By Emily Ethridge, CQ Roll Call

July 26, 2013 -- Health care providers are ready with a variety of payment models they say have already worked in the private sector and should be recognized under the Medicare physician payment system created in a House bill.

Under the House bill (HR 2810) that would replace Medicare's current physician payment formula, physicians would be allowed to enter into alternative payment models—some already in progress and some yet to be created. The House Energy and Commerce Committee will mark up the measure this week.

"We always hear about organizations finding ways in the private sector to lower costs. This system is a way to test and then introduce those same saving models to Medicare," Bruce Harvie, aide to bill sponsor Rep. Michael C. Burgess, said in an email.

The bill does not specify exactly which payment models would be approved under the new system, but provider groups say there are several that could work and that have already been tested by Medicare and in the private sector. Among those most frequently cited are accountable care organizations (ACOs) and patient-centered medical homes, both for primary and specialty providers.

Doctors, who have clamored for a more stable system yet would experience change in the way they are reimbursed by Medicare, do have suggestions as House members' development of the measure continues.

Shari Erickson, vice president of government affairs and public policy at the American College of Physicians, said that although the bill would allow providers to remain in fee-for-service, it should contain more hardship exemptions for providers who aren't able to move to the new program, such as those nearing retirement—although no one "needs to have a free pass," she said.

"I think that this whole new system does need to lead us into a different payment delivery system over time, and that means there will be change, and sometimes uncomfortable change for physicians," said Erickson.

Under the measure, the Department of Health and Human Services (HHS) would have two tracks for approving the alternative payment models – one for models that already have data on their effectiveness, and another for models that could be developed and tested for up to three years.

The new models are meant to encourage cost savings and improved quality through collaboration, and to move away from the fee-for-service system that many providers criticize for rewarding volume of services over value.

The measure does not address the question of offsets, which is to be determined later. The Congressional Budget Office estimates the cost of repealing the current payment formula at $139.1 billion over 10 years.

Although most providers may choose to stay in the bill's enhanced fee-for-service system, Burgess said, providers could choose to opt into an alternative payment system at any time – and switch back.

"Somebody says, 'Look, I'm getting out of residency, I'm going to this big ACO, do I need to be worried about any of this stuff' – no!" the Texas Republican said in an interview. "If they leave the ACO, would they be able to be in the modified fee-for-service? Yes they would."

Physician groups are pushing for a wide array of "Alternative Payment Models (APM)," the term used in the bill, to accommodate a variety of providers nationwide. The models would be known, respected and researched, but not necessarily widely used now in Medicare. The bill calls for a transfer of $2 billion from the Medicare Part B trust fund to help with development and payments made under the alternative payment models.

"The new models must be accessible to physicians in all practice sizes and settings so the country's physicians can have a stable practice environment that allows them to invest in their practices in order to provide high value care for Medicare patients," said American Medical Association Ardis Hoven in a statement.

One model that providers say is ready to go is the patient-centered medical home, which organizes primary care services and encourages collaboration between several providers. In that model, the team of providers in the medical home is responsible for meeting the majority of a patient's physical and mental health needs, and to focus on the patient's needs, culture, and preferences.

"From our perspective, the most promising and prevalent model at this point is the patient centered medical home," said Erickson. "I think that that will be a big chunk of what would be the alternative payment model program."

The American Academy of Family Physicians also praised the bill for promoting the development of patient-centered medical homes and recognizing that they could function as an alternative payment model.

The bill would encourage medical homes by directing the HHS Secretary to establish new Medicare payment codes for services provided by a medical home for managing complex chronic conditions. To qualify for those services, a provider must have achieved a certain level of certification as a medical home by the National Committee on Quality Assurance (NCQA), or equivalent certification.

Erickson noted that the NCQA's standards and certifications would help provide "a meaningful avenue" as the administration determines which standards and criteria it will use to approve the alternative payment models.

According to the NCQA, more than 27,500 clinicians have earned its patient-centered medical home recognition, and more than 150 practices apply for the recognition each month.

The NCQA also has a certification standard for patient-centered specialty practice – a model similar to the medical home that includes specialists who coordinate with primary care physicians. The focus in those groups is the same: organizing care around patients and including patients and their families in planning care and managing health conditions.

"I could see that as another APM that really wouldn't take that much to roll out more broadly," said Erickson.

In addition, Harvie said he expected ACOs, some of which are already participating in Medicare, to be able to participate as an APM. ACOs are groups of doctors, hospitals, and other providers that coordinate care and share any savings they achieve for Medicare by delivering quality care. Medicare currently offers three different ACO programs.

By Rebecca Adams, CQ HealthBeat Associate Editor

July 26, 2013 -- Implementing the health law requirement that insurers provide free preventive services remains a bit confusing for some patients and plans, especially when it comes to women's medical needs, say advocates, insurers, and physicians.

National groups are collecting examples of glitches that they hope can be fixed.

"We have been listening and have asked our physicians, 'Are you seeing any problems?" Jeanne Conry, president of The American Congress of Obstetricians and Gynecologists, said in an interview.

The National Women's Law Center has a toll-free hotline and an email account ([email protected]) devoted to helping women with any problems they are encountering in getting insurers to pay for contraception. The group plans to release a white paper on the issue later this year. Last month, it posted an updated "tool kit" on its website to help women understand what the health law requires and give them sample language to use with insurers that have inappropriately charged copays or refused to cover contraceptive benefits.

"We've heard from many women about how much this coverage has helped them, but we've also heard about some women encountering problems while trying to get these services without cost sharing," said a 42-page booklet in the toolkit.

The provision requiring women to get contraception without copays or other cost sharing has gotten national note because some employers with religious objections have filed lawsuits attempting to avoid the mandate. Late last week, a federal circuit court of appeals refused to issue an injunction to one such company.

But so far, less attention has been paid to the practical problems with implementing the rules.

Anecdotally, physicians and patients report a range of problems, including difficulty in getting insurers to pay for long-acting contraception, such as IUDs or rings. Some women have been charged copays during a visit to get a contraceptive device inserted because a physician also gave the patient a pregnancy test, which is an important step to take before putting in a contraceptive device. ACOG also is watching to see if insurers are requiring doctors to prescribe one type of birth control, such as the pill, rather than longer-acting contraception, which is more expensive.

The health care law (PL 111-148, PL 111-152) requires all new or updated health plans to cover women's health preventive care, including contraception; breast-feeding support, supplies and counseling; screening for domestic violence; tests for gestational diabetes; DNA testing for high-risk strains of human papilloma virus; counseling for sexually transmitted infections, including HIV, and HIV testing; and check ups. The provisions took effect almost a year ago, on Aug. 1, 2012, for new plans or those that make substantial changes to their benefits.

A separate part of the law that took effect in 2010 requires coverage of a broad range of preventive services including such women's health benefits as mammograms, genetic testing for cancer, prenatal exams, smoking cessation and diabetes counseling.

An Implementation Challenge

Insurers acknowledge that there may be implementation problems, but say they are working hard to properly understand the provision and implement it the right way.

"We do know that there have been some coding challenges," said Susan Pisano, a spokeswoman for America's Health Insurance Plans. "It has to be coded as a preventive benefit to be paid that way and there's still some issues with that that could come into play." For instance, some doctors may use a billing code that insurers recognize as an office visit but the physician may fail to add a modifier identifying the visit as one for preventive care.

Pisano said it is difficult to talk about specific cases without knowing all the details.

One question patients who believe they have been inappropriately charged copays or denied coverage have to ask is whether the plan has to comply. Plans that are grandfathered—those that existed when the law passed in March 2010—do not have to provide the coverage until they make significant changes in the benefits.

Some of the problems may be a result of insurers not understanding the federal requirements.

If a doctor gives a woman a pregnancy test because she or he wants to make sure the patient isn't pregnant before a birth control device like an IUD is inserted, federal officials say that plans should cover it.

"Our guidance says that services related to follow-up and management of side effects, counseling for continued adherence, and for device removal are included in the scope of required services," said Alicia Hartinger, a spokeswoman for the Centers for Medicare and Medicaid Services, which is implementing the law. "We expect plans to make a reasonable, good-faith interpretation of our guidance. We believe that this includes the services necessary for the safe and effective use of a medical device—such as a pregnancy test—as determined by a woman's physician, as part of the patient's medical management."

But in other cases, insurers may be justified in charging copays. If the primary reason someone goes to doctor is for a medical concern that is not related to birth control or other preventive care, then insurance companies can charge copays, even if a doctor discusses birth control with a patient. If a patient gets a preventive service from a medical provider that is out of the plan's network, then the plan can charge copays, Hartinger said.

And one particularly murky part of the requirement allows plans to exercise "reasonable medical management."

"It's pretty unclear even to me what that means exactly," said Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center; she is an expert on the law and is overseeing the group's efforts to check for problems. "The federal guidance says they have to cover all methods but don't have to cover every single brand and every single thing on the market. That gets confusing to everyone."

Most experts agree that under the exception, insurers have to cover a variety of types of birth control, including sterilization, IUDs with or without hormones, injections, pills, a patch, rings, diaphragms, sponges and cervical caps with spermicide. They also agree that insurers can require patients to get generics or particular brand-name drugs rather than other brand-name drugs.

However, patients who have difficulty getting insurers to cover a particular type of birth control pill are still supposed to be able to get it without having to pay copays if a doctor says it's necessary for a medical reason.

Beyond that, the interpretation of what the preventive care requirement includes is still evolving, particularly given that the benefit is relatively new.

"Plans are working very hard to implement this provision properly but the other issue is sometimes new circumstances come up that haven't been thought of before," said Pisano. "When that happens, we seek guidance about it. It's the plans' intention to implement it properly."

Waxman agreed that in the future, any glitches will get worked out as people learn more about the details of the law.

"Over time, more people will know and a lot of companies will get it together," she said.

The women's groups are doing all they can to raise awareness of the benefits so that the law can be implemented as intended.

"How many women know about this?" said Waxman. "Let's face it: Half the women don't know the law passed, let alone know that you can get your birth control without a copay."

By John Reichard, CQ HealthBeat Editor

July 25, 2013 -- CVS Caremark plans to roll out a program at its 7,400 retail drug stores and 6,500 clinics to educate customers about coverage opportunities under the health care overhaul law.

The program includes trying to have "Navigator" organizations set up on site to give people individualized help in learning about the law, their coverage options, and the costs involved.

Walgreens has already announced plans for an educational program at its 8,000 stores that includes distributing information brochures and setting up a website in coordination with Blue Cross Blue Shield plans.

Depending on how robust the efforts of these chains are, it's potentially an important channel for the Obama administration to reach uninsured Americans who may qualify to obtain coverage at little or no cost or for sizeable subsidies to sharply lower their premium costs.

CVS Caremark, for example, has stores in 42 states. It says they serve five million people per day, and that 75 percent of Americans live within three miles of a CVS pharmacy.

But polling shows that there's a huge lack of understanding of the law and what it offers, which creates a big education challenge.

A new CVS Caremark survey suggests awareness of the law is growing, but that knowledge is still very limited. It found that 74 percent of the public has some awareness of the overhaul, up from 57 percent in 2011.

But the poll also revealed that 36 percent of respondents who are likely to enroll in health exchanges need help in understanding how the new marketplaces work. Many of those with the least understanding fall into the 18 to 35 age group. Those with the most questions also include Hispanics who are "newer to the country," the company said. The Obama administration and insurers are already engaged in a massive campaign to reach the Latino community.

The survey found that many people don't realize they can get tax credits that would lower their premiums. "Only 48 percent of those who are eligible for a subsidy believe that they are," CVS Caremark said in a news release. "We have a tremendous opportunity to help Americans understand the new health care law and how it affects them so consumers receive the coverage that best fits their families," said Helena Foulkes, the company's executive vice president.

More Than The Chains?

How broad based the effort by pharmacies will be to help with enrollment is unclear.

How willing, for example, will the owners of individual pharmacies be to cooperate with the health law (PL 111-148, PL 111-152)? Kevin Schweers, a spokesman for the National Community Pharmacists Association, said "it will be an owner by owner decision," he said. Pharmacists may get more heavily involved after exchanges open and customers have questions about whether their stores fill prescriptions covered by plans offered in exchanges, he said. They will try to help individuals who have problems getting their prescriptions covered, he predicted.

In general, chains might be more heavily involved. The National Association of Chain Drug Stores has named "implementation of health care reform as one of the top priorities for the association," spokeswoman Chrissy Kopple said in an email message. Opinion polling shows that pharmacies "are among the most highly trusted sources of health information," she said. "These actions may range from distribution of information at pharmacies to more formal roles in patient education. "

Foulkes said in an interview that the chain serves many uninsured customers who could benefit from knowing more about the health law.

"If you look at the 50 million Americans who did not have health insurance, last year 55 percent of them filled a prescription," she said. "When people fill a prescription at any one of our stores and don't have insurance, it's pretty clear to us that they don't have insurance because they just pay cash. We see a real opportunity to find these people as they are filling their prescriptions and educate them.

"We hope we can help them get to the right plan if that's what they're interested in," she added. "I think the most impactful thing that we can do is provide brochures and material in all of our stores to help people."

The chain also plans "retail events" in some of its outlets. "This fall we have about 375 stores that are in low-income communities where we think we can be very helpful" as part of a eight-year-old program called Project Health that does screenings to help people find out if they have diabetes or high cholesterol or some other health issue.

"Eighty-six percent of the people who have participated are African American or Hispanic, and 45 percent of the people do not have insurance," she said. "Our thought is to continue to have that screening program and add on to it a component where they can also learn more about the Affordable Care Act and their options on the exchanges." Those screenings will largely be in states with big uninsured populations, such as Florida, Texas, Georgia, California, and New York.

"Our goal is to make all our stores available to navigators," Foulkes added. "We're hopeful that many of them will take advantage of that."

The health law is a significant business opportunity for drug store chains, says Paul Heldman, an analyst with the Potomac Research investment firm. Heldman said in an interview that as insurance coverage grows so does the number of people going to pharmacies to get their prescriptions filled. Chains like CVS Caremark also have primary care clinics that would be used more heavily as coverage increases, he added.

One issue that could affect pharmacy involvement is the divisive nature of the health care law. Senate Republican leaders recently leaned on the National Football League not to become involved, with apparent success, raising the question whether they will apply similar pressure on other businesses.

"I wouldn't rule it out," said Heldman. But he also drew a distinction between the NFL and health companies. For health-related businesses, the health law represents an opportunity to grow revenues and Republican leaders may recognize that, he said. And if they do apply pressure anyway, there's a greater chance health businesses will resist it, he said.

"The NFL's business does not depend on whether they get people covered," Heldman said. But that's not the case with health companies, he added. "They have to run a business. It's like in Casablanca where Rick says 'your business is politics, mine is running a saloon," Heldman joked.

For her part, Foulkes of CVS Caremark said she has gotten no resistance from Republicans for the planned outreach effort. "Not at all," she said. "I think as a health care company it's very different than being the NFL. It's a very natural role for pharmacists. And it's very similar to 2006 when the Medicare prescription drug benefits was rolled out. "Our pharmacists were really critical in terms of helping seniors" enroll in Part D plans. "So we have history doing it. It's in our DNA. It's I think something customers would expect from us. So I don't think it's viewed as a political issue."

By Dena Bunis, CQ HealthBeat Managing Editor

July 24, 2013 -- Pennsylvania State University is joining an increasing number of large employers by rolling out a comprehensive wellness program this fall. But the educational giant has decided to use a stick rather than a carrot to get its workers to participate.

Penn State's human resources department recently sent an email to faculty and staff, outlining three steps that employees must take to avoid a $100-a-month surcharge. They have to fill out an online wellness survey; promise to get a physical exam during the 2013–2014 school year; and submit to biometric testing, which includes a fasting blood test, height and weight measurements and a blood pressure screen. If they do not comply, the HR notice says, $100 will be deducted from their paychecks each month.

In a July 15 email to her faculty and staff obtained by CQ HealthBeat, Susan Welch, dean of the College of Liberal Arts, said it took her 15 minutes to complete the online profile and she advised them to "have a tape measure handy," presumably because one of the online questions asks for one's measurements. "Ignoring these messages from OHR [Office of Human Resources] will cost you an additional $1,200 in your health insurance premiums in 2014," Welch wrote. "Our office will NOT be able to help you if you do not complete the requirements by the deadlines listed below." Employees must have the biometric screening by Oct. 8 and fill out the online wellness survey and physical exam attestation by Nov. 22.

Since then, faculty and staff members have been circulating emails in which they say they are worried about such issues as medical information privacy and the fact that the notification was sent out during the summer when much of the faculty is away. They raised questions about why the university decided to encourage participation in the laudable goal of making its people healthier with a penalty, rather than a financial incentive.

Employees said they also fear these steps are just the beginning. Will this be followed up with a program that charges smokers, those who are overweight or have high blood pressure higher health insurance premiums?

"It would seem just from looking at this they are using a really big, hard-to-resist incentive to get the information," said Karen Pollitz, a fellow at the Kaiser Family Foundation who has been studying these wellness programs.

Penn State spokeswoman Jill Shockey said in an email that "it is important to emphasize: Penn State will not have access to an individual's health records, will not ask for those records and will not charge an employee additional fees based on the results of any medical test or physical examination." Shockey also pointed to a 2012 Aon Hewitt nationwide survey that showed that more than four-fifths of its employer clients offer biometric health screenings to help inform employees of their health status.

Pollitz still questioned whether this is the first step towards more restrictive policies.

"If they are making you pay that much so they can get the information, they are going to want to do something with it at some point," she said in an interview. "This is not curiosity."

Employer wellness programs are becoming increasing popular. According to Mercer's 2012 national employer survey, 54 percent of large employers (500 or more workers) and 66 percent of very large employers (5,000 or more employees) have wellness programs that involve incentives to participate. Most often, the Mercer report says, those incentives involve cash payments or reductions in premiums to workers who join.

Such programs have been part of the health benefit landscape for decades. But in the past, they consisted mostly of discounts for gym memberships, newsletters encouraging employees to take care of themselves and smoking cessation programs.

Penalties Unusual

Howard Kraft, a Mercer partner who leads the firms health management practice in the Northeast, said he has seen penalties and surcharges used most often when it comes to smoking or case management programs associated with people who are very sick.

"We have only seen some organizations move to penalties on health promotion activities," Kraft said. "It's not the norm." Without specifically commenting on what Penn State is doing, Kraft said health promotion activities include such steps as filling out health surveys and getting physical exams.

"If Mercer was to express a point of view, we think that for things that are health-promotion oriented, encouraging people to know more about their health status, exercise more, eat better, probably an incentive approach is more effective,'' Kraft added.

Under the health care law (PL 111-148, PL 111-152), employers have been given the ability to charge up to 30 percent higher premiums to workers who have health issues. They can charge 50 percent more to smokers.

In the final wellness rule released in May jointly by the departments of Health and Human Services, Treasury and Labor, federal officials made it clear that employers offering "health contingent wellness programs" must offer a "reasonable alternative standard" so that all participants, regardless of their health status, can still meet the reward even if they don't achieve the program's specific goals.

Based on the results of the Mercer survey, the kind of penalty-based program Penn State has instituted is still the exception. Among the large employers that participated in its survey, 46 percent don't attach any incentives to their wellness programs and 42 percent use financial rewards. Only 15 percent use financial penalties to get workers to comply.

One Penn State professor, who asked not to be identified for fear of reprisals, said what's most disturbing about this is the penalty nature of the program.

"It's all phrased in the way of punishment," he said. "It would have been wonderful if it had been couched in a different way: join a program, you get a discount. The more you lose weight, the more you eat better, the more discounts we'll give you."

Asked why the university decided to impose a penalty rather than a reward, Shockey said in an email that "Penn State has had robust, voluntary wellness programming for more than a decade. Voluntary participation, however, has not positively impacted the health care cost curve at all. As a result, Penn State is implementing a more aggressive strategy.

"In order to offer an incentive, the University would have had to artificially inflate health care premiums for all employees and then discount for those who participate,'' she added. "Those involved in drafting and implementing the plan felt it was important to be straightforward about how the costs will be assessed. The current strategy, while employing a financial disincentive, keeps premiums stable for all with no hidden costs."

At the Employee Benefit Research Institute, senior research associate Paul Fronstin says the fact that the health law increased the incentive percentage employers can levy and is sanctioning such health management programs is probably leading more employers to use them.

He suggested that programs like Penn State's may lead to such actions as a third party getting the information and a nurse calling an employee who has high blood pressure or is pre-diabetic about ways to keep the condition from going any further.

"If you can find some people at risk for certain diseases it's a win-win," Fronstin said. It's a win for the employer whose health costs can be reduced with a healthier workforce and it's a win for the employee who gets healthier, he said.

By John Reichard

July 24, 2013 -- The current federal deadlines that providers face for adopting health information technology (IT) are too tight and could stop adoption of the electronic system in its tracks, even leading to safety problems, representatives of hospitals and vendors told the Senate Finance Committee last week.

Without easing deadlines "many providers may opt out of further participation," said John P. Glaser, who heads a unit at Siemens Medical Solutions that sells health IT and medical imaging and laboratory equipment.

Glaser was formerly an aide to David Blumenthal when Blumenthal was the National Coordinator for Health Information Technology. Blumenthal was the architect of the "meaningful use" program that temporarily pays doctors and hospitals higher Medicare and Medicaid rates if they make effective use of health IT—and eventually lowers their payments if they don't.

Committee Chairman Max Baucus, D-Mont., listened attentively to Glaser and other witnesses who urged a slowdown. Baucus noted that rural health clinics "can't get funding for installing the technology," and said "we must correct this error."

But after giving critics a lot of time to air their views, Baucus gave no indication that he favors letting the deadlines slip. Obama administration officials told the committee at a hearing last week that changing the deadlines would be a mistake. The officials said they instead favored giving more help to providers that are lagging behind, particularly those in rural areas.

Glaser testified that the deadlines for the three-stage program could either cause the current adoption rate to "plateau" without showing further growth, or "rush the implementation" among the many doctors and hospitals—particularly smaller practices and facilities in rural areas—that haven't installed electronic medical record systems.

The technology requires an intensive effort by doctors and nurses to redesign the way they work, he noted. Moving too fast will keep that from happening and could cause unsafe care, he said.

The chief executive of a 20-bed hospital in Auburn, Nebraska, echoed that point. "These systems, especially when they are upgraded under severe time constraints, can, and unfortunately do, introduce risk when things go wrong," said Marty Fattig, who runs Nemaha County Hospital.

"We installed a software upgrade some time ago and all of the allergies listed in the patient record disappeared," he said. "We were able to catch this problem before patients were harmed, and restored the allergies to the record, but this is the kind of thing that can happen."

Fattig added that "most rural hospitals have yet to meet the exceedingly complex requirements for Stage 1 of meaningful use. And they worry that time is running out, as the positive incentives quickly turn to penalties."

Meanwhile, Stage 2 requirements that aim to begin the process of "interoperability," the exchange of patient data with other providers, are fast approaching. Stage 2 requires all doctors and hospitals to adopt a "2014 Edition" certified electronic health record in fiscal 2014.

"This means that vendors will need to support over 500,000 physicians and hospitals in a single year," Fattig said. Executives of rural facilities, which are lower on the priority list for vendors, "have significant concerns about whether the vendor community has the ability to support all of those upgrades in such a short period of time," he added.

In a statement submitted for the record, the Federation of American Hospitals suggested that deadlines for Stage 2 implementation should perhaps be tied to the timing of availability of certified 2014 electronic medical records.

In a position that appeared to be supported by other witnesses who favored delay, Glaser of Siemens urged moving the deadline for Stage 2 implementation from Oct. 1, 2014 to Oct. 1, 2015. Those who are ready to go to Stage 2 could do so as currently scheduled, he said. But moving the deadline would give others more time. But they should be given no more than one added year, he said.

Glaser also called for changing the timing of deadlines so that "each stage is separated by three to years." In a joint letter to Health and Human Services, the American Hospital Association and the American Medical Association also urged such a step.

But Janet Marchibroda of the Bipartisan Policy Center told Finance members that current deadlines should stick.

The National Partnership for Women and Families also urged no change in a statement submitted for the record that faulted the committee for not including patients and family caregivers among the witnesses at the hearings. Their perspective "is an essential voice because patients' health and health care at stake," the statement said. Implementation is difficult "yet often the difficulties have less to do with technology and more to do with culture change," the group said.

Baucus said in response to a reporter's question after the hearing that he does not favor stretching out the deadlines. "Not yet," he said. Asked how he would address industry concerns if there is no delay, he said "they just gotta do it." But "clearly everybody raised that question," he added referring to testimony about the need for more time. "So who knows." The committee "has a responsibility to see the degree to which they're right.

"I've got to go back and dig into it with my staff, and say, 'What do you figure; what makes sense here?' But so far, no."

By Rebecca Adams, CQ HealthBeat Associate Editor

July 23, 2013 -- Perhaps the most overlooked beneficiary of President Barack Obama's health care law is the Spanish language channel Univision.

Univision Communications Inc. and other Spanish-speaking media outlets are at the center of a multi-million-dollar effort to explain the overhaul to Latinos, who are critical to the law's success because one of every three uninsured people in the United States is Hispanic.
For example, Univision is getting millions of dollars from the insurer WellPoint to post information about the law on its website, hold monthly town hall meetings in cities around the country, and detail, in Spanish, the benefits on radio and television.

The state of California is paying Univision, Telemundo, and other Spanish-language outlets a total of $10 million of the $290 million that federal officials provided the state for publicity about the law, say state officials.

The outreach effort to Latinos by insurers, unions, consumer advocates, the seniors group AARP and, most of all, by Obama administration officials, is ramping up with 70 days to go before open enrollment begins in the new marketplaces created by the health care law (PL 111-148, PL 111-152).

Obama administration officials are making plenty of live appearances to Latino audiences, including a recent speech by First Lady Michelle Obama at the nationwide conference of the National Council of La Raza, an advocacy organization. Other administration experts on the health care law have also been at the conference and at a related health summit.

"The goal is to get folks to sign up for the insurance so they have the care they need to stay healthy," the first lady told the crowd in Washington, D.C. "As leaders in our communities, we are going to need your help to make this happen. And I know that you all were briefed on this new law by senior [federal] administrators at the Health Summit that was recently held here. So here's what I'm asking you to do. Are you listening? The minute you get back home from this conference, we need you to get out there and educate everyone you know about what health reform means for them."

Obama pressed especially hard for Latinos in California, Florida and Texas to tell young people to enroll, "because one-third of the young people we need to reach live in those states."

Health law supporters can use the media to amplify their message.

That's why WellPoint, a major insurer affiliated with the Blue Cross and Blue Shield Association that operates in 14 states, is partnering with Univision to run short television spots initially in California, Colorado, Georgia and New York, four states with a large number of uninsured Latinos. And there are plans to expand the effort.

Blitz Campaign in California

In California, where nearly half of the uninsured are Latino, the state is using federal dollars for a new partnership—known as Asegúrate, or "Get Covered"—with four major Spanish-speaking media outlets: Univision, Telemundo, La Opinion and impreMedia. The media campaign will deliver information in Spanish through TV, radio, digital and print media, as well as telethons and live events.

The Spanish-language media partnership received not only the $10 million in federal money via the state of California, but $40 million from the California Endowment, a nonprofit whose mission includes expanding health care coverage to the poor. The California Endowment's total budget for telling people about the law and helping them enroll is about $240 million, said Daniel Zingale, senior vice president at the Endowment. The president praised the Latino media initiative during a visit to the state in June.

The health care law in many ways represents an opportunity for Democrats to build on their support with Hispanic voters. While some Latino leaders are frustrated by the slow pace of action on an immigration overhaul, the health care law is widely popular among Latinos who know about its benefits. In California, promoters of the law are not shying away from using the tag "Obamacare," because the term does not connote controversy among Latinos as much as other groups, said Zingale.

The push to promote support among Latinos of the health care law is not all that different from Obama's political campaigns among that group. The White House already has extensive connections to Hispanic leaders that it is tapping for its outreach efforts on the law.

The administration's message will be highly visible on Univision.com, the website Latinos use most often. The company is in the midst of building a new section within its site that will be supported financially and substantively by the federal government, state governments, health insurers and non-governmental organizations that are helping with enrollment.

The site will be designed to give readers all the information they need about the health overhaul. It will provide directories of local groups that will help Hispanics enroll and determine how much of a federal subsidy they should expect. It will link to healthcare.gov, the Health and Human Services (HHS) platform for the health care law; websites of state marketplaces heavily involved in the rollout, such as Covered California; and tools such as subsidy calculators or social media sites. The Univision website will be partly produced by Hola Doctor, a company that specializes in Latino media, marketing and translation.

The Univision site will guide Latinos to a call center with Spanish-speaking health care experts or live online chats so that readers can ask questions about the overhaul. It also will feature videos of health care experts talking in Spanish about the health law. People will be able to sign up for electronic newsletters about the overhaul or find resources for more information.

"We have teamed together to provide Hispanics a multimedia experience that provides important up-to-date information about the ACA [Affordable Care Act] including timing of implementation, how to select a health plan and information about subsidies that may be available to them," said Jorge Daboub, Univision Communications senior vice president of business development.

Already on the Univision/Hola Doctor website is detailed information about the law and the new marketplaces that mirrors information released by federal officials. On the site, a picture of a smiling Obama and HHS Secretary Kathleen Sebelius pops up in a photo slide show touting the benefits of the health care law.

Both the look of the media presentations as well as the coordination with federal officials seems seamless. The online Univision slide shows and news may not stand out to Hispanics as information that came originally from the federal government, which some Latinos may view with skepticism, but instead looks like an integral part of the trusted news site.

Close Univision-White House Collaboration

Univision and Hola Doctor producers stay in touch with Obama administration officials such as Mayra Alvarez, a former Senate Democratic staffer who directs public health policy at HHS and has been traveling the country with officials like HHS Deputy Assistant Secretary for Minority Health Nadine Gracia to promote the law. Their work is supported by White House officials including Cecilia Munoz, the director of the White House domestic policy council and a former vice president at LaRaza.

Over the past couple of months, the Obama administration held a series of webinars to train staff at Univision, Telemundo and Entravision on the health law. HHS officials have hosted twitter town halls with its Latino media partners. In June, HHS officials launched new Twitter and Facebook handles—@HHSLatino and @CuidadodeSalud—which tout a call center line for Spanish-speaking people with questions about implementation of the law.

Those efforts dovetail with the creation of another website by the seniors' group AARP, mileydesalud.org, which is expected to launch Aug. 1. The English-speaking version is healthlawanswers.org.

The digital, radio and TV media also are intended to increase attendance at community events where people can find out more about enrollment, such as Spanish-speaking health fairs where booths staffed by experts on the law can provide more details.

"Spanish media has been the key" to driving participation, said Zingale, whose organization has been part of recent health fairs. When the group sponsored one health fair without coordinating with local Spanish radio and TV announcers who could publicize it, Zingale said, "We got a third of the numbers when we had Spanish media pushing it."

The administration has consistently reached out to Latino media with Spanish language press conference calls and interviews with Spanish-language outlets. On July 16, Obama was interviewed by four anchors from local Spanish-language networks.

HHS officials, including Sebelius in some cases, have provided remarks for the National Association of Latino Elected Officials conference, town halls in Washington for La Raza, the League of United Latin American Citizens and the National Hispanic Medical Association.

Through the HHS Promotores de Salud/Community Health Workers Initiative, which was launched in Obama's first term with the goal of reducing health disparities among minorities, HHS officials are in close contact with Spanish-speaking community health workers and advocates. They hold quarterly meetings and frequent informal conversations. The administration's faith-based office has been hosting monthly Spanish-language webinars over the last year and a half on the health care law.

"As one of the most disproportionately uninsured populations, Latinos are a key group to reach ahead of open enrollment in October," said HHS spokeswoman Joanne Peters. "That is why we are engaging in ambitious outreach and educational efforts aimed at helping Latinos and all Americans to prepare for the new opportunities."

• Healthcare.gov in Spanish (pdf)
• Univision site (pdf)