“As the backlash over narrow physician networks continues to make headlines and lawmakers start the August recess, a new nationwide survey found 76 percent of likely voters support a bipartisan proposal to give Medicare patients better medication access and more choice of pharmacy.
Bait-and-switch. That’s the common refrain expressed by patients in recent articles about the narrow network trend, from Morning Consult to The New York Times to USA TODAY. Patients report either not knowing or being misinformed about restrictions on their access to the doctor of their choice. As a result some are racking up significant, unanticipated out-of-pocket costs. Now both regulators and insurance plans alike are reassessing the situation and contemplating adjustments for 2015.
It’s not just doctors, however. Patient access to medication and consultations on its proper use with the pharmacist they know and trust are also suffering. Particularly in Medicare drug plans, insurance middlemen are telling some patients to pay more – sometimes significantly more – or switch pharmacies, even if it means traveling 20 miles or more.
But perhaps unlike the physician narrow network conundrum, there is an easy, obvious solution to the narrow pharmacy network issue in Medicare drug plans: H.R. 4577, the Ensuring Seniors Access to Local Pharmacies Act.
The bipartisan proposal would give seniors in medically underserved areas more convenient access to medication at discounted or “preferred” copays at additional pharmacies that are willing to accept the plan’s terms and conditions. Currently, independent community pharmacies are usually locked out of these smaller or “preferred” networks. Moreover, when community pharmacists offer to accept the same terms and conditions they are still kept out. Independent pharmacies make up approximately half of all rural pharmacies, so their patients must pay this “rural tax” or travel great distances to reach a “preferred” pharmacy.
Three out of four likely voters (76 percent) support this proposal, according to a recent nationwide opinion survey conducted by Penn Schoen Berland, or PSB Research. Support runs across party lines as well as demographic ones, such as gender and age.”
“Businesses with fewer than 50 workers are exempt from the most stringent requirements for larger employers under the federal health-care law. But that doesn’t mean they’re off the hook entirely.
Smaller employers aren’t required under the Affordable Care Act to offer coverage for their full-time workers—as larger firms must by 2016 or face penalties, for instance. But many owners of small ventures and startup entrepreneurs are nonetheless facing big changes to how they obtain their own health coverage, as well as to the benefits they’re able to offer employees.
“It’s a myth that smaller firms aren’t being hit” by the health law, albeit in less obvious ways, says James Schutzer, president of the New York State Association of Health Underwriters, referring to employers with fewer than 50 workers.
Several thousand of the nation’s smallest business owners—sole proprietors and the self-employed—were kicked off their small-business plans by carriers earlier this year. That is because new guidelines define “employers” as having at least two full-time employees, not including a spouse, in order to be eligible for group plans.”
“One of the ongoing questions about the Affordable Care Act (ACA) is its impact on rural areas, many of which had lacked a competitive individual market for health insurance. Would the ACA foster competition among plans in these areas? Or would they be dominated by one or two insurers and face higher premiums and fewer plan choices than their urban counterparts?
This data brief examines 2014 premiums, issuers, and plans offered to residents of urban and rural counties. In 2014, while it appears that residents of rural counties, as a whole, did not face higher premiums than residents of urban counties, substantial differences emerge within a number of states and between states of varying degrees of rurality. In particular, states with largely rural populations face fewer choices and higher premiums. These are the states to watch in the coming months as new issuers enter the marketplaces and 2015 premiums are filed.”
“A year ago, investors worried that WellPoint Inc. would lose more of its small business customers than it could offset by signing up individuals in the Obamacare exchanges.
The first half of those concerns were justified—and then some. Indianapolis-based WellPoint is seeing its small business customers dump their group health plans and move their workers to the Obamacare exchanges at a faster clip this year than it expected.
Already in 2014, WellPoint has watched 218,000 members of its health plans disappear because their employers have ended their group health plans. That’s a 12-percent drop in WellPoint’s overall small group membership.
As I have reported before, the Obamacare tax credits for individuals have proven quite attractive for many employers with fewer than 30 workers. That’s not to say all are taking this route. Most other health insurers have reported that small employers are ending their health plans more slowly than expected.
But WellPoint expects the trend of its small business customers ending their group health plans to play out in just two years, with roughly $400 million in annual profit disappearing.
“We think [that] will be in a more accelerated timeframe over a shorter window of time, meaning this year and next, than over a longer period of time,” said WellPoint Chief Financial Officer Wayne DeVeydt during a July 30 conference call with investors.”
“Republicans were quick to pounce Monday on Florida’s announcement that residents buying health insurance on the individual market for next year will face a 13.2 percent average increase in monthly premiums — one of the steepest rate hikes announced for any state. “Obamacare is a bad law that just seems to be getting worse,” said Florida Gov. Rick Scott, a Republican who is running for re-election.
But consumer advocates and Sen. Bill Nelson, D-Fla., the state’s former insurance commissioner, blame the increases on Florida lawmakers’ decision last year to suspend the state’s authority to negotiate and approve premiums on policies sold to people who buy insurance themselves instead of getting it through an employer.
The Republican-controlled Florida legislature voted to cancel that authority until 2016 because it did not want to have any involvement with insurance plans sold through the Affordable Care Act, saying that job should be done by the Obama administration. The federal government has authority to review but not change insurance rates.”
“CHATTANOOGA, Tenn. — The dominion of Tennessee’s largest health insurer is reflected in its headquarters’ lofty perch above the city, atop a hill that during the Civil War was lined with Union cannons to repel Confederate troops.
BlueCross BlueShield of Tennessee has used its position to establish a similarly firm foothold in the first year of the marketplaces created by the health law. The company sold 88 percent of the plans for Tennessee individuals and families. Only one other insurer, Cigna, bothered to offer policies in Chattanooga, and the premiums were substantially higher than those offered by BlueCross.
Though insurers have been regularly vilified in debates over health care prices, BlueCross’ near monopoly here has been unusually good financially for consumers. Its cut-rate exclusive deal with one of three area health systems turned Chattanooga into one of the 10 least expensive insurance markets in the country, as judged by the lowest price mid-level, or silver, plan. The premium for a 40-year-old for that plan is $181 a month, 30 percent less than for the median cheapest silver plan nationally.”
“Giving health-care providers a lump sum payment for certain treatments – touted as a way to save money and improve coordination of care — yielded disappointing results for some major California hospitals and insurers, a study found.
The RAND Corp. study, funded by a $2.9-million federal grant, looked at “bundled payments” for care of insured orthopedic patients under 65 at a handful of large hospitals and insurers in California.
Six of the state’s biggest insurers and eight hospitals started out in a pilot program in 2010, but only three insurers and two hospitals actually decided to enter contracts to adopt bundled payments. The others dropped out because they didn’t think bundled care, such procedures as total knee replacement surgery, would change the delivery of care significantly or lower costs, according to the study, published in the journal Health Affairs Monday.
The pilot project resulted in such a small number of hospital cases that it was hard to draw conclusions about how bundled payments affect health care quality or costs, which were the initial goals of the study, the researchers reported. Two ambulatory surgery centers managed to partner with an insurance company and had a higher volume of cases, but generally health plans have been slow to contract with them, the study found.
“That was unexpected,” said Susan Ridgely, the lead author of the study and a senior policy analyst at RAND, a Santa Monica, Calif.-based think tank. “They were a bit more flexible and also wanted the business, but hospitals began to see that it required too much time and effort or maybe that it was not in their best interest.””
“Newly hired employees who don’t sign up for health insurance on the job could have it done for them under a health law provision that may take effect as early as next year.
But the controversial provision is raising questions: Does automatic enrollment help employees help themselves, or does it force them into coverage they don’t want and may not need? A group of employers, many of them retail and hospitality businesses, want the provisions repealed, but some experts say the practice has advantages and is consistent with the aims of the health law.
By enrolling people unless they opt out, “you’re changing the default option,” says Caroline Pearson, vice president at Avalere Health, a research and consulting firm. The health law does the same thing by requiring people to have insurance or face penalties, she says.
“You’re not eliminating people’s choice or forcing people into things they don’t want,” Pearson adds.
Under the health law, companies with more than 200 full-time workers have to enroll new, full-time employees in one of the company health plans unless the employee chooses not to join. The Department of Labor said that employers aren’t required to comply until the agency issues regulations spelling out how to do so. The department delayed its initial plan to issue regulations by 2014, and at this time there’s no additional information available about when regulations will be issued, according to a DOL spokesperson. Industry experts are split on when to expect those regulations, with some believing regulations could take effect in 2015, while others say that is unlikely.”
“The Affordable Care Act may be the law of the land, but some states are still doing their best to avoid it. Nearly half the states have refused to participate in the law’s expansion of Medicaid. Some describe this reluctance as tantamount to a moral crime—see Virginia Governor Terry McAuliffe’s recent statement that expansion’s opponents are “prevent[ing] their own constituents from getting access to health care.”
As a doctor, I know this isn’t true. Medicaid is sold to the public as a magic pill that will solve the poor’s inadequate access to medical care. But reality isn’t so simple.
Simply put, Medicaid gives patients terrible access to medical care. A recent study found that nearly a third of doctors no longer accept new Medicaid patients. In some states, as many as 60 percent don’t. Why not? Because Medicaid operates in a world without economic logic.
Bureaucrats in Washington dictate how much money doctors receive for the treatments and services they provide. Unfortunately, on average they reimburse at less than the actual cost—the average Medicaid reimbursement is 40 percent less than the reimbursement from private insurance.
Medicaid payments don’t even match the reimbursement rates for Medicare. Primary care receives 59 cents for every Medicare dollar. Obstetric care receives 78 cents. Overall, Medicaid receives 66 cents for every Medicare dollar—a one third cut for the exact same service.”
“The top federal prosecutors from South Dakota and North Dakota say they have increased their efforts to fight healthcare fraud.
U.S. Attorney Brendan Johnson of South Dakota said he has restructured his office to allow lawyers in the criminal and civil divisions to devote “significant time” to investigating medical fraud. He predicted it will be among the fastest-growing area of criminal investigation and wants his office to be in position to pursue increasing “complex and egregious” cases.
“My advice to the medical community is to stay away from gray areas or outright fraud that wastes tax dollars, because we will be watching,” Johnson told the Sioux Falls Argus Leader. “The end result in many of these cases will be that the taxpayers get their money back with interest and penalties, and the medical professional loses their license.”
Johnson’s office recently settled an alleged fraud case involving two doctors at Dakotas-based Sanford Health. Court documents show that Sanford paid $625,000 to settle the lawsuit, in which the doctors and the hospital did not admit wrongdoing. Cindy Morrison, Sanford’s executive vice president for marketing and public policy, said the hospital settled to avoid distraction.
“For us, it’s the issue of time and expense,” she said.”