Weekly Health Care Reform Update at the Federal and State Level

Week of  October 5, 2009

The Senate Finance Committee essentially wrapped up its work on a health care reform bill last week, though additional changes are still possible as the bill is put to a vote of the full Committee later this week. A number of changes made to the bill at the 11th hour last week already are generating concerns about the direction of the legislation.

For example, one amendment approved by the Committee would result in a significant weakening of the individual coverage requirement (see below). This requirement is the cornerstone on which a host of insurance market reforms are supported.

The bill also would levy significant new fees and taxes on different sectors of the health care system, such as health insurance, without adequately tackling the true drivers of health care costs.




As health care reform moves toward floor debate in the House and Senate, the industry will monitor events closely and weigh in on issues of substance. While this summer's town hall meetings were an important part of the process, there will be no more important time for all Americans to stay informed and be involved than in the weeks ahead. 

Federal 

The Senate Finance Committee last week finished moving through dozens of amendments, paving the way for a vote on the finished bill sometime this week after the Congressional Budget Office provides a cost estimate. While many amendments were rejected, the panel did approve at the last minute some significant changes to the bill introduced by Chairman Max Baucus (D-MT) in mid-September. 



One amendment adopted would weaken the individual coverage requirement by delaying and reducing penalties attached to the requirement. The maximum penalty for a family of four would start at $200 in 2014 and rise to $750 in 2017.
Significantly, an estimated 2 million people who would face financial difficulties would be exempt from buying even the cheapest insurance available -- those who would have to pay more than 8 percent (a change from 10 percent) of their adjusted gross income for the cheapest plan would be exempt.

The Committee rejected amendments for a public plan option, but it did include a mini-public plan option for those under 200 percent of the federal poverty level. To help pay for the legislation, new fees and taxes would be levied on insurance companies, drug makers, medical device manufacturers, and some families. Senate leaders already have begun looking at ways to blend together the Senate Finance Committee bill and a competing Senate HELP Committee bill so that floor debate can begin later in October. 


States 

INDIANA:  Hearings resumed last week on the Health Provider Patient Limit Study supported by the Indiana Medical Association. The Health Finance Commission is required to study:

1.    health plan provider contract provisions that would require a contracted provider to mandatorily accept more than a certain number of patients (open access clause); and

2.    whether an insurer should be required to directly reimburse an out-of- network health care provider (assignment of benefits). 

Arguments were presented on both sides of these issues.  In addition, HEA 1300 requires the Indiana Department of Insurance (DOI) to collect information regarding the costs of initiation and operation for recognizing assignment of benefits and report to the Health Finance Commission on its actuarial findings. 

The data has been collected by DOI, which will present its final findings on assignment at the October 19 Health Finance Commission meeting.  A final report from the Health Finance Commission is due to the Legislative Council by November 1. 

TEXAS: The Department of Insurance has prepared a working draft of rules concerning physician ranking requirements and notice requirements that would limit health plans' ability to publish physician rankings. These draft rules would implement the provisions of legislation recently passed establishing standards for the use of physician ranking systems by health plans. The legislation outlines a process to be used by the TDI in determining nationally accepted standards for provider rankings.

The standards used must be disclosed to each affected provider, as well as the details of a process that may be used to dispute the rankings. The measure also prohibits physicians from taking action that would prevent a patient from participating in an evaluation of the physician’s performance. Insurers / payors worked throughout the session with the bill’s authors to ensure that the final version tracked the patient charter and national best practices. Insurers / payors will continue to work with TDI in the crafting of its final rules.

WASHINGTON: Insurers / payors are working with the state and other industry stakeholders to determine the feasibility of maintaining the state's Universal Vaccine Program for children. Due to budget cuts, the state is scaling back the vaccine program next spring to cover only low-income children.  


Currently, the program is available for all vaccinations for any child residing in the state, even those with private insurance. Due to the state's purchasing power and its ability to distribute vaccine effectively, there are multiple benefits to the state continuing the program.

No World Borders provides services to health care payors / insurers and providers as well as in other industries.

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Weekly compilation of health care reform developments in Washington, D.C. and state legislatures 9/24/09

While the proposals being considered by Congress to help reform the health care system could make significant strides in addressing health care access problems, many remain concerned that the proposals made to date do not do enough to take on the overarching problem of rapidly rising health care costs.

To help draw more attention to this daunting problem, some large insurance firms recently were sponsors of the September/October edition of the journal Health Affairs, which is devoted to "bending the cost curve." The current issue and the launch event highlighted innovative solutions that could have a significant impact on the future cost of health care. Bending the cost curve is the key -- if we don’t make health care more affordable, other reforms will have little value.

Federal

Medicare Policy Might Discourage Proper Care for Hospital-Acquired Infections

Medicare's recent policy of refusing to pay hospitals' additional costs to treat hospital-acquired infections fails to adequately incentivize prevention and proper treatment of these complications, associated with 99,000 deaths annually. Read more from the healthcare blog

Senate Finance Committee Chairman Max Baucus released his "mark," which is the Senator's offering to the full Committee of the legislative pathway he thinks the Committee should follow to pass health care reform. While those on both the left (Senator Rockefeller) and on the right (Senator Grassley) expressed negative views on the mark, all the headline posturing ceases when the committee officially begins to review and amend the mark this week. The key for Chairman Baucus is to garner sufficient support to pass the bill out of committee in a fashion that bodes well for floor passage. Right now the prospects are far from certain.

States

ARIZONA: The Department of Insurance has issued a bulletin summarizing several insurance-related bills enacted during the 2009 legislative session. The bulletin expressly notes: the revision of the acceptable medical references an insurer may use in its determination of whether a drug has been found to be safe and effective for treatment of a specific type of cancer and the amended definition of "network plan" to include a plan under which the financing and delivery of health care services are provided through a defined set of providers under contract with a hospital, medical, dental or optometric service corporation; the ability of service corporations to issue subscription contracts free of many state-mandated benefits and also reduce the allowable uninsured period for small groups to qualify for state vouchers for free coverage; and the permissibility of issuing coverage to uninsured individuals without being subjected to many of the state's mandated benefits.

CALIFORNIA: Proponents of a new statewide initiative to return the legislature back to a part-time status are attempting to collect the 700,000 signatures necessary to qualify for the ballot in 2010. The measure would cut the current legislative calendar to 90 days. Supporters of the initiative say that the full-time legislature, authorized by voters in 1966, has failed to produce the results promised. After another rocky legislative year marked by a soaring budget deficit and a failure to address education spending and health reform issues, broad support for the measure seems likely. However, a bipartisan group of three former state lawmakers have formed an alliance to fight the effort, arguing that it would not allow the legislature sufficient time to address the state's serious problems.

CONNECTICUT: The General Assembly is holding September 23 and 24 to take up several bills needed to implement the new, two-year budget that took effect September 8. The “implementer bills” are required to put in statute the policy changes necessitated by passage of the budget. The session bears watching because of a trend of late to attempt to include non-budget-related proposals in these implementer bills. In the past, ideas that died in the regular session came back to life during an implementer session, only to expire again once they were publicized.

FLORIDA: The Agency for Healthcare Administration has asked carriers to participate in a workgroup regarding Explanation of Benefits (EOB) sent to members. The goal of the workgroup is to develop best practices for information contained on an EOB and assure the EOB is clear to consumers.

ILLINOIS: The Department of Insurance's (DOI) proposed rules for preferred provider programs and networks were heard last week by a legislative panel. These rules would affect both insurers and network administrators that offer incentives to insureds to utilize the services of contracted providers. At the hearing DOI agreed to remove objectionable language to business and insurance groups that would have limited a consumer's exposure to 50 percent of out-of-network billed costs by a provider. The DOI Director was given discretion on the rest of the proposed rule and agreed to hold it for 30 days and meet with the industry to discuss other objections. The two major issues that remain for business and insurance groups are: a provision stating that a provider's written approval must be obtained whenever an insurer or administrator buys another network, if it represents a material change to the contract; and the effect of language that would require insurers and administrators to hold beneficiaries harmless for out-of-network physician costs. The industry is preparing for meetings with DOI.

MASSACHUSETTS: The Division of Health Care Finance and Policy (DHFP) has introduced amendments to the Employer Fair Share Contribution regulation. The proposed amendments clarify that to be considered a contributing employer, an employer must maintain a written plan document for its group health plan. In addition, the employer must be able to document in writing its offer to employees to make a percentage premium contribution and the minimum number of hours that the employees are required to work to be eligible for full-time benefits. The amendments also clarify that a Premium Reimbursement Arrangement (in which an employee enrolls in an individual plan and is reimbursed by the employer for a portion of the premium expense) may qualify as a group health plan, provided there is written plan documentation that designates a particular plan for use by employees.

NEW JERSEY: Legislation requiring disclosure of certain serious reportable events was recently enacted by Governor Jon Corzine. Under the new law, the Department of Health and Senior Services will annually issue a report of specific hospital Patient Safety Indicators (PSI) as enumerated under federal guidelines by CMS. Additionally the law prohibits hospitals from charging for certain "never events." These events, for which reimbursement cannot be sought, include: transfusion reaction; air embolism; foreign body left in during a procedure; surgery on wrong side, body part, or person; and performing the wrong procedure on a patient. Also, the Department of Banking & Insurance adopted regulations establishing minimum benefits standards for health benefits plans, dental plans, and prescription drug plans. The regulations, among other things, set maximum cost-sharing and network copayment limits.

SOUTH DAKOTA: The Division of Insurance has issued a three-sentence, proposed regulation addressing the relationship between Centers of Excellence and access plans. The proposed regulation currently states that each contracted Center of Excellence and each contracted network of a Center of Excellence must be included in a health carrier’s access plan. For purposes of network adequacy, the health carrier’s entire Center of Excellence network, including both direct–contracted Centers of Excellence and contracted networks, shall be considered. A health carrier may not contract with a Center of Excellence network or any other network that is not registered pursuant to South Dakota law. When originally circulated, this regulation also contained a definition of Centers of Excellence, placed restrictions on carriers with Centers of Excellence for transplant services, and required “closed plans” to have certificates of authority to operate as HMOs. The new language is strongly preferable. A hearing regarding these proposed regulations is scheduled for October 21, 2009.

UTAH: The Utah Insurance Department (UID) has issued amendments to the state's requirements for the Basic Health Care Plan to bring the rules into compliance with new statutory requirements that were enacted in 2008 and 2009. Individual and small group health insurers are required to offer the Plan until January 1, 2010. The Plan includes the following maximum benefit limitations: 1) a lifetime maximum of no less than $1 million per person, 2) a minimum $250,000 annual maximum per person, and 3) out-of-pocket maximums on various cost-sharing obligations. After January 1, 2010, the Plan will be replaced with a new basic health care plan that is defined as: 1) a federally qualified, high-deductible health plan (HDHP), 2) has the lowest deductible that qualifies as an HDHP, and 3) has an out-of-pocket maximum no greater than three times the annual deductible.

If your company is a medical provider, health care insurance payor, or you need to gather insights on the coming changes in electronic health care, HIPAA, and ARRA related health care developments,

Click Here to Schedule a Discussion with One of Our Industry Experts

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Process Owners & Social Productivity – Changing Corporate DNA

While these concepts can be applied to all industries (see Harvard Business Review Blog "Lessons from GE's Approach to Personal Productivity"), the daunting complexity of moving to new health care data interchange standards such as HIPAA 5010 and medical coding standard ICD-10 suggest the traditional process owner and new social productivity concepts could converge for significant gain to enable cost savings, productivity improvement, and ultimately faster adoption and implementation of electronic health care record technologies.

As hospitals, and other health care organizations review their practices and begin to make changes to meet the needs of regulatory legislation, patients and payors, the roles and responsibilities of employees at all levels are affected. To support process-centered environment, management roles must be re-aligned to support the key processes. The need for strong leadership and regular communication are important, as is the role of the process owner. Social media can be used to help, and in fact the most serious social media minded companies are working to rewire their corporate DNA to function very effectively as a social computer, although we have seen nothing like this yet inside of health care companies.

Here is a look at the two concepts.

Social Productivity

Social productivity has been defined as the “…efficient conduct of social interactions, management of social relations, and collaborative social activity.” It has also been argued that social productivity is a form of inter-personal exchange founded on the idea of reciprocity using wikis, workflow, and other media inside a corporation to encourage greater sharing and contributions to collective work. As the activities are socially valued, efforts are expended in return for monetary or non-monetary rewards. Strong internal motivations for engaging in activities, including the need for self-agency and for self-esteem may help explain why people stay involved in activities, which may not offer monetary rewards commensurate with effort.

Process Owner

The Process Owner is the person “…who is responsible to design the processes necessary to achieve the objectives of the business plans that are created by the Business Leaders.” The Process Owner is responsible for the creation, update and approval of documents (procedures, work instructions/protocols) to support the process. Many Process Owners are supported by a process improvement team. The Process Owner uses this team as a mechanism to help create a high performance process. The Process Owner is the only person who has authority to make changes in the process and manages the entire process improvement cycle to ensure performance effectiveness. This person is the contact person for all information related to the process.

The responsibilities of the Process Owner follow the Plan, Do, Check, and Act Cycle.

Plan: The Process Owners create and own the process performance objectives of the organization. The Process Owner first needs to understand the external and internal customer requirements for the process. This person uses the business plans as a source to help understand the long term and short term customer and business requirements. This person translates these requirements into process performance objectives and establishes product (includes service) specifications. This person establishes process performance metrics to measure the process’s capability to meet the product specifications and overall process objectives. The set of metrics that are to be reviewed by Operational Managers and Process Operators are called Key Performance Indicators (KPIs). The Process Owner then designs process steps to describe work that when performed will have the capability to produce product that meets the customer and business requirements.

Do: The Process Owner is responsible to communicate to the Operational Managers the details of the processes that the Operational Managers are responsible to execute. As the Operational Managers and Process Operators perform the processes, the Process Owner is responsible to build bridges and remove barriers that will allow the process performance objectives to be met. The process performance metric data is produced and collected as the process is performed by Process Operators. The Process Owner is continually involved with the Operational Managers and Process Operators as they use Kaizen to continually improve the process as they are performing the work.

Check: The Process Owner periodically analyzes the process performance data and use it to visualize the process’s capability to operate within control limits over time (performance trends), compare actual performance against performance targets, and identify performance issues.

Act: The Process Owner is responsible to create improvement actions to address the performance issues that are identified during their analysis of the process performance data. Improvement actions may include the initiation of Lean projects to reduce waste from the process or projects to reduce variation in the process. Improvement actions may include the use of problem solving tools that would include risk assessment and root-cause analysis. Risk assessment is used to identify and reduce, eliminate, or mitigate risk within the process. This is the proactive approach to avoid problems being created from the process. Root-cause analysis is the reactive way to respond to problems that occur from the process. Root-cause analysis is used to identify the causes of problems within the process and identify and implement improvement actions that will ensure these problems do not occur again.

Key Lessons

Compare your calendar with the priorities. Label the purpose of every regular or recurring activity on your quarterly calendar and highlight those activities that are connected with your top five priorities. This simple exercise will reveal where you're squandering your time.

Be ruthless. Instead of persuading yourself why you can't give up the time you've been devoting to underperforming operations or overly demanding customers that seem important even if they aren't connected to a strategic priority, start with the attitude that you simply cannot deal with them anymore. In some cases, you'll realize that you've been treating the symptoms of the disease and should finally cure the disease. In others, you'll discover that the task will provide a growth opportunity for someone else.

Ask your team to do the same. Then discuss together how jobs could be recast and how the group as a whole could better spend its time. Make it clear that everything can be challenged — down to the PowerPoint slides presented regularly at meetings. Do you really need 20? If you could only have, say, two, which ones would they be?

Make time for your people and yourself. When you're rebuilding your calendar, be sure to include quality time for your team to get together to brainstorm about the strategy, the organization, and new opportunities. Last but not least, absolutely include time to pursue personal priorities that will help you grow and make you more valuable to your organization.

Weekly Health care Reform Developments at the Federal and State level

With Congress now recessed for the summer, much attention has shifted to the home front where many Senators and Representatives are conducting town hall meetings to gauge public opinion toward health care reform. It has been widely reported that tempers have sometimes flared at these events.

Federal

• Senate Finance Committee continued its health reform negotiations last week in what is the last hope for a bipartisan bill from Congress. Senators left Washington late last week to start their August recess, but Finance Committee members have vowed to continue negotiations throughout the month.
  

• A bipartisan group of six Senators on the Committee, led by Chairman Max Baucus, briefed President Obama on their work Thursday, and they also conducted a conference call with a dozen governors. The emerging legislation would expand Medicaid coverage to millions of additional people, and the governors are concerned about the impact on state budgets. No details of the still-developing proposal have been officially released, but participants have indicated the package could shave $100 billion off the cost of the legislation over the next decade, providing coverage to 94 percent of the nation, expanding Medicaid, abandoning the government-insurance option and possibly replacing it with a state-based co-op plan, and taxing insurance companies that offer health care benefits under the richest plans. Baucus has set a Sept. 15 deadline for a bipartisan deal.

States

ARIZONA: The State Senate last week postponed a vote on a plan to close the state's estimated a $3.2 billion budget deficit using spending cuts, funding delays, borrowing, and federal stimulus funds. Approved by the House on July 31, the plan's health-related provisions include: eliminating the KidsCare Parents Program; reducing AHCCCS (Medicaid) reimbursement rates to non-institutional providers by 5 percent but not reducing AHCCCS reimbursement rates to institutional providers; delaying one month's capitation payment to AHCCCS contracted health plans; and requiring AHCCCS to comply with the federal False Claims Act.

NORTH CAROLINA: In a very positive development, a new budget was issued by the legislature last week that includes no premium tax increases. Previous budget proposals included increases from 1.9 to 2.25 percent, effective January 2011. Several carriers and trade associations, worked to educate legislators and oppose a premium tax increase. A final vote on the budget is expected soon.

OREGON: Governor Ted Kulongoski has signed legislation enacting a 1 percent premium tax that will be used to expand access to affordable health care for children. The premium tax will be assessed beginning October 1, 2009 through September 30, 2013. Rate filings submitted for approval may include the premium assessment as a valid administrative expense or retention element. The law also establishes the Health Care for Oregon Children program, which includes an expansion of SCHIP and a premium assistance program administered by the Office of Private Health Partnerships (OPHP). Under the premium assistance program: Children in families with incomes at or below 200 percent of the federal poverty level (FPL) and who have access to employer-sponsored coverage will receive a subsidy equal to the full cost of the premium; children in families with incomes above 200 percent but at or below 300 percent of FPL will receive assistance on a sliding-scale basis as determined by the OPHP; and children in families with incomes exceeding 300 percent of the FPL will not receive premium assistance but will have the opportunity to purchase coverage through the new OPHP private health option.

TEXAS: With Dallas saddled by the most expensive health care in the state, Mayor Tom Leppert and a local health insurer last week took a step toward changing the city's direction. They are working on scheduling a North Texas health care summit on Sept. 30 at which company and government executives hope to agree on payment, practice and transparency fixes leading to greater competition based on quality and cost efficiency. In its national quality-to-cost ranking, Texas is rated third worst, behind Mississippi and Louisiana. Dartmouth Institute for Health Policy data indicates that on average Dallas health care providers submit $10,100 in Medicare claims for every enrollee, the highest among Texas cities with more than 50,000 residents. Dartmouth's data shows that higher health care spending is not associated with better quality outcomes.

No World Borders observation:

• Health care providers and payors (insurance) firms: The requirements to move to new electronic health care records including the electronic transfer of claims data (HIPAA EDI 5010) and the new medical coding standard (ICD-10) will require all the time health care companies can get. Don't wait while the legislators debate the issues. Process impacts as well as data and electronic transfer issues have been under-estimated by may companies. Move ahead now. We can help. See our capabiliites brief and brochure. Business process models of the "as is" and "to be" will be important items to share among business stakeholders.
  

• Individual consumers & employers: Respectful participation in the Democratic process is important, and no one should be discouraged from an important opportunity to be heard on health care reform. If you would like to attend a future town hall meeting or express your views, your Senator can be found online as well as your Representative.

Weekly compilation of health care reform developments in Washington, D.C. and state legislatures

Week of August 3, 2009

The timetable for federal health care reform was delayed again. No vote on health care reform by the full Senate or House is possible before September, and it could be much longer before debate ends and votes are cast.

The difficulties were all too apparent in the Senate Finance Committee last week, which has so far not been able to achieve the bipartisan bill its Chairman Max Baucus (D-MT) clearly wants. The Finance Committee had to issue an official denial to counter a Washington Post article touting a breakthrough deal among the six Senators (three Republicans and three Democrats) forging a compromise bill for the whole Committee to consider.

To emphasize the tenuous nature of the negotiations, Committee Member Senator Mike Enzi (R-WY) responded to the Post article by noting the story was "off the mark" and "not helpful."

Federal

As much as it has tried over the last week, Congress has only marginally moved the needle on health care reform. The Finance Committee will go home for the recess without a deal but with a promise to continue negotiating during the break, and with a target date of September 15 for Committee action.

In the House, the Blue Dog Coalition of 52 conservative Democrats put a halt to the Energy & Commerce Committee's process for 10 days when seven coalition members refused to proceed without concessions and compromises on the House health reform bill: a public plan that is optional to providers and that negotiates rates; preservation of the role of agents/brokers; keeping the bill under $1 trillion; and allowing state-based exchanges.

The compromise reached allowed the committee to continue its mark-up and ultimately approve the bill. There are 50 additional amendments that the Committee intends to address prior to floor debate in the Fall. The House will try to meld all three Committee versions into one bill in anticipation of a full House debate and vote in September, at the earliest. The Blue Dogs have made it clear that the larger coalition of 52 has not signed off on anything and that the compromise was chiefly designed to allow the Committee process to proceed. No sooner was the Energy & Commerce Committee/Blue Dog compromise struck when opposition came from both the House progressive caucus and the Congressional Black Caucus.

The bottom-line is that neither the House nor the Senate will be voting as a Chamber on health care reform until the Fall, when there will be a major confrontation of all competing interests.

States

ILLINOIS: The Illinois Department of Insurance (DOI) published second notice of proposed rulemaking regarding regulation of Preferred Provider Programs that will be considered for adoption by the Illinois Joint Committee on Administrative Rules (JCAR) on August 18. These rules affect both insurers and network administrators that offer incentives to insureds to utilize the services of contracted providers. For example, new network adequacy language would require that when a beneficiary has made a good faith effort to utilize network providers for a covered service but the appropriate preferred specialty providers are not under contract, then the administrator shall ensure that the beneficiary is provided the covered service at no greater cost than if the service had been provided by a preferred provider.

NEW YORK: The Departments of Health and Insurance released their report by the Urban Institute that examines several proposals to reform the state's health insurance system. The study analyzes the cost and coverage implications of:

1) the Public-Private Partnership proposal that would simplify and expand existing public programs and reform private health insurance;

2) New York Health Plus, which would give all New Yorkers an option to enroll in Family Health Plus;

3) Public Health Insurance for All, a single-payer public health insurance option; and

4) the Freedom Plan, an option that relies on regulatory flexibility and tax credits. Due to the growing state deficit and interest in federal reform, no immediate action is expected on these proposals. However, legislation based on one or more of the models is likely to be introduced, or reintroduced in 2010.

The report's key findings include: Three of the four proposals would cover all New Yorkers. The Freedom Plan would leave 13.3 percent of New Yorkers uninsured, down from the current 15.8 percent. There would be minimal change in employer-based coverage under the Public-Private Partnership and the Freedom Plan proposals. However, employer coverage would drop significantly under New York Health Plus and end altogether under Public Health Insurance for All. The individual insurance market would cease to exist under Public Health Insurance for All and New York Health Plus. Individual coverage would increase under the Public-Private Partnership and the Freedom Plan. Post-reform expenditures by employers and individuals would also vary widely. Under Public Health Insurance for All, employer and individual spending would be eliminated. New York Health Plus would reduce both individual and small employer spending. Individual spending would remain constant under the Public-Private Partnership proposal while small employer spending would drop slightly. The Freedom Plan would increase individual spending but somewhat reduce small employer spending.

OREGON: Oregon's health care reform efforts this year included passage of a 1 percent premium tax on health insurers. Recently, the Division of Insurance offered a draft opinion that the tax should be collected on group policies issued in Oregon and polices issued in other states that cover Oregon residents. The Division opinion is contrary to longstanding NAIC guidance and would result in the imposition of a double-tax on all group policies, as well as administrative hurdles in tracking where individuals reside.

No World Borders observation: The requirements to move to electronic health care records including HIPAA EDI 5010 for the electronic transfer of claims data, and the new medical coding standard ICD-10 will require all the time health care companies can get. Don't wait while the legislators debate the issues. Process impacts as well as data and electronic transfer issues have been under-estimated by may companies. Move ahead now. We can help. See our capabiliites brief and brochure.