“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.”
“Nancy Pippenger and Marcia Perez live 2,000 miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers.
“They said, ‘We take the old plan, but not the new one,’” says Perez, an attorney in Palo Alto, Calif.
In Plymouth, Ind., Pippenger got similar news from her longtime orthopedic surgeon, so she shelled out $300 from her own pocket to see him.
Both women unwittingly bought policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks. Such plans existed before the health law, but they’ve triggered a backlash as millions start to use the coverage they signed up for this year through the new federal and state marketplaces. The policies’ limitations have come as a surprise to some enrollees used to broader job-based coverage or to plans they held before the law took effect.
“It’s totally different,” said Pippenger, 57, whose new Anthem Blue Cross plan doesn’t pay for any care outside its network, although the job-based Anthem plan she had last year did cover some of those costs. “To try to find a doctor, I’m very limited. There aren’t a lot of names that pop up.””
Words mean what they say. That’s the basis for the decision of the U.S. Court of Appeals for the D.C. Circuit in Halbig v. Burwell invalidating the Internal Revenue Service regulation approving subsidies for Obamacare consumers in states with federal health insurance exchanges.
The law passed by Congress, Judge Thomas Griffith explained, provided for subsidies in states with state-created exchanges, but not in states with federal exchanges. That’s factually correct, and under the Constitution, the government can’t spend money not authorized by Congress.
This has not prevented Democrats from calling the decision “judicial activism,” which makes as much sense as the claims that the Supreme Court decision overturning the Obamacare contraception mandate cuts off all access to contraception.
“We reach this conclusion,” wrote Judge Griffith, “with reluctance.” Judge Roger Ferguson, writing for the Fourth Circuit whose King v. Burwell decision upholding the IRS was announced the same day, wrote that those challenging the government “have the better of the statutory construction arguments.”
One has a certain sympathy with both judges. They’re being asked to overturn a regulation that has paid most of the cost for health insurance for some 4.7 million Americans. But the problem arose not from sloppy legislative draftsmanship.
Under previous court decisions, Congress can’t force state governments to administer federal laws. So congressional Democrats, seeking to muscle states into creating their own health insurance exchanges, chose to provide subsidies only for those states. Those opting for the federal exchange would have to explain to voters why they weren’t getting subsidies.
“The Obama administration signaled Thursday it’s not backing down from the controversial health law employer mandate that has been delayed twice and is the centerpiece of the House’s lawsuit against the president.
The IRS posted drafts of the forms that employers will have to fill out to comply with the Obamacare requirement that employers provide health insurance to workers.
Some business groups said the information was still too tentative and too incomplete to let them prepare for new obligations under the health law. “Our immense frustrations with the IRS continue,” Christine Pollack, vice president of Government Affairs at the Retail Industry Leaders Association, said in a statement.
An administration official said the White House is sticking to the timeline announced earlier this year. Companies with 50 to 99 employees will have another year — until 2016 — to start the coverage. Companies with 100 or more employees do have to comply next year, although they have two years to phase up so that they are covering 95 percent of their workers. Smaller businesses are exempt.”
“The essential health benefits (EHBs) countdown is on for 2016.
That’s when this provision of the Affordable Care Act, which sets out 10 specific health services that must be covered by plans sold on the exchanges, will likely be reviewed by the Department of Health and Human Services. Business interests and consumer advocates are already making their positions clear – the former pushing for greater consciousness of premium costs and the latter looking to safeguard consumers’ coverage.
During a July 21 Capitol Hill briefing, members of the Affordable Health Benefits Coalition, a business interest group including the U.S. Chamber of Commerce and the National Retail Federation, said they would push to reshape essential benefits, arguing that current regulations have led to unaffordable hikes in insurance premiums.
Current policy requires plans cover emergency services, pre- and post-natal care, hospital and doctors’ services, and prescription drugs, among other things. The rule lets states decide how specifically to interpret those categories.”
“The two contradictory appeals court decisions that cast the future of Obamacare into uncertainty Tuesday morning largely center on a question of intent: When the Affordable Care Act was conceived and drafted, did its creators mean to withhold health care subsidies from people living in states that refused to set up their own exchanges?.
This latest legal challenge focuses on four words in the mammoth law authorizing tax credits for individuals who buy insurance through exchanges “established by the States.” Thiry-six states declined to set up their own exchanges — far more than the law’s backers anticipated — and in those states, consumers have been shopping for health care on exchanges run instead by the federal government. Now the D.C. Circuit Court of Appeals has ruled that these consumers are not eligible for subsidies because, well, they bought their insurance on exchanges not “established by the States.”
This is a tremendously literal interpretation of a small but crucial part of the law, and it’s one that was arguably never intended by its creators. The plaintiffs in these challenges have argued that the ACA always meant to exclude noncooperative states from subsidies as a way of incentivizing those states to create their own exchanges. Supporters of the law — including the Obama Administration — counter that such intent would never have made any sense in the larger context of a law aiming to expand health insurance to as many people as possible.”