Cooperating for better care.

Uncategorized

Category Archives

Clay Masters: Death of a big healthcare co-op in Iowa

(Clay Masters is a Iowa Public Radio journalist.)

It was a heck of a Christmas for David Fairchild and his wife, Clara Peterson. They found out they were about to lose their new health insurance.

“Clara was listening to the news on Iowa Public Radio and that’s how we found out,” Fairchild says. They went to their health plan’s Web site that night. “No information. We still haven’t gotten a letter about it from them.”

The two are the sole employees of a cleaning service and work nights. Fairchild has chronic leukemia but treats it with expensive medicine. Last year they saved hundreds of dollars switching from the insurer Wellmark to a plan run by CoOportunity Health. For the first time in a long time, Fairchild says, they felt like they had room to breathe.

Married couple David Fairchild and Clara Peterson stand in the living room of the Story City home. They own a small cleaning business and were on CoOpportunity Health before it faltered (Photo by Clay Masters/IPR)

“Basically it covered our office visits; covered exams,” he says. “It covered all but $40 of the medicine every four weeks. It was just marvelous. It probably was too good to be true.”

It was for them. CoOportunity Health has failed. The Affordable Care Act set aside funding for healthcare co-ops, to enable the organizations to compete in places where there aren’t many insurers. CoOportunity Health was the second largest co-op in the country in terms of membership, and one of the largest in terms of the federal funding it received.

But then CoOportunity hit a kind of perfect storm, says Peter Damiano, director of the University of Iowa’s public policy center. First, the co-op had to pay a lot more medical bills than those in charge expected.

“CoOportunity Health’s pool of people was larger than expected, was sicker than expected,” Damiano says. “So their risk became much greater than the funds that were available,”

The reason the co-op’s customers were sicker has a lot to do with what the insurance market looked like in Iowa before Obamacare. The largest insurer by far in the state was and still is Wellmark. But Wellmark decided not to offer any plans on Iowa’s health exchange, leaving just CoOportunity and one other insurer — Coventry — offering plans on the exchange throughout the state.

On top of that, when the Obama administration in late 2013 allowed people to keep the insurance plan they already had, many customers happy with Wellmark stayed put. Damiano says this meant many of the customers who flocked to CoOportunity tended to be like Fairchild — people with expensive health problems who’d had trouble paying for insurance before, in the market Wellmark dominated.

“It was always going to be a challenging market to try to reach,” says Damiano, “and on top of that, the whole idea of co-ops was relatively new and experimental. But it was to try to create competition, on that private sector approach,” says Damiano.

Not only were the patients sicker, but CoOportunity’s leaders initially thought they would enroll about 12,000 people in Iowa and Nebraska. They got about ten times that, according to Nick Gerhart, Iowa’s insurance commissioner.

Also, Gerhart says, the co-op thought it was going to get more federal money.

“On December 16 around 4 o’clock we were informed they weren’t going to get any further funding,” he says. “Nothing was pulled — it just wasn’t extended further.”

Gerhart is now essentially the CEO of the co-op because the state has taken it over. He likens the situation to a small business suddenly having its credit shut off by the bank. Even though CoOportunity is not officially dead yet, Gerhart is telling its customers to switch insurers.

Co-Opportunity Health is housed in West Des Moines, Iowa (Photo by Clay Masters/IPR).

He says it’s too early to make predictions about the fate for all co-ops.

“Ours was the second largest in the country, so you’ve got to look at it that way.” Gerhart says. “If the second largest can’t make it, how viable are the other ones? I don’t know. But at the end of the day they didn’t have enough capital to support 120,000 members.”

In a written statement, Dr. Martin Hickey, chairman of the board of the National Alliance of State Health Co-Ops, said, “The news about CoOportunity Health is not a statement on the health insurance co-op program or the co-op concept. It’s a reflection on the fact that all insurers — not just co-ops — are operating in unique markets with unique business plans and varying state regulations. The circumstances for CoOportunity Health in Iowa are not the same as those in the 23 other states in which co-ops are currently operating.”

But the co-op’s failure in Iowa has left David Fairchild and Clara Peterson scratching their heads.

“I mean the whole Affordable Care Act is [about] competition between insurance companies, and now we’re back down to what?” says Peterson.

For them, only one option: Coventry. They’ve already applied through healthcare.gov and now they’re now waiting for approval for a plan that will cover a lot less of Fairchild’s medicine expenses.

This story is part of a partnership between NPR and Kaiser Health News.

 


The NP invasion continues

New York State nurse practitioners in New York  will have greater independence and, probably more income now that new rules under the state’s  Nurse Practitioner Modernization Act are in effect.

”The rules stipulate that nurse practitioners with more than 3,600 hours of clinical practice no longer need to work under a written collaborative agreement with a physician. The required clinical experience equates to about two years in clinical practice. Nurse practitioners with less than the required amount of experience will still be required to work under a physician….”

“The only requirement that remains that will tie experienced nurse practitioners to physicians or hospitals is that they must maintain an established relationship for referral or consultation.”

The rules also let NP’s diagnose illness, and perform therapeutic and corrective measures. Up until Jan. 1, 2015, nurse practitioners could only perform these functions within collaboration with a physician.

The effect of the new rules, besides making primary-healthcare more accessible just by sheer force of added staffing over time, will be to tend to pull down the income of physicians, especially internists and family practitioners. After all, you can train and put to work more NP’s more quickly than you can physicians and NP’s will usually be paid less.

The payers, be they private and public insurers and patients, will see the rise of NP’s as opportunity for more primary care at lower cost. A big question, of course, is how specialized NP’s might  also erode the very high compensation of such specialists as cardiologists.


Integrating general pediatrics and mental health

As part of a much wider push for integrated care, psychiatrists are teaming up with general pediatricians

Indeed, as this Wall Street Journal story reports:

”Now, more pediatricians are embedding mental-health professionals into their practices, where they can help spot problems early, provide care fast or reassure parents that a child’s behavior is normal.”

This integrated care … has other advantages: ”Pediatricians often see patients annually for a decade or more and follow families closely. If issues arise, instead of giving parents a referral, they can do a ‘warm handoff,’ personally introducing them to a therapist down the hall. In some practices, mental-health professionals evaluate patients and devise treatment plans that pediatricians or nurses carry out.”
Further, “there is less stigma associated with a doctor’s office than a mental-health clinic, so families are more receptive to treatment.”

Insurance-coverage rules have kept integrated care from catching on more widely and there aren’t enough psychiatric social workers and clinical psychologists. But physicians are getting insurers’ attention that this needs to change.

 

 

 

 

 


Flood of young stroke victims

 

Research from the Centers for Disease Control and Prevention show the rare of ischemic stroke jumping for younger people even as it has been falling for older people. This poses new challenges for long-term care and rehabilitation programs, both for hospitals and outpatient facilities.


A push to make physician telementoring easier

The Houston Chronicle editorializes that overregulation of  medical training in some states  hurts efforts to train physicians in surgery and other specialties. In this case it refers to  telementoring, an educational initiative between doctors. not to be confused with telemedicine, the distance relationship between physician and patient.

The problem is that most states, including Texas, ”require a physician to obtain a medical license in that state before serving as a mentor.”The Chronicle asserts that this  regulation ”is overkill and makes no sense. Doctors and surgeons should be able to learn from and teach doctors around the country no matter where they are licensed. Texas could become a national leader in physician best practices by clarifying its licensing requirements to allow doctors and surgeons in all areas of practice to enter into mentor relationships with experts and learners out of state. ”


Share of patients delaying care plunges

The Commonwealth Fund reports that the  number of Americans who delayed needed medical care fell substantially last year,  information that suggests that the Affordable Care Act might be substantially improving  access to healthcare.

The Minneapolis Star Tribune said the fund reported that “from 2012 to 2014, the share of consumers delaying a recommended test or treatment or not filling a prescription fell by nearly a third. And the percentage who reported problems with medical bills fell by almost a quarter,” the first such declines recorded by the fund.



 

 


Reinhardt’s plan for changing physician-management model

* Develop ”five-year plans on the premise that the traditional, cost-plus reimbursement model will persist for very long is a bad idea. It probably won’t.”

* Consider ”the upfront losses {they} take on newly employed physicians as just another investment in the long-term future of your enterprise.”

* Don’t ”treat physicians as regular employees. Work to avoid their resentment against too distant and too opulent a C-suite. Instead, … make physicians feel part of the management team that jointly makes or breaks your enterprise. That includes regularly sharing managerial and financial data on your enterprise.”

* Consider “a workable alternative to employing physicians—e.g., the Kaiser Permanente model, the mother of all ACO’s.”

New beneficiaries not fueling Medicare Advantage growth

 

Kaiser Health News reports that ”the majority of people who signed up for Medicare Advantage plans in recent years were switching out of the traditional Medicare program, according to a recent study. The findings contradict the popular belief that growth in Medicare Advantage has been fueled primarily by people who choose it when they first become eligible for Medicare.”

Translation: The switchers liked the mix of prices and services provided by Medicare Advantage plans even though they can have narrow provider networks.


Execs say the ACA too entrenched to be killed

 

trench

 

Top healthcare executives say that the Affordable Care Act is far too entrenched to be killed  by Republicans on Capitol Hill.

Repeal of the ACA “is not a possibility,” George Scangos, chief executive at biotechnology company Biogen Idec Inc., told Reuters . “They {the Republicans} would somehow have to explain to millions of people that they will lose health insurance.”

Aetna Inc. said it is talking to Republicans and Democrats about a possible “grand bargain” to salvage  the ACA if the U.S.  Supreme Court rules against key elements of the law later this year.

“Blowing up the (Affordable Care Act) is like shutting down the government,” Aetna Chief Executive Officer Mark Bertolini told some investors. “So we are having conversations on both sides of the aisle about what … things you change in the ACA, what we could introduce, about how to make a grand bargain should the Supreme Court decide.”

 

 


Surprising recoveries in Boston

250px-Folio_171r_-_The_Raising_of_Lazarus
 

Primary-care intern Jessica Hoy, M.D., writes in MedPage Today’s ”I, Intern” series about unexpected recoveries  of patients in the past six months at Brigham and Women’s Hospital. in Boston.

 


Page 362 of 369First...361362363...Last

Contact Info

info@cmg625.com

(617) 230-4965

Wellesley, Mass