Obama Health Care

As a physician legislator, I have the opportunity to scrutinize almost every program that Arizona funds. One of the largest is our state Medicaid program, AHCCCS. In the hospital, I treat many AHCCCS patients, but the more I learn about the program in the Legislature, the more impressed I am with it. Arizona may be sitting on the solution to our national health-reform debate.

Public-private partnership

The Arizona Health Care Cost Containment System was created in the 1980s to serve as our state Medicaid program. The last state to establish such a program, Arizona used a new model that had not been previously attempted: managed care instead of fee-for-service.

This setup relies on a partnership between the state and private health plans. The health plans have a profit cap and voluntarily bid for contracts. The winning bidder receives a large guaranteed pool of patients.

AHCCCS-eligible patients get to choose an available health plan in their region and a primary-care provider. More than 80 percent of the primary-care doctors in Arizona are contracted. Prescription-drug coverage is broad and low-cost. Members can go to just about any hospital when needed. About 1.3 million Arizonans, 20 percent of our population, rely on AHCCCS for their health coverage.

Quality, efficiency

Unfortunately, some people assume care provided through AHCCCS is of low quality. That assumption is absolutely wrong. AHCCCS covers Arizonans with a remarkable degree of quality and efficiency. In fact, the benefit package for AHCCCS members is as good as or better than most private plans.

Furthermore, AHCCCS requires contracted health plans to focus on prevention, including weight management, immunizations, cancer screenings, blood pressure, cholesterol and diabetes checks. This keeps patients out of the hospital, saving money in the long run.

Most efficient in U.S.

The Kaiser Family Foundation recently ranked AHCCCS as the least expensive to operate of all 50 state Medicaid programs, citing the low cost per member per month. Combined with the impressive set of benefits AHCCCS provides, Arizona taxpayers get the most bang for their buck. Overhead costs are among the lowest in the nation at only 3.3 percent, and provider-reimbursement rates are surprisingly competitive.

We have in AHCCCS an efficient government program that provides excellent coverage to qualified families through a public-private partnership within a health-insurance exchange that has won national recognition for its success.

AHCCCS has been working well for the people of Arizona for more than two decades. This model for health-care delivery works. Health-reform proponents would be well served to closely examine AHCCCS and learn from its accomplishments.

Focus on the people

One of my patients recently shared his thoughts about health reform from his hospital bed saying, “It’s time for the human family to come together and take care of itself.” I appreciated the compassion and civility in his words as he assessed our ongoing efforts. If we truly are committed to resolving the problems facing our health system in a meaningful way, we will keep the focus on patients and people, and we will come to a solution. I suggest that we look to AHCCCS as a proven, efficient model for national health reform.

Rep. Matt Heinz, a Dem

Chad
http://www.articlesbase.com/insurance-articles/ahcccs-a-model-for-nation-matt-heinz-1258461.html

According to a March 5, 2007, Reuters newswire story, pediatricians throughout Texas and the U.S. are warning that new high-deductible health plans (HDHPs) are compromising patient care, especially among poorer children, with the unintended consequence of increasing medical costs.

The HDHPs, called “consumer-directed” plans by supporters, encourage people to take a more active role in their medical care.

But the American Academy of Pediatrics has joined other plan critics who fear high deductibles in the plans will lead patients to skip preventive care, most importantly immunizations and annual physicals for children. And this could lead to costlier treatment down the road, for example, if a patient winds up in an emergency room.

“Faced with difficult choices, families may seek to ‘load up’ on a scheduled visit to save money or delay care until after the deductible is met,” the group wrote in the March issue of Pediatrics, the official journal of the American Academy of Pediatrics,. The Academy represents 60,000 physicians in the United States specializing in treating children.

The report comes as the share of U.S. employers offering health insurance has been slipping, according to the nonprofit Kaiser Family Foundation. Roughly 60 percent offered health coverage during 2005, down from 69 percent in 2000. Health insurance reform has become a national issue as the ranks of the uninsured rises steadily, now at 46.6 million, or 17 percent of the U.S. population.

In 2005, in lieu of dropping health coverage, about 30 percent of large and midsize corporations offered the high-deductible plans. These plans are typically are coupled with a pre-tax Health Savings Accounts (HSAs) used to pay for health costs. That compares with seven percent of companies polled by employee benefits consultant Watson Wyatt in 2004.

The nation’s biggest health insurance companies, such as UnitedHealth Group and WellPoint Inc., have touted high-deductible plans to employers as a way to rein in medical costs, by encouraging better health-care choices.

The plans are able to exempt preventive services from the deductible requirement, and about 30 percent of the existing plans do so, according to the pediatricians’ group. It recommends changing the tax code to compel the plans to exempt preventive care, in other words to not require a deductible. Deductible would, however, still apply to minor illnesses that can balloon to major illnesses without proper treatment.

The pediatrician’s group also worries that high-deductible plans will lead to a “destabilization” of employer-sponsored health insurance.

Some high-deductible plan critics also say patients with these plans are more likely than those with traditional insurance to skip prescriptions and fail to follow up with their doctors.

There are High Deductible Health Plans on the market that encourage customers to focus on preventive care.

Melih Oztalay
http://www.articlesbase.com/non-fiction-articles/pediatricians-in-texas-concerned-about-hdhps-124057.html

HIPAA stands for Health Insurance Portability and Accountability Act. It is a federal law enacted in 1996 as an attempt at incremental health care reform and experts consider it to be the most significant health care legislation since Medicare in 1965.

HIPAA’s intent is to reform the healthcare industry by reducing costs, simplifying administrative processes and burdens, and improving privacy and security of patient’s information.

There are two separate and distinct laws that fall under the HIPAA umbrella: HIPAA Privacy and HIPAA Security.  HIPAA Privacy relates to the protection and privacy of individuals’ protected health information (PHI) while HIPAA security relates to the protection and privacy of individuals’ protected health information in electronic form (ePHI).  HIPAA Privacy is what most of us think about when we hear the term HIPAA ( HIPAA Awareness Training, Notice of Privacy Practices, Authorization forms, etc )whereas HIPAA Security tends to be more the focus of an organization’s IT department because it deals with encryption, electronic security, disaster recovery, etc.

Do you have to worry about HIPAA?  There are two main classifications under HIPAA: Covered Entities and Business Associates.  Covered Entities are those types of organizations/individuals that deal directly with protected health information and consist of healthcare providers, health insurance providers, and employer sponsored group health plans. Anyone outside of those categories is considered a business associate.  Business associates include medical billing companies, medical storage, marketing organizations, software companies, medical device manufacturers, etc. 

While the DHHS (Department of Health and Human Services) regulates covered entities, business associates are regulated by the covered entities they work with through a business associate agreement (alternatively called business associate contract).

HIPAA compliance involves two main components: one being HIPAA training of employees and the other implementing processes, procedures, and forms related to HIPAA.

While alot of regulations in HIPAA may seem like common sense, think of them as just providing some level of standardization so an individual and the organizations involved in their care can know what to expect of each other.

HIPAA compliance does not have to be a complicated process and once setup, can be relatively little effort to maintain.

John Grisham
http://www.articlesbase.com/regulatory-compliance-articles/what-you-should-know-about-hipaa-and-hipaa-compliance-592407.html

2009 is a critical year. Promised economic recovery and healthcare reform legislation are opportunities for meaningful financial commitments to mental health and addictions services and mental healthcare organizations are offering a practical actionable agenda:

- The integration of primary care services in behavioral health settings: The Healthcare Collaborative Project brings together behavioral health and primary care organizations offering a bi-directional approach for care. The need for behavioral health services in primary care is widely accepted. But the integration of primary care services in behavioral health settings remains controversial despite the fact that individuals with serious mental illness appear to have the worst mortality rates in the public health system. Therefore, mental healthcare organizations are actively pursuing single points of accountability to enhance continuity of care for this underserved population.

- Cost-based-plus financing that supports service excellence: People want and deserve quality services but quality services depend on skilled staff. Low salaries have created – and are perpetuating – a recruitment, retention, and quality crisis for behavioral healthcare. We need a workforce of skilled staff delivering nationally recognized practices within organizations that live by the rule “If you don?t measure it, you can?t improve it.”For mental healthcare organizations, healthcare reform is an opportunity to bring “parity” to public mental health services by ending the second class status of community mental health and addiction providers in America?s safety net.

- Federal mental health funding stream dedicated to mental health and integrated treatment services for the uninsured: The uninsured have exceptionally high rates of untreated mental illnesses with co-occurring addiction disorders and there is no safety net. State plans to cover the uninsured have all but disappeared and federal universal coverage plans may well be incremental. We have large numbers of individuals with treatable mental illnesses and addictions in our overburdened emergency rooms, in jails, and on the streets with no access to services that can engage them, treat them and return them to work. We must stop denying our economy productive taxpayers and wasting human lives.

- Eligibility for social security disability for people with addiction disorders: Addiction has come a long way from the days when it was perceived as merely a failure of will. Today, there is growing public awareness and acceptance of addiction as a chronic, relapsing condition that requires continual monitoring and management, as do other chronic illnesses like diabetes, asthma, and hypertension and yes, mental illness. If we accept addiction as a chronic illness then we must advocate that people with addiction disorders be eligible for disability support.

- Funds to support investments by behavioral healthcare organizations in information technology: We talk about information technology and service transparency, but behavioral healthcare organizations that move forward to automate their clinical systems get no support, funding, or technical assistance. We and those we serve cannot continue to be marginalized. Healthcare reform and economic recovery will depend upon the expansion of information technologies and behavioral health providers must be included.

- Expansion of research-based education and prevention practices: There are mental health and addiction prevention and education programs that work. These include research-based prevention initiatives that reduce the risk of childhood serious emotional disturbance by treating maternal depression, the Nurse-Family Partnership Program that has an array of consistent positive effects across multiple trials, and Mental Health First Aid – an evidence-based mental health literacy program. Now we must adequately fund and support the spread of these interventions to communities across the country.

Linda Rosenberg
http://www.articlesbase.com/mental-health-articles/economic-recovery-and-healthcare-reform-opportunities-for-mental-health-and-addictions-725163.html

While the dust has not settled on the Obama health care reform bill  which was signed into law, I am attaching several good summaries of the bill as it impacts insurers and coverages. There will likely be a series of amendments coming as the House and Senate finalize their deliberations on the bill.

There are several provisions that will go into effect shortly after the bill is finalized.

• Prohibition on lifetime limits
• Yet to be determined restrictions  on imposing annual limits on “essential health benefits”
• Rescission restricted to fraud or intentional misrepresentation (effective 6 months after enactment) For us this is a non event since these are the only conditions today that we would rescind coverage for.
• Requires plans to cover preventive health services with no cost sharing (6 months after enactment)
• Extends dependent coverage to 26 (again 6 months after enactment)
• Several new requirements on consumer information plans must provide
• Emergency room coverage can’t impose out of network cost sharing  (6 months after enactment)
• Requires plans to establish an appeals process for coverage or claims disputes (we already have that)
• No pre-ex for children under the age of 19 (6 months after enactment)
• A temporary national high-risk pool will go into effect within 90 days of enactment
• Imposes medical loss ratio requirements on individual and small group plans commencing in 2011 (Definitions and supporting rules will be developed by the HHS Secretary and the NAIC) As a note, currently state insurance departments who  govern rates and rate increases in the individual and small group market require actuarial documentation justifying the rates being charged. The measurement generally focuses on “lifetime loss ratios” meaning the average loss ratio expected over the life of the policy. There has been a considerable amount of discussion between the house and the senate and the NAIC regards this measurement issue. At present this is supposed to be worked out and be finalized by the end of November, 2010.

Most of the other provisions that will affect our business are slated for a 2014 effective date. That’s a long way off. But one thing is for certain, premiums will increase in the individual market. Between the imposition of no medical underwriting/guaranteed issue, a 3 to 1 age band (which incidentally will drive up rates for  25 year olds by 60%, for 30 year olds by 48%, and for 35 year olds by 28% given our current age banded rates), unisex (which again will increase rates for males under age 55 by anywhere from 10% to 20%) females will get a corresponding reduction so it won’t materially impact families, coverage parity for mental nervous ( this could be a huge inflator given guaranteed issue), an ineffective mandate which may depending on the penalties for “late enrollees” allow for people to wait until they come down with a serious medical condition to buy coverage, to name a few drivers of premium increases.

The bill does allow policyholders who have coverage in force prior to 2014 to retain their coverage presumably for as long as they want.

The CCH Tax briefing does a good job of explaining how the premium tax credits for people between 100-400% of federal poverty would work. So the presumption is that  while rates will go up in the  individual market the poor folks get a break. Notice however that there is no adjustment for age. At present the tax credits are only available if coverage is obtained through a state insurance exchange (which coincidentally many states are already fighting)

I also am including a letter from NAHU talking about the role a Certified Health Care Access Advisor should play for exchange customers. Please note that one of my roles at AHIP has been to work with NAHU on developing a certification program for health insurance agents. That work is nearing completion.

While Obama Health Care Reform it is a long way off, I believe the best service an agent can offer their customers is to ensure they have a plan in force before 2014 and advise them it is not in your best interest to wait unless you are likely to be eligible for a huge tax credit,  are old enough that the 3 to 1 age rule won’t have a big impact,  or  are either an older male or a younger female.

I will continue to provide updates as appropriate.

Ben Cutler