R&B Healthcare Blog

As number of hospitalists soars, so do lawsuits against them

As number of hospitalists soars, so do lawsuits against them March 22, 2013 | By Ashley Gold, FierceHealthcare

The number of hospitalists is soaring–and so is the number of lawsuits being filed against them.

It’s partly because liability insurers have recently separated the evaluation of hospitalists’ risk from their claims experience with general internists, Medscape Today reports. Hospitalists have generally been insured at the same rate as primary care physicians, but that will start to change as insurers realize the greater malpractice risks faced by hospitalists.

According to the Society of Hospital Medicine, the hospitalist specialty includes 35,000 physicians.

“We have seen a slightly higher frequency in number of claims and severity in cost of claims in lawsuits against hospitalists,’ Robin Diamond, senior vice president and chief patient safety officer at Napa, Calif., based The Doctors Company, the largest national insurer of physicians, told Medscape Today. “We believe that as hospitalists continue to fill more roles within the hospital and higher demands are placed on them, the risk for being sued may also increase.”

What makes hospitalists different? “Hospitalists’ patients tend to be sicker than those of primary care physicians, given that they are already hospital inpatients,” reports Medscape. “Hospitalists also lack the long-standing relationship with patients that primary physicians have, so they have less knowledge of the patient’s personality and background, and less experience with how the patient communicates.”

In January, a Johns Hopkins study of hospitalists and their heavy workloads found 40 percent of physicians surveyed said their typical inpatient census exceeded safe levels at least once a month, and more than a third (36 percent) said it happened weekly.

“Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something,” Danielle Scheurer, M.D., chief quality officer at the Medical University of South Carolina, writes in The Hospitalist.

She suggests breaking old habits, dropping the ones that may be weighing down hospitalists.

“It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed,” she writes.

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Maine wants 100% of Medicaid expansion costs covered for 10 years

Maine wants 100% of Medicaid expansion costs covered for 10 years March 22, 2013 | By Dina Overland, FierceHealthPayer Maine is considering expanding Medicaid, but not without some special conditions. Republican Gov. Paul LePage wants the federal government to cover 100 percent of all expansion-related costs for at least 10 years–seven more years than allowed under the reform law.In a letter to U.S. Department of Health & Human Services Secretary Kathleen Sebelius, Maine Health and Human Services Commissioner Mary Mayhew asked the agency to completely fund the state’s Medicaid expansion.The reform law covers 100 percent of Medicaid expansion costs for the first three years and pays 90 percent of the tab thereafter.

Maine also requested more flexibility to operate the program, including a “global waiver” that lets state officials change how they run the Medicaid program, according to the letter.

“Frankly, even where it is permissible, it is incredibly bureaucratic and administratively burdensome” to change state Medicaid policies, Mayhew told the Bangor Daily News. “We know that health care delivery is changing rapidly and Medicaid’s policies need to keep pace.”

After expanding Medicaid in 2003, HHS penalized Maine through lower reimbursement rates. “While some argue the state cannot afford to turn down the expansion of Medicaid, the simple truth is that by accepting a lower rate of federal funding than other states are being offered, Maine would continue down an unsustainable and unaffordable path,” Mayhew wrote in the letter. “For the expansion of Medicaid to be a viable option to consider, we would need for this penalty to be lifted, creating parity between Maine and the non-expansion states with regards to the federal match rate.”

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ObamaCare’s Looming Security Risk

ObamaCare’s Looming Security Risk Gary Baldwin MAR 6, 2013 2:14pm ET, Health Data Management

Millions of people stand to enroll in health plans via state-based insurance exchanges as the federal health reform effort rolls out. But unless states and payers take precautionary measures, those exchanges could prove to be a goldmine for scammers and others seeking to defraud the health care system.

At HIMSS13 in New Orleans, Michael L. Nelson, vice president, strategy and business development at national credit bureau Equifax, described how the health care industry, already teeming with fraudulent activity, faces a tidal wave of even more unless steps are taken now. “Why is there so much fraud?” he asked. “It’s easy money.”

Nelson said that payers have traditionally attacked fraud after the fact, using the “pay and chase” model of detection. But it’s an expensive undertaking, he said, urging payers to take a more proactive approach and try to identify likely culprits before fraud occurs. Nelson noted that fraud detection activity is an administrative activity that can throw off the medical-loss ratio—another regulated area under health reform. The medical loss ratio describes how much of a payer’s budget must go to clinical claims, so a payer has limited resources it can draw on for fraud detection.

Equifax developed a customized fraud prevention system for a commercial payer seeking to pre-screen providers who signed on with the health plan. Equifax’s system combed through some 1,900 variables, including past credit history, geographic data and other professional sanctions, noted Erik Rolf, a principal at the company, to come up with a custom fraud risk score. Nearly 4 percent of the providers Equifax analyzed posed significant or elevated fraud risks, he said.

In the case of insurance exchanges, states will need to closely monitor who is applying for health insurance, verifying that the person enrolling is who they say they are, Nelson noted. That will stop one type of fraud in which consumers present themselves as plan enrollees but in fact have no insurance. Knowledge-based authentication systems—in which someone logging onto a site must answer a series of personal questions—can help, Nelson said. But he cautioned that while many vendors offer this technology, often the questions can be answered by searching publicly available databases.

Predictive analytics crunching numbers from large data repositories can go a long way toward pointing out likely scammers, Rolf said. He added that Medicare is relatively easy to scam because so many of its provider enrollment processes are manual, requiring staff to shift through reams of paper documentation.

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President Clinton at HIMSS13: Fundamental Health Reform Must Continue

President Clinton at HIMSS13: Fundamental Health Reform Must Continue Joseph Goedert MAR 7, 2013 1:22pm ET. Health Data Management

The jokes were sparse as a somber former President Bill Clinton took on the ills of the health care system during his HIMSS13 keynote speech, and urged his information technology audience to accelerate their work to support improvements.

The politics and social impact of the health reform law have yet to be fully determined, Clinton noted, because that depends on how fully the law is implemented and many contentious issues have not yet been resolved. The politics of reform continue to resonate deep, he reminded. Health care reform politically killed supporting congressional candidates in 2010, then the politics changed and reform politically killed candidates opposed to the law in 2012.

Clinton warned of budget fixes that would further transfer health care costs to consumers, which would be a real burden. In this political and budgetary maelstrom, health information technology will be vitally important to learn how to keep costs down and give consumers information that can give them huge collective clout to get more value at lower cost, he emphasized. And he reminded his audience that all of them will be in the middle of the maelstrom.

Fundamental reform and changes in how health care is operated and financed must come, he asserted. “Eventually, almost every system gets long in the tooth. There are huge transactional costs that don’t get taken care of. You can’t keep defending the status quo, that’s just the way it is.”

The former president also spoke of other forces affecting the health care industry. The world, he said, is still highly unequal and unstable, and not sustainable because of the effects of climate change, “which will have a huge impact on health care.” To those who doubt climate change, he reminded that the Pentagon in 2000 declared the changing climate a national security priority and began supporting green initiatives.

The spiraling cost of care imperils economic growth and consumer’s pocketbooks in many ways, Clinton said. He noted that many U.S. workers have not had significant raises in a decade or more, and that employers want to give the raises but are spending all their extra money on paying health care premiums.

The United States spends 17.8 percent of gross domestic product on health care and no other advanced nation spends more than 12 percent–with better outcomes, he noted, and that’s about a trillion dollars a year being unnecessarily spent. “So, what lies before us is the necessity to reform.”

The absence of financial transparency and information technology means health care consumers have no idea what the cost of their care will be, and Clinton praised health information exchange applications that can educate and empower consumers. “We need much more transparency in pricing.” He also called for more I.T. to help consumers take a bigger role in their treatments, take better of themselves, and to know what is going on. For instance, too many people are dying because they don’t know that Oxycontin can’t be mixed with alcohol.

He proudly spoke of the seminal work down on human genome sequencing during his presidency and the knowledge that has come from it. “I spent $3 billion of your taxpayer dollars to do that thing.” Now, the information technology that supported genomic research also can support fundamental, structural changes in health care, he added. “We cannot continue to spend money the same way or perpetuate inequality the same way, or we will be devastated.”

Clinton also talked of the work of his foundation to improve global health, working with pharmaceutical firms to get huge price cuts for AIDS, tuberculosis and malaria drugs in underserved nations, and partnering with other organizations to build clinics and reduce overhead costs in foreign aid to get more funds in the field. The foundation also has worked to combat child obesity in the United States, getting school food manufacturers to reduce calories and increase nutritional value, and getting soda makers to substitute healthier drinks in schools.

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Cigna opts not to compete in statewide exchange

BY GREG BORDONARO

3/4/2013

HBJ FILE PHOTO David Cordani, CEO, Cigna Access Health CT got a strong initial response from insurers with nine health plans announcing their intentions to offer coverage within the state’s health insurance exchange once it becomes operational later this year.Almost all the major players in the state — Aetna, Anthem, Connecticare, and United Healthcare — said they plan to compete for business from the estimated 200,000 individuals who may seek coverage through the exchange, which will be an online marketplace where consumers can shop for coverage.But there was one noticeable hold out.

Bloomfield insurer Cigna Corp. is opting not to participate.

The decision may have been a surprise to some, but Cigna has not been a major player in the individual or small business insurance market, which the exchange is primarily serving. It was just a few years ago that Cigna dropped out of the exchange operated by the Connecticut Business & Industry Association, which serves small businesses.

Still, a Cigna official said the company will participate in some statewide exchanges, just not Connecticut’s, at least initially.

“We have been analyzing the exchanges and had several meetings with the Connecticut Exchange to understand their approach to building a state-based exchange,” said Cigna spokesman Joe Mondy. “We expect to enter a select number of exchange markets where our offerings will best meet the needs of the customer. While we have a strong offering in Connecticut, we would not be able to meet the needs of the CT exchange customer at the level we believe is required and consistent with our mission of improving the health, wellbeing and sense of security of the people we serve. ”

Mondy said Cigna has not ruled out joining Connecticut’s exchange in the future but it likely won’t happen anytime soon.

That is because insurers who choose not participate in Connecticut’s exchange when it starts up later this year, will be locked out for a two-year period, said Jason Madrak, a spokesman for Access Health CT.

That two-year lock out rule was established by the exchange board to create an incentive for insurers to begin offering coverage within the exchange right away. The idea is to reward insurers willing to take a risk by offering plans in a new marketplace, and to prevent new competition from coming in right away only after they have seen success.

“The Exchange would like as many carriers as possible to participate in order to offer residents a broad array of plan options, as well as spur competition in this new marketplace,” Madrak said. “We hope that as the Exchange launches and we begin to see it operating successfully, carriers who are not currently participating will reassess their approach and decide to join us.”

Madrak said there is still an opportunity for Cigna to change its mind and join the exchange by October, but that decision would have to be made soon. Insurers will have to begin submitting health plans for approval to the Connecticut Insurance Department in the coming months.

The two-year lock-out period could also mean bad news for Massachusetts nonprofit health plan Harvard Pilgrim, which is looking to break into the Connecticut market. Harvard Pilgrim is going through the regulatory process to get licensed in Connecticut, but that might not happen soon enough for Harvard Pilgrim to be ready to offer coverage in the exchange, sources say.

Although Cigna is one of the largest health insurers in the country, they only have a small market share in their home state. And the company has never been a major player in the individual health insurance market.

In fact, Cigna only offers individual plans in 10 states, including Connecticut, said Mondy, the Cigna spokesman.

At the end of 2010, the latest data available from the Connecticut Insurance Department shows Cigna had $113 million in health insurance premiums in the state, which represented only 2.3 percent of the nearly $5 billion market.

Cigna has largely focused on selling health plans to commercial customers, although their strategy has started to shift with the major expansion of health insurance coverage that will begin next year thanks to federal health care reform.

The Accountable Care Act requires most Americans to buy health insurance and provides tax credits and benefits to qualifying small businesses and individuals to help them find more affordable coverage. The law also significantly expands Medicaid eligibility.

Cigna CEO David Cordani has said publicly that his company sees federal reform and specifically the exchanges as more of an opportunity than a threat, because the company doesn’t have a huge book of individual or small business customers that may opt for coverage through the exchange.

Getting buy in from the insurance industry is a make or break issue for the exchange to have a shot at being successful. The other issue, of course, will be whether or not health plans offered in the exchange will be affordable.

With the exchanges being a key part of federal health care reform, the stakes are extremely high.

Insurers faced a Jan. 4 deadline to notify Access Health CT of their intent to participate in the state’s exchange.

Five health insurers including Anthem, Aetna, Connecticare, United Healthcare, and HealthyCT have notified Access Health CT that they plan to offer coverage within the exchange.

Meanwhile, four other insurers including MetLife, Delta Dental, The Guardian Life Ins. Co., and Renaissance Dental have told the state they plan to offer dental insurance coverage within the exchange.

Keith Stover, a lobbyist for Connecticut’s insurance industry, said the exchange’s leadership team has been doing a good job making health plans feel welcomed, which is why most insurers signaled their intent to join.

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4 more states will partner with HHS to run health exchanges

March 8, 2013 | By Dina Overland, FierceHealthPayer

The U.S. Department of Health & Human Services has granted conditional approval to four more states to set up a health insurance exchange.

Iowa, Michigan, New Hampshire and West Virginia all received the go-ahead from HHS to establish a so-called State Partnership Marketplace in which the states will jointly operate the exchanges with HHS,reported The Hill’s Healthwatch.

In most cases, HHS will assume more responsibility with states handling customer service and health plan approvals, the Associated Press reported.

“HHS will continue to work collaboratively with all states to build the Marketplace,” HHS Secretary Kathleen Sebelius said Thursday in a statement. “Working together, we will be ready in seven months when consumers will be able to use the new marketplace to easily purchase quality, affordable health insurance plans.”

But receiving HHS approval is no guarantee that a state will actually implement a state-run marketplace. In Michigan, for example, many state senators oppose accepting federal money to operate an exchange and may try to block the state from taking on any exchange-related responsibility, reported the Detroit Free Press.

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HHS spends $3M to market, promote federal exchanges

HHS spends $3M to market, promote federal exchanges October 4, 2012 | By Dina Overland, FierceHealthPayer

The U.S. Department of Health & Human Services has signed a $3.1 million contract with public relations company Weber Shandwick to market the federal-run health insurance exchanges, reported The Hill’s Healthwatch. “This will help our educational effort to ensure more Americans have access to quality, affordable health insurance,” said a spokesman for the Centers for Medicare & Medicaid Services. Weber Shandwick is supposed to promote early awareness and engagement, helping consumers learn more about coverage available through exchanges. The HHS-Weber deal comes sonly a few days after Republican lawmakers blasted California for using its HHS-funded money to promote exchanges on popular TV shows.Article

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More docs accept reform law, but public remains ill-informed

More docs accept reform law, but public remains ill-informed March 21, 2013 | By Alicia Caramenico, FierceHealthcare

Time flies when you’re trying to reform the healthcare system. Although it’s been three years since the Affordable Care Act became law, 57 percent of Americans and 67 percent of uninsured adults still don’t know how it will affect them, according to a new Kaiser Family Foundation poll.

Moreover, many Americans continue to misidentify which provisions are actually included in the law and which are not; for example, 57 percent mistakenly think the reform law creates a government-run health plan.

Three years in and the public remains almost split over the ACA, with 37 percent in favor of the law and 40 percent against it, according to the poll.

The findings also show that Americans hold a more negative outlook of how the law will affect healthcare costs and quality, Kaiser Health News reported.

Patients’ lack of understanding and education can drive up healthcare costs, going against the law’s intentions. So hospitals have been ramping up efforts to keep patients informed about their care under new ACA provisions, such as holding educational forums and offering online resources, healthcare leaders previously told FierceHealthcare.

Meanwhile, physicians are showing “constrained optimism” over healthcare reform, despite concerns about losing clinical autonomy and compensation under its provisions, MedCity News reported.

In a new survey from Deloitte, 44 percent of doctors said the ACA is a good start to dealing with healthcare access and cost problems. Singling increasing acceptance, only 38 percent of physicians said the reform law is a step in the wrong direction, down from 44 percent last year.

To mark the ACA’s third birthday, the U.S. Department of Health & Human Services is celebrating how it says the law is successfully incentivizing high-quality, low-cost care–particularly through the creation of accountable care organizations and penalties for excessive readmissions, according to a Health Affairs blog post.

“Taken together, these improvements are providing more value for your health care dollar and helping to fuel historically low cost growth rates in Medicare and Medicaid,” HHS Secretary Kathleen Sebelius wrote yesterday in the post.

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Expanding Medicaid with private insurers garners more interest

Expanding Medicaid with private insurers garners more interest March 27, 2013 | By Dina Overland, FierceHealthPayer

The federal government, in its effort to promote states’ expansion of Medicaid under the health reform law, is likely to benefit insurers as well. That’s because the most recent movement in Medicaid expansion is for states to hire private insurers to administer their programs.

Arkansas started the recent trend, proposing to use federal dollars provided under the reform law to pay private insurers to insure the expanded Medicaid population. Ohio and Virginia officials have also signaled interest in a private Medicaid expansion option.

It appears that the U.S. Department of Health & Human Services just might approve this GOP-led idea. HHS officials gave the go-ahead to the Arkansas and Ohio governors, granting them tentative approval of the private option, reported Stateline.

“It’s a potential turning point for states that are on the fence” about expanding Medicaid, said Matt Salo, director of the National Association of Medicaid Directors. “If Arkansas and Ohio can find a path through this thicket, it could give a lot of other states that have either said ‘No’ or are on the fence a reason to think again.”

If officials in Arkansas and Ohio can forge ahead to pay private insurers to run Medicaid, Louisiana, Florida and Texas might not be far behind. The new “no, but …” option, as an Associated Press article referred to it, lets Republican officials and lawmakers take federal money without completely breaking from the party’s overall opposition to health reform.

One key question, though, is how much money states can funnel to private insurers to run Medicaid. HHS Secretary Kathleen Sebelius has said the agency will provide more details on that issue “in the very near future,” NPR’s Shots reported.

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Only 2% of insurers cover mandated essential health benefits

Only 2% of insurers cover mandated essential health benefits March 8, 2013 | By Dina Overland, FierceHealthPayer

Very few insurers–only 2 percent–offer all the benefits they will be required to provide next year under the reform law, according to a new analysis from technology company HealthPocket.

Based on an analysis of 11,100 private health insurance plans available for individuals and families, HealthPocket determined insurers will need to to bridge a “significant gap” between now and January to ensure they’re providing all the reform law’s mandated essential health benefits.

The U.S. Department of Health & Human Services outlined the specific essential health benefits insurers must cover in the file rule issued last month.

“Coverage will become more complete starting in 2014, and the vast majority of plans in the market today will no longer be sold after the end of this year in their present form,” Kev Coleman, head of research and data at HealthPocket, said last week in a statement.

Particularly missing from health plans’ benefits are coverage for maternity and newborn care, pediatric dental and vision care, mental health services and substance abuse services, the analysis found. But insurers already offer doctor visits, emergency room care, hospitalizations and lab tests as standard benefits.

“We couldn’t find a single plan that had every feature fully satisfied,” so insurers will “have to change to survive,” Coleman told McClatchy Newspapers. “Consumers will be entitled to more health benefits in 2014 than ever before, and this will require existing health plans to expand coverage or close and be replaced by entirely new plan designs.”

HealthPocket also analyzed coverage based on state, with Massachusetts health plans providing 94 percent of the reform rule’s essential benefits. Rhode Island insurers covered 93 percent, Hawaii plans covered 90 percent and California, Maryland and Vermont insurers each provided 89 percent of benefits.

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