brantes said.
When he worked as a program leader for General Electric Corporate Health Care Programs in the mid-1990s, de Brantes said, GE required its health plan administrator to deliver the data — or lose the company’s business.
“We would use those data constantly to figure out: What do we need to do as an employer to improve cost and quality? Where are there problems? And even to do accurate modeling of what would be the impact of, say, increasing our co-pay on ER visits,’’ de Brantes said. “How many people would that impact? And who’s going there more often? Is it people who have chronic illness, or those seeking routine service?
“You wouldn’t even know that,’’ he said, “if you didn’t have the claims data.’’
Miami-Dade could also take a cue from other large private employers, such as aerospace giant Boeing, and negotiate contracts directly with hospitals and other healthcare providers, said Joe Smith, a physician and engineer who chairs the board of West Health Policy Center, a Washington, D.C.-based nonprofit that studies healthcare reform.
“Healthcare has enough middlemen,’’ Smith said of plan administrators. “The employers are not ignorant at this. They’re good at negotiating contracts, and can also use market power to gain information.’’
De Brantes questioned AvMed’s incentive to reduce Miami-Dade’s annual healthcare costs since the insurance company pays claims with the county’s money, and receives an administrative fee of $31 per employee per month — regardless of the rates it negotiates with providers.
“They don’t care because it’s not their money,’’ de Brantes said. “That’s the bottom line.’’
For 2014, AvMed’s fee is estimated to be $16 million, about 4 percent of annual claims, according to county reports.
In The Dark
Without price transparency — and a review of AvMed’s negotiated rates — there’s no way for Miami-Dade to evaluate AvMed’s job performance, said Fitch, the healthcare consultant to SEIU 1991.
Fitch expressed concern that AvMed could be giving preferable treatment to Baptist Health South Florida, the largest hospital system in the region and the top-paid provider in the county’s employee health plan.
AvMed is the administrator for both Baptist Health’s employee health plan and Miami-Dade’s, Fitch pointed out, creating “a perception that there is unfair dealing.’’
At a meeting of the county healthcare committee, Fitch asked Repp how AvMed manages to negotiate rates on behalf of Miami-Dade with a hospital system that is also AvMed’s client.
“Very delicately,’’ Repp said. “We do have clients who are also providers. We keep those two divisions of the organization separate from each other.’’
Christine Kotler, a Baptist Health spokeswoman, declined to address price variances between the system’s hospitals and others in Miami-Dade’s plan. She said Baptist Health hospitals score high marks in clinical safety and consumer satisfaction surveys.
“In discussions about cost and price,’’ she said in a written statement, “it’s important to also talk about quality.’’
Miami-Dade employees do express a preference for Baptist Health centers when using a hospital, according to analyses by Gallagher Benefits Services, a county consultant. Consequently, most of Miami-Dade’s healthcare dollars go to Baptist Health hospitals — more than $61 million in claims for 2013, Gallagher reported, well above the second-highest paid provider, the University of Miami Health System, which received $24.3 million in payments.
But county officials have lacked the specific payment rate data they need to properly evaluate plan changes that could save Miami-Dade taxpayers money, according to a Gallagher analysis of all medical claims for the year ending June 30, 2012.
For example, the report noted that county employees have “unusually high” rates of emergency room use, likely because their copays for the service are low. But county administrators didn’t have the payment data to determine whether raising the copays to steer employees toward cheaper “urgent care” centers would save enough money to be worthwhile.
Instead of payment rates and claims data, county officials were given average costs per member, showing that Baptist Health facilities cost an average of $12,988 per overnight admission.
Baptist wasn’t the most expensive by that metric. Aventura Hospital and Medical Center, owned by Hospital Corporation of America, cost the county plan $14,975 per admission.
But Gallagher’s analysis showed that visits to Baptist ERs that year cost Miami-Dade more per encounter, an average $2,427, higher than any of the top 14 providers in the plan network.
Gallagher noted another interesting figure during recent meetings of the county healthcare committee.
In 2013, Miami-Dade’s plan paid Jackson Health hospitals an average of $9,380 per overnight admission. The average paid to all other hospital systems: $15,513 per patient — a difference of $6,133.
Gallagher projected that if all hospitals in the county employees’ network were paid at the same level as Jackson, Miami-Dade could have saved nearly $77 million in claims.
“We think there’s a lot of room for savings because of this price variation,” said Martha Baker, president of Jackson’s labor union for physicians and nurses.
Repp and others, including Jackson Health’s chief financial officer, Mark Knight, disputed that number.
“We don’t know the mix of the patients,” Knight said. “That $15,000 average could have been based on a bunch of really bad, train wreck patients who were in a bad motor vehicle accident and intensive care for a month. You can’t tell.”
But Knight did illustrate one potential drawback for the consumer when it comes to price transparency: When Jackson officials read the Gallagher report showing the health system was being paid the lower rate in 2012, they went back to AvMed and renegotiated prices — higher.
The result? It now costs Miami-Dade more for its employees to use Jackson Health, though the plan still saves money when its members choose Jackson over a higher-priced competitor.
Unless consumers and employers know beforehand how much a medical service costs, they’ll never be able to make informed — and cost-saving — choices.
“Just like the individual needs choice,’’ said Smith, of the West Health Policy Center, “Miami-Dade County needs choice as it thinks about who it’s going to contract with. Otherwise, there’s just too much risk of hiding the ball.’’
The average Medicare payment for a knee replacement at a South Florida medical center in 2012 ranged from a low of $9,700 at Holy Cross Hospital in Fort Lauderdale to a high of $24,000 at Jackson Memorial Hospital in Miami — even though Holy Cross’s average charge of $63,000 was about $2,000 higher than Jackson’s.
Private commercial insurers do not publish their payments like Medicare does, but healthcare experts say the prices they pay hospitals for the same procedure can vary just as much — and the reason often depends on more than just the hospital where the knee replacement was performed.
For most insured Americans, the reasons for such variance in healthcare prices also can include the medical condition of the patient, complications that may arise, physicians’ fees, market competition, and even who’s paying for the procedure and how.
That’s a lot of moving parts for anyone to nail down a firm price, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County.
“Healthcare pricing,’’ he said, “is probably the most complex, convoluted pricing of anything that I’ve ever seen in my life.’’
One way to begin unraveling the twisted threads of healthcare pricing is to understand the difference between charge and price. Every hospital establishes a list of charges or so-called “charge masters’’ for medical services, but almost no one pays those rates.
Charges include a hospital’s costs for all services provided to a patient plus a variety of factors unique to each hospital, said Karen Godfrey, corporate vice president of revenue management for Baptist Health South Florida, the largest hospital system in the region.
Some hospitals may have higher costs due to high-intensity services, such as organ transplants, trauma centers and neonatal intensive care units. Or they may have higher mission-related expenses, such as teaching, medical research or caring for the uninsured.
“That may sound simple and straightforward,’’ Godfrey said. “It’s not. If you come in for emergency services, since we don’t know what’s wrong with you, we don’t ultimately know what the charges are going to be.’’
What the hospital collects in payment is the price, and that can range depending on the payer.
For government payers, such as Medicare and Medicaid, prices are publicly available and the rates are set, with provisions made for so-called “outlier” patients whose conditions are especially complex or severe. Typically, Medicare and Medicaid pay less than a hospital’s actual cost to provide care.
So hospitals recoup their operating losses, plus a small margin, in their contracted prices with commercial insurers, Sacco said.
When insurers and hospitals meet behind closed doors to negotiate payment rates, insurers are trading market reach and patient volumes for discounts on hospitals’ rates. Hospitals are leveraging their range of services, quality ratings — and size.
Pat Geraghty, president of Florida Blue, the state’s oldest and largest health insurance company, agreed that a hospital system’s geographic reach can be “critical” in negotiations, but said quality and customer satisfaction may matter more.
“It really matters will the service be redone because it wasn’t done as well in one setting versus another setting,’’ he said. “It really does matter that if it could be done outpatient as opposed to inpatient that we use that setting, or if someone’s disease state could be managed from home as opposed to in any setting.’’
Geraghty said healthcare payments are moving in the direction of packaged prices for episodes of care, and arrangements that hold providers more accountable for healthy patient outcomes if they want to earn higher rates.
“If the patient’s condition worsens and requires more care,’’ Geraghty said, “then the provider takes the loss financially. But if the provider manages the patient’s care efficiently, then he gets to keep the savings.’’
Right now, most hospitals are paid a daily rate or a fee per service or diagnosis group.
Advocates for payment reform argue that under the fee-for-service system, hospitals and other providers have an incentive to over-treat because they're reimbursed by procedure.
But when consumers know the prices for some services across all providers, they’re more likely to comparison shop — according to a recent study published in the journal Health Affairs that found publishing MRI prices led to lower patient costs and reduced price variation.
How the government calculates insurance subsidies makes the cheapest bronze plans more costly for young people relative to those aged 54 to 64, reports The Philadelphia Inquirer. Meanwhile, Oregon budgets $2 million for a lawsuit fight with Oracle over its health insurance marketplace.
The Philadelphia Inquirer: Subsidy Formula Makes Some Policies Costlier For The Young
Young adults are paying as much or more in premiums for the cheapest bronze plans purchased on the Affordable Care Act marketplace as people ages 54 to 64, according to a University of Tennessee Health Science Center study. The study, published online last week in the Annals of Internal Medicine, found that the reverse premium age curve -- premiums should be cheaper for younger people, who use less health care -- is the result of how tax credit subsidies are calculated under the law. It could mean that paying the penalty for not buying insurance as required by the individual mandate would be less than the monthly premiums for those low-premium policies (Calandra, 9/14).
The Associated Press: State Budgets $2M For Cover Oregon Lawsuit
Oregon has budgeted $2 million for its legal fight with software giant Oracle over the state's failed health care exchange website. The state sued the Redwood City, California, company in Marion County Circuit Court last month, claiming that Oracle officials lied, breached contracts and engaged in "a pattern of racketeering activity." Meanwhile, the company has sued the state in federal court alleging breach of contract. Oracle was the largest technology contractor working on Oregon's health insurance enrollment website, known as Cover Oregon. The public website was never launched, forcing the state to hire hundreds of workers to process paper applications by hand. The issue became a political liability for Democratic Gov. John Kitzhaber (9/14).
The New York Times: A Rebound Takes Root In Michigan, But Voters’ Gloom Is Hard To Shake
Yet the economic recovery taking root in Michigan -- among the states hit hardest by the 2008 recession -- has not translated into an improved political environment for officials in either party. ... On the lower end, the worst of the desperation has subsided, helped in part by government action. Barbara Grinwis, 63, executive director of Oasis of Hope, a free health clinic on Leonard Street, spends much of her time signing up patients for Michigan’s insurance exchange or expanded Medicaid under the president’s health care law (Weisman, 9/12).
Also, developments in the Medicaid expansion debates in Texas and Florida are tracked --
Texas Tribune: In Health Care, Organizers Find Issue To Spur Hispanics
When Armando Rodriguez opened the front door of his home here on the city’s west side, Chris Ornelas of the Texas Organizing Project met him with one question. “What are some of the biggest concerns you have in your life right now?” Ornelas asked in Spanish. Health care, Rodriguez replied, and whether his family could afford it. The conversation was familiar for Ornelas, who goes door to door to talk to residents as part of efforts by the Texas Organizing Project to increase voter participation among minorities. The group’s field organizing team often meets minority voters who list health care as a top concern, and it is looking to leverage that issue to get more Hispanic voters to the polls in November (Ura, 9/14).
Orlando Sentinel: Crist Team Explores Medicaid Expansion
Democratic gubernatorial candidate Charlie Crist said his team is researching the prospect that he could sign an executive order on his first day in office to immediately and unilaterally expand the state's Medicaid program to cover uninsured Floridians. In a day of dueling politics in Orlando – with both Crist and Gov. Rick Scott appearing – Crist started by announcing his interest in an executive order while speaking to the Florida Nurses Association on Saturday at the Florida Hotel and Conference Center (Powers, 9/13).
The Wall Street Journal: Some Cancer Experts See 'Overdiagnosis,' Question Emphasis On Early Detection
Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword. While it's clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm (Beck, 9/14).
Gilead Sciences says its next generation drug to combat hepatitis C, slated to launch next month, will be more expensive than $1,000-a-pill Sovaldi, in part because the new treatment will be shorter and simpler. Gilead also struck a deal with Indian generic drugmakers to sell lower-cost versions of Sovaldi in poor countries.
Reuters: Gilead To Raise Price For New Hepatitis C Drug
The next generation version of Gilead Sciences Inc's $84,000 hepatitis C drug, already under fire for its record-breaking costs, is going to be even more expensive. Gregg Alton, Gilead's executive vice president of corporate and medical affairs, declined to give an exact price for the new medicine, the first all-oral treatment for the virus which is expected to launch next month. The total cost of the current treatment is $95,000, which includes Sovaldi and two older medicines, ribavirin and interferon, according to Gilead. The price of the new drug would be based on that cost, Alton said in an interview (Beasley, 9/12).
The New York Times: Maker Of Hepatitis C Drug Strikes Deal On Generics For Poor Countries
The maker of one of the costliest drugs in the world announced on Monday that it had struck agreements with seven Indian generic drug makers to sell lower-cost versions of its $1,000-a-pill Hepatitis C drug in poorer countries (Harris, 9/15).
Also, a report about scant supplies of an increasingly popular alternative to hospital dialysis -
Los Angeles Times: Shortage Of In-Home Dialysis Solution Has Patients Worried
Joanna Galeas relies on an increasingly popular at-home alternative to treat her kidney failure. Galeas, a 30-year-old Los Angeles resident, is among tens of thousands of U.S. residents who use peritoneal dialysis at home. She fills her abdomen with a sterile solution that helps remove toxins from her blood, a function ordinarily performed by healthy kidneys. Now, Baxter International Inc., the nation's leading supplier of the home dialysis solution, says it can't keep up with demand and has started rationing the product, directing physicians to limit the number of new patients to whom they prescribe the treatment and reducing the size of shipments sent to existing customers (Pfeifer and Terhune, 9/12).
News outlets examine what the future could hold for the health law especially as the Senate increasingly appears to be within GOP reach.
Politico: A GOP Senate Could Take On Obamacare — But Not Repeal It
A Republican-controlled Senate cannot repeal Obamacare, no matter how fervently GOP candidates pledge to do so on the campaign trail this fall. But if they do win the majority, Senate Republicans could inflict deep and lasting damage to the president’s signature law. Republicans are quick to say they are not yet measuring the proverbial drapes. But they are taking the political measurements of repealing large parts of the health law, considering which pieces could be repealed with Democratic support, and how to leverage the annual appropriations and budget process to eliminate funding or large pieces of the law (Haberkorn, 9/15).
Politico: Would a GOP Senate Be King Of The World?
If the Republicans win the Senate in November, the first thing they’ll say is: Finally, we can pass all of our bills and force President Barack Obama to deal with them. The second thing they’ll say is: Oh, wait a second. This is the Senate. That tension — between their desire to bring Obama to his knees and their ability to actually do it — is the political reality that will determine the Republicans’ legislative strategy if they win the Senate majority (Nather, 9/14).
Politico: Senate Showdown: GOP Frets Over Harkin Seat
Few states are more important than Iowa in the battle for the Senate this fall. But anxiety is rising within Republican ranks that deep-pocketed conservative donors and outside groups are not doing enough, as Democrats outspend them by millions of dollars to retain the seat of retiring liberal Sen. Tom Harkin. Since GOP nominee Joni Ernst won the June primary, Democratic Rep. Bruce Braley and his allies have outspent Ernst and her supporters by more than $2.1 million .... Meanwhile, interest groups from the left are piling on. ... Braley's allies stress that he has also been getting hammered with attack ads — many over absences from House Veterans Affairs Committee hearings in the House and support for Obamacare. (Hohmann, 9/14).
The Washington Post: In Just A Year Obamacare Goes From Top Congress Issue To Barely Mentioned
It was last September when Republicans sparred with Democrats over the future of the health-care law, a disagreement that prompted a 17-day federal government shutdown and overall chaos. It was pretty much [all] anyone on Capitol Hill talked about. Republicans wanted you to know how terrible it was for America, and Democrats wanted you to remember to sign up on Oct. 1. In that month, a mere 12 months ago, the word Obamacare was uttered on the House and Senate floor 2,753 times, ... With just one full week of work left this month, members of Congress have brought up Obamacare in floor speeches just 27 times (Itkowitz, 9/13).
The Hill: Elections Poised To Expand ObamaCare
Democrats running in five highly competitive governors races this year have vowed to expand Medicaid coverage through ObamaCare if they are elected, something that could result in 1.7 million new people getting covered. The dramatic stakes in the governors’ races come even as Democrats are fearful they could lose the Senate .... If federal Medicaid programs are expanded in the five states — Florida, Maine, Kansas, Wisconsin and Georgia — it would also have a dramatic effect on the federal budget. ... Republicans are favored to gain seats in the House and Senate, but the party is playing defense in the race for state houses (Ferris, 9/12).
In other related news -
The New York Times: Building Legacy, Obama Reshapes Appellate Bench
Democrats have reversed the partisan imbalance on the federal appeals courts that long favored conservatives, a little-noticed shift with far-reaching consequences for the law and President Obama's legacy. ... The shift, one of the most significant but unheralded accomplishments of the Obama era, is likely to have ramifications for how the courts decide the legality of some of the president's most controversial actions on health care, immigration and clean air (Peters, 9/13).
And, here's news regarding how issues like Medicare and over-the-counter birth control are playing on the campaign trail -
The Wall Street Journal's Washington Wire: OTC Birth-Control Fight Hits Airwaves In Colorado, North Carolina
Planned Parenthood’s political arm is ratcheting up its fight with some Republican Senate candidates over the issue of possible over-the-counter contraceptives, calling the candidates' support of [over-the-counter] pills "empty gestures." Planned Parenthood Votes jumped into the middle of hotly-contested Senate races in Colorado and North Carolina with television ads denouncing GOP candidates there, Rep. Cory Gardner (R., Colo.) and Thom Tillis (Burton, 9/12).
Tampa Bay Times: PolitiFact: Medicare, That Favorite Campaign Attack Line
When it comes to claims about Medicare, some political talking points just never die. In Iowa and Virginia, Republicans have accused Democrats of cutting Medicare to pay for Obamacare. In Florida, a Republican was slammed for ending the Medicare "guarantee." Other Medicare-related attacks have been deployed in Arkansas and Kentucky Senate races. The point of all the attacks is to convince midterm voters that one side or the other won't protect the program (Jacobson and Holan, 9/12).
The Department of Health and Human Services has identified the key problems the Centers for Medicare & Medicaid Services needs to address to ensure that states pay their fair share of the state-federal low income insurance program.
The Washington Post: How States Have Gamed Medicaid For Hundreds Of Millions Of Dollars
States have developed various ways to avoid paying their fair share of Medicaid expenses over the years, in some cases costing the federal government hundreds of millions of dollars in extra funding for the program. The Department of Health and Human Services, which runs Medicaid through its Centers for Medicare and Medicaid Services (CMS), has known about the issue for more than a decade, but states still find ways to game the system. The agency’s inspector general this year listed the issue among 25 key problems the agency needs to address (Hicks, 9/15).
Also in the news, a report details how the American wealth gap is putting the squeeze on state revenue and spending for Medicaid -
The Associated Press: US Wealth Gap Putting The Squeeze On State Revenue
As the growth of tax revenue has slowed, states have faced tensions over whether to raise taxes or cut spending to balance their budgets as required by law. “Rising income inequality is not just a social issue,” said Gabriel Petek, the S&P credit analyst who wrote the report. “It presents a very significant set of challenges for the policymakers.” Stagnant pay for most people has compounded the pressure on states to preserve funding for education, highways and social programs such as Medicaid. Their investments in education and infrastructure have also fueled economic growth. Yet they’re at risk without a strong flow of tax revenue (9/15).
The money will go to expand primary care services, stay open longer and provide expanded services not always available at the clinics across the United States.
Kansas Health Institute News Service: Kansas, Missouri Health Clinics Get $9.6M For Primary Care
Twenty-five health centers in Missouri and 16 in Kansas have been awarded $9.6 million in federal funds to expand primary care services. The funding is part of $295 million awarded to 1,195 health centers nationwide under the Affordable Care Act, or Obamacare. The money is to be used to hire new staff, help the clinics stay open longer and provide oral health, mental and behavioral health, pharmacy and vision services (Margolies, 9/12).
Seattle Times: $7.5M To Boost Care At Low-income, Minority Health Clinics In Washington
Health clinics in Washington that largely serve low-income and minority residents will receive nearly $7.5 million in federal grants to increase access to primary care. The U.S. Department of Health and Human Services is awarding more than $295 million to community clinics nationwide, according to an announcement made Friday. In Washington, the money will go to 25 community health centers that treat medically underserved communities. The grants will help pay for an estimated 104 full-time health-care providers and benefit roughly 40,000 new patients. The Affordable Care Act and its expansion of health-care coverage has increased the number of people seeking medical care, putting added strain on a primary care system that was already stretched thin in places (Stiffler, 9/12).
Georgia Health News: Georgia Health Centers Get Funding To Expand Care
A federal agency has awarded $6.9 million in Affordable Care Act funding to 30 community health centers in Georgia that will help expand their primary care services. That funding was part of $295 million awarded nationally to 1,195 health centers by the Department of Human and Human Services (HHS) (Miller, 9/14).
But in Charlotte, a health center reduces hours after financial troubles --
Charlotte Observer: Financially Troubled Health Center Reduces Hours, Patients
C.W. Williams Community Health Center, a federally funded clinic that’s provided medical care for low-income patients in Mecklenburg County for more than 30 years, has temporarily reduced hours at its Wilkinson Boulevard clinic after closing its satellite clinic on East Boulevard. A notice posted on the door at the Wilkinson location says it remains open three days a week – Monday, Wednesday and Thursday – instead of the usual five, that it has one staff physician instead of three in the past and that only 25 adult patients with appointments can be seen in a day. ... C.W. Williams is the only federally qualified health center in Mecklenburg and one of 32 in the state. Based on the latest federal data, the health center got an 18 percent increase in federal funding from 2011 to 2013, but treated 22 percent fewer patients in the same period. C.W. Williams’ federal funding increased from $955,000 in 2011 to $1.1 million in 2013, according to the U.S. Health Resources and Services Administration. In the same period, the number of patients served dropped from 10,169 to 7,908 (Garloch, 9/14).
The law, which was ruled unconstitutional last month, would allow Texas to close more than half the state's abortion facilities.
Kaiser Health News: Appeals Court Weighs Texas Abortion Law
A federal appeals court in New Orleans is reviewing whether 11 clinics that provide abortion in Texas must immediately close their doors because they don’t comply with a state law requiring that they meet all the standards of an outpatient surgical center (Feibel, 9/12).
The Associated Press: Texas Asks Court To Allow Closure Of Most Clinics
Texas asked a federal appeals court Friday to allow the state to immediately enforce a law requiring all abortion clinics to adhere to costly standards required for walk-in surgical clinics, which would close more than half of the state's abortion facilities. Texas Solicitor General Jonathan Mitchell asked the 5th U.S. Circuit Court of Appeals to temporarily reinstate the requirement, which was ruled unconstitutional by a lower court last month. The New Orleans-based appeals court has already upheld another new abortion restriction that has shuttered several abortion clinics in Texas (McConnaughey, 9/12).
State Highlights: Calif. Prop 45 Ad Truth Check; S.D. ER Doctors Give Care In Kansas; Medi-Cal Autism Coverage
A selection of health policy stories from Florida, California, Kansas, Illinois, Washington state and Minnesota.
San Jose Mercury News: New Anti-Prop. 45 Ad Is Partiallly Misleading
Proposition 45 would give California's elected insurance commissioner the authority to reject excessive health insurance rate hikes, a power the commissioner already wields for auto and homeowners insurance rates. The campaign against it -- for which the insurance industry has so far put up $37.3 million -- is now airing a 60-second radio ad narrated by a nurse named Candy Campbell. What does the ad say? Campbell says voters have a choice between letting the state's "new independent commission" negotiate rates and reject expensive plans, or handing that power over to "one politician" who can "take millions in campaign contributions from special interests." Is it true? The "commission" Campbell is referring to is the board of Covered California, the state's new health insurance exchange created by the Affordable Care Act, commonly called "Obamacare." Covered California is indeed an independent part of state government. But it's somewhat misleading to describe the board as "independent." The board members are appointed by politicians -- the governor and the Legislature (Richman, 9/13).
Kansas Health Institute News Service: Specialists In South Dakota Use Telehealth System To Give ER Care In Kansas
A new nurse was on duty a few weeks ago in the emergency room at the Phillips County Hospital when paramedics arrived with a critically injured patient. She immediately pushed the red button on some newly installed equipment. Seconds later, a seasoned ER nurse and board-certified doctor sitting at a bank of monitors 380 miles away in Sioux Falls, S.D., were using a high-definition camera and other diagnostic equipment to monitor the patient, give advice and document everything the on-site nurse was doing to save the patient’s life. The Phillipsburg hospital is the first in the state to sign up for a 24/7 telemedicine program operated by Avera Health, a Catholic health care system based in Sioux Falls. For a flat fee of about $65,000 a year, it and the other hospitals in the network can make unlimited use of the eEmergency system (McLean, 9/15).
Kaiser Health News: California To Broaden Autism Coverage For Kids Through Medicaid
A new initiative seeks to help level the playing field. Starting Monday, September 15, thousands of children from low-income families who are on the autism spectrum will be eligible for behavioral therapy under Medi-Cal, the state’s health plan for the poor. California is among the first states to respond to a recent rule by the U.S. Centers for Medicare & Medicaid Services that requires the therapy to be covered, when deemed medically necessary, as part of a “comprehensive array of preventive, diagnostic and treatment services” for low-income people 21 and under (Hernandez, 9/15).
Miami Herald: Health Care Prices: Many Moving Parts Veiled By Confidentiality Agreements
Private commercial insurers do not publish their payments like Medicare does, but health care experts say the prices they pay hospitals for the same procedure can vary just as much -- and the reason often depends on more than just the hospital where the knee replacement was performed. For most insured Americans, the reasons for such variance in health care prices also can include the medical condition of the patient, complications that may arise, physicians’ fees, market competition, and even who’s paying for the procedure and how. That’s a lot of moving parts for anyone to nail down a firm price, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County (Chang, 9/14).
Chicago Sun Times: Emanuel Socks City Retirees With 40 Percent Health Insurance Hike
Mayor Rahm Emanuel on Friday dropped another financial bombshell on Chicago’s 25,000 retired city workers and their dependents: their monthly health insurance premiums will be going up by a whopping 40 percent -- in spite of a pending lawsuit and a precedent-setting Illinois Supreme Court ruling. Last year, Emanuel announced plans to save $108.7 million a year by phasing out the city’s 55 percent subsidy for retiree health care and forcing retirees to make the switch to Obamacare. For the city, the Year One savings was $25 million. For retirees, that translated into an increase in monthly health insurance premiums in the 20 percent and 30 percent-range. On Friday, city retirees and their dependents got hit again -- only this time, even harder. The city notified them of a 30-percent to 40-percent increase that will cost most of the retirees between another $300 to $400 a month (Spielman, 9/12).
Los Angeles Times: Medi-Cal Official To Leave Health Care Post In January
The official who led California's giant public health care services department through a tumultuous implementation of Obamacare reforms -- including a months-long period during which hundreds of thousands of Medicaid applications have languished, waiting to be processed -- will depart his position in January, state officials have announced. Toby Douglas directed the state's $91-billion Department of Health Care Services for four years (Brown, 9/12).
California Healthline: Douglas Resigns as DHCS Director
Toby Douglas announced his resignation Friday as director of California's embattled Department of Health Care Services. Appointed director by Gov. Jerry Brown (D) in 2011, Douglas oversaw tumultuous change in the growing department as the state expanded its Medicaid program and launched several initiatives as part of California's response to the Affordable Care Act (Lauer, 9/12).
The Associated Press: WSU Regents Approve Plan For New Medical School
Washington State University's board of regents on Friday unanimously approved the administration's controversial effort to start a new medical school in Spokane, citing the "dire need" for more doctors in the state. ... WSU's plan is opposed by the University of Washington, which operates the state's only publicly funded medical school. While approving WSU President Elson S. Floyd's pursuit of the independent medical school, the regents said the university should continue its partnership with the University of Washington's WWAMI program, which trains doctors for the states of Washington, Wyoming, Alaska, Montana and Idaho (Geranios, 9/12).
The Associated Press: Kids Go To Adult Trauma Centers, Treatment Delayed
Florida state guidelines require children with traumatic injuries to be taken to a trauma center specializing in pediatric care. Yet, in recent years, dozens of Florida kids have instead gone to adult centers that weren't able to treat them, according to an investigation by the Tampa Bay Times. The Times reported Sunday that in years past, children went to adult centers only when those facilities were significantly closer than ones designated for pediatric care, or because paramedics believed the child wouldn't survive a longer journey. Experts say 50 miles is considered a reasonable distance to fly an injured patient for proper care. Since 2009, though, the state has approved six new Hospital Corporation of America trauma centers. And at least 100 children have been taken to those facilities instead of pediatric centers even though in most cases they were not more than 50 miles away. Of that group, than 60 children then had to be transferred to pediatric trauma centers (9/14).
Minneapolis Star Tribune: New Minnesota Law Pushes Mental Health System To A Crisis Point
Hundreds of people with severe mental illnesses are languishing for weeks or even months without proper medical treatment, in part because of a law that requires state psychiatric facilities to admit some jail inmates ahead of hospital patients, regardless of clinical need or cost. The longer waits for mental health beds are an unintended consequence of 2013 legislation that was designed to shrink the swelling population of mentally ill people housed in county jails. The law, known as the “48-hour rule,” required inmates to be transferred to a state psychiatric facility within 48 hours after being committed by a state judge. Though the rule was hailed by law enforcement officials, it has raised safety concerns in hospitals (Serres, 9/14).
Sacramento Bee: Think Sacramento Is All About State Workers? Health Care Sector Is Surging
Sacramento has long been known as a state worker town. These days, it’s just as accurate to call it a health worker town. The health care sector in the four-county Sacramento region has grown steadily and significantly for more than a decade, according to the California Employment Development Department. While most other sectors shed jobs during the recession, hospitals, doctor’s offices and nursing homes held strong, adding 10,000 workers between 2008 and 2014 (Reese, 9/15).
Hospitals attribute the 30 percent reduction in uncompensated care to the expansion of Medicaid and private coverage under the federal health law. Meanwhile, insurers are pushing back against a wave of hospital mergers nationwide.
Seattle Times: Obamacare Helps Slash Hospital Charity Care Costs In State
Washington hospitals provided nearly $154 million less in charity care in the first half of this year than in the first half of 2013, in many cases boosting the hospitals’ bottom lines. Hospitals attributed the plunge in charity care -- about 30 percent -- to the Affordable Care Act’s focus on reducing the number of uninsured patients. This year, for the first time, low-income and uninsured patients whose care was previously covered under hospitals’ charity-care programs were able under the ACA to qualify for Medicaid coverage or subsidized private insurance. About 600,000 Washington residents signed up for health insurance through Medicaid under expanded eligibility guidelines or through private plans (Ostrom, 9/14).
Forbes: Insurers Fight Hospital Mergers As ACA Snubs Fee For Service Medicine
A wave of hospital mergers and acquisitions spreading across the U.S. has the health insurance industry attempting to stand in the way with legalese, Congressional lobbying and in the court of public opinion. America’s Health Insurance Plans, the powerful lobby and trade group representing the biggest names in commercial insurance appears to be leading the charge battling deals in New York, Chicago and beyond. In Chicago, Advocate Health Care and NorthShore University HealthSystem want to merge to form the 11th largest tax-exempt health system in the nation. The stakes are high for health insurance companies as they manage millions and millions more newly insured subscribers thanks to the Affordable Care Act, the signature legislative achievement of President Obama (Jaspen, 9/14).