October 23, 2014 – Last week a federal health agency unveiled how it intends to spend a major slice of a $10 billion account established to try ideas for improving the practice of medicine.

The latest plan from the Center for Medicare and Medicaid Innovation is the $840 million Transforming Clinical Practice Initiative. While other programs within the center focus on changing practices within hospital and physician practices, the new initiative is designed to more intensely involve nurses, physicians' assistants and pharmacists, as well as primary-care doctors, the agency said in a fact sheet.

"We look forward to a large number of applications," said Patrick Conway, the Centers for Medicare and Medicaid Services (CMS) deputy administrator for innovation and quality and chief medical officer, on a call with reporters.

The 2010 health law (PL 111-148, PL 111-152) provided $10 billion for the innovation center at CMS, meant as an engine to move federal health programs away from the fee-for-service model and toward more integrated forms of health care.

The challenge for the innovation center is to test out ideas for improving medical practice. This money runs out in fiscal 2019. In the current budget environment, gaining another large infusion of funds for such testing of ideas may prove difficult.

For the newly announced initiative, the bulk of the money comes from funds provided through the 2010 health law for the Center for Medicare and Medicaid Innovation, with the remaining $40 million taken from money approved for the Quality Improvement Organization program.

CMS expects to make awards of $2 million to $50 million each for participants in the four-year practice transformation network program, which is part of this new initiative. Organizations expected to participate in this program include health and hospital systems and large-group practices.

The goal is to foster cooperative sharing and mentoring within the medical community on best practices, said Health and Human Services Secretary Sylvia Mathews Burwell in a statement.

"We want everyone who is willing—large, medium, and small practices—to be able to practice medicine with a focus on quality," she said. "We're not seeking to impose reforms from the top down. We want to help you innovate. And we can draw inspiration from physicians, providers, and medical professionals all over the country who are doing just that."

By John Reichard, CQ HealthBeat Editor

October 21, 2014 -- Relatively few uninsured Americans as of early October knew when they'd next have a chance to buy coverage under the health law, according to a survey, and almost half weren't aware they could get subsidies to help pay their premiums. Nevertheless, most said they'd get insured in the next few months.

The Kaiser Family Foundation's latest health law tracking poll, conducted October 8 to 14, surveyed 1,503 insured and uninsured adults. It showed insurers face a tough challenge for the open enrollment period running from Nov. 15 through Feb.15, during which government officials are aiming to enroll twice as many Americans.

While experts say it's better not to heavily promote health coverage when people can't actually sign up, messages about when enrollment begins, and the availability of help paying premiums, could get the period off to a faster start.

The survey found that 89 percent of uninsured respondents didn't know that open enrollment begins in November. Two-thirds of the group says they know "only a little" or "nothing at all" about insurance exchanges where they can sign up. And 53 percent said they were unaware they could get financial assistance to get coverage.

Yet 59 percent of the uninsured said they would get covered in the next few months. Eighteen percent said they expected to remain without coverage because they don't think they could find an affordable plan. And 12 percent of uninsured respondents said they expected to stay that way because they don't want to be forced to buy anything; the cohort included 3 percent who said they'd rather pay a fine for not getting covered than foot the costs of health insurance.

In the overall sample, 43 percent of Americans said they view the health law (PL 111-148, PL 111-152) unfavorably while 36 percent regarded it favorably. Fifty-six percent of Americans said the law had had no direct effect on their family. Among those saying the law had a direct impact, 26 percent said it hurt then and 16 percent said it helped them.

The survey had a margin of error of three percentage points for the full sample and nine percentage points for the uninsured group.

October 21, 2014 -- Total enrollment in the Children's Health Insurance Program (CHIP) grew by 32 percent from 2005 to 2012, according to a report released last week, while spending on the program grew by more than 45 percent during that time period.

The report from The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation found that on an annualized basis, costs for the program grew at a compound rate of 5.5 percent a year from 2005 through 2012.

Most of the spending is covered by the federal government, which provides matching rates that ranged from 65 percent to a maximum of 81 percent in fiscal 2013.
Over the time period studied, total national health expenditures rose by a compound rate of 2.7 percent per year.

In fiscal 2012, CHIP covered 8.1 million children and about 200,000 adults, according to the report.

The data provide some additional context for lawmakers in Congress considering the program's future. Federal funding for CHIP expires on Oct. 1, 2015. A coalition of children's advocates is pushing Congress to extend funding for the program for another four years. The health care law (PL 111-148, PL 111-152) allowed legislative authority for the program to continue until 2019.

Supporters of CHIP say that the program has played a vital role in expanding coverage for children in the United States. The report noted that the share of uninsured children fell from 15 percent of all children in 1997 to 9 percent in 2012. U.S. Census figures released last month found that the percentage of children without insurance fell to 7.6 percent in 2013.

October 24, 2014 -- The top lobbyist for health insurers expressed optimism that the next open enrollment period under the health law will proceed more smoothly but warned that a lobbying battle looms over networks that could lead to higher premiums.

Visitors to federal and state health insurance exchanges will have a much easier time enrolling when the marketplaces reopen Nov. 15 to start selling coverage for the 2015 plan year, America's Health Insurance Plans President Karen Ignagni predicted in an hour-long interview with CQ HealthBeat last week.

Ignagni was unconcerned about the lack of a major outreach effort earlier this year to make the uninsured aware of the upcoming enrollment period and the availability of federal subsidies to help some pay their premiums.

Ignagni described insurance companies as well-prepared to retain existing exchange enrollees and to keep plan renewal rates high. "This is what they do," she said.
She was careful not to project enrollment for the second year of plan sales under the law. Such predictions could be cited as evidence of failure if things don't go well. "Our job isn't to worry about prognostications but to do the best job on the ground for each individual customer," she said.

But Ignagni elaborated at length on a major area of concern to the industry: that powerful providers will exercise lobbying clout to muscle their way into the narrower networks insurers use to keep low-cost plan options available in insurance exchanges. A big battle is brewing and costs could "explode" if providers get their way, she said.

Ignagni said the debacle surrounding last fall's launch of the federal insurance website healthcare.gov that served 36 states is a thing of the past.

The government has spiffed up the "front door" of exchanges covering the shopping and sign-up process. And health plan officials have provided guidance about how to facilitate enrollment, she said.

"We've marshaled the best and the brightest people on the operations side in the plans to work collaboratively with the federal officials that are running the exchange," she said. "The technical people with the plans have been working for a very long time now, for more than a year, with exchange officials."

"What consumers will see this year in the front door is definitely an improved experience from last year," she said.

Ignagni said consumers who are new to the exchange will see a considerably shortened application and will be able to go through the process fairly quickly. Federal officials say that about 70 percent of first-time marketplace customers will use an application that uses 16 computer screens, down from 76.

Less far along is the "back door" –the administrative processes associated with the exchange and its interactions with insurers.

For all the improvements, health plans are uncertain whether the reenrollment process for existing customers will run smoothly. 

"We're in uncharted waters because we've never gone through a reenrollment process," she said.

Among the challenges are ensuring that existing enrollees update any changes to their marital status, incomes, and other changes affecting the size of subsidies for 2015 coverage. It will be important for customers to know what their 2015 subsidies are when they are evaluating coverage choices, Ignagni said.

Health plans are doing a great deal of outreach to make sure people know they need to update their information at the exchange, Ignagni said, adding that AHIP was "very pleased" to see that the Obama administration launched a similar effort last week.

Industry outreach efforts include setting up storefronts in local communities to assist with the enrollment process and maintaining 24-hour consumer call centers, AHIP officials say. One example are storefronts in Harlem and Queens, N.Y., operated by New York-based insurer EmblemHealth.

Consumers will get a letter before the Nov. 15 start of open enrollment telling them about any premium or other changes in their plan for next year. Consumers can consider coverage alternatives if they want to stretch their dollars, Ignagni said.

Ignagni said insurer outreach draws on health plans' experience in other markets, such as Medicare Advantage and Medicare Part D prescription drug plans.

Asked how confident she is plans will be able to get good renewal rates, Ignagni said "they know how to do this work."

She shrugged off questions about whether a more aggressive government or private outreach effort should have been launched by now to bring in new customers by targeting the uninsured.

A poll released this week by the Kaiser Family Foundation found 89 percent of the uninsured surveyed in early October didn't know that the next open enrollment period starts in November. Slightly more than half weren't aware that in many cases, subsidies are available to help pay premiums.

"It wouldn't have made sense in September to start this outreach effort because you want to do it close to open enrollment," Ignagni said.

Ignagni also addressed consumer concerns that some networks are too narrow and leave out some of the most important hospitals in a service area. 

The National Association of Insurance Commissioners is working on revising its model state law on the adequacy of networks. Health and Human Services Secretary Sylvia Burwell has said that federal officials will monitor those efforts before deciding whether they will take added steps to ensure that the number and types of providers in a network are adequate.

Ignagni said that one major difference between tight networks in the HMOs in the 1990s and the current environment is that consumers in exchanges have a choice of plans. Back then, it was the employers not the consumers making the choices, she said.

"They make those decisions themselves and they are getting lower premiums as a result" if they choose tighter networks, she said.

Ignagni said that providers are beginning to lobby "to see whether or not they can be written into specific networks and to have regulations and legislation which forces them in."

The risk for consumers "is that would not only be bad for affordability, that will make costs explode," she said, adding the NAIC has an important job balancing these issues.

"Without a doubt, there are provider groups that don't want to reduce their prices and are looking to regulation and ultimately legislation to protect them," Ignagni said.

The health plan lobbyist said it's "going to be important this time for regulators and legislators to understand that this is a whole different situation because consumers are choosing for themselves and they're balancing all this information at their kitchen table."

"Now the public is much more interested in this question of what are the prices being charged, as opposed to simply what are the premium prices," she said, noting that the costs for medical procedures in the United States are far higher than in other nations.

October 23, 2014 -- The health insurance industry recently released a 22-page guide to help consumers understand how to enroll in coverage, evaluate different plans' provider networks, and recognize that costs may be higher when a patient gets care from a provider that is not in a plan's network.

The information is designed to help patients, especially those gaining coverage for the first time, realize that there are financial consequences if they are not treated by doctors and hospitals within an insurer's network.

The issue has gotten notice because some consumer advocacy groups and providers have recently charged that the networks health plans are offering through the new insurance marketplaces are tighter than insurers have provided in the past or for other types of coverage.

The National Association of Insurance Commissioners is working on revising its model state law on the adequacy of networks and will be holding a call to discuss those changes.

Health and Human Services Secretary Sylvia Burwell said that federal officials will monitor those efforts before deciding whether they will take additional steps to ensure that the number and types of providers that consumers can use is sufficient.

"Over the next few weeks, families across the country will be making important decisions about their health care coverage," America's Health Insurance Plans Foundation President Karen Ignagni said. "Empowering consumers in their health care decisions is a key priority, and this guide is designed to help individuals navigate and understand the choices available to them."

The next marketplace sign-up period runs from Nov. 15 to Feb. 15.