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Saving safety-net hospitals in the ACA age

March 16, 2015by Robert Whitcomb in Uncategorized tagged "safety net'' hospitals, ACA, Affordable Care Act

This piece in HealthAffairs looks at the future of safety-net hospitals.

“N}national, state, and local government agencies historically have provided supplemental funding to these systems to offset unreimbursed and under-reimbursed care. Under the Affordable Care Act, however, that is changing. With the expectation that most people will be insured under the new law, policy makers have planned to reduce much of this supplemental funding. In this view, safety-net systems will either become financially independent or close.”

The authors write: “Our recent study of eight safety-net hospital systems indicates that while system redesign is needed to meet the demands of the current healthcare environment, the association between strategic system redesign and operating margins is weak. Critical additional factors affecting the safety-net systems’ operating margins are their business strategies and their competitive positions in local markets.”

Video: Healthcare costs and the future of the ACA

March 16, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Avik Roy

Video: Avik Roy, of the conservative Manhattan Institute, looks at the slowing of some healthcare costs and the future of the Affordable Care Act.

Calif. counties need to step up for uninsured

March 13, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Anthony Wright, Center for Labor Research and Education, Covered California, Health for All Act, Medi-Cal

By JENNY GOLD, for Kaiser Health News

With millions of Californians gaining coverage under the Affordable Care Act, counties need to strengthen their health programs to serve the remaining 3 million uninsured people, nearly half of whom are living in the state illegally, according to a report by a statewide advocacy coalition.

Under state law, each county is responsible for providing care to low-income Californians who are uninsured. But eligibility restrictions in county programs vary dramatically, leaving the uninsured with uneven access to care across the state, according to the report by Health Access California.

The coalition, which surveyed all 58 counties last fall, found that 48 of them preclude residents who are in the country illegally from enrolling in county programs, and 43 exclude any resident earning more than twice the federal poverty level. (The poverty level is $11,770 per year for an individual and $24,250 per year for a family of four.)

In 2014, counties worked hard to enroll as many of their residents as possible into new coverage options through the Affordable Care Act, said Anthony Wright, executive director of Health Access. Because millions were enrolled either through the insurance exchange, Covered California, or through Medi-Cal, the government program for the poor, the counties experienced a significant decline in the number of people enrolled in their programs.

But significant pockets of uninsured people remain – especially immigrants living here illegally, who are mostly ineligible for state and federal programs.

In counties with strict eligibility criteria for their programs, such as Merced, Placer and Tulare counties, no residents are enrolled. But counties with expansive programs that cover the undocumented and higher-income residents are still seeing high levels of enrollment. In Los Angeles, for example, 81,000 people were signed up with My Health LA, the county program.

The widely varying levels of enrollment among counties suggest that local governments “need to re-adjust their programs,” said Wright in a press release. “We need counties and the state to reorient their safety-net programs to serve the need that continues to this day.”

Few counties have adjusted eligibility requirements for their programs in the past two years, Wright said. Instead, they have taken a “wait-and-see” approach until the effects of the ACA and the state’s reallocation of safety-net funds were clear. Many are reconsidering how to manage their safety-net health programs as of 2016, and advocacy groups such as Health Access are hoping the counties will expand their eligibility requirements, particularly to allow immigrants here illegally to enroll.

“These county efforts should ultimately be a bridge to a statewide solution, where all Californians can be covered regardless of immigration status,” said Wright. “Immigrants are part of our economy and society, they should be fully included in our health system as well.”

But some in the state say that expanding health coverage to additional residents would be too costly. A bill currently moving through the state legislature, for example, would expand insurance options to immigrants living in the state illegally. That bill, called the Health for All Act, would cost the state between $424 million and $436 million in 2019, according an analysis from the University of California at Berkeley’s Center for Labor Research and Education and the University of California at Los Angeles Center for Health Policy Research.

Clinical empathy’s emotional and financial rewards

March 10, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, American Association of Medical Colleges, clinical empathy, Medical College Admission Test, Medicare reimbursement

The Washington Post reports on “Oncotalk,” developed by medical faculty at Duke, the University of Pittsburgh and several other medical schools and part of a ”burgeoning effort to teach doctors an essential but often overlooked skill: clinical empathy….{C}linical empathy is the ability to stand in a patient’s shoes and to convey an understanding of the patient’s situation as well as the desire to help.”

{”A} spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship.

”Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors. Beginning this year, the Medical College Admission Test will contain questions involving human behavior and psychology, a recognition that being a good doctor ‘requires an understanding of people,’ not just science, according to the American Association of Medical Colleges.”

Further, “Patient satisfaction scores are now being used to calculate Medicare reimbursement under the Affordable Care Act. And more than 70 percent of hospitals and health networks are using patient satisfaction scores in physician compensation decisions.”

Much of ACA would survive anti-subsidies ruling

March 6, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Supreme Court

Here’s a look at how much of the Affordable Care Act would survive a Supreme Court ruling against subsidies.

Hospitals hunt for options before Scotus ruling

March 6, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Aurora (Wis.) Health Care, Mike Lappin

“The Skeleton in the Closet” (hand-made quilt, bleached denim, leather, fabric), by BEN VENOM, at Samson Gallery, Boston, this month.

Hospitals are trying to formulate contingency plans in case the Supreme Court decides, in response to a Republican-inspired lawsuit, to end insurance subsidies under the Affordable Care Act in most of America.The revenue gains that hospitals have gotten from having a a big increase in insured patients from the ACA will disappear if subsidies for people who buy health plans from the federal exchange disappear.

“The uncertainty and the instability make it difficult for systems just to plan,” Mike Lappin, the chief administrative officer for Aurora (Wis.) Healthcare, told Modern Healthcare.

”Nonetheless, the health system’s leaders will attempt to game out multiple scenarios in the months between Wednesday’s oral arguments and the decision expected in June.

”That will include coming up with a strategy to communicate with the estimated 48,000 patients who received premium subsidies through the state’s federally run insurance exchange,” Mr. Lappin told Modern Healthcare.

A rejection of subsidies ”could threaten credit ratings for not-for-profit health systems, credit rating agencies have warned. On the for-profit side, however, analysts have estimated the loss of subsidies would jeopardize less than 4% of pre-tax earnings,” the publication reported.

After ACA ruling, a move to free market?

February 27, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Kimberly, Kimberly Strassel

In The Wall Street Journal, Kimberly Strassel looks forward to a Supreme Court ruling on Affordable Care Act subsidies that would let the GOP start moving healthcare reform to the free market.

GOP could lose by winning court case

February 25, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Avik Roy, Bill Frist, Dick Armey, King v. Burwell, Mitt Romney, Terry Holt

By JULIE ROVNER, for Kaiser Health News

Republican efforts to replace the federal health law have been given new urgency by the U.S. Supreme Court.

As soon as this spring, the court could invalidate health insurance subsidies available to millions of Americans if it rules for the challengers in a case called King v. Burwell.

Republicans who hate the Affordable Care Act are rooting for the court to do what they have been unable to accomplish – dismantle a key part of the law. But as the party that controls Congress, some Republicans also fear the potential for a backlash if they don’t have a plan to help those who would effectively be stripped of coverage, many of whom are voters in Republican-led states.

There’s another reason to agree soon on a replacement for the law, instead of continuing their long campaign to repeal it. If Republicans present a reasonable alternative, it could help swing a justice or two who might otherwise worry about the possible ramifications of cutting off the subsidies. Or so the reasoning goes.“The Republicans would love to give the justices some comfort that if they rule against the Obama administration, there will be something there to deal with the fallout,” says Dean Clancy, a Republican strategist and former aide to former House Majority Leader Dick Armey.

Those pushing the case argue that language in the law limits help to pay for insurance to residents of states that have established their own health insurance exchanges. So far only 13 states have – the rest use the federal healthcare.gov exchange. The administration contends that Congress clearly intended that the subsidy — tax credits based on income — be available in all states, and has declined to discuss any possible contingency plans.

If the court rules against the administration, the impact will fall heavily on Republican-led states, such as Florida and Texas, that didn’t create their own exchanges, increasing pressure on Congress to act. free

“I really do believe that this situation has concentrated the minds of many people on [Capitol] Hill,” says Avik Roy, a senior fellow at the Manhattan Institute and a former health adviser to GOP presidential candidate Mitt Romney. If the Supreme Court rules that subsidies cannot be provided through the federal health exchange, he says, Republicans in the House and Senate “realize if they don’t do something, they will be held accountable for that. Because they are running Congress now, so they can’t blame it on the Democrats.”

Still, putting something on the front burner does not guarantee it will get done. Republicans have been vowing to “repeal and replace” the Affordable Care Act almost since it became law in 2010. So far, the GOP-controlled House has held more than 50 separate votes to repeal or otherwise cancel parts of the law. Replacing, however, has been another story.

“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what,’” says Dean Rosen, a health-policy consultant who was a top aide to former GOP Senate Majority Leader Bill Frist and to the House Ways and Means Committee.

Republican health strategist Terry Holt, a former aide to the GOP House leadership, agrees. He says Republicans “are serious about a replacement” for the Affordable Care Act, “but it’s the law, and it’s harder to change law than to make it.”

There are several efforts underway to come up with a consensus Republican alternative to the health law. The repeal bill the House approved Feb. 3 includes language requiring the four main committees that handle health legislation in that chamber to approve a replacement, but no time limit is specified. Separately, three of those committee chairmen were tasked by House Majority Leader Kevin McCarthy in January to come up with a health bill, again with no specific deadline.

Across the Capitol, two GOP senators with deep backgrounds in health — Finance Committee Chairman Orrin Hatch (R.-Utah) and Richard Burr (R.-N.C.) — along with House Energy and Commerce Committee Chairman Fred Upton (R.-Mich.) have unveiled the outlines of a plan that was first floated last year.

And House Ways and Means Committee Chairman Paul Ryan (R.-Wis.) has said Republicans in the House are working on a short-term “bridge” for those who could get stripped of their insurance subsidies, although again, no specifics have been offered.

Even with new incentives, getting to specifics won’t be easy, says Clancy, for much the same reasons that have kept Republicans from being able to agree on a health overhaul for the past five years.

“There are pro-business Republicans and pro-market Republicans, and you see the divide on lots of issues, including healthcare,” he says.

For example, the more pro-market, libertarian types “would say let’s get the federal government out of the health insurance business altogether if possible, or at least create a much more voucher-like system with as little centralized control as possible,” he says. But the more traditional pro-business Republicans “are not going to be keen on blowing up the employer-based system.” Currently a majority of Americans still get their insurance through their or a family member’s job.

Another complication, says Rosen, is the impending presidential campaign, and the possibility that several sitting members of the Senate may run. “And you can see that the people who are posturing to be candidates … don’t just want to do Obamacare light,” he said.

Still, the prospect of millions of people in states run by Republican governors and Republican legislatures losing their insurance could be the deciding factor, says Holt. “These are people who have been promised something and are expecting it to continue, and it’s hard to see how you cut people off,” he says.

White House blocks plans without hospital benefits

February 23, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Alden Bianchi, American Staffing Association, Edward Fensholt, Edward Lenz, HHS, hospital benefits, Lockton Companies

By JAY HANCOCK, for Kaiser Health News

The Obama administration has blocked health plans without hospital benefits that many large employers argued fulfilled their obligations under the Affordable Care Act.

Companies with millions of workers, mainly in lower-wage industries such as staffing, retailing, restaurants and hotels that had not offered health coverage previously, had been flocking toward such insurance for 2015.

Plans lacking substantial coverage of hospital and physician services do not qualify as “minimum value” coverage under the law and so do not shield employers from fines of $3,000 or more per worker, the Department of Health and Human Services said late Friday.

The move closes what many saw as a surprising loophole, first reported by Kaiser Health News in September, that let companies bypass the health law’s strictest standard for large-employer coverage while at the same time stranding workers in sub-par insurance. Employees offered such plans would have been ineligible for tax credits to buy more comprehensive coverage in the law’s online marketplaces.

The agency did decide to allow such plans for this year only if employers had signed contracts by Nov. 4.

However, it also granted relief to workers offered such coverage, saying they may receive tax credits according to their income to buy more comprehensive insurance in the online exchanges. Ordinarily, employees offered coverage qualifying as minimum value aren’t eligible for the subsidies.

Despite what Washington and Lee University law Prof. Timothy Jost called “a lot of pushback” from employers, HHS has now followed through on earlier guidance that it intended to disallow such coverage.

A plan without hospital benefits “is not a health plan in any meaningful sense,” the agency said in a large batch of regulations issued Friday. Scoring such a plan as minimum value “would adversely affect employees (particularly those with significant health risks) who understandably would find this coverage unacceptable. …”

The ruling ends a debate that erupted last summer over HHS’ official, online calculator for determining minimum value in a large-employer plan.

The Affordable Care Act does not specify “essential health benefits” in large-employer plans, such as hospitalization and drugs, as it does for individual and small-business insurance. Instead, the minimum-value test requires large companies to cover at least 60 percent of expected medical costs.

One way to certify a plan as minimum value is to plug its parts — benefits, deductibles and so forth — into the official calculator. Many were shocked to learn that the calculator gave passing scores to plans with no inpatient hospital coverage.

Now HHS is saying: Ignore the calculator. Large-employer plans must pay for substantial amounts of hospital care no matter what.

“What remains a mystery is whether the calculator was at fault,” Alden Bianchi, a lawyer who advises many companies that were considering such plans for 2015, said via email. “The regulators don’t say. Rather, they take the [position] (not unreasonable or nutty, in my view at least) that a plan with these services is not real health insurance.”

Even with its allowance for companies that had signed contracts by Nov. 4, HHS stopped short of employer pleas for more flexibility. Industry groups wanted a green light to temporarily offer plans without hospital benefits if companies had made substantial preparations to do so but hadn’t signed a deal.

It’s unclear how many firms will offer such coverage for 2015. Nearly half of the 1,600 employer members of the American Staffing Association, which employ 3 million temporary employees on any given day, had committed to offer or were considering the plans last fall before KHN reported that regulators were moving against them.

While some members followed through and adopted such coverage, most did not, said Edward Lenz, senior counsel for the association, a trade group of temp and recruiting firms.

Calculator-approved plans lacking hospital benefits are comparatively rich in such outpatient services as doctor visits. Consultants selling the coverage had argued it was a good first step for lower-wage, high-turnover employers that had never offered major-medical insurance.

“I’ve had a couple of discussions in the last several days with clients who were interested but disappointed they were too late to install them for 2015,” said Edward Fensholt, a benefits lawyer with brokers Lockton Companies. Other companies “leapt on them,” he said.

For employers that planned to offer such coverage but hadn’t pulled the trigger by Nov. 4, “this is very disruptive news,” Bianchi said. “Best I can recall, I have about a half dozen clients that are in this position.”

Anne Lennan is president of the Society of Professional Benefits Administrators, whose members process claims for self-insured employers.

“A very small number of non-hospital plans were implemented by my members — as a percentage of all the plans they administer,” she said via email.

Low-income Californians happy with ACA effects

February 17, 2015by Robert Whitcomb in Uncategorized tagged Affordable Care Act, Blue Shield of California Foundation, California Primary Care Association, Carmela Castellano-Garcia, Covered California, Medi-Cal, Peter V. Long

By ANNA GORMAN, for Kaiser Health News

agorman@kff.org | @AnnaGorman

Low-income Californians are increasingly satisfied with the healthcare they receive, underscoring the impact of changes made by clinics and providers since the Affordable Care Act went into effect, according to a report released Wednesday.

More than half of low-income patients – 53 percent — rated their quality of care as excellent or very good in 2014, up 5 percentage points from 2011, according to the survey by the Blue Shield of California Foundation. That means that about 400,000 patients were happier with their care, the report said. (Kaiser Health News receives funding from the foundation.)

Compared with patients who were uninsured in 2011, low-income residents who in 2014 had coverage through the state’s insurance exchange, Covered California, reported much higher satisfaction with their care. Low-income Californians were defined in the survey as having household incomes less than 200 percent of the federal poverty level, or $48,000 for a family of four.

Some of the biggest gains in satisfaction were at community health centers, which see the largest share of the low-income population and received billions of dollars underthe health law to improve their services. Patients there gave higher scores to courtesy and cleanliness than in 2011, and more said somebody at their facility knew them well.

Community clinics have undergone a culture shift because of the Affordable Care Act and started to focus more on patient satisfaction, said Peter V. Long, president of the foundation.

“They realized, ‘We have to do things differently or it’s going to be a challenging world for us,’” he said. “They have prioritized this and actually made a difference.”

Many, for example, began assigning patients to a specific doctor. That continuity of care makes a big difference to patients and helps them develop a relationship with the community clinics, Long said. “Having the same doctor and having someone who knows me and cares about me builds that level of trust,” he said.

There is still room for improvement, the report said. Just 34 percent of patients at clinics serving low-income patients gave high marks for wait times. And low-income patients in general said it was difficult to get a night or weekend appointment and to access specialists.

Carmela Castellano-Garcia, president of the California Primary Care Association, said there was an understanding among clinics that the environment would be more competitive after the health law took fuller effect. Under Obamacare, many uninsured patients became eligible for free coverage through Medi-Cal or subsidized plans through

Covered California, the insurance exchange. As a result, they had more choices about where to seek care.

To retain patients, Castellano-Garcia said they devoted significant resources to improving both care and customer service. The survey showed that the changes made a difference, she said.

“This is a great shot in the arm and shows the clinics that their efforts and investments are paying off,” she said.

Researchers surveyed more than 1,500 Californians between August and October of 2014. The margin of error was plus or minus 4 percentage points for the low-income sample. The survey included patients at community clinics, public and private clinics, as well as doctors’ offices and other settings.

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