A project of the Galen Institute

Issue: "Quality/Access"

Narrow Networks Bill Passes Floor Vote

David Gorn, California Healthline
Fri, 2014-08-29
"The Assembly this week approved a bill to limit narrow networks in California's health plans. The legislation already passed a Senate vote and is expected to get concurrence today on the Senate floor and move to the governor's desk for final approval. SB 964 by Sen. Ed Hernandez (D-West Covina) directs the Department of Managed Health Care to develop standardized methodologies for health insurers to file required annual reports on timeliness compliance, and requires DMHC to review and post findings on those reports. It also eliminates an exemption on Medi-Cal managed care plan audits and requires DMHC to coordinate those plans' surveys, as well. "I introduced the bill in response to complaints we’ve heard about inadequate networks in the Medi-Cal program, as well as at Covered California," Hernandez said.

Cover Oregon turnaround consultant's bills grew to $600,000-plus as exchange obstacles multiplied

Nick Budnick,The Oregonian
Fri, 2014-08-29
"The price tag of the Cover Oregon health insurance exchange fiasco continues to grow. As Clyde Hamstreet, the corporate turnaround expert hired to lead Cover Oregon in April, wraps up his work he leaves behind a stabilized agency – and a hefty bill. Initially signed to a $100,000 contract, Hamstreet ended up staying longer than expected, with two associates joining him at Cover Oregon after Gov. John Kitzhaber essentially forced out three top officials there in a public display of house-cleaning. Through July, Hamstreet has billed $598,699 on an amended $750,00 contract. He hasn't submitted his August invoice. He says the price tag was driven by the exchange's increasing needs, as his firm stayed longer and did more than initially planned. "We didn't do this job to make a lot of money off the state," he said Thursday. "Our philosophy was to try and help get the boat righted and try to help clean things up and basically help the state. ...

As many as 1 in 5 exchange enrollees affected by technical problems, staff concedes

Carol Ostrom, Seattle Times
Fri, 2014-08-29
"A lack of transparency in describing and fixing technical problems became an issue in Thursday’s Washington Health Benefit Exchange Board meeting. Board member Bill Hinkle grew testy at what he said was mutual staff back-patting and excuses for the problems still plaguing thousands of accounts. “C’mon you guys, let’s quit blowing smoke here,” Hinkle said. “I’m tired of patting people on the back….We’re not doing great yet.” Board member Teresa Mosqueda pressed staff for numbers of enrollees affected by technical problems. “We really need to have the data in front of us to manage some of these issues,” she said.

Beware Of Higher Charges If You Go To An Out-Of-Network Emergency Room

Michelle Andrews
Kaiser Health News
Fri, 2014-08-29
"When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.) That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.

3 ways insurers can discourage sick from enrolling

The Associated Press
Thu, 2014-08-28
"Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul. But consumer advocates warn that companies are still using wiggle room to discourage the sickest — and costliest — patients from enrolling. Some insurers are excluding well-known cancer centers from the list of providers they cover under a plan; requiring patients to make large, initial payments for HIV medications; or delaying participation in public insurance exchanges created by the overhaul. Advocates and industry insiders say these practices may dissuade the neediest from signing up and make it likelier that the customers these insurers do serve will be healthier -- and less expensive. “It’s the same insurance companies that are up to the same strategies: Take in as much premium as possible and pay out as little as possible,” said Jerry Flanagan, an attorney with the advocacy group Consumer Watchdog."

Medicare Limbo: A Question Seniors Need To Ask If They're In The Hospital

Northwestern Mutual team
Forbes magazine
Wed, 2014-08-27
"Bill Jacobs spent four nights in a hospital in Florida battling pneumonia. His kids visited each day, fluffed his pillows, brought his favorite Sudoku puzzles and got regular updates from his nurses and doctors. Imagine their surprise when they found out that their 86-year-old father was never actually admitted; instead, he was treated as an outpatient under what Medicare refers to as “observation status.” What difference does that make? Actually, more than you might think. If your parents are on Medicare, the difference between being considered an inpatient or an observation patient could be thousands of dollars out of their pocket, if not more. First, Medicare Part A will cover all hospital services, less the deductible, but only if you’re admitted to the hospital as an inpatient. The one-time deductible covers all hospital services for the first 60 days in the hospital. Doctors’ charges are covered under Medicare Part B.

When Medical Care Is Futile, Other Patients Pay The Hidden Price

Richard Knox
WBUR
Wed, 2014-08-27
"Every day in intensive care units across the country, patients get aggressive, expensive treatment their caregivers know is not going to save their lives or make them better. California researchers now report this so-called “futile” care has a hidden price: It’s crowding out other patients who could otherwise survive, recover and get back to living their lives. Their study, in Critical Care Medicine, shows that patients who could benefit from intensive care in UCLA’s teaching hospital are having to wait hours and even days in the emergency room and in nearby community hospitals because ICU beds are occupied by patients receiving futile care.

Cover Oregon: At least 2,000 Oregonians need to change coverage due to health exchange errors

Nick Budnick, The Oregonian
Wed, 2014-08-27
"Cover Oregon will hold a special open enrollment period for 1,400 Oregonians who were incorrectly enrolled into the low-income Oregon Health Plan by the state's troubled health insurance exchange. Starting Aug. 31, the people affected will have no coverage through the OHP, the state's version of Medicaid. However, they will have the option to sign up for coverage from private insurers and to qualify for tax credits through Cover Oregon to bring down premiums. Meanwhile, Cover Oregon is contacting at least 700 people who should have been enrolled in the Oregon Health Plan, but were incorrectly enrolled in a commercial health plan instead. If they were receiving tax credits for private plans, those will go away immediately, though they can keep their plan. Cover Oregon is currently negotiating with the federal government over whether those people will have to refund to the IRS all the tax credits they received incorrectly, said Amy Fauver, Cover Oregon communications director.

Pharma tells the Federal Government: Transparency Works Both Ways

Peter Loftus
Wall Street Journal
Wed, 2014-08-27
"File this under ‘how ironic.’ Drug makers are asking for more transparency from the government agency that is requiring them to be more transparent about how much they pay doctors. The Pharmaceutical Research and Manufacturers of America, or PhRMA, is calling on the Centers for Medicare and Medicaid Services to further explain why the agency has removed one-third of the payment information from an online database that is due to be made public by Sept. 30. Earlier this month, CMS said it would withhold about one-third of the payment data from the so-called “Open Payments” system. The agency also said it would return the records to drug makers because they were “intermingled,” including the erroneous linking of payment information for some doctors to still other doctors with similar names.

Universities nationwide limit student employment to comply with Obamacare

Caleb Bonham, Campus Reform
Wed, 2014-08-27
"Middle Tennessee State University (MTSU) is restricting student work because of compliance issues associated with the Affordable Care Act (ACA), commonly known as Obamacare. In an email last week, MTSU President Sidney McPhee explained that “due to our interpretation of the reporting requirements of ACA,” graduate assistants, adjunct faculty members, and resident assistants are barred from working on-campus jobs that exceed 29 hours of work per week. "[E]ffective beginning with the fall semester, we will no longer allow part-time employees, or those receiving monthly stipends from the university, to accept multiple work assignments on campus." Tweet This Now, they cannot take on multiple campus jobs. “[E]ffective beginning with the fall semester, we will no longer allow part-time employees, or those receiving monthly stipends from the university, to accept multiple work assignments on campus," the email stated. McPhee noted that violations of the law “could add up as high as

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