Viewing entries tagged with 'MA'
ICYMI: AHIP Statement on AMA "Report Card"
Posted by The Campaign on June 14, 2010 at 1:54 PM
Statement from AHIP Press Secretary Robert Zirkelbach on the AMA report card:
"Health plans and providers share the responsibility of making the innovations and investments needed to improve efficiency in our health care system. A recent AHIP survey found that nearly one-fifth of all provider claims are not submitted to health plans electronically, and more than 1 in 5 claims are submitted by providers at least 30 days after the delivery of care.
"Health plans are investing in cutting-edge technologies to make it easier for providers to submit claims electronically and receive payment quickly. For example, health plans are working with providers in New Jersey and Ohio to implement portals that would simplify administrative processes and enable doctors in these states to spend more time with their patients.
"Government data show that soaring medical costs - not health plan administrative costs - are the key drivers of rising health care costs. In fact, the percentage of premiums going toward health plans' administrative costs has declined for six straight years."
Of Note:
According to AHIP's most recent health care claims receipt and processing time survey:
- Nearly one-fifth of all provider claims are not submitted to health plans electronically.
- There is often a notable lag before health insurance plans receive claims from health care providers. In 2009, 22 percent of claims were received from health care providers more than 30 days after the date of patient service, and 12 percent of claims were received more than 60 days after the date of service.
- Health insurance plans processed nearly 99 percent of "clean" claims within 60 days, and 97 percent within 30days.
- In 2009, approximately 75 percent of claims were adjudicated automatically -- that is, using automated verification and validation processes that do not require manual intervention -- up from 68 percent in 2006 and 37 percent in 2002.
According to AHIP's survey on out-of-network charges:
- "Some out‐of‐network providers are charging exorbitant prices - several hundred or even over a thousand percent of the Medicare reimbursement for the same service in the same area. Recent examples: $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558."
FACT CHECK: Previous Medicare Advantage cuts caused seniors to lose their coverage
Posted by The Campaign on March 08, 2010 at 1:59 PM
FACT CHECK: Previous Medicare Advantage cuts caused seniors to lose their coverage
- According to CMS, enrollment in Medicare Advantage (then known as Medicare+Choice) experienced multi-year declines following enactment of the Balanced Budget Act of 1997.
- Between December 2001 and December 2002, Medicare Advantage enrollment declined by more than 900,000.
- From 1999 to 2003, nearly 2.4 million Medicare beneficiaries were impacted by plan withdrawals and service reductions. (Source: CMS Medicare Managed Care Geographic Service Area Reports)
What Happened Last Time: Following the Medicare Advantage cuts in the Balanced Budget Act of 1997, millions of seniors across the country saw higher premiums, a reduction in benefits, and loss of coverage:
- Medicare Cuts Threaten Florida HMOs (Orlando Sentinel, 1/31/1999)
"Now the Clinton administration is warning health-care providers that the president's proposed budget for fiscal 2000, due Monday, may call for even deeper cuts to Medicare...HMOs could also feel the pinch...If further cuts are made, more elderly and disabled people could lose their managed-care plans."
- Plunging HMO drug benefits leave Medicare patients in a pinch (The San Diego Union-Tribune, 2/27/2002)
"Beginning this year, however, HMOs placed a far heavier financial burden for drugs and other medical services on patients...The situation stems from limits imposed by federal legislation in 1997 that kept Medicare health plans from receiving health-cost reimbursement increases above 2 percent a year, despite soaring health care costs."
- Two More HMOs to Drop Medicare Patients in Louisiana (Times-Picayune, 7/16/1999)
"It is the second consecutive year that thousands of Medicare recipients have been displaced nationwide...after Congress voted to reduce reimbursements. Industry officials say more shakeouts are in the offing with another round of cuts on the horizon.
This year, Louisiana ranks behind only New York in the number of Medicare beneficiaries who will be forced to look elsewhere for the generous drug coverage and preventive health benefits of government-sponsored managed-care insurance."
- More Health Plans Quit Medicare; 711,000 Elderly, Disabled to Lose Broad HMO Coverage (The Washington Post, 6/30/2000)
- BCBS follows trend, drops area Medicare HMO (Jacksonville Business Journal, 9/13/2002)
"Even federal officials admit the program is underfunded. The Medicare Plus Choice program is in ‘bad shape,' said Thomas Scully, administrator of the Centers for Medicare and Medicaid Services."
- Dozens of HMOs Quit Medicare, Patients Face Upheaval (Washington Post, 10/4/1998)
- Seniors in California's Central Valley See Medicare HMO Options Reduced (The Fresno Bee, 3/20/2002)
- Elderly will be forced to change health plans as HMOs plan to withdraw from Medicare (The Philadelphia Inquirer, 6/29/2000)
- Medicare HMO Bills Will Grow: Premiums, Higher Fees Should Start by Jan. 1 (Orlando Sentinel, 11/5/1999)
"Since the cuts, health insurers have bailed out of the Medicare HMO business at alarming rates...The Medicare cuts are being felt most in states such as Florida with large numbers of retirees."
- Many H.M.O.'s For the Elderly Cut or Abolish Drug Coverage (The New York Times, 1/25/2002)
- HMO Cuts Coverage of 11,000 Seniors (The Boston Globe, 7/6/2000)
- California-Based HMO to Drop Medicare Coverage in Three Arizona Counties (The Arizona Republic, 6/30/2000)
FACT CHECK: Seniors in Medicare Advantage Receive Higher Quality Care
Posted by The Campaign on March 08, 2010 at 1:57 PM
Seniors in Medicare Advantage spent fewer days in a hospital, were subject to fewer hospital re-admissions, and were less likely to have “potentially avoidable” admissions, for common conditions ranging from uncontrolled diabetes to dehydration, according to an analysis of publicly available AHRQ data.
The study analyzed statewide datasets on hospital admissions in California and Nevada compiled by the Agency for Healthcare Research and Quality (AHRQ). The unique data in these states allows for direct comparisons of utilization rates among enrollees in Medicare Advantage plans and in FFS Medicare. These comparisons were adjusted for health status using the Medicare risk score process for age, sex, and 70 Hierarchical Condition Categories that are used as a basis for Medicare risk adjustment. Key findings from the report include:
- Medicare Advantage beneficiaries in California spent 30 percent fewer days in the hospitals than patients with FFS Medicare, and in Nevada, seniors in Medicare Advantage plans spent 23 percent fewer days in the hospital.
- Medicare Advantage enrollees were re-admitted to the hospital in the same quarter for the same condition 15 percent less often in California and 33 percent less often in Nevada compared to FFS Medicare.
- In both California and Nevada, seniors in Medicare Advantage were 6 percent less likely than seniors in FFS Medicare to be admitted to the hospital for conditions described by AHRQ as “potentially avoidable,” such as dehydration, urinary tract infection, or uncontrolled diabetes.
Press Release | Full Report (updated)
This analysis follows a previous AHIP study comparing utilization rates among patients in eight Medicare health plans compared to seniors in FFS Medicare. This study among seniors with certain chronic conditions also found that:
- Medicare Advantage beneficiaries spent an average of 18 percent fewer days in the hospital than seniors in FFS Medicare.
- Seniors in Medicare Advantage had an average of 27 percent fewer visits to the emergency room than those seniors in traditional Medicare.
- Seniors enrolled in Medicare Advantage health plans also experienced a 42 percent lower rate of hospital re-admissions than those seniors in FFS Medicare.
- Avoidable admissions to the hospital were 13 percent lower among seniors in Medicare Advantage plans than those in traditional Medicare.
Full Report (updated) | Slide
FACT CHECK: Small Businesses and Health Care Costs
Posted by The Campaign on November 03, 2009 at 2:56 PM
There has been a lot of focus recently on small businesses and health care costs. Below please find some facts about health care costs and reform proposals put forward by health plans that could help small businesses provide affordable coverage to their employees.
According to the U.S. Government, Premium Increases Mirror Increases in Medical Costs
According to government data, health insurance premiums track directly with the underlying cost of medical care. As the cost of providing medical care increases, premiums rise accordingly. Some employers and families have chosen plans with lower premiums and higher cost-sharing (deductibles, co-pays, and coinsurance) to offset the increase in premiums.
Source: PricewaterhouseCoopers, A Shared Responsibility: Advancing Toward a More Accessible, Safe, and Affordable Health Care System for America, p.7
States Heavily Regulate Premiums
Every state imposes restrictions on the premiums that may be charged for health insurance coverage.
Every state requires certification that premium increases are consistent with actuarial standards with respect to cost trends and benefits provided.
Health Plans Have Put Forward Proposals to Help Make Coverage More Affordable and Accessible for Small Businesses and Their Employees
- Essential Benefits Plan: We propose the creation of new health plan options for small employers and their employees, as well as individuals. These "essential benefits plans" would be available nationwide and would include coverage for primary care, preventive care, chronic care, acute episodic care, and emergency room and hospital services. Alternatively, "essential benefits plans" should include coverage that meets an actuarial equivalence standard, along with the opportunity to include enhancements such as wellness programs, preventive care, and disease management. To maintain affordability, the essential benefits plan should not be subject to state benefit mandates that do not apply to the generally larger employers that enter into self-funded health care coverage arrangements.
- Tax Credits or Other Incentives to Assist Small Business: We support the establishment of tax code incentives or other types of assistance that encourage both small business owners to offer coverage to their employees and employees to take up coverage. We recognize the special challenges, both administrative and financial, that small businesses face in offering contributions toward their employees' coverage. Providing assistance can encourage these contributions and help enable employees to take up coverage which improves predictability and stability in the small group market.
- Improving Coordination of Private and Public Programs Strengthens Small Group Coverage: Premium or other assistance offered to low-income individuals and working families can be applied to and work with employer-sponsored coverage. This is important whether the assistance is provided through Medicaid, the Children's Health Insurance Program (CHIP), or other expanded programs designed to help individuals and families obtain coverage. Improved coordination allows workers to take up coverage offered by small businesses by leveraging both public and private sources of assistance, and benefits the firms' employees as a whole by increasing rates of participation in the small group plan.
- Micro-firms: "Micro-firms" (those with fewer than 10 employees) face special challenges in offering coverage. Statistics show that only about one-third of these firms offer coverage. This reflects the administrative, financial, and logistical challenges many micro-firms face in setting up and establishing plans and offering and contributing to their employees' coverage. To help these firms meet these challenges, enhanced tools could be developed that would allow those micro-firms that have found it impractical to offer coverage, to contribute to coverage purchased on a pre-tax basis by individual employees. As part of comprehensive health care reform, employees could then use these contributions to help purchase coverage in a reshaped health care system that combines an individual requirement to obtain coverage with reforms in the individual market.
- One-stop information source: All small firms will benefit from collaborative efforts between health plans and the public sector (e.g., insurance commissioners) to ensure that small employers and individuals have one-stop access to clear, organized information that allows them to compare coverage options. This "one-stop shop" also could allow individuals to confirm eligibility for tax credits or other assistance and even provide a mechanism to aggregate premium contributions from multiple sources. By providing a mechanism to combine even modest contributions from multiple sources (public and private), this new one-stop shop could be especially helpful to employees who may hold multiple jobs.
THE WHITE HOUSE: Medical Liability Reform Pilot Project Announcement
Posted by The Campaign on September 17, 2009 at 10:42 AM
The White House today announced the launch of a new demonstration initiative that will help states and health care systems to test models of medical liability that meet the following goals:
- Put patient safety first and work to reduce preventable injuries;
- Foster better communication between doctors and their patients;
- Ensure that patients are compensated in a fair and timely manner for medical injuries, while also reducing the incidence of frivolous lawsuits; and
- Reduce liability premiums.
POLL VAULT: New Poll Shows Americans Support Medical Liability Reform
Posted by The Campaign on September 10, 2009 at 2:16 PM
A new nationwide poll commissioned by Common Good and the Committee for Economic Development, and conducted by Clarus Research Group, reveals that a strong majority of America's voters want Congress to include lawsuit reform in any overhaul of the health care system.
Here are some key findings:
83 percent of the nation's electorate want Congress to address reform of the medical malpractice system as part of any health care reform plan.
72 percent of voters think the fear of being sued often changes the way doctors deal with patients.
67 percent of voters favor special health courts deciding medical malpractice cases rather than the regular court system.
Only 43 percent of Americans have confidence that a lawsuit "without merit" that was filed against them would be resolved in their favor, and only 30 percent have confidence it would be resolved quickly and efficiently.
Click here to read the full press release. Click here for a presentation of the findings.
ICYMI: Washington Post Editorial -- Medical Malpractice System an Expensive Lottery
Posted by The Campaign on September 10, 2009 at 6:38 AM
Here is an excerpt from the Washington Post editorial from this morning:
"The medical malpractice system is an expensive lottery that does a poor job of both assigning blame and compensating victims; the threat of liability encourages some doctors to order unnecessary tests and procedures."
ICYMI: AHIP on Medical Malpractice
Posted by The Campaign on September 08, 2009 at 6:52 AM
Roll Call reports on the role medical malpratice reform is playing in the reform debate. The story includes this perspective from AHIP's Mike Tuffin:
"Medical liability reform has to be a part of the plan to make health care affordable and make the system sustainable. The current system has created an epidemic of defensive medicine. It is raising the costs for patients and putting doctors and nurses out of practice in some cases."
For the full story click here (subscription required).
FACT CHECK: Health Plan Proposals Would Help Small Businesses
Posted by The Campaign on August 31, 2009 at 2:48 PM
Helping small business owners be able to provide health insurance for their employees is a critical part of the reform debate. Health plans recognize this and have put forward several proposals that would help make coverage more affordable and accessible for small businesses and their employees.
Some of these proposals include:
Essential Benefits Plan: We propose the creation of new health plan options for small employers and their employees, as well as individuals. These “essential benefits plans” would be available nationwide and would include coverage for primary care, preventive care, chronic care, acute episodic care, and emergency room and hospital services. Alternatively, “essential benefits plans” should include coverage that meets an actuarial equivalence standard, along with the opportunity to include enhancements such as wellness programs, preventive care, and disease management. To maintain affordability, the essential benefits plan should not be subject to state benefit mandates that do not apply to the generally larger employers that enter into self-funded health care coverage arrangements.
Tax Credits or Other Incentives to Assist Small Business: We support the establishment of tax code incentives or other types of assistance that encourage both small business owners to offer coverage to their employees and employees to take up coverage. We recognize the special challenges, both administrative and financial, that small businesses face in offering contributions toward their employees’ coverage. Providing assistance can encourage these contributions and help enable employees to take up coverage which improves predictability and stability in the small group market.
Improving Coordination of Private and Public Programs: Premium or other assistance offered to low-income individuals and working families can be applied to and work with employer-sponsored coverage. This is important whether the assistance is provided through Medicaid, the Children’s Health Insurance Program (CHIP), or other expanded programs designed to help individuals and families obtain coverage. Improved coordination allows workers to take up coverage offered by small businesses by leveraging both public and private sources of assistance, and benefits the firms’ employees as a whole by increasing rates of participation in the small group plan.
Reforms for Micro-firms: “Micro-firms” (those with fewer than 10 employees) face special challenges in offering coverage. Statistics show that only about one-third of these firms offer coverage. This reflects the administrative, financial, and logistical challenges many micro-firms face in setting up and establishing plans and offering and contributing to their employees’ coverage. To help these firms meet these challenges, enhanced tools could be developed that would allow those micro-firms that have found it impractical to offer coverage, to contribute to coverage purchased on a pre-tax basis by individual employees. As part of comprehensive health care reform, employees could then use these contributions to help purchase coverage in a reshaped health care system that combines an individual requirement to obtain coverage with reforms in the individual market.
One-stop information source: All small firms will benefit from collaborative efforts between health plans and the public sector (e.g., insurance commissioners) to ensure that small employers and individuals have one-stop access to clear, organized information that allows them to compare coverage options. This “one-stop shop” also could allow individuals to confirm eligibility for tax credits or other assistance and even provide a mechanism to aggregate premium contributions from multiple sources. By providing a mechanism to combine even modest contributions from multiple sources (public and private), this new one-stop shop could be especially helpful to employees who may hold multiple jobs.
FACT CHECK: The Individual Insurance Market
Posted by The Campaign on July 21, 2009 at 10:58 AM
FACT CHECK: The Individual Insurance Market
89% of individuals applying for coverage in the individual market were offered coverage.
Consumers in the individual market were offered a wide range of benefits, including mental or behavioral health, prescription drugs, preventive, and maternity benefits.
Forty percent of these offers were at standard premium rates and 49 percent were offered at lower (preferred) rates.
Inpatient and outpatient behavioral health and substance abuse benefits were included in approximately 85 percent of policies purchased.
For more facts on the individual insurance market, check out AHIP’s study: “Individual Health Insurance 2006-2007: A Comprehensive Survey of Premiums, Availability, and Benefits”.
The individual market is an important source of quality, affordable coverage for millions of Americans. But it needs to be improved to make sure no on falls through the cracks. Health plans have proposed new market rules and consumer protections including:
- Guaranteed coverage for pre-existing conditions,
- Discontinuing rating based on health status or gender,
- Ensuring continuity of care and portability of coverage, and
- Ensuring all Americans are covered with a personal coverage requirement.
To read more about AHIP’s proposals click here.
