2010 Health Reform Implementation Guidelines

Health Care Reform Compliance Guidelines

This article addresses the implementation schedule for the health care reforms that apply to private health insurance plans under the Patient Protection and Affordable Care Act and the Public Health Service Act stipulations. It is important to note these new provisions impact both self-insured and fully insured group health insurance plans and are incorporated into ERISA and IRS rules.

COMPLIANCE MANDATES FOR 2010

1. COBRA- this provision has been extended from nine months to fifteen months for eligible participants and their dependents. If you were unemployed before February 28, 2009, you may be eligible for a COBRA benefit extension for your group insurance benefits and a federal subsidy for the insurance premiums. The COBRA subsidy was enacted under the American Recovery and Reinvestment Act of 2009 and requires eligible employees to pay a minimum of 35% of the COBRA premium expense (as opposed to 100% previously). Employers are required to administer the extension for qualifying employees and their family members.

NEW PLANS ADOPTED IN 2010 MUST CONFORM

2. Most of the health care reform provisions are not effective until 2014, however for health plans that begin on or within six months of the enactment date of the law(s), October 1, 2010 is the compliance target.

EXTENDING MEDICAL INSURANCE FOR ADULT CHILDREN

3. Medical coverage for adult children can be extended from age 23 to age 26 for children who are covered dependents, whether or not they are married or filing separate tax returns, and is effective in 2010. Plans which existed prior to March13, 2010 will have until January 1, 2011 to comply with the mandated plan change for covering adult children. The question is, what if they are not on the plan now, and will those adult children be able to adversely select against the parent’s medical plan based on their health needs? For example, if the child has coverage through employment but it is not as attractive, can they refuse that coverage in favor of the parent’s plan? So parents, your married kids who are living in their own residence can now be covered on your medical plan. It seems like they will never leave the nest.

UNIFORM BENEFIT EXPLANATIONS-2012 TARGET DATE

Uniform Explanations of Coverage must be provided by either the health plan insurance provider or the plan administrator and an electronic summary must be available. Personally, I think this is a good thing. In 1999, when I was building web sites for paperless plan communication and documentation, most insurance companies were not embracing the paperless process. It makes sense when the health care delivery system is converting to electronic medical records that the insurance industry also converts to paperless plan benefit information. This requirement will simply be an enhancement of the Summary Plan Description materials employers have to provide now. Also, if corporations are offering employee benefits it is incumbent on the group to provide understandable plan benefit information and one would hope the participants are already getting this kind of information. The Uniform Benefit Explanation code requirements will be provided by Health and Human Services within 12 months of enactment of the law, which means by March 2011, for published guidelines. Employers will have 12 more months to comply, so at a minimum that would mean March 2012 or at the plan anniversary, which could mean as late as January 2013.

COMPLIANCE BY 2014

MANDATES FOR HEALTH INSURANCE PLAN CHANGES EFFECTIVE IN 2014

The Patient Protection and Affordable Care Act, section 1304(b) stipulates that the group insurance market is divided into two segments for administration of the law, groups with over 100 employees, and those with fewer than that. There is a provision that allows states to designate that firms with less than 50 employees will be considered their standard for the small group exemption definition. This exception means small employers will not have to pay the per-employee tax (roughly $166.67/FTE/month Re. the Reconciliation bill amendment) if they don’t offer insurance to full time employees. It is expected that most states will accept the more liberal 50 and under criteria. Other provisions that will impact group medical plans include:

1. Group Health Insurance Plans Cannot Impose Annual Limits on Medical Benefits.

2. Health Insurance Plans Cannot Rescind Coverage except in cases of fraud or misrepresentation.

3. Preventive care must be provided without any co-payment.

4. Pre-existing condition clauses are not permitted.

INSURANCE COMPANY REPORTING COMPLIANCE DATES

5. Effective in 2014, Transparency and disclosure of claims utilization rate setting, and other financial data for insurance companies and third party administrators will be standardized. Those identified as insurance administrators or companies will have to provide the same information to the public, in an electronic format, which the government run health insurance exchanges are also required to provide. This includes clear explanations of claims payment standards, financial data disclosure, plan enrollment statistics, rate development information, participant cost-sharing, out of network payment information, and participant rights under the act, as determined by Health and Human Services. Though this is a comprehensive health care transparency law, much of this information is already available to plan administrators and this just codifies it and makes understandability a program performance value. For health care consumers this is a good thing because they will be able to see how their premium contributions are spent.

Plan Reporting Changes by 2014

6. Nondiscrimination rules previously only required under Section 105-H Executive Health Care Plans will now apply to fully insured group health plans and will be phased in by 2014. We can expect to see some new reporting requirement, including a nondiscrimination test probably under a provision in the Department of Labor Form 5500 filings.

7. Codification and reporting of health plan quality will be required by 2014, but no standards are expected from Health and Human Services until 2012. The standards will most likely address disease management programs for high cost chronic diseases like diabetes, hypertension, and COPD. Also, health promotional activities will be required to develop reporting standards. Case management will also be reviewed, as health programs that perform better will be rewarded for quality. Medicare has stipulated an increase in Medicare payments for quality indicators, which will ultimately be adopted in the private insurance sector as well. Complex health care systems already have sophisticated quality measurement programs, so the purpose of this provision is to spread the process improvements throughout the United States. Quality measurement is an important criterion for efficacy of program value and performance. I expect quality reporting to be included in the DOL 5500 reporting standards by 2014.

8. Claims utilization ratios and expenditures from health plans will have to be reported, but this is already available for most firms who have 100 or more employees enrolled on their health and welfare plans, so this is a standardization process. What is new is the requirement that insurers post a minimum loss ratio if they want to work in the insurance exchange market. This will encourage insurers to leave the small group marketplace, which will mean small employers will be relegated to the government insurance exchange offerings. A local nonprofit insurance group in Washington has already decided to leave the small group market and lay off about 25% of its workforce.

9. Uniform External Review Model

Health plans must have an acceptable external audit process, such as the one recommended by the National Association of Insurance Commissioners, which is a consumer protection process.

OBSERVATIONS

The Patient Health Safety Act quality reporting provisions will benefit health care patients who will see more quality indicator reporting. It is valuable to have knowledge of surgical and recovery outcomes by facility before going under the knife. In a perfect world this information will only be a click away in two years, but expect that the implementation for non-alpha organizations will be several years away and 2014 is the target date for mandatory compliance.

Get used to the term “Portal” as the federal government is using this euphemism to describe the mega web site it is creating for the Health Insurance Exchanges, which will serve as a one-stop-shop for various public and private health insurance programs. Portal pricing and plan information as stipulated in Section 2718 of PSACA will apply to plans with inception dates of September 23, 2010 and later. A phase-in period will apply for existing health and welfare plans. Currently data collection is on-going from state insurance commissioners, insurance companies, and Medicaid officials and Health & Human Services is expected to have a preliminary program activated by June 14th, with a “live date” by the July 1, 2010 statutory deadline. High Risk State Insurance Pools (providing health insurance for people who were considered uninsurable in the private sector and ineligible for a public plan) were to have reported their data to state insurance commissioners by May 21, 2010. There must be a lot of overtime at HHS right now!

When I first started writing this article I thought it would be a breeze, but the density of the changes is significant, so if it is a challenge for this policy analyst, I can only imagine how private sector plan administrators will feel. Ideally the government will hire some insurance experts to implement the rules in an effective manner, but that may require private sector experience, and governments are loath to hire anyone from the “for profit” world. My fingers are crossed hoping that some efficiency will emerge from this tsunami of change.

This article was written by Roberta E. Winter, MHA, MPA, a health policy consultant in Seattle and may be reprinted with her permission.

Citations taken from the US Department of Health Human Services web site.

Insurance Changes from the Patient Protection and Affordable Care Act

How Insurance Companies, Employers, and Insureds will fare under the PPAC Act.

Some of the legislators think the healthcare reform bill, signed by President Obama is a catastrophe, but from this angle it looks like a big win for the insurance industry. Though lots of things are missing from the bill, such as cost containment, this is the single biggest health care reform since Medicare was enacted in 1965. This article reviews how the current Patient Protection and Affordable Care Act impacts the insurance industry and its offerings.

Top 10 changes to the Insurance Industry with the PPACA law
1. Creation of the Federal Supplementary Medical Insurance Trust, funded through a panoply of new taxes to provide subsidies and expansion of health insurance programs, both government and private sector for the uninsured.
2. Medical insurance is now required for most U.S.A. residents (AKA lots of new customers!!!)
3. Removal of excessive waiting periods prior to commencement of insurance coverage
4. Removal of lifetime limits on benefits for medical insurance contracts
5. Insurers Required to post a Minimum Loss Ratio if participating in federal health plans like Medicare Advantage plans.
6. Extension of healthcare benefits for children to age 26
7. Closure of the prescription drug “donut hole” exclusion for Medicare recipients
8. Drug Rebates are provided for oral medicines that are re-formulations of existing drugs in an attempt to lower the cost of certain prescription medications
9. Establishment of health insurance exchanges and drug purchasing cooperatives
10. No changes in Cafeteria Plans until December 31, 2013

Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008. But no matter how you look at this provision, it mandates more people buy medical insurance, which is a HUGE win for the insurance sector.

Funding of Insurance Mandates
The healthcare reform bill uses health insurance as a means to improve access to health care services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums.
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for the health care industry. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll, although the Obama Administration forecasts an additional 32,000,000 will obtain some form of health insurance, either government or private sector with this bill. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.

Medicaid Changes
Medicaid changes are a bright spot for healthcare providers as more people will be eligible for Medicaid, versus having no healthcare coverage now, which should reduce the stress on the under-funded population pass-through costs to private sector insurance participants. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans.
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.

Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%

Individual Penalties for Residents who do not Obtain Health Insurance
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax.

The combination of insurance tax subsidies, coerced employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast the level at this time. According to Hewitt Associates, when the COBRA subsidy kicked-in, enrollment increased by 20% for those beneficiaries. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.

Insurance Company Tax
Insurers will be assessed a premium tax to help pay for the provisions of health care under the Patient Protection and Affordability Act. Basically there is a formula that excludes certain activities from tax, has an offset, and has provisions for insurers that derive 80% or more of their revenue from low-income (re. Molina Healthcare), elderly (Medicare supplements), and disabled populations.
Health Insurance Luxury Plan Tax
High cost or “luxury” health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. If the cost of your health insurance exceeds that threshold a tax will be assessed on the residual. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family, which is indexed for medical inflation. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor? This tax may force some plans to reduce some benefit levels to comply.

Medicare Changes
Medicare enrollees benefit by the following changes in reimbursements:
1. Closure of the prescription drug “donut hole” exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs.
2. Changes in Medicare Advantage (HMO) payments
Qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Transparency about plan expenses and administration costs
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government.
5. Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status. This is part of Medicare’s efforts to improve primary care for Medicare patients by strengthening the primary care relationship.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.

Other New Taxes
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive and will be passed directly through to the ratepayers and healthcare consumers. Also, in a nod to medical tourism, since this is an excise tax, even if you obtain healthcare outside of the United States, the device, if manufactured in this country, you will pay the tax.
Estate and Trust Tax
A tax equal to 3.8% will be levied on estates and trusts

Administrative Changes
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts. I just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.

Insurance Changes from the Patient Protection and Affordable Care Act

How Insurance Companies, Employers, and Insureds will fare under the PPAC Act
Some of the legislators think the healthcare reform bill, signed by President Obama is a catastrophe, but from this angle it looks like a big win for the insurance industry. Though lots of things are missing from the bill, such as cost containment, this is the single biggest health care reform since Medicare was enacted in 1965. This article reviews how the current Patient Protection and Affordable Care Act impacts the insurance industry and its offerings.
Top 10 changes to the Insurance Industry with the PPACA law
1. Creation of the Federal Supplementary Medical Insurance Trust, funded through a panoply of new taxes to provide subsidies and expansion of health insurance programs, both government and private sector for the uninsured.
2. Medical insurance is now required for most U.S.A. residents (AKA lots of new customers!!!)
3. Removal of excessive waiting periods prior to commencement of insurance coverage
4. Removal of lifetime limits on benefits for medical insurance contracts
5. Insurers Required to post a Minimum Loss Ratio if participating in federal health plans like Medicare Advantage plans.
6. Extension of healthcare benefits for children to age 26
7. Closure of the prescription drug “donut hole” exclusion for Medicare recipients
8. Drug Rebates are provided for oral medicines that are re-formulations of existing drugs in an attempt to lower the cost of certain prescription medications
9. Establishment of health insurance exchanges and drug purchasing cooperatives
10. No changes in Cafeteria Plans until December 31, 2013

Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008. But no matter how you look at this provision, it mandates more people buy medical insurance, which is a HUGE win for the insurance sector.
Funding of Insurance Mandates
The healthcare reform bill uses health insurance as a means to improve access to health care services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums.
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for the health care industry. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll, although the Obama Administration forecasts an additional 32,000,000 will obtain some form of health insurance, either government or private sector with this bill. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Medicaid Changes
Medicaid changes are a bright spot for healthcare providers as more people will be eligible for Medicaid, versus having no healthcare coverage now, which should reduce the stress on the under-funded population pass-through costs to private sector insurance participants. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans.
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Individual Penalties for Residents who do not Obtain Health Insurance
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax.
The combination of insurance tax subsidies, coerced employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast the level at this time. According to Hewitt Associates, when the COBRA subsidy kicked-in, enrollment increased by 20% for those beneficiaries. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Insurance Company Tax
Insurers will be assessed a premium tax to help pay for the provisions of health care under the Patient Protection and Affordability Act. Basically there is a formula that excludes certain activities from tax, has an offset, and has provisions for insurers that derive 80% or more of their revenue from low-income (re. Molina Healthcare), elderly (Medicare supplements), and disabled populations.
Health Insurance Luxury Plan Tax
High cost or “luxury” health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. If the cost of your health insurance exceeds that threshold a tax will be assessed on the residual. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family, which is indexed for medical inflation. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor? This tax may force some plans to reduce some benefit levels to comply.
Medicare Changes
Medicare enrollees benefit by the following changes in reimbursements:
1. Closure of the prescription drug “donut hole” exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs.
2. Changes in Medicare Advantage (HMO) payments
Qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Transparency about plan expenses and administration costs
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government.
5. Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status. This is part of Medicare’s efforts to improve primary care for Medicare patients by strengthening the primary care relationship.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
Other New Taxes
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive and will be passed directly through to the ratepayers and healthcare consumers. Also, in a nod to medical tourism, since this is an excise tax, even if you obtain healthcare outside of the United States, the device, if manufactured in this country, you will pay the tax.
Estate and Trust Tax
A tax equal to 3.8% will be levied on estates and trusts
Administrative Changes
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts. I just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.

How Hospitals will fare under the 2010 Public Health Service Act

Listening to some of the law makers you would think the healthcare reform bill, signed by President Obama was an apocalypse now, rather than a process, albeit a messy one, of change in our democracy. Certainly lots of things are missing from the single biggest healthcare reform (cost containment) since the initiation of Medicare in the sixties, but this article reviews how the current Public Health Services Act impacts hospital systems. And you can thank-me-in-advance for compressing the 153-page bill into only 4 pages for you to digest.
Medicare Changes
Medicare changes will have an impact on hospitals, as the majority of their patients are typically Medicare eligible.
1. Closure of the prescription drug “donut hole” exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs. Also, the difference in cost sharing between generic and name brand drugs will continue at 7% until 2020 when it will increase to 25% for Medicare participants.
2. Changes in Medicare Advantage (HMO) payments
There is a planned phase out of indirect costs associated with medical education for medical plans with capitated rates (HMO’s) and replaced by modified benchmarks. This is an extremely complicated calculation, which I won’t cover, except to say that qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Changes in Medicare Administration
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government. This provision applies to insurance companies or health systems that include sponsored health plans.
5. Market Basket Update for reimbursements
The Medicare Market Basket is a reimbursement adjustment category and under this act, the percentage point adjustment will be as follows: .03 in 2014, .02 in 2015 &2016, and .75 in 2017-2019. Have fun with that you svengallis of finance & accounting.
6.Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status, but for hospitals that have a high proportion of Medicaid patients, implementation has been delayed until December 31, 2010.
7. Changes in Imaging Payments
This is a modification to the current schedule of reimbursement for imaging services, beginning 2011, a 75% utilization rate will be assumed for this service for Medicare patients. Department managers in laboratory and X-ray units will want to review this to assess the impact on revenues and budget.
8. Repeal of Medicare prepayment medical review limitations.
Disproportionate Share Funding
For hospitals that serve indigent populations, making them eligible for Disproportionate Share Funding from the federal government, the current reduction is 1.5% and this will become 1% in 2014 and then increase to 2% in 2017. Though it appears that states with heavy indigent and Medicaid populations will feel this DPS reduction less than wealthier states, because of a complex modification formula. Hospitals with a low percentage of uninsured patients will experience a reduction in this reimbursement. Everybody has to share the pain I guess.
Medicaid Changes
Medicaid changes are a bright spot for hospitals as more people will be eligible for Medicaid, versus having no insurance now. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans. This is for the calculation of reimbursement for primary care physician services, which will benefit clinics especially. The formula for the FMAP change is as follows:
2014-50%
2015-60%
2016-70%
2017-80%
2018-90%
2019-100%
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Tax Subsidies and Funding of Insurance Mandates
The healthcare reform bill uses health insurance as one of the means to improve access to healthcare services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums. Here is the schedule for tax credits to finance health insurance purchasing:
Federal Poverty/ Level Premium Assistance/ Final Assistance %
Up to 133%/ 2%/ 2%
133% to150%/ 3%/ 4%
200% to 250%/ 6.3%/ 8.05%
250% to 300%/ 8.05%/ 9.5%
300% to 400%/ 9.5%/ 9.5%
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for healthcare. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008.
Health Insurance Luxury Tax
High cost or “luxury” health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor?
Individual Penalties
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels.
The combination of tax subsidies, employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast at this time. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive.
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts, lets just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.

This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.

Obama Signed the most significant Healthcare Reform Bill since the Creation of Medicare

Whew! I must say I am surprised that any agreement was reached on a healthcare bill, but President Obama was presented with a bill and he signed it. Having read all 153 pages of the bill, I am NOT going to write one review of the bill, but this week, I will break it down into three articles. The first article will feature healthcare changes for hospitals, the second article will address insurance changes, and the third article will showcase how these regulatory changes will impact consumers. The only way to digest this mammoth piece of legislation is in smaller bites. So watch for more from the healthpolicymaven this week.

Medical Tourism and Quality Measures

Medical Tourism or the exportation of health care services and procedures is in full swing in the United States consumer driven health care movement. Since deregulation of the airlines with the Reagan administration Americans have increasingly become global travelers and consumers, so why not health care services as well? This article explores the private sector health care population that is seeking health care outside of the United States and examines some quality issues.
Previously Americans seeking health care overseas were expatriates working offshore, residents with family ties in other countries with westernized medical services, or the wealthy. Since 2000, there has been a tremendous increase in middleclass Americans seeking medical services abroad. Approximately twenty billion dollars annually are spent by U.S. residents who obtain medical care off shore. The primary medical services accessed outside of the U.S.A. purview are cosmetic surgery, orthopedic repairs, cardiac procedures, organ transplants, and fertility treatments. These are also high profit services for medical facilities in the United States. Insurance companies, largely at the behest of privately insured employers, are including coverage for medical procedures provided off shore at an increasing rate in their contracts. Even the nonprofit hospital group, Christus Health in the Southwest purchased a hospital in Mexico, in order to offer lower cost procedures within their network. This triad of insurance companies, employer groups, and USA health care providers has created a tsunami of change in the provision of health care.
In 2003, I conducted research on medical tourism for Seattle Cancer Care Alliance and Fred Hutchison Cancer Research Center, for a marketing project to encourage transplant patients to obtain care in Seattle. At that time, no thought was given to patients seeking transplant procedures outside the United States for the exportation of medical care. My survey included facilities on the east and west coasts. Though I was very enthusiastic about the potential for business development for world class transplant centers, this was not shared by my direct reports. I recall how a Miami Florida facility had a very advanced patient support system, including housing, interpretation, and other assimilation services. How things have changed in a mere seven years, now United States transplant facilities must compete with international facilities who are obtaining Joint Commission International accreditation, and can offer the same services as U.S. health centers for less than half of what the same services would cost in the states, inclusive of travel expenses!
The next step to assuring a safe process for adventurous or maybe even frugal patients, who seek medical care outside U.S. oversight, is to identify quality indicators on a global scale, and incorporate quality measures into certification, and contracting of services throughout the globe. India and Thailand both have international centers that cater to western patients and other countries are rapidly developing their ability to serve global patients.
For any medical procedure involving surgery, infection is one of the risks, and is a frequent complication post-op. Infection rates by procedure and facility should be tracked and reported in a transparent manner for a primary quality indicator. A second indicator would of course be mortality, incidence of death, again, by procedure and facility. A third quality indicator would be the re-admission rate for complications from a procedure, which could include complications from co morbidities and device or surgical failure rates. Another quality indicator would be certification of facilities and clinical staffers. A part of this certification should include the frequency with which they perform the contracted procedures and their patient success and failure rates. Meaning, surgeries that go as planned as well as those with unintended consequences, including death. Cost or value should also be included in the scorecard for determining an international medical center’s performance. Administrative functioning and efficiency should also be considered in contracting for quality with an international facility. Finally, the patient’s experience should also be included in a facility’s quality assessment. These seven criteria provide a good basis to create a quality benchmark from which to gauge an off shore healthcare facility’s excellence prior to contracting for services.
Though all of these criteria are important in attempting to pre-qualify an international medical facility’s ability to perform as contracted, the patient’s health status and mobility are also essential elements of any surgical intervention. Insurance companies, who incorporate medical tourism into their contracts, should require a U.S. physician to examine each patient’s ability to seek services at a non-local facility. If the patient may be certified as healthy enough to seek services off shore, then the insurer would approve the procedure. Also, U.S. physicians are reluctant to release patients to clinicians they do not know and facilities for which they are unfamiliar. Insurance companies and health care providers should find ways to build confidence between professionals as needed. I won’t address the legal implications of off shore medical services, but I am sure it is just a question of time before a malpractice or wrongful death suit is filed under medical tourism.
This article was written by Roberta Winter, MHA, MPA, President of Praevalere Inc., a Seattle based health care consulting firm, and may be reprinted with her permission.

Hope for the Holidays

Bring It On 2010
With the country seemingly fomenting from one crisis to the next this past year, many of us are looking forward to a new beginning, let’s bring on that extra digit for 2010! This article highlights what one family did to make a difference in a social need, providing a little hope for the holidays.
Nursing Shortage
As the United States population continues to age, more of us will become hospital patients, which is of concern given the current 135,000 nursing vacancies across the country. Despite the economic downturn, a shortfall in nursing supply continues and is expected to grow to 260,000 in the next fifteen years. Which means, when we are older and more vulnerable, who will be there to care for us?
Mid-course correction
Donna grew up a middle child of seven, in the Great Lakes land of Swedes and Norwegians. When she became an adult she had seven children, four of them before age 24. After several cross-country moves she returned to school and completed her R.N. program shortly before her fiftieth birthday. She worked for 25 years as a charge nurse in a community hospital before retiring. During that time she absorbed the changes of many for-profit corporate takeovers and saw a decline in the quality of care due to decreased staffing in the facility. Finally, she retired at age 72, not out of fatigue, but from frustration with the diminishing resources available to care for increasingly more vulnerable patients.
One Person Can Make a Difference
For Donna’s seventieth birthday, a scholarship was created in her name through the Texas Nursing Association. The award was designed to finance nursing school for community college enrollees who are displaced homemakers. The first scholarship recipient was a survivor of both Hurricanes Katrina and Rita and mother of three children. Despite the loss of her home and damage to her school she stayed on track for completion. The second scholarship was just granted in November, to a fifty-year-old woman who is just entering nursing. Each year, Donna contributes significantly to the fund, even though she is now a retiree, but most importantly, helping someone else still inspires her.
One person, one family, reached out to a community to address the need to recruit and train more nurses in the long term. In a more immediate sense, two families are better off now than before. Thanks Mom.
Happy Holidays to all and to all a good night!

Retort to Change in Breast Cancer Prevention Protocols

This week, lurid headlines were in all United States papers proclaiming a government charged task force of “experts” recommended rolling back frequency of breast mammograms from annually to once a decade if you are age 40 or wait fifteen years if you are age 35. My first reaction was WTF, followed by; I wonder how much they paid for this study. Since I am twice a breast cancer survivor, I consider myself to be somewhat of an “expert” and I have a health policy background. According to the Center for Disease Control, 74.6% of women in the United States who were forty and older received mammograms in 2005. The latest recommendation published in the Annals of Internal Medicine could have an adverse impact on the mammography rate for American women. In order to be fair, let us examine this from a rational perspective.
The most salacious reason cited for reducing the prevalence of mammography in pre-menopausal women was the potential harm of the screening process. Excuse me, you mean the harm of having to obtain a second mammogram because of careful screening and a potential false positive result? This is a good thing as the level of scrutiny for abnormal breast tissue is high in order to save lives. If these folks are concerned about the radiation exposure, the exposure from the sun is worse and certainly contributes to more incidence of cancer than prophylactic breast radiation. Or perhaps it was the horror of the stereo tactic needle biopsy, about as challenging as a blood draw. What exactly are the harmful effects this panel of experts was talking about, a poke in your boob? Or are women really so shallow that a mark or scar on their breast is more important than surveillance for a potentially fatal disease.
In 1993, when I had my first BC diagnosis, I was told that 6,500 women who were under age forty in the United States died from the disease each year, and that I was an anomaly. I was also given literature on how slow growing the disease was and that it primarily impacted grandmothers. Since I was 35 at the time, I decided to do my own research, finding European data on treatment for pre-menopausal women. I knew several women who had died of this disease at the time and the only thing we had in common was an education and a career, which typically meant late or not-at-all child bearing. In my case there was no family history of breast cancer that was disproportionate with the general population.
The proviso this panel of experts make that high-risk women should obtain mammograms excludes one consideration, we don’t typically know who these people are, unless they have been to an oncologist, which would include mammography. The difficulty in preventing cancer mortality is due in part to the elusiveness of the disease indicators and the optimal way to prevent deaths is to have broad population cancer surveillance. Breast cancer mortality is affected by patterns of early detection and quality of care. According to a recent report in the Cancer Journal for Clinicians, which reviewed breast cancer data from 1996 to 2006, breast cancer mortality is declining in the United States. The article also reviewed global breast cancer data and noted the mortality reduction in breast cancer cases was indicative of the early screening, detection, and therapeutic treatments. Why would the United States want to reduce the gains made in saving lives with this virulent form of cancer?
In 2003, ten years after my initial diagnosis, my oncologist informed me, that I had the same type of cancer in my other breast. At that time I was 46 and based on the recommendations from the aforementioned expert panel, I would have come under the high-risk category and have been able to obtain a mammogram with regularity. Of course I would have died at age 36 without my initial mammogram, since baseline mammograms for women under age 50 are not a recommendation from the panel. At the time of my second diagnosis, I was a graduate student in a top ten public university and a widow with a seven-year-old child. Mammography, which I had annually, was the thing that saved me both times. Was my life not worth saving, according to this panel it was just an anomaly.
Second finding, breast self-exams are not beneficial in diagnosing early stages of breast cancer. Duh, someone finally figured this out. First of all if there is a lump in your breast and you can feel it, that is a big tumor. Mine was two centimeters and I couldn’t feel it at all. Secondarily, many lumps are benign or noncancerous. Finding a lump is not an effective early detection method for cancer.
Thirdly, the inference that the emotional trauma from a potentially false positive mammogram is too overwhelming for females smacks of condescension. Aren’t women responsible for their own health? Why not let women make decisions after they have all of the facts. Note to self, the American Cancer Society does NOT agree with these new recommendations to curtail mammography for women that are under age fifty. For those females who feel that having their boob squeezed is not worth potential cancer prevention, that may not be the most well informed choice, but it their option.
Fourth finding, that mammograms for younger women aren’t reliable because of the difficulty in scanning dense breast tissue. What a bunch of huey! I had less than 17% body fat during my initial diagnosis, which found the presence of abnormal tissue in my first mammogram. Mammograms can be performed for women with all breast densities, especially by the better centers. It is helpful to have your “boob shot” taken at the same center so they become familiar with your tissue anomalies. Also, for those professionals who feel they are challenged with imaging more youthful breast tissue, become competent at your job.
Finally, I am concerned about the implications for insurance reimbursement, which may choose to limit coverage for breast cancer diagnostic procedures for women under age fifty. Hopefully some university professor is currently assigning a cost benefit analysis project about mammograms for women under age fifty. In conclusion, for women who may not feel they can cough up the money for a mammogram, I ask you, what is your life worth? Also, there are nonprofit organizations like the www.cancerlifeline.org that have funds to pay for these services. If in doubt, get a second opinion, and keep asking questions until you feel informed about your own health.

European Country going back to Private Insurance

PBS had an interesting program about The Netherlands Health system last night. The Netherlands (Dutch), has been on the cutting edge of a number of health care issues over the years, including policies for physician assisted suicide for the terminally ill and allocation of resources for maternity and child care. Recently, the Dutch decided to switch from a single payer health care system to an open market, privately insured system, where every resident has a health care budget. This approach could work for the United States, but a number of changes would have to be made to the insurance regulatory infrastructure. This article addresses those system delivery concerns.
Question of Scale
First of all, lets talk about scale, The Netherlands is a tiny country compared to the United States, with excellent public transportation and health services in place for the entire country. In the USA, if you have a car, transportation is excellent, though costly, but access to healthcare in rural and poor areas is much more limited in America than in The Netherlands. Secondly, the country has the same health care insurance standards for everyone in the country, not fifty different standards like the states.
Health Insurance Regulation
In America, the Insurance Commissioner of each state regulates the health insurance industry and though commissioners have a national organization with some standardization recommendations, each state is free to do what it wants for health insurance regulation. There is very little standardization in health care insurance or service delivery in the United States, which is partly the cause of the incredible disparity in cost of care per capita compared to other industrialized countries. Also, about half of the USA health care system is financed by private employer plans and for those employers who choose to take some risk and self insure their health plans, there is an exemption from most of the insurance commissioner regulatory authority. So, this begs the question, how would you standardize the process? The answer is an amendment to the ERISA law, which created this health insurance loophole in the first place. Though it may be easier just to do the pay or play and provide the allowance/subsidy as needed, than to dictate benefit design to these stakeholders.
Lack of Standardization
It is one thing for The Netherlands to take its existing long established policies on basic care, palliative care, and eldercare and change their financing system, but the USA doesn’t yet have standardized policies for health care services. Also, since the administrative cost for private insurance is about three times that of the largest government run program, Medicare, it is hard to see how administrative savings will be made in this scenario. The government has more control to drive system delivery changes with Medicare than it would have with several hundred insurance companies. I can just see the marketing geniuses working on their differentiation campaigns now.
Potential Applications from Netherlands Style Market Based Health Plan
The Dutch have a few options to select from for health care insurance, from basic, to deluxe, and pay an individual cost accordingly. Dental, vision, and luxury services are in the latter package. The United States health care reform movement should require a minimum level of care for all of its eligible residents, including primary care, hospitalization, and prescription drugs. A secondary plan may include basic dental and vision services, whereas the deluxe plan could include better coverage in those areas. One consequence of providing an individual health care allowance is the individual would have to take more responsibility in accessing and choosing health care. Theoretically this policy would reduce unnecessary services.
Evidence Based Treatment
In The Netherlands, new prescription drug and other treatments are subject to an administrative review to determine medical evidence and efficacy of the intervention before approving the treatment. This concept would also be a sound mechanism to thwart excess profiteering in the U.S. health care system. Though some patients may be concerned that they are not receiving the latest treatment, this does not necessarily mean their treatment isn’t effective. There are many instances in health care where a lower tech treatment is just as effective as the more technological one. For example, in wound care, the individual vacuum devices that are affixed to the patients wound are less costly and often more effective than hyperbaric treatment. U.S. citizens have to learn to access quality data when making health care decisions.
Universal Availability of Health Quality Data
Though alpha health care organizations, like Virginia Mason Medical Center, have been integrating quality reporting into their system for years, there is limited national standardization of quality reporting. The NQA or National Quality Association has good data available, but it has not been integrated into all health care delivery systems. Quality measures are complex, but leading health care organizations, like Seton Family of Hospitals, a division of Ascension Health, have incorporated quality into their program development measures for years. If you look at medical standards nationally, each specialty has its own education group that advocates for certain treatment protocols. Perhaps the start of a national standardization movement for basic health care is to create a roll-up of these separate quality measures and continue to refine the process.
Accountability and Reporting
Again, given the scale of The Netherlands compared to the U.S.A. and the fact they migrated from a standardized program initially, their reporting issues are less problematic than for the U.S. migration into a standardized health program. Reporting simplicity, transparency, and auditing would be crucial to maintaining equity in a national health care program. Given the Unites States recent bouts with criminal banking activities and the usual health care fraud scams, the importance of tracking private insurance payers is even more crucial. Since the banking industry has wanted to get into the health care industry for years, this may be their opening, so beware of the foxes in the hen house.

Pay or Play or Pay and Pay; Obama versus Baucus Health Plans

Baucus Health Plan
Senator Baucus of Montana broke away from his committee to present his approach to a United States health care overhaul. His plan proposes a complicated series of benefit changes in Medicare/Medicaid, along with taxes on health care suppliers, employers, and individuals, depending on the health care scenario. It is like trying to look through depression era glass for the economy in this approach. First of all, I don’t think adding more taxes to an already expensive health care delivery system will make it less expensive. If anything, this type of proposal will drive more people into the government option Obama plan.
Both the Obama and Baucus health plans rely on the employer system for health care financing, as opposed to a program based on individuals selecting their health plan from regional cooperatives, with a tax credit allowance, and some employer allowance. I am often asked why we expect employers to provide health care in the USA and my only answer is, “because that is the way it is now.” It would be interesting to hear what employers, both large and small think about their preferred level of contribution to health care for their workers. According to the Employee Benefit Research Institute’s 2009 Health Confidence Survey, 83% of their constituent’s support a public health option. An employer mandate for a national health plan gleans 75% support as well. This organization is a conservative, employer, and insurance based entity, so if this is what their subscribers are saying, Brunhilde has finished her aria, and the curtain is coming down on the current health care marketplace.
Similarities
Similarities between the Baucus and Obama plans include the following features: guaranteed ability to obtain coverage regardless of pre-existing conditions, less predatory pricing based on gender and age, and a reduction in the uninsured populations. These are all good mechanisms to get more people eligible to obtain treatment, so their medical conditions can be better managed and less expensive in the long run.
Differences
Baucus recommends the use of nonprofit health care purchasing cooperatives (Community Health Plans or Health Maintenance Plans), to meet the needs of the uninsured population. Does he mean HMO’s or CHP’s? The problem with spreading the cooperative method to the entire United States population is scale; these are localized primary care provider organizations, not national health care institutions. Also, Community Health Plans deliver primary care at a lower cost than HMO’s although their history is briefer. The Obama public option would have the advantage of existing scale with the government already providing a number of health care services. The government is in a position to negotiate the largest discounts for supplies (theoretically) and prescriptions. Since insurance companies will be prohibited from dropping sick individuals from their plans and they will be required to accept all new applicants, there will be some attrition in the number of providers. Depending on your economic perspective, this is either an intended or unintended consequence of the policy change.
Medicare Reform
Obama’s plan expressly closes the gap in prescription drug coverage for seniors, called the donut hole, which is good. I also like his intent to improve quality and care coordination for Medicare recipients. Most of us will be on Medicare coverage someday and that is when we will experience our highest health care expenses. Since the costs for Medicare are escalating beyond sustainability, as a population we should be reviewing this program for efficiencies as a part of our national health care reform initiatives.
Things I would change in Medicare payments include the following:
-Establish an evidence based payment policy for orthopedic treatments (including hip transplants), that considers value delivered over life expectancy
-Tighten up on medical supply payments for motorized wheelchairs and other areas of abuse
-Optimize government purchasing power for the Medicare prescription program
-Stop paying for Viagra on Medicare (increases the risk of a cardiac event)
-Align reimbursements with optimized treatment protocols, which offer sound clinical results and affordable treatments
Finally, I would also institute a fee schedule for Medicare premiums based on earnings, which was voted down by the AARP years ago. Note to the AARP, look you are relying on the current taxpayers to finance your health care, and you are going to have to compromise a little. Be nice to the young people, we will need them when we are old.
My verdict on the Baucus Plan is that it is DOA, but it certainly contributes to an improved level of discussion on health care reforms, when someone else had the guts to reveal his plan. Like the Greek God of wine, Senator Baucus, I raise a glass to you.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission, 9/17/2009