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April 23, 2012

Washington Health Policy Week in Review Archive c05d6d80-7f10-4315-86b2-52e738b5b642

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Commonwealth Fund: Individual Market Problematic for Those Who Lose Insurance Coverage

By Nellie Bristol, CQ HealthBeat Associate Editor

April 19, 2012 -- More than 60 percent of those who reported losing health insurance in 2011 had difficulty finding affordable alternatives in the individual insurance market, according to a Commonwealth Fund survey released last week.

One-quarter of adults between 19 and 64 surveyed had gaps in insurance coverage in 2011, and nearly 70 percent were uninsured for a year or more, the report says. When searching for coverage in the individual market during the previous three years, 62 percent said they found it very difficult or impossible to find affordable policies; 38 percent said it was hard to find the coverage they needed; and 31 percent were turned down, charged a higher price or had a medical problem excluded from coverage because of a preexisting condition. Overall, 73 percent had some sort of difficulty purchasing a plan. Respondents also reported difficulty comparing plans, including problems sorting out what benefits were covered and comparing premium costs and out-of-pocket or other cost-sharing responsibilities.

Researchers concluded that the individual insurance market is a "weak stopgap option" for those who lose employer-sponsored insurance or Medicaid. Those who were dropped from insurance most commonly lost coverage because they lost or changed their job or started working part time. Those who were no longer on Medicaid generally became ineligible because of a change of age or income or because they did not re-enroll when required. Low- and moderate-income adults were much more likely to have gaps in health insurance than those with higher incomes, they added.

Gaps in coverage, not surprisingly, led to less medical care, a situation that had "potentially serious implications for [respondents'] health as they lose contact with health care providers, skip needed care and recommended preventive care and screening tests," said Karen Davis, president of The Commonwealth Fund.

Strong backers of the health care overhaul (PL 111-148, PL 111-152), Commonwealth Fund researchers said provisions of the law would reconfigure the individual market, making it more affordable and accepting of those with preexisting conditions.

The survey is part of a series of reports that The Commonwealth Fund is conducting to establish a baseline of insurance coverage before provisions of the health care law go into effect. It included a nationally representative sample of 2,134 adults who completed an online survey in either English or Spanish between June 24 and July 5, 2011. The margin of error was plus or minus 3 percentage points.

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Health Spending Growth Prompts a New Examination of Causes

By Jane Norman, CQ HealthBeat Associate Editor

April 18, 2012 -- There is a need to slow down the unsustainable growth in U.S. health care spending, panelists at an Alliance for Health Reform event recently agreed. But they found much less consensus on what or who is to blame, be they doctors, hospitals, insurers, patients, or a complicated brew of all four.

Leaders of the non-profit alliance are organizing three sessions to encourage a discussion of spiraling U.S. health care costs, a familiar problem that's dogged policy makers for decades.

The health care law (PL 111-148, PL 111-152) included such cost containment measures as federal reviews of certain health insurance premium increases. But the law's emphasis overall was on access for the uninsured to health insurance rather than reining in spending.
Yet costs are a major problem for government programs like Medicare and Medicaid as well as private insurers. And it's touchy because changes likely will involve tough choices about who gets what health care and how much of it.

Politically, it's difficult. "The bottom line is everybody wants a lot of stuff and they don't want to pay for it," said Michael Chernew, health care policy professor at Harvard Medical School and a member of the Medicare Payment Advisory Commission.

Dan Mendelson, CEO and founder of Avalere Health, was blunt. "I think by and large our elected officials are cowards," said Mendelson, a former associate director for health at the Office of Management and Budget in the Clinton administration. He pointed to the fiery debate over "death panels" that consumed discussions of the health care overhaul for a time as an example of how difficult it is to talk about any limitations on health care.

The wonk-heavy session at the Kaiser Family Foundation featured an all-star cast of health policy panelists talking about the nation's $2.6 trillion in health expenditures in 2010. Data from the foundation shows that the rate of spending has slowed in comparison to the 1990s. But it's still growing faster than national income and that trend is expected to continue.

The alliance organized the forum as an overview of the drivers in health care costs but not a session necessarily focused on solutions. It is to be followed May 29 by another session on the roles of technology and chronic illness in increasing costs. A third forum on June 12 will look at real-world examples of techniques that have been used to reduce costs.

Chernew said that "health care spending is not sustainable" as its share nears 18 percent of gross domestic product. Growing rates of obesity and the health conditions that come along with obesity, such as diabetes and heart problems, likely contribute to spending growth, said Chernew. Yet even before the obesity epidemic, health care spending was growing faster than gross domestic product during every 10-year period since World War II, he said.

The long-run drivers of growth include better medical technology, aging, rising incomes, more generous insurance coverage, inefficiency and fears of liability, he said. Yet "the benefits might justify the costs and that's the crucial question," he said. The public portion of spending growth can be controlled by shifting more of the costs to patients. But that presents problems as well, he said.

Henry J. Aaron, a senior fellow in economic studies at the Brookings Institution who's also served in government, said the health care law does contain cost control provisions though many are pilot programs or don't go far enough. If the law survives a Supreme Court challenge, it will be a "way station along the road to transformation of the U.S. health system," and a recognition that budget constraints will be needed to rein in spending, said Aaron.

The budget constraints will have to come from some political body, perhaps one eventually made up of the state-based health benefits exchanges that are authorized by the law, he said.

Gail Wilensky, a former top Medicare official, said reports are that Americans don't stay in the hospital as long and see physicians less often than citizens of other countries. But once that visit or stay occurs, "it's gang busters in terms of what happens," she said, referring to the intensity of services provided to a patient. There will be budget constraints in the future, she predicted, whether it is through the Independent Payment Advisory Board authorized in the health overhaul or other means.

In a report, the alliance singled out national per capita income, age and disease prevalence as national top-line factors driving U.S. health spending. "There is no 'right' level of spending or rate of increase, but it is clear that the United States is at levels and future growth rates that are viewed by most observers as too high," the alliance report said.

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A Health Law Program States Actually Like? Yes, in the Case of Duals Demo

By John Reichard, CQ HealthBeat Editor

April 19, 2012 -- The deep disdain expressed by many state officials for "Obamacare" doesn't extend to everything in the health care law—witness their response to a program to test the widespread use of managed care for the so-called dual-eligible population.
Melanie Bella, the head of a new office created by the law (PL 111-148, PL 111-152) to improve care for people eligible for both Medicare and Medicaid, said that 28 states want to take part in the managed care demonstration. It's expected to start in January and enroll up to two million duals.

In response to questioning during a meeting of a Medicaid advisory group, Bella said that the program has not drawn partisan fire. She added that in her testimony at two congressional hearings and in meetings with Hill staff, the demonstration, called the "financial alignment program," has not sparked opposition. Hill staffers "have a lot of questions, but there is no opposition to doing this," she said.
With the U.S. Supreme Court weighing a decision that might strike down the entire law, such apparently broad-based support could help ensure that the duals program continues, no matter how the justices rule.

Better care for the duals excites both those are most concerned with controlling spending and those who want to improve the quality of their care.

It's the sickest, frailest populations in Medicare and Medicaid that accounts for a disproportionately large chunk of spending—old people in nursing homes with multiple chronic conditions, and younger disabled people who have severe illnesses or are developmentally disabled, for example.

Many providers and multiple tests and medications are involved in delivering their care. But there is no one quarterbacking their treatment. That leads to medication errors and preventable trips to the hospital, poor preventive care, duplication of services or omission of treatments. These are all things that drive up costs or threaten patient well-being.

Most of the states that plan to participate in the demonstration intend to automatically enroll duals in managed care plans as part of a broad, dramatic push to better coordinate their treatment. While that would fulfill the goal of policy makers who have urged such a step for two decades, it arouses great anxiety about whether such new arrangements will, in practice, actually be a good match for the particular needs of the dual population.

Bella said that CMS has "every intention" of seeing states do what is known in the field as "intelligent assignment." In other words, an individual dual-eligible would not simply be assigned at random to a plan but an assessment would be made of whether it has the providers and medications that the dual needs.

Members of the advisory group Bella spoke to, the Medicaid and CHIP Payment and Access Commission (MACPAC), praised the demonstration program but wanted to be sure that the automatic enrollment process doesn't harm people who are very vulnerable and that intelligent assignment actually occurs. Commissioner Andrea Cohen suggested that Bella be more "proactive" in making sure states do the kind of enrollment that best protects the duals. Bella said that guidance documents issued by her office, which is known as Medicare-Medicaid Coordination Office, have language about ensuring continuity of care. "Your point's well taken," Bella added.

Bella also assured commissioners that "we really are testing the passive enrollment" and will take a hard look at things like "opt-out rates"—the percentage of people who decide they don't want to stick with the plan to which they are assigned.

Commissioner Robin Smith, the adoptive parent of special needs children covered by Medicaid, underscored the stakes involved for the duals who will be enrolled in the project. "Their care is going to dictate the type of life they have," Smith said. "The team that's dealing with them has to be really good."

Smith then singled out Bella for praise, and other commissioners similarly lauded her efforts, her office, and its programs. Many Medicaid analysts and state officials want to see all three continue at CMS long after the fate of the health law is resolved. Executive Director Matt Salo of the National Association of Medicaid Directors (NAMD) said "there's no question" no matter how the ruling on the law comes out "there is strong bipartisan support for the office of the duals." Added Andrea Maresca, the director of federal policy at NAMD, "I think HHS would work very hard to figure out how to make it work under existing authority."

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PCORI Official Forecasts Busy Agenda

By Rebecca Adams, CQ HealthBeat Associate Editor

April 17, 2012 -- The next month will be a busy one for the Patient Centered Outcomes Research Institute (PCORI). At a briefing last week on comparative effectiveness research, the chief operating officer provided specific dates for upcoming decisions and gave more details about how the group is approaching its work.

The Patient Centered Outcomes Research Institute (PCORI) was created by the 2010 health care law (PL 111-148, 111-152). Its mission is to fund research that will give patients and medical providers better information about what works best in medicine, including studies comparing different ways of caring for or preventing a disease.

The institute's COO, Anne Beal, said that before the end of April, PCORI officials will tell the public how it plans to prioritize different types of research. The group released a draft research agenda in January and received comments on it, some of which criticized the group for being too vague. The final version will be out in about 10 days, Beal said at an event sponsored by the Journal of the American Medical Association.

On May 10, Beal said that a major report that will give researchers guidance on what types of methodologies they should use in their research will be sent to the board of governors and released for public comment soon after. The much-anticipated report will seek to help researchers understand how the group will prioritize questions, what types of study designs might be most effective for different types of questions, and how the perspective of patients could be incorporated into studies.

On May 21, a PCORI will issue a funding announcement that many groups have been waiting for: It is expected to give researchers a clearer idea of the types of projects that PCORI plans to fund in its first broad funding awards, which are expected in December.
PCORI is also expected to announce who will receive about $13 million in pilot project grants next month.

Beal said that the researchers for every project that PCORI funds will have to explain how their findings will be communicated to the public.
"JAMA is not enough," said Beal. She gave examples of town hall meetings, briefings and op-eds in newspapers as examples of ways that researchers might want to propose getting out the word about their work.

Part of the challenge is that the group wants patients, not just clinicians, to hear about research findings. The group wants researchers to propose ways of explaining results to hard-to-reach populations or patients who could particularly benefit from the studies, such as those in particular geographical areas and members of certain minority or ethnic groups.

The PCORI staff also plans to help with dissemination by holding conferences and workshops.

Beal noted that there is no guarantee in the law that PCORI's funding will last beyond 2019, so the group is already thinking about its legacy. The research that is most likely to get funded, she said, is relevant work that will answer real questions and can be communicated widely in a way that will impact patients' medical treatments.

"It's not just is it interesting, but can we actually improve care for people?" said Beal.

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AHRQ: Measures of Disparities in Access to Care Show Declines or No Gain

By John Reichard, CQ HealthBeat Editor

April 20, 2012 -- The nation is either making no progress or is heading in the wrong direction in reducing racial, ethnic, and income-related disparities in access to care, the Agency for Healthcare Research and Quality (AHRQ) said in a recently released report.

A second report released at the same time, the agency's annual snapshot of the quality of care in the United States, found slow improvement on quality performance measures between 2002 and 2008.

Fifty percent of the measures that tracked disparities in access to care showed no improvement, and another 40 percent showed gaps widening between 2002 and 2008, the disparities report said.

AHRQ Director Carolyn M. Clancy suggested in a news release that the health care law, which extends coverage to some 30 million uninsured Americans, would reverse the trend. "The health care law's groundbreaking policies will reduce health disparities identified in the report and help achieve health equity," Clancy said. Of course, the law (PL 111-148, PL 111-152) is under review by the U.S. Supreme Court and may be modified or repealed by that body. If it does pass muster with the court, it could be canceled next year if Republicans make big gains in the fall elections.

Hispanics, American Indians and Alaska Natives experienced worse access to care than whites on more than 60 percent of access measures. Blacks experienced worse access on slightly more than 30 percent of the measures. Asian-Americans experienced worse access than non-Latino whites on 17 percent of the measures.

Examples of access measures included the percentage of a particular group who are uninsured all year and the percentage reporting delaying or skipping needed dental or medical treatment for financial reasons. Taking the two reports together, the data show that health care quality and access are "suboptimal," AHRQ said, "especially for minority and low-income groups."

"Urgent attention is warranted to ensure continued improvements in quality and progress on reducing disparities with respect to certain services, geographic areas and populations," including diabetes care, disparities in cancer screening and access to care, and states in the South, the agency said.

Only one disparity in access to care contracted: the gap between whites and Asian-Americans.

The disparities report also examined diversity in the health care workforce. For almost all occupations, whites and Asian-Americans were "overrepresented" while blacks and Hispanics were underrepresented.

However, the report noted, "blacks are overrepresented among licensed practical and licensed vocational nurses while Hispanics are overrepresented among dental assistants." The report noted that of the health care occupations tracked, "these two required the least amount of education and have the lowest median annual wages."

The quality of care report card showed that people on average received preventive services tracked by the researchers 60 percent of time, appropriate acute care services 80 percent of the time and recommended chronic disease management services 70 percent of the time. Of the performance measures relating to acute care, 77 percent showed improvement. That was the case for only about half of quality measures relating to preventive care and management of chronic diseases.

In addition to access differences, "disparities in quality of care are common," the report noted. Thus, adults age 65 and over received worse care than adults of age 18 to 44 for 39 percent of quality performance measures. Blacks received worse care than whites for 41 percent of quality measures. "Poor people received worse care than high-income people for 47 percent of measures," the report noted.

While minorities generally fared worse in access to care and quality of treatment, that's not always the case. Racial and ethnic minorities often experienced better cardiovascular care than whites, said William Freeman, one of the authors of the two reports. He said, for example, that a higher percentage of blacks than whites reported receiving blood cholesterol screenings in the past five years.

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CMS Announces More Small Health Plans with 'Unreasonable' Proposed Rates

By John Reichard, CQ HealthBeat Editor

April 16, 2012 -- A Centers for Medicare and Medicaid Services official recently announced that two insurers in five states have proposed rate hikes that are "unreasonable."

The insurers, Time Insurance Company, a unit of Assurant Life, and United Security, will be able to charge the rates, which consist of increases ranging from 12 percent to 22 percent. But they must state on their websites and on the CMS website that reviewers have found the rates to be unreasonable and explain why they are imposing them anyway.

Health and Human Services Secretary Kathleen Sebelius said in a news release that it's time for the companies to "immediately rescind" the rate hikes, "issue refunds to consumers or publicly explain their refusal to do so."

The announcement is part of the ongoing effort by CMS to highlight health law provisions intended to benefit consumers.

The number of enrollees in the plans announced last week total 46,087. In the case of the United Security rates, Gary Cohen, director of the Oversight Group in the CMS Center for Consumer Information and Insurance Oversight, the rates were both "unreasonable and unjustified," he said in a press call.

"That means that those increases not only are excessive, but also that they failed to provide sufficient information to us to determine whether their proposed increase was based on sound data," Cohen said.

Assurant Health said in a statement that "We maintain our recent rate filings are actuarially justified and appropriate.

"Our premium rates are based on sound actuarial practices, backed by decades of experience and expertise in the individual and small group markets. Assurant Health uses medical trend data that factors in both the rising cost of health care and the utilization of medical services and prescription drugs by our customers in determining premium rates."

CMS has authority under the health care law (PL 111-148, PL 111-152) to decide whether premium increases of more than 10 percent in the individual and group markets are unreasonable. It named Time Insurance Company in a separate announcement in late March as charging unreasonable rates.

Cohen said the rate review provisions are also having an impact on insurance companies that cover tens of millions of Americans. Because of the rate review provisions of the health law, they are either charging lower rates to begin with or are scaling back the increases they originally said they would charge, Cohen said.

Cohen cited rates levied by Time Insurance Co. in Louisiana, Montana, Missouri, Nebraska and Wyoming. The United Security plans are in Arizona and cover 340 people.

Sebelius said that "thanks to the Affordable Care Act consumers in every state are getting a straight answer from insurance companies who raise their rates by 10 percent or higher."

Cohen said that the number of states with some authority to reject unreasonable rate hikes has risen from 30 before the health law to now 37. The law provided funds to states to beef up rate review if they obtained authority from their state legislatures to reject hikes deemed unreasonable.

Cohen said CMS is sending letters to the other 13 states noting the availability of the funds.

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