By Nellie Bristol, CQ HealthBeat Associate Editor

February 7, 2012 -- While expanded coverage under the health care overhaul will increase health care access, primary care improvements will still be necessary to make sure people can see a medical provider in a timely way instead of relying on a hospital emergency room, findings from a recent Commonwealth Fund survey indicate.

The survey showed that 44 percent of adults with incomes under 133 percent of the federal poverty line, with or without insurance, said they went to an emergency room during the evening or on weekends, compared with 23 percent of adults with incomes above 400 percent of poverty. In addition, 35 percent of insured adults with incomes under 250 percent of poverty indicated using an emergency room to get a prescription, compared with 17 percent of insured adults with incomes of 250 percent of poverty or above. People who needed after-hours care were most likely to go an emergency room or urgent care provider, the study said.

The findings indicate that income-related differences in people's ability to access care may continue even after insurance enrollment is increased through the health overhaul (PL 111-148, PL 111-152), researchers concluded. The overhaul's goals include ensuring consistent services for as many people as possible both to improve quality of care and reduce costs associated with avoidable hospital admissions and high levels of emergency room use for routine care.

"The survey findings suggest that more low- and moderate-income adults with health insurance resort to emergency rooms for non urgent care than do higher income insured adults," researchers said. Further, they said, findings indicate that increased coverage "is a necessary, though not sufficient, condition for ensuring equal access to timely health care across income levels. People will need both health insurance and timely access to physicians and clinics who know them and their medical histories."

In an effort to improve care, the health law temporarily increases Medicaid payment rates for primary care physicians. It also allows states to provide extra compensation to providers who develop health homes for Medicaid recipients with chronic health problems. The project is designed to provide patients with more timely and comprehensive care. The act also includes $11 billion over five years in increased funding for community health centers, although expected funding for the program was reduced by $600 million for fiscal year 2011 during budget deficit negotiations.

The survey, according to lead researcher Sara Collins, vice president of Affordable Health Insurance at the Fund, "really does point to the need for the other provisions in the law that are aimed at bolstering the primary health care system, in particular, the large expansion and resources for community health centers."

Strong supporters of the health overhaul, the Commonwealth Fund, says coverage and health delivery system changes enacted under the act will reduce disparities in access to care, including preventive services. The survey found that uninsured adults were much less likely to be up to date on recommended preventive services like cancer screenings and cholesterol testing. Among adults with incomes under 250 percent of poverty, ten percent without insurance had received a recommended colonoscopy compared to 50 percent of those with insurance.

The Commonwealth Fund surveyed 2,134 adults aged 19-64 between June 24 and July 5, 2011. The survey has a margin of error of plus or minus three percentage points.

The report is the first in a series the group is planning to track changes in coverage resulting from the health law. Overall, the survey found that 57 percent of adults in families earning less than 133 percent of poverty were uninsured at some point in 2011 and 41 percent were uninsured for one or more years. Among adults in households with moderate incomes (between 133 and 249 percent of poverty), 36 percent lacked insurance during 2011 and 23 percent had been uninsured for one or more years. Researchers note that while the economy has been improving, unemployment is still high and new jobs being created may not have the same level of benefits.

"Many jobs lost during the recession have been solidly middle-class positions in large firms and state and local governments, with health care and retirement benefits," they say. "Much of the new job growth, in contrast, has been in the retail and food services industries, typically positions with low wages and no benefits."

By Emily Ethridge, CQ Staff

February 7, 2012 -- House Ways and Means Committee Republicans Tuesday turned to the private market for inspiration on a new physician payment system, while Democrats emphasized the role government can play in improving the quality and efficiency of care.

Health Subcommittee Chairman Wally Herger said at his hearing that it was important to hear from the private sector about ways "competition and market forces" could be incorporated into the Medicare program to reduce costs. He again called for a full replacement of the sustainable growth rate (SGR), the often-ignored formula that determines reimbursement rates for physicians who see Medicare patients.

"Our end goal in all of this remains addressing the Sustainable Growth Rate formula through comprehensive physician payment reform done in a fiscally responsible manner," said Herger, R-Calif., at the hearing.

Democrats said that although the replacement discussion is important, lawmakers must turn their attention to a more urgent problem: the Feb. 29 expiration of the current "doc fix." Physicians will face a 27 percent cut in payment rates once the temporary payment patch expires.
"We keep avoiding the topic of Sustainable Growth Rate formula, in favor of the easier conversations about delivery system reforms, around which we have much stronger agreement," said ranking member Pete Stark, D-Calif.

Witnesses discussed advancements their groups have made to develop new payment methods, including accountable care organizations and medical homes, which the 2010 health care law (PL 111-148, PL 111-152) encouraged.

The keys to success for new payment systems are transparency and physician involvement, the witnesses agreed.

"Without full engagement of physicians, explicit vision and purpose, and a focus on community ... any payment system will fall short," said David Share, vice president of value partnerships at Blue Cross Blue Shield of Michigan. He warned that providers will resist any system that payers attempt to impose without first getting their input.

Lewis G. Sandy, senior vice president for clinical advancement at UnitedHealth Group, said his company had implemented successful assessment programs that rate physicians' quality and effectiveness and give feedback to both providers and consumers. He said that making the quality criteria transparent helped providers know what they were doing well and where they could take action to improve.

His group is also trying pilot programs in 13 states for patient-centered medical homes, primary care practices designed to improve care coordination for the chronically ill.

John Bender, the president and CEO of Miramont Family Medicine in Colorado, said the committee should "compel the Department of Health and Human Services to immediately deploy the patient-centered medical home standard nationally."

He said it would help the primary care workforce, increase quality of care and reverse rising costs.

Share and Sandy said their groups were also working on accountable care organizations, which bring providers together under new payment incentives to help streamline care.

Several witnesses said that the government and private payers could work together to encourage new payment system advances in both sectors.

Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, said that collaboration would help providers have one set of standards to follow, rather than forcing them to meet a variety of different requirements from private payers and the government.

American College of Cardiology CEO Jack Lewin said Congress should move quickly on payment incentives to spur progress. He praised the new grant program under the Center for Medicare and Medicaid Innovation but said it would take a few years before the program has real results.

Lewin suggested that CMS run a series of national demonstration programs for payment models wherein the savings are shared between Medicare and the provider community. That will help payers move away from the fee-for-service model, without losing income due to the reduced volume of services. With a different financial incentive, providers would be motivated to adopt new models more quickly, he said.

Nichols said the health care law brought about the end of "business as usual," and that all groups should work together to find savings—or else face blunt cuts across the board.

"We could cut our way to fiscal balance, and in so doing, reduce access to care for millions of Americans. I fear this pathway would likely fail," said Nichols. "Alternatively, we could align incentives so thoroughly that we actually link the self-interest of clinicians with our common interest in cost reduction and quality improvement while covering all Americans."

By Dena Bunis, CQ HealthBeat Managing Editor

February 9, 2012 -- People who renew or buy health insurance after Sept. 23 will receive a four-page briefing in plain English explaining what health plans will cover and what limitations or exceptions will apply to the policies they buy under a final rule three federal departments recently issued.

The "Summary of Benefits and Coverage" rule (SBC) was required under the health care overhaul law (PL 111-148, PL 111-152). The statute said the requirement for the explanation was supposed to take effect on March 23 but officials moved the date to Sept. 23 because they had missed the original March 2011 target for issuing the rule. Insurers and business officials had asked federal officials to delay implementation of the rule even longer.

On a conference call with reporters, Steve Larsen, head of the Office of Consumer Information and Insurance Oversight, said that the new effective date would still be in time for most consumers to review the summaries before they had to make decisions about their health insurance for 2013 and that there would be enough time to get the materials ready.

Karen Ignagni, president of America's Health Insurance Plans, said in a statement that while the final regulation makes some improvements over the proposed rule, her industry needs more time and flexibility.

"Health plans and employers regularly update the materials they provide to ensure consumers have clear, user-friendly information about the benefits and costs of their health insurance policies," Ignagni said. "The final rule requires an almost complete overhaul and redesign of how information must be provided to consumers. The short time frame in which to implement this new requirement creates significant administrative challenges that will increase costs and result in duplication because many plans are already developing materials for employers whose policies take effect October 1, 2012."

The requirement for the marketing materials will apply to all commercial insurance plans in the group and individual markets. And large employers will also have to comply. Officials at the U.S. Chamber of Commerce had urged federal officials to exempt self-insured employers, saying they already have clear ways of communicating with their workers about their benefit packages.

The final rule did listen to business concerns in at least one aspect: the summaries will not have to include premium and out-of-pocket costs, something that insurers and business officials said could be difficult to list in the shorthand format and that particularly for tiered insurance products, the explanations could be confusing.

"There will be other vehicles for that information,'' Larsen said. "The goal of this provision of the ACA (Affordable Care Act) was really to focus in on the benefits and coverage."

The final rule also scaled back—from three to two—the number of coverage scenarios that the summaries will have to include as a way for consumers to determine how they would be covered for specific illnesses.

In the final rule, the SBCs will have to lay out how a plan would cover the treatment of diabetes and maternity care. Originally, breast cancer was going to be included, something the National Association of Insurance Commissioners had recommended.

That was dropped, Larsen said, because "breast cancer was a more complicated treatment scenario." The treatment for breast cancer, he said, isn't one that's standardized. "We concluded that for now the simplest and most effective way was to proceed with the simpler circumstances like maternity and diabetes." He said he anticipates they might add more scenarios but didn't have a time table as to when that might occur.

The new information tool will also include a uniform glossary of terms commonly used to describe insurance coverage, such as deductibles and co-payments.

Larsen said the penalties for insurers who do not comply with the new regulation will be up to $1,000 per enrollees. The rule will be enforced in part by the states and the federal government, he said.

AARP Senior Vice President Joyce Rogers said in a statement that her group is encouraged by the final rule.

"All Americans should have clear and accessible information about their health insurance coverage to make the best possible decisions for themselves and their families,'' Rogers said. "AARP is encouraged by today's announcement and looks forward to continued conversations around developing these tools to provide consumers with a better understanding of their health insurance coverage."

• Final Rule (pdf)

By Nellie Bristol, CQ HealthBeat Associate Editor

February 8, 2012 -- While progress has been slow on sharing patient health information electronically, experts recently said that new payment and service delivery models could drive rapid adoption in the next several years.

"We want to see exchanges take off this year," said Claudia Williams, director of the State Health Information Exchange for the Health and Human Services Office of the National Coordinator for Health Information Technology. She spoke at an event sponsored by the Brookings Institution.

Policy analysts have long dreamed of a system in which basic components of the health care system—hospitals, doctors, pharmacists, insurers, nursing homes and so on—are tied together in an electronic data network that can instantly share clinical data and handle reimbursement claims. The aim is to ensure speedy and accurate transmittal of test results, medical imaging, prescriptions and other medical data, and so avoid duplicate testing and medical errors that occur from inaccurate or incomplete information.

For example, one major barrier to this information exchange is a business model based on payments for volume of services that rewards providers for doing duplicate tests. "In a health care system that pays for volume and not quality, it's very rational not to see a lot of exchange occurring," Williams said. "There's not a strong business case under that model."

But as changes to the health care system encourage greater coordination of care, "we're seeing a great increase in interest and a great increased focus in exchange, and really the value case is there," she said.

Janet Marchibroda, chairwoman of the Health Information Technology Initiative at the Bipartisan Policy Center, agreed. "Right now we reward doing more, volume as opposed to quality and outcomes, so it makes no sense for a hospital or a physician from a business standpoint to check to see whether a lab test result has already been done or an MRI—one just does one over. So we've got to tackle that first, and that's probably the biggest thing," Marchibroda said.

While the federal government has long been interested in encouraging both information exchange and electronic health records, difficulties in establishing common digital communication standards and ensuring patient privacy have slowed the effort.

"We're not in great shape," Williams said. She said that "even the most basic care coordination tasks like getting a discharge summary when your patient is discharged" from the hospital occurs slowly. "We see that about a quarter of the time that occurs within two days, and almost never electronically," she added. Those summaries are critically important to improving care and reducing readmissions, she said.

In addition, only about 19 percent of hospitals have mechanisms to share clinical information outside their own systems. "We are starting at a fairly low bar, and we have a lot of improvement to make," Williams said.

Both private payers and the Centers for Medicare and Medicaid Services are encouraging new models that will require greater health data exchange, Marchibroda said. "We've got a business case on the horizon with payment reform and delivery system reform and for the first time . . . I see an appetite for coming to agreement around a set of policies [and] standards," she said.

HHS is expected to publish regulations within a month for stage two of the "meaningful use" payment incentive program to encourage providers to use health information technology to improve care and cut costs.

Under the program, eligible providers, including physicians and hospitals, that meet certain milestones, such as electronic prescribing and providing patients with electronic copies of their health information, receive higher payments from Medicare and Medicaid. Williams also said her office will publish this quarter proposed rules outlining standards for the Nationwide Health Information Exchange Network.

Brookings released a report last week that examines state health information exchanges. It found that while efforts to create exchanges have made progress, significant barriers remain. "Many states and localities have experienced difficulties in producing consensus on strategies and approaches, and identifying consistent revenue streams," the report says. "Some question whether the state level is the proper unit for [health information exchanges] given natural marketplaces centering on localities or regions. Until those problems are overcome, it will be impossible for [exchanges] to achieve their full potential."

By John Reichard, CQ HealthBeat Editor

February 8, 2012 -- Under pending proposals by House Republicans and the White House, one in four Medicare enrollees by 2035 would be on the hook for monthly premium surcharges now paid only by beneficiaries with very high incomes, says a new study.

A Medicare enrollee today who makes as little as $47,000 a year is among the one in four Medicare beneficiaries with the highest annual incomes, notes the study by the Kaiser Family Foundation.

That income figure illustrates that the premium surcharge requirement, which under current law applies to fewer than one in 20 beneficiaries, would eventually apply to a pretty big chunk of the middle class under either proposal.

Under current law, an individual making at least $85,000 a year or a couple making at least $170,000 a year must pay much higher monthly premiums for two Medicare programs: Part B doctor care and Part D prescription drug benefits.

Those income levels won't be increased to adjust for inflation until 2019, throwing more people into the group whose premiums increase because of their "upper income."

House Republicans and President Obama have proposed to go beyond that by not adjusting the income levels for inflation until fully one quarter of the Medicare population pays the surcharges. In the case of both proposals, that will occur in 2035, the study says.

"Requiring higher-income beneficiaries to pay more might seem to be a reasonable approach to addressing fiscal concerns about Medicare," the study observes. "Yet given the relatively low incomes of most people on Medicare, significant savings from such proposals are only possible by going relatively far down the income scale to reach a sizeable share of beneficiaries," it adds. At that point, "the affordability of these additional costs could be called into question."

Last week, Democrats on the House-Senate conference committee considering an extension of payroll tax cut legislation rejected the House Republican proposal to expand the population paying the higher premiums. Republicans pointed out the Obama has proposed a similar approach. But Democrats said he did so in the context of deficit reduction, not to find pay-fors for the payroll tax measure.

The policy of charging different premium amounts based on income has sparked concern that political support for Medicare at the upper end of the income scale could erode over time.

By CQ Staff

February 7, 2012 -- Information about central line-associated bloodstream infections, which federal officials have made a priority to get under control, will now be included on the government's Hospital Compare Web site, Medicare officials recently announced.

"Including central line-associated bloodstream infections (CLABSI) information on Hospital Compare will save lives and cut costs," said acting CMS Administrator Marilyn Tavenner. "Adding this information to Hospital Compare extends the administration's commitment to make American health care safer."

CMS officials said that these infections are among the most serious of all health care-associated infections. They result in thousands of deaths each year and nearly $700 million in added costs to the U.S. health care system.

CMS estimates that in 2009, there were about 41,000 such infections in U.S. hospitals. Studies show that up to 25 percent of patients who get a CLABSI will die from the infection. Caring for a patient with a CLABSI adds about $17,000 to a hospitalization. These infections prolong hospitalizations and can cause death.

"Today, consumers are getting access to data provided to hospital leaders and clinicians to monitor progress in reducing CLABSIs," CDC Director Thomas R. Frieden, said in a statement. "This information allows CDC and CMS to highlight prevention and pinpoint where more work is needed on these avoidable infections."

CMS began a project, Partnership for Patients, in an effort to combat people from getting sick while in the care of the health system. Last fall, CDC also announced that central line infections had declined by 33 percent in 2010.

• Hospital Compare site