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How Health Care Reform is Supposed to be Working
The RAND Corporation has published a study, “Effects of the Affordable Care Act on Consumer Health Care Spending and Risk of Catastrophic Health Costs.”
RAND provides the following summary of the study:
This study examines the likely effects of the Affordable Care Act (ACA) on average annual consumer health care spending and the risk of catastrophic medical costs for the United States overall and in two large states that have decided not to expand their Medicaid programs (Texas and Florida). The ACA will have varied impacts on individuals’ and families’ spending on health care, depending on income level and on estimated 2016 insurance status without the ACA. The authors find that average out-of-pocket spending is expected to decrease for all groups considered in the analysis, although decreases in out-of-pocket spending will be largest for those who would otherwise be uninsured. People who would otherwise be uninsured who transition to the individual market under the ACA will have higher total health care spending on average after implementation of the ACA because they will now incur the cost of health insurance premiums. The authors also find that risk of catastrophic health care spending will decrease for individuals of all income levels for the insurance transitions considered; decreases will be greatest for those at the lowest income levels. Case studies found that in Texas and Florida, Medicaid expansion would substantially reduce out-of-pocket and total health care spending for those with incomes below 100 percent of the federal poverty level, compared with a scenario in which the ACA is implemented without Medicaid expansion. Expansion would reduce the risk of high medical spending for those covered under Medicaid who would remain uninsured without expansion.
You can read the Study online or download a copy here.
Thousands Of Mississippi Consumers May Not Be Offered Insurance Subsidies – Kaiser Health News
Tens of thousands of uninsured residents in the poorest and most rural parts of Mississippi may be unable to get subsidies to buy health coverage when a new online marketplace opens this fall because private insurers are avoiding a wide swath of the state. No insurer is offering to sell plans through the federal health law’s marketplaces in 36 of the state’s 82 counties, including some of the poorest parts of the Delta region, said Mississippi Insurance Commissioner Mike Chaney. As a result, 54,000 people who may qualify for subsidized coverage would be unable to get it, estimates the Center for Mississippi Health Policy, a nonpartisan research group.
See on www.kaiserhealthnews.org
Private commercial insurance companies are making this decision to deny healthcare coverage to thousands of poor rural Mississippians. This is not the fault of Obamacare. What is the solution – to give those people access to healthcare or not. State legislatures can no longer ignore the poor — the point is why should the private healthcare insureres be allowed to pick and choose like this – if they want to be licensed in Mississippi, they should be required to provide coverage throughout the state.
Overcoming Obstacles to Better Health Care
Transforming the American health care system could include offering safe harbor from malpractice suits for doctors who demonstrate high-quality care. See on www.nytimes.com
Meaningful healthcare reform needs tort reform so that healthcare providers can spend less time (and less insurer’s money) on defensive medicine and more time (and arguably less insurer’s money) on preventive medicine and thereby achieve more accountable medicine.
Actually, Mr. Brill, Fixing Healthcare Is Kinda Simple | Wired Science | Wired.com
When you need health care, you enter not a market but a con game in which you’re first a guarantor and source of profit, and second a patient. Wired Science blogger David Dobbs explains why the government needs to step up. See on www.wired.com
Patients have no clout in so-called market driven healthcare because of its fragmented delivery and billing systems. Having insurance further mystifies the process and hides the information necessary to make market decisions. Something like a patients union is needed to equalize the playing field. For now, Obamacare is all that patients have to give them some protection against the two Titans in healthcare who have all the market power.
Your EHR needs a population health management system
Office-based medical practice is changing fast. The government is providing incentives to those practices that use electronic prescribing and electronic records systems and will soon penalize those that don’t. Health reform will shortly deliver many newly insured patients to your office. A host of new patient care models aimed at making healthcare more team-based are emerging. Reimbursement tied to outcomes will demand a greater level of patient management and engagement in the care process.
Often, though, an EHR alone cannot provide the functionality necessary to manage a specific population of patients.
There are many reasons a practice may need to identify and proactively work with a defined group of patients. Primarily, it’s to insure they are receiving care according to the evidenced-based standards agreed upon by the practice. See on www.kevinmd.com
Many physicians are re-evaluating their first choice of EHR and are changing to others as they learn how they work and what is needed for their medical practices. This is just one more instanceof making saure your EHR is robust enough to add new important components as the need develops.
Recent Criminal and Civil Enforcement Actions
From Akerman’s Health Law Rx Blog:
POSTED BY JOSEPH W. N. RUGG ON FEBRUARY 15, 2013
In 2009, the Health Care Fraud Prevention and Enforcement Action Team (“HEAT”) initiative was formed as a joint effort between the Departments of Justice and Health and Human Services, and combating health care fraud continues to be a major focus of federal and state authorities. The Office of Inspector General (“OIG”) publishes a list of the criminal and civil enforcement actions and the punishment that has been meted out to those convicted of some sort of healthcare fraud. Here are three examples from February listings where jail time or substantial fines or both have been imposed.
- On February 1, a 50-year-old pharmacist who owned and operated 26 pharmacies in the Detroit area was sentenced to 17 years in prison. The evidence presented at trial showed that during 2006 through 2011 the pharmacies had billed Medicare and Medicaid more than $57 million, at least 25% of which billings were fraudulent as being either medically unnecessary or never actually dispensed. Similar fraudulent activities occurred with respect to commercial insurance. The pharmacist’s business model was to pay kickbacks to physicians in exchange for writing prescriptions for expensive medications or for controlled substances without regard to medical necessity. In addition to the jail time, the defendant was required to repay Medicare and Medicaid $17.3 million and commercial insurers $1.5 million.
- On February 4, two patient recruiters for a Miami home healthcare company pleaded guilty for their participation in a $20 million home health Medicare fraud scheme. The recruiters admitted that during 2007 through 2009, they recruited patients for which the home health agency could bill Medicare, and the home health agency’s owners paid them kickbacks and bribes. Medicare was billed for home health care and therapy services that were either medically unnecessary or not provided. The recruiters face jail time and fines, and each of the two home health agency’s owners have already been sentenced to over 6 years in jail.
- On February 7, St. Joseph’s Medical Center, a hospital located in Towson, MD, agreed to pay $4.9 million in connection with its submission of false claims to Medicare, Medicaid, and other federal healthcare programs. The hospital stated that during 2007 through 2009 it admitted patients for short stays – typically one or two days – that were not warranted by the patient’s medical condition but which would result in larger insurance payments than was appropriate.
If you are aware of potentially fraudulent or even inadvertent noncompliant activities in your healthcare business, you need to seek assistance to fix those problems before they become the object of an investigation. Because former employees and business partners of healthcare providers are often the ones reporting the fraudulent activities to the authorities, problems cannot be ignored.
Since the the above blog was posted on the Akerman Health Law Rx Blog, the following was posted by the OIG:
Cardiologist admits taking cash kickbacks for patient referrals — According to a February 14, 2013 press release from the Office of the U.S. Attorney, District of New Jersey:
Shashi Agarwal, 60, of Edison, N.J., who has his own cardiology practice in East Orange, N.J., pleaded guilty before U.S. District Judge Claire C. Cecchi in Newark federal court to an Information charging him with one count of soliciting and receiving more than $100,000 in cash kickbacks in violation of the federal health care anti-kickback statute.
Agarwal is the 10th person to plead guilty in the government’s investigation into the scheme to pay cash to health care providers who referred patients to Orange Community MRI, LLC (Orange MRI) in Orange N.J., for diagnostic testing.
Florida Medicaid Managed Care Receives Green Light From HHS
From Akerman’s Health Law Rx Blog:
POSTED BY SHERYL D. ROSEN AND BRUCE D. PLATT ON FEBRUARY 6, 2013
Florida has been working on a plan to shift the state’s Medicaid population into managed care for nearly two years – ever since the Florida Legislature directed the change in 2011. On Monday the state received the approval it needed from the federal government.
By letter dated February 1, 2013, the U.S. Department of Health and Human Services granted Florida’s request to waive certain provisions of the Social Security Act, allowing the state to transfer some Medicaid recipients from the traditional fee-for-service program into a Medicaid managed care plan for individuals needing long-term care.
The federal waiver is limited to the state’s Medicaid Long-Term Care Managed Care recipients. It will allow up to 36,795 Medicaid recipients to receive long-term care services from health maintenance organizations (“HMOs”) or provider services networks (“PSNs”) in the recipient’s local area. Such a transition would include access to services including adult day health care and case management, instead of more costly nursing home care. The waiver goes into effect on July 1, 2013, ahead of the state implementation deadline of October 1, 2013. On January 15, the Florida Agency for Health Care Administration (“AHCA”) posted notices of intent to award Medicaid Long-Term Care Managed Care contracts to PSN American Eldercare and HMOs including UnitedHealthcare of Florida and Sunshine State Health Plan.
A second waiver request is pending with HHS. If granted, it will allow Florida to shift the majority of remaining fee-for-service Medicaid recipients into the Managed Medical Assistance program via an HMO or PSN in the recipient’s area. On December 28, 2012, AHCA issued the invitations to negotiate seeking managed care organizations to provide Mandatory Managed Medical Assistance to Medicaid recipients in Florida. It is anticipated that AHCA will post the notice of intent to award these contracts on September 16, 2013. If the second waiver request has been granted by this time, the anticipated contract execution date is December 31, 2013.
Health Care Reform – Should Employers Reduce Expected Health Costs in 2014 by Transitioning Some Full Time Employees to Part Time Status Now?
From Akerman’s Health Law Rx Blog:
POSTED BY BETH ALCALDE ON FEBRUARY 1, 2013
2013 is shaping up to be a very busy year for employers in all industries, with the continued implementation of the Patient Protection and Affordable Care Act (“ACA”). Recognizing that in 2014, applicable large employers will avoid ACA-related penalty taxes by offering required affordable group health plan coverage just to full-time employees (i.e., those working an average of 30 hours or more per week, as calculated in a number of permitted ways), some applicable large employers have already begun examining whether to cut their employees’ hours.
Considerations in the reduction of hours decision will vary by industry and by employer, and there is no one-size-fits-all approach. Some of the factors to weigh should include the following:
- How much will the costs of health coverage continue to rise for this employer? What portion of those costs are expected to be specifically attributable to these employees?
- What tax savings are currently available for the employer-sponsored coverage for these employees?
- Are there employee morale, recruitment, productivity, and/or retention issues to consider?
- Are there public relations or government relations issues to consider?
- How many part-time employees does the company currently have? Does the company’s business model permit a shift away from full time employment?
- Will salary increases be needed if no insurance is offered to these employees?
- How many of these employees are expected to be eligible for subsidized health insurance coverage in a state or federal exchange? (Note that employers are not advised to solicit pledges from employees to not seek a subsidy in exchange for continued full time employment.)
Akerman’s Health Law Rx Blog
I am pleased to announce my firm’s new health law blog, Health Law Rx Blog.
Akerman’s Health Law Rx Blog provides timely updates on the latest health law issues, keeping the firm’s clients, friends, and readers up to date on pertinent legal developments. Akerman attorneys regularly update the blog with changes in the law and other relevant news. As this is meant to be an interactive site, your comments and contributions are appreciated. I am one of the contributors, so I hope you will visit the blog often and participate in any discussions that interest you. I plan to shadow post articles from the blog that I think you will find interesting.
Content on Akerman’s Health Law Rx Blog is intended to inform you about legal developments, including recent decisions of various courts and administrative bodies. It should not be construed as legal advice or a legal opinion, and you should not act upon the information without seeking the advice of legal counsel.
With more than 550 lawyers and government affairs professionals and a network of 19 offices, Akerman is ranked among the top 100 law firms in the U.S. by The National Law Journal NLJ 250 (2012). The firm’s Healthcare Practice Group includes over twenty attorneys and professionals representing health systems, physicians, health insurers, and other clients in all aspects of healthcare law across Florida and throughout the United States.
Preventive Services, Including Contraceptive Coverage, Under the Health Care Law
All Women Should Have Access to Preventive Health Services, including Contraception, Without a Co-Pay, and Have It No Matter Where They Work
The health care law makes preventive care more accessible and affordable to millions of Americans by making certain preventive services, including all FDA-approved contraceptive methods, available without co-payments or other cost sharing requirements. This is especially important to women, who are more likely than men to avoid needed health care, including preventive care, because of cost. This requirement is a huge step forward for women’s health. Over the next few years, as an increasing number of health plans come under the law’s reach, more and more women will have access to a wide range of preventive services without co-payments or deductibles.
See on www.nwlc.org
Joseph Rugg's Health Law Blog 