Medical Loss Ratios: A Good Start at Hol

Medical Loss Ratios: A Good Start at Holding Insurance Companies Accountable for Unreasonable Rates

Last week, the US Department of Health and Human Services issued new regulations requiring
insurance companies to report their “Medical Loss Ratios,” or the portion of insurance
premiums they spend on health care and quality improvement (ironically named “medical loss”),
administration and profits.

These new regulations are great news for individuals, families and small businesses worried
about high insurance rates. The Affordable Care Act (ACA) established the medical loss ratio
(MLR) provision to make the insurance marketplace more transparent and make it easier for
consumers to buy insurance that provides better value for their money. Strong MLR regulations
give consumers and small businesses peace of mind that their health insurance dollars are going
to their medical care, not insurance company salaries and profits. This provision also sheds the
light on how insurance companies spend our premiums.

And if insurers do not meet the new MLR standard, they have to provide rebates to
policyholders. HHS estimates that in 2012, up to 9 million people could receive rebates from
their insurer.

These new rules were drafted by the National Association of Insurance Commissioners – NAIC
– which is comprised of insurance commissioners from all 50 states, including Ohio’s Mary Jo
Hudson. The NAIC engaged in a lengthy, open process with substantial input from consumer
and other interest groups. The rules represent a balance of interests between increasing value for
consumers and protecting the stability of the insurance market.

Read HHS Secretary Sibelius’ blog on the new MLR standards: http://ow.ly/3gWM1

National Family Caregiver Support Progra

National Family Caregiver Support Program (NFCSP), funded the Older Americans Act, helps unpaid caregivers for people 60+ http://ow.ly/3aIol

The longer we live, the more important e

The longer we live, the more important elder care is. But who looks after the caregivers? http://ow.ly/3aIcf

Stuck in the Middle With You: Caregiving

Stuck in the Middle With You: Caregiving for Older Family Members http://ow.ly/3aIvK

Tomorrow, November 17th, marks the launc

Tomorrow, November 17th, marks the launch of the “Year of the Family Caregiver”!

A Daily Dose of Truth #1: Medicare in Health Care Reform

From Faithful Reform in Health Care:

When health care reform was passed in March 2010, our nation’s seniors became the beneficiaries of a strengthened, improved, and re-structured Medicare system.  A number of provisions will improve Medicare services for enrollees and extend Medicare’s solvency for another ten years.

Direct benefits of health care reform for  Medicare beneficiaries

• Prescription drugs. The prescription drug coverage gap (the “doughnut hole”) will be eliminated over ten years.  In 2010, the coverage gap will be reduced by $250 in the form of rebate checks that have already been sent to millions of beneficiaries who have reached the doughnut hole.  In 2011, program enrollees will receive a 50% discount off the price of brand name drugs during the coverage gap.  In ten years, the doughnut hole will be closed completely. Other provisions will expand assistance for some low-income beneficiaries enrolled in the Medicare drug program.
• Preventive care. For traditional Medicare beneficiaries, in 2011 co-pays and deductibles will be eliminated from most preventive services.  An annual comprehensive wellness visit and personalized prevention plan are added, which are not subject to coinsurance or deductibles.
• Medicare Advantage plans. The private-for-profit Medicare Advantage plans will be prohibited from charging beneficiaries higher cost sharing for services than is allowed in traditional Medicare.  Plans that offer extra benefits will be required to give priority to wellness, preventive care services, and cost-sharing reductions over benefits not covered by traditional Medicare.
• Physician incentives. Generous incentives are in the Affordable Care Act to increase the number of primary care physicians and to encourage primary care physicians to treat Medicare beneficiaries.
• Low-income program. Outreach and enrollment assistance will be increased to beneficiaries eligible for the Part D low-income subsidy program.

$500 billion savings to the system

The $500 billion in cuts that are being denounced in attack ads are NOT cuts to benefits. They are cuts in waste, fraud, abuse, and government subsidies for private-for-profit insurance.

• Private-for-profit Medicare Advantage. Payments to private-for-profit Medicare Advantage plans will be restructured.  Excess payments will be rolled back, and performance bonuses will reward quality plans.  Part of the argument to privatize Medicare is that the private market can provide the same or more benefits at a lower cost than the federal government can do it.  Supporters believe that competition will keep the prices down and the quality up.  However, recent research is showing that the government is actually paying $1000+ more for Medicare enrollees in private plans than those in traditional Medicare.  Further, only 20% of Medicare beneficiaries are in the private plans subsidized by the government, but 100% of enrollees are paying for those subsidies!
• Waste, fraud, abuse. Penalties will be enhanced on providers for waste, fraud, and abuse.
• Hospital readmissions. Reimbursements to hospitals with excess preventable readmissions and hospital-acquired infections will be reduced.
• Coordinated purchasing. Value-based purchasing for hospitals, ambulatory surgical centers, skilled nursing facilities, and home health agencies will be established.

THE TRUTH (with the “big T”): Because of the 2010 reform of U.S. health care, Medicare is strengthened; beneficiaries will receive increased benefits; and costs will be controlled by cuts in waste, fraud, abuse, and government subsidies to private insurers.

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For more information:

Faithful Reform in Health Care: What Health Care Reform Means for Medicare

Kaiser Family Foundation: Summary of Key Changes to Medicare in 2010 Health Reform Law (Issue Brief)

AARP:  What You Need to Know about the New Health Care Law (webinar)

HealthCare.Gov: Health Care Reform for Seniors (video & other info)

Medicare Rights Center: Health Reform and Medicare (Issue Briefs)

Cross-post: Americans for Quality Health Care on Care Coordination… What is it?

Anyone who’s ever requested customer service from their cable provider knows the meaning of poor coordination.  I had one such experience recently when I called my cable company and spent more than an hour alternating holding and repeating my problem to no fewer than five representatives, none of whom had any knowledge of what I had discussed with the prior representative.  Wouldn’t it be more helpful and effective if representatives talked to each other before answering my call, or if the details of my complaint were logged into some internal system available to all company employees?

We can just as easily ask these questions of our health care system.  Better communication and transfer of information would improve my dealings with the cable companies, but more importantly our health care needs would also be more effectively met with coordination of care among a health care team, including patients, providers, and support staff.  Older adults with multiple chronic health conditions have an average of 37 doctor visits, 14 different doctors, and 50 different prescriptions each year.  Without coordination, the difficulty of tracking this kind of complex care—test results, medication lists, patient preferences—can lead to poorer quality and more expensive care.  Tests are repeated, drug interactions overlooked, and follow up care neglected.  As a result, one in five older adults with a complex chronic condition is readmitted to the hospital within 30 days because they lacked the support or information needed to take care of themselves.

Coordination is a key component of quality, patient-centered care. The sharing of information among participants in the care of a patient—including the patient him/herself—prevents overuse or misuse of care, and allows patients to be active members of their health care team.  Giving physicians and patients a complete overview of a patient’s health needs also allows everyone to establish a proactive plan of care that reflects the patient’s physical, psychological, and social needs. In this way, responsibilities are also clarified so that no step in the care process is overlooked and repetition is avoided. When care is coordinated, all participants see better outcomes.

The principles of care coordination can be seen in many of today’s health care issues.  For example, as the Centers for Medicare and Medicaid Services work to lower rates of hospital readmission, effective communication of follow-up care information to a patient plays an important role.  Coordination is also closely linked to the much-discussed topic of payment reform by stressing that best outcomes are achieved through the right kind of care, as opposed to the amount of care.  The current payment system of rewarding quantity over quality contradicts the basic principles of care coordination.  Because coordination leads to better quality of care, its implementation is key to successful reform.

For this reason, there’s no doubt care coordination is essential to the goals of Aligning Forces for Quality (AF4Q) and other efforts to improve health care quality.  There are things you can do to promote care coordination in your AF4Q Alliance including:

• supporting performance measurement that evaluates care providers on their coordination of care;
• advocating for patient-centered medical homes in which coordination is a key feature; and
• working with hospitals in your community to find out how they can best coordinate the care they deliver, particularly when patients are transferred to a hospital or from a hospital to another facility.

However, the first and most important step you can take to become an advocate for care coordination is educating yourself further on the issue. The Campaign for Better Care is a great resource for learning more about care coordination and finding ways you can advocate for quality, patient-centered care. To learn more, visit www.campaignforbettercare.org

A blog posting by Perry Sacks

Program Assistant, Americans for Quality Health Care

Telling the Truth to Seniors About the Affordable Care Act

Amid cries of “ repeal and replace” and charges that health care reform is sacrificing seniors and families it was refreshing to see Sunday’ s New York Times editorial debunking these lies.

One of these distortions is contained in a Chamber of Commerce ad run in Ohio and other states claiming that the Affordable Care Act will “ gut” Medicare by $500 billion and cause 620,000 Ohio Medicare beneficiaries to face reduced benefits. No mention is made that starting in January Medicare beneficiaries will receive preventive benefits like mammograms without a co- pay and in 2011 they will see the price of brand name prescription drugs cut to 50% when they hit the “ donut hole.”

So what is this about “ gutting” $500 billion? Congress decided to level the playing field between the Medicare Advantage plans and traditional Medicare, cutting out the extra 14 percent paid to Advantage Plans. The quarter of the Medicare population who buy Advantage Plans have received extra benefits, such as dental or free eyeglasses. When Advantage Plans have to provide care with the same amount of money that traditional Medicare pays they may change their plans or raise their prices.

In fact, because of a tough stand taken by HHS Secretary Kathleen Sebelius Advantage Plans prices have not gone up this year.
Will there be some changes for some seniors? Yes. But will Medicare be fairer and more stable into the future? Absolutely.

Blaming Insurance Increases on Health Reform – But Not For Long

It’s amazing that they keep getting away with it, but opponents of health care reform continue to blame this year’s sharp premium increases on The Affordable Care Act, (or, “ACA,” the new health care reform law).  But it looks like the tide is turning against the insurance industry, thanks to new tools in the ACA tool box.

 

Across the country, news media are reporting steep rate hikes and several leading insurance companies have blamed increases on the ACA. In a recent post, we reported on HHS Secretary Kathleen Sebelius’ sharp warning to the insurance industry to stop spreading false information.

 

Now, as reported in the Dayton Daily News (Monday, October 11, 2010), our Ohio regulators are speaking out – that is, stating the facts.  Doug Anderson, chief policy officer at the Ohio Department of Insurance, told the DDN that the new provisions of health reform taking effect next year “will contribute <span>only marginally</span> to the total cost of health plans being presented to workers this fall during the open enrollment season” (emphasis mine).  Doug Anderson reportedly said that premiums for families and individuals could increase 8 to 18 percent this year, depending on benefits. Read the whole DDN story here.

 

For as long as I can remember, small businesses and individuals have been getting hit yearly with double-digit rate hikes. This year, as the down economy continues to inflict pain, the health insurance industry is one of the few to enjoy hefty profits. Their CEOs continue to receive million-dollar bonuses and compensation packages.

 

So it’s simply outrageous that insurance companies are blaming their usual double-digit increases on the ACA.  It’s scary to think that some people actually believe them, despite numerous reports from experts that the ACA’s impact on premiums is minimal.

 

Insurance companies spent over 500 million dollars opposing health reform because they knew they would face increased public scrutiny over their rate increases. States, including Ohio, have received grants from the Affordable Care Act to strengthen oversight of insurance rate increases. And ACA requires public reporting so we’ll know what they are doing with our premium dollars. So, thanks to health care reform, the days of unchallenged double-digit rate increases coupled with bloated profits may be numbered.

My Mother Deserves Better Care – Does this Sound Familiar?

Two years ago, my 87-year old mother had surgery to fix a broken shoulder. She was discharged from the hospital with little information. A week later, she was back in the hospital with a bad urinary tract infection — a preventable surgical complication. Doctors kept running tests on her, but we could not figure out why, or get the results or figure out which doctor was looking out for her best interests.Then, a doctor performed a procedure that gave her pancreatitis, an extremely painful inflammation treated by abstinence from food or water.. After a week living on morphine, my mother got better and fled the hospital.

My mother’s story is all too common: 1 in five Ohioans on Medicare who visit the hospital end up back in the hospital within 30 days – often for preventable reasons. People with multiple specialists have trouble getting doctors to communicate with each other or the family. People get conflicting information from different doctors and no one seems to be in charge – especially patient and family. And this fragmented care – with avoidable hospitalizations and procedures – is expensive.

The Affordable Care Act is a giant toolbox, filled with tools for us to use in building a health care system that provides high quality, coordinated, comprehensive care to everyone – especially vulnerable people with chronic health conditions. But tools need people to design what we want and build it.

Ohio’s Health Coverage and Quality Council, created to advise the Governor on implementing health reform in the Buckeye state, is focusing its efforts on transforming primary care, into high quality, coordinated, comprehensive, patient-centered care (often called “patient-centered medical homes” among health experts). For patients, this includes:

• * 24/7 access to care (by phone, if necessary);
• * coordination of patient care across all settings;
• * team-based care to provide patients with whole-person care;
• * engaging patients as partners in their health care; and
• * use of electronic medical records.

Primary care practices involved in the “Enhanced Primary Care Medical Home” initiative are going through rigorous practice changes to get through the first level of national “medical home” certification. At the same time, insurers, employers and providers are figuring out how to change how we pay for this new, improved coordinated primary care. Most experts agree our current way of paying for care – paying for services, but not paying for coordinating among doctors or patient education – needs to change. But how to pay for better care – or “payment reform” – could involve winners (patients and their improved primary care providers) and losers (those providers getting paid for performing high volumes of tests and procedures without regard to patient outcomes).

Providers, insurers and employers are busy figuring out how to use the tools in ACA and what they are going to build. UHCAN Ohio wants to make sure that consumers join the mix to make sure we get the high quality, coordinated, patient-centered health care system we need and deserve.

Check out the Ohio Campaign for Better Care – the UHCAN Ohio-led campaign to build a strong, lasting consumer voice in building a system that provides high quality, coordinated care, particularly for older adults and their family caregivers. www.uhcanohio.org Read more at the national Campaign for Better Care website: www.campaignforbettercare.org . What to read more? Contact me at clevine@uhcanohio.org.