Health Reform in the "Bullpen"

The bullpen is not the one associated with baseball. This is the one associated with bulls, that produce copious amounts of B.S. and greenhouse gases.

Jones Calls Anthem's Rate Hike 'Unjustified and Unreasonable'

On Wednesday, California Insurance Commissioner Dave Jones (D)criticized Anthem Blue Cross of California's nearly 9% average rate hike as "unjustified and unreasonable," Modern Healthcare reports.

Details of Rate Hikes

Starting April 1, Anthem imposed an average rate increase of 8.7%, affecting about 170,000 members (Modern Healthcare, 4/22). Meanwhile, about 4,000 policyholders saw increases of up to 25% (Terhune, Los Angeles Times, 4/22).

According to Modern Healthcare, the rate increases apply only to grandfathered health plans -- those that were purchased prior to the Affordable Care Act going into effect and therefore do not need to comply with its coverage requirements (Modern Healthcare, 4/22).

Jones' Criticism

Jones said that Anthem had failed to justify its most recent rate hike, alleging that the insurer had exaggerated its past and future expenses.

The state Department of Insurance's actuaries determined that a 1.5% increase was justified. Jones said the lower rate hike would have saved customers about $33.6 million. He added that Anthem in the last two years has increased rates by 26.5% on average for grandfathered plans without changing benefits 

Anthem Response

Anthem defended its rate increase, noting that it "reflects the fact that escalating health care costs are an economic reality faced by the entire industry."

In filings, Anthem reported that its medical costs for policyholders with grandfathered plans were projected to rise by 9.5% in 2015, in large part because of higher costs for prescription drugs.

Anthem spokesperson Darrel Ng said, "More high-cost, mass-market specialty drugs are expected to be released in the next year, further increasing medical costs and contributing to higher premiums."

Anthem added that the rate increases could be attributed to aging consumers "because new younger, healthier members are not able to sign up for grandfathered plans" (Los Angeles Times, 4/22).

The insurer added, "Even with the rate change, in many cases, these policies have a lower monthly premium than those sold on the individual market today" (Russell, San Fernando Valley Business Journal, 4/22).

Comments from Readers

Joey Torcellini

Peter Lee and the Covered CA Board of Directors are silently and gleefully cheer leading these increases. These increases are going to eventually increase the Covered CA enrollment numbers, which is all Peter and the lame BOD seem to care about. Low on their priority list are fixing the narrow networks and the lousy and costly ACA health plans. Peter Lee and the CCA BOD need to be replaced with members/leaders that will champion the consumer.

April 23, 2015 at 12:23 PM

Earl Dworkin

Now the fun begins. There will be a large movement of the grandfathered people to the ACA within Anthem. As this becomes a reality, the new ACA policyholders will have a wakeup call that their providers that serviced the grandfathered plan will not accept their new ACA plan. Always check ahead to see if Providers will accept before changing plans!

April 23, 2015 at 10:57 AM

David Wiltsee

Proving, yet again, 1) what damn fools the voters are and 2) that Big Medicine is public enemy #1 in the decline of the middle class. And where is Covered California cowering, pretending to stick up for the public interest?

April 23, 2015 at 10:27 AM

Mark Miller

Good comments Scott!

April 23, 2015 at 9:43 AM

Scott Terpstra

Grandfathered plans currently offer a great deal in comparison to current small group and individual non-grandfathered plans. It is inevitable that grandfathered plans will eventually lose their luster. These old grandfathered plans had lower rates because those participating in them were made up of a risk pool of healthly people, with a continual in-flow of more healthy people. Those two reasons are now gone. The grandfathered pool of business will slowly deteriorate. This is just the beginning.

April 23, 2015 at 9:28 AM

Top Hospital Ratings Prove Scarce In Medicare's Latest Tally :

Top Hospital Ratings Prove Scarce In Medicare's Latest Tally : Shots - Health News : NPR:

Are our hospitals really this bad ? Or is the bar set too  high favoring large institutions due to their ability to adopt CMS EHR regulations ?

Top Hospital Ratings Prove Scarce In Medicare's Latest Tally

Vacuum cleaners get them. Movies get them. Now hospitals are being given star ratings to help patients decide which ones to use.

On Thursday the federal government awarded its first star ratings to hospitals based on the opinions of patients. Some of the nation's most lofty hospitals—the ones featured in best hospital lists—received mediocre ratings, while the maximum number of stars often went to small, regional hospitals and others that specialize in lucrative surgeries.

Evaluating hospitals is becoming increasingly important as more insurance plans offer patients limited choices. Medicare already uses stars to rate nursing homes, dialysis centers and private Medicare Advantage insurance plans. Medicare publishes dozens of quality measures on its Hospital Comparewebsite, but many are tough to decrypt. Most consumers don't use them.

Many in the hospital industry fear Medicare's 5-star scale won't accurately reflect quality and may place too much weight on patient reviews, which are just one measurement of hospital quality. Medicare also reports the results of hospital care, such as how many patients died or got infections during their stay, but those are not yet assigned stars.

"We want to expand this to other areas like clinical outcomes and safety over time, but we thought patient experience would be very understandable to consumers so we started there," Dr. Patrick Conway, chief medical officer for the Centers for Medicare & Medicaid Services, said in an interview.

Medicare's new summary star rating, posted on Hospital Compare, is based on 11 facets of patient experience, including how well doctors and nurses communicated, how well patients believed their pain was addressed, and whether they would recommend the hospital to others.

In assigning stars, Medicare compared hospitals against each other, essentially grading on a curve. It noted on Hospital Compare that "a 1-star rating does not mean that you will receive poor care from a hospital" and that "we suggest that you use the star rating along with other quality information when making decisions about choosing a hospital."

SHOTS - HEALTH NEWS

What's A Patient To Do When Hospital Ratings Disagree?

The American Hospital Association offered its own caution, saying: "There's a risk of oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons."

Nationally, Medicare awarded the top rating of five stars to 251 hospitals, about 7 percent of all the hospitals Medicare judged, a Kaiser Health News analysis found. Many are small specialty hospitals that focus on lucrative elective operations such as spine, heart or knee surgeries. They have traditionally received more positive patient reviews than have general hospitals, where a diversity of sicknesses and chaotic emergency rooms make it more likely patients will have a bad experience.

A few five-star hospitals are part of well-respected systems, such as the Mayo Clinic's hospitals in Phoenix, Jacksonville, Fla., and New Prague, Minn. Mayo's flagship hospital in Rochester, Minn., received four stars.

Medicare awarded three stars to some of the nation's most esteemed hospitals, including Cedars-Sinai Medical Center in Los Angeles, NewYork-Presbyterian Hospital in Manhattan, and Northwestern Memorial Hospital in Chicago. The government gave its lowest rating of one star to 101 hospitals, or 3 percent. (You can see all hospital ratings here.)

On average, hospitals scored highest in Maine, Nebraska, South Dakota, Wisconsin and Minnesota. Thirty-four states had no one-star hospitals.

Hospitals in Maryland, Nevada, New York, New Jersey, Florida, California and the District of Columbia scored lowest on average. Thirteen states and the District of Columbia did not have a single five-star hospital.

In total, Medicare assigned star ratings to 3,553 hospitals based on the experiences of patients who were admitted between July 2013 and June 2014. Medicare gave out four stars to 1,205 hospitals, or 34 percent of those it evaluated. Another 1,414 hospitals — 40 percent — received three stars, and 582 hospitals, or 16 percent, received two stars. Medicare did not assign stars to 1,102 hospitals, primarily because not enough patients completed surveys during that period.

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Doctors Applaud SGR Bill's Malpractice Protection

Doctors Applaud SGR Bill's Malpractice Protection: "Doctors Applaud SGR Bill's Malpractice Protection"

Positive Move in the Malpractice Arena

Medical groups are applauding the overwhelming vote in the US Senate Tuesday to prohibit plaintiffs from using a physician's performance on federal quality measures in a medical malpractice lawsuit.

The provision included in the legislation to repeal the Medicare Sustainable Growth Rate (SGR) formula would stop plaintiffs from using a doctor's quality improvement performance as the sole basis for a medical liability lawsuit or to prove negligence.

Language in the law states that "the development, recognition, or implementation of any federal health care guideline or standard shall not be construed to establish a duty of care in medical malpractice claims."^[1]

The bill was passed in the Senate by a vote of 92-8 and was previously approved by the House of Representatives in a 392-37 vote. President Obama has said that he will sign the legislation.

For example, plaintiffs won't be able to include in a lawsuit the fact that a doctor didn't earn an incentive under the Physician Quality Reporting System (PQRS), or if a preventive care service covered under the Affordable Care Act (ACA), such as screenings, isn't performed and the patient is ultimately diagnosed with a disease. The fact of ACA coverage of the service can't be used to demonstrate malpractice or negligence.


This feature, largely ignored by the media, and not well known even amongst physicians preempts any attempt by plaintiff attorney to denigrate a physician defendant.

The Top Health Care Social Media Accounts

The Top Health Care Social Media Accounts

#FEDS GET SOCIAL

Social media has a major influence's and news disseminating source for health professionals.

News often breaks in social media platforms.   Health care is determined now in major ways by state and federal regulations. OMB has issued several regulations and guidance for social media (what the government does best, set regulations)

The Federal Social Media Accounts You Should Follow

The Office of Management and Budget released its “Legal Advisory on the Standards of Conduct and Social Media” to the Federal workforce this April after a flood of inquiries for proper use of social media. Good thing … Feds are making user engagement an art. Here are some of the best Federal social media accounts to check out.

Top patient care performers are most profitable hospitals - FierceHealthcare

Top patient care performers are most profitable hospitals - FierceHealthcare: "Top patient care performers are most profitable hospitals"



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Top patient care performers are most profitable hospitals

Patients rank the most profitable hospitals as top  performers for many metrics. Hospitals with high performance scores in patient care are more profitable, according to a new Press Ganey report. The top 25 percent of U.S. hospitals with the highest scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question about performance were, on average, the most profitable and had the highest clinical scores, suggesting that patient experience, coupled with clinical outcomes, can mean financial profitability for the institution.

"It is interesting to note that the only hospitals that showed a positive profit margin were those that were highly rated by their patients," the report states. "...Although there is not a lot of difference in the clinical measures among the four groups of hospitals segmented on patient rating score, the top quarter of hospitals based on HCAHPS overall rating score also have the highest average clinical score. Taken together, these [results] suggest that excellence in patient experiences, clinical outcomes and financial profitability often occur together."

The work of CMS to improve quality of care is a doublel edge sword. Implementing these change increases operating expenses, leaving less capital and decreasing profits. Those hospitals who manage finances best experience a higher profit resulting in better scores.

NetAppVoice: Here's Why I Hired A Hacker [100 Words Into The Future] - Forbes

NetAppVoice: Here's Why I Hired A Hacker [100 Words Into The Future] - Forbes:



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SUSTAINABLE GROWTH RATE: FORMULA REPEALED AFTER 17 YRS

The Sustainable Growth Rate which was established in 1995 has been a 'trojan horse' lurking and waiting to strike each year at budget time. The SGR caused severe angst to providers and hospitals each year distracting health care providers with a ghost law.

HISTORY--Doc Fixes Began With "The Biggest Backroom Deal"

Congress created the SGR formula in 1997 to put the brakes on Medicare spending for physician services. The formula sets annual spending targets based partly on changes in the gross domestic product. If Medicare spending comes under the target, physician payment rates go up the following year. But if spending exceeds the target, rates are reduced to make up the difference.

The formula became a definite nemesis of organized medicine in 2002 when SGR math yielded a 4.8% pay cut. Another 4.8% dip followed in 2003, and on February 13 of that year, Congress enacted the first of its doc fixes, replacing the 4.8% cut with a 1.4% raise.

The first doc fix was a backwater provision in an omnibus appropriations bill that one lawmaker called the "biggest backroom deal" in the history of Congressional spending, according to the New York Times. It was a 338 to 83 vote in that House that day, 76 to 20 in the Senate.

The history of the SGR and it's real meaning became apparent this year.  The Sustainable Growth Rate was never mean to sustain growth, nor to be enforced. The SGR was designed to be used as pawn in the trade of eliminating the onerous clause  in return for approval of the Pay for Value rembursement system presently in development by CMS.

For years, organized medicine warned that a rate reduction on the magnitude of 21% would drive physicians out of Medicare and leave seniors in a lurch. Likewise, medical societies constantly chastised Congress for postponing past SGR-triggered pay cuts — kicking the can down the road, they called it — instead of repealing the formula outright. Such "doc fixes," in Congressional parlance, caused the cuts to accumulate into the monster that came to life on April 1.

Organized medicine now has its SGR victory, but not everyone is sanguine about the future of Medicare reimbursement. Last week, the chief actuary of CMS issued a report saying that under MACRA, annual Medicare raises for physicians would not keep pace with rising practice costs in the long run. By 2048, the gap between payments and practice expenses would be greater than if Congress had let the SGR formula take effect, according to the report.

Breaking News on April 14, 2015

Congress Repeals Medicare SGR Formula

After 17 previous Congressional holding actions going back to February 13, 2003, the Senate today clinched the approval of a bipartisan bill that finally repeals Medicare's sustainable growth rate (SGR) formula for physician compensation and averts a 21% pay cut this year.

The Senate vote was 92 to 8.

The House overwhelmingly approved the bill, called the Medicare Access and CHIP Reauthorization Act (MACRA), last month. Now the legislation goes to President Barack Obama, who has promised to sign it.  Buried within the law (H.R.2 - Medicare Access and CHIP Reauthorization Act of 2015) are many fine points about calculations, bundled care, and giving the Secretary of  HHS unbridled powers to determine physician and hospital fees.

The bill will freeze Medicare rates at pre-April levels through June, and then raise them 0.5% in the second half of the year. They will continue to increase 0.5% each year from 2016 through 2019. At the same time, MACRA will shift Medicare compensation from fee-for-service to pay-for-performance.

Add to this formula the effects of the Affordable Care Act

The IFTTT is the swap between SGR and conversion to a pay for value system of reimbursement.