‘On A Collision Course’ Recent Cuts to Taxes Meant to Fund Affordable Care Act Have Hospital Officials Concerned

Image result for Taxes Meant to Fund Affordable Care Act Have Hospital Officials Concerned imagesSource: Enid News & Eagle

With recent cuts to taxes meant to fund the Affordable Care Act, rising premiums and no plan to adjust for the cuts, hospital officials warn the health care system is on a collision course that could result in more uninsured patients, rising levels of bad debt for hospitals and even higher costs to people who do have insurance.

The most recent cuts to the Affordable Care Act (ACA), sometimes referred to as Obamacare, came at the end of a three-day federal government shutdown in January.

The stop-gap budget plan signed by the president to reopen the government on Jan. 22 included $31 billion in tax cuts over the next decade, in addition to the $1.5 trillion in revenue cuts approved in the 2017 tax bill.

Those additional tax cuts included a delay in implementing three taxes meant to fund ACA insurance coverage over the next 10 years: the medical device tax; the so-called Cadillac tax, which taxes employers with more expensive health insurance plans; and the health insurance tax.

Hospital officials worry that lost revenue, meant to cover the cost of the ACA, hasn’t been replaced by an alternative — leaving the possibility the system will implode, with expensive consequences to health care providers and customers alike.

“What he (President Trump) did was take away some of the funding sources for the Affordable Care Act, and we have not replaced that or significantly changed the structure of the Affordable Care Act,” said St. Mary’s Regional Medical Center CEO Krista Roberts. “So, we are on a collision course, and the system as it’s designed today is not sustainable long-term. They will have to go back and visit this.”

Unable to afford to keep it or use it

The cuts come on the heels of significant premium increases for ACA plans offered on the state exchange, which has only one provider for Oklahoma: Blue Cross and Blue Shield of Oklahoma.

Insurance plans on the state exchange increased an average of 76 percent in 2017 and another 7.8 percent increase for 2018.

Those cost hikes already have increased the number of uninsured patients showing up at the hospital, Roberts said.

“We did see patients [in 2017] that were unable to continue paying their premiums,” she said, “because their premiums rose so much in 2017 on the state exchange.”

Along with premiums, deductibles also rose in 2017, leaving many who do have insurance unable to pay the cost of using it.

“What we’ve seen is a lot of people come in who used to have a $500 deductible, now have a $1,000 or $5,000 deductible,” said Integris Bass Baptist Health Center President Finny Mathew.

Many of those patients can’t afford the deductibles, he said, making their insurance plan essentially useless to them.

“For a family living around the median household income, they’re effectively uninsured,” Mathew said.

Rising prescription drug costs also have hit patients after a visit to the hospital.

“What happens then is when we discharge patients from the hospital, if they’re not able to pick up their prescription pills, and they don’t take their medications, they go into a cycle where they end up back in our emergency room,” Roberts said.

‘We provide for people’

Roberts said the effects of rising costs, paired with cuts to government subsidies meant to pay for the ACA, are cause for concern across the health care industry.

“The concern is we’re defunding it [the ACA], and we haven’t changed the structure of the plan,” Roberts said, “and the funding is not going to be there for the plan.”

Without funding for the plan, or the implementation of a replacement, it’s likely more people will go uninsured, Mathew said.

“It is very much a concern,” he said, “because the premiums under the ACA were heavily subsidized under the government, and even Medicaid in the state was heavily subsidized under the government, so as those federal funds go away, those plans on the marketplace will be unaffordable and unattainable for a lot of the population.”

If the marketplace plans fail without a workable alternative, Mathew said the numbers of working uninsured Americans likely will significantly increase.

“The working poor will have to go without care,” Mathew said, “unless not-for-profit hospitals like us step up and continue to offer care.”

Hospitals would continue to provide care in that scenario, both Roberts and Mathew said.

“This doesn’t change how we provide for people,” Roberts said. “We continue to provide for the needs of the community, regardless of what’s going on in Washington.”

‘People with insurance end up subsidizing people without insurance’

But, decreases in insurance coverage likely will lead to more uninsured patients coming into emergency rooms for care that otherwise — if covered by insurance — would be provided in less expensive outpatient appointments.

And, that, Roberts said, could add up to increases in hospitals’ bad debt or debt that cannot be recovered.

“I think when patients come to our door, regardless of their ability to pay, we take care of them, and we worry about the money part later,” Mathew said. “But, we still have to find ways to compensate our employees and pay the utility bills, just like everybody else.”

Paying those bills in the face of government cuts means the money to care for the uninsured will have to come from somewhere else. And some of that burden, Mathew said, likely will fall on the rest of the patient population.

“Ultimately, what happens is people with insurance end up subsidizing people without insurance,” Mathew said, “whether it be through higher premiums or higher payments to hospitals.”

Justice Dept. scrutinizing data on opioid prescribers

Image result for justice department opioid imagesThe Justice Department is providing data from the CMS and coroners to its Opioid Fraud and Abuse Detection Unit, which is using the information to go after “pill mills.” The reports include information on physicians who prescribe opioids at high rates, how far patients travel for appointments and any deaths among patients who receive opioid prescriptions.

Bloomberg (free registration)/The Associated Press (1/1)

States Freeze CHIP Enrollment, Get Ready to Move Kids to New Plans

Image result for children's health insurance program images

Source: Modern Healthcare

As federal lawmakers continue to bicker over how to fund the Children’s Health Insurance Program moving forward, states across the country are freezing enrollment and preparing for the worst.

CHIP funding lapsed Sept. 30 and has yet to be renewed by Congress, leaving states to patch together funding with monies redistributed by the CMS. But most of those dollars will run out by March at the latest, and states will have to finish processing all claims by the end of January and find a new plan to cover CHIP-enrolled children.

Connecticut and Colorado will shutter their programs Jan. 31 if funding doesn’t come through and will shift its CHIP kids to Medicaid or a qualified health plan on the exchanges. Alabama will freeze CHIP enrollment starting Jan. 2 and would also need to close its program by Jan. 31, according to an official at the Alabama Children’s Hospital.

In a late-breaking twist, Texas will not immediately freeze enrollment. The state, which was due to run out of its own funds in February, will get an additional $135 million in redistributed funds from the CMS.

Bruce Lesley of the Washington-based advocacy group First Focus, said moves like this by the agency further muddy the prospects for other states, as the CMS hasn’t set out clear policies for how they allocate the redistributed money. Texas officials had sought $90 million in their original request.

Meanwhile, Lesley said, states like Minnesota and Arizona are out of money, and Oregon and California soon will be, according to the last projections by the congressional Medicaid and CHIP advisers.

The sudden end to CHIP programs would trigger a special enrollment period for kids who need to move to a qualified health plan. As of deadline, the CMS did not respond to a query about how the agency would manage the enrollment period for the federally facilitated marketplace.

CMS officials are planning to launch talks with children’s health policy experts to figure out the best way to transition kids out of CHIP if they need to, said one Washington-based children’s advocate who asked not to be identified.

Colorado, which runs its own state-based exchange, would run a 60-day special enrollment period set to start Jan. 31 when a child’s CHIP coverage ends. The enrollment period would let kids start their new coverage on the first of the month following their application, says Luke Clarke, communications director at Connect for Health Colorado.

Congress has five working days left to keep CHIP running, but the GOP tax overhaul will take up most of the week before lawmakers will finalize the continuing budget resolution to keep the government open past Dec. 22.

House lawmakers led by Rep. Tom Emmer (R-Minn.) and Rep. Ryan Costello (R-Pa.) arranged a stopgap measure to allow states to apply any surplus from last year to fund their programs through year-end.

This has mitigated the immediate crisis for Minnesota, which had run out of its own funds in October, but children’s healthcare advocates are skeptical of how much good this will do in the long run as Congress continues to delay.

“There are states that are out of money,” Lesley says. “There’s no kicking the can down the road.

He added: “It’s a crisis, and they’re pretending like it’s not.”

Republican Tax Bill Fuels Anxiety Across the Nation’s Healthcare System

Image result for anxiety doctors hospitals imagesSource: Los Angeles Times

Doctors, hospitals, patient advocates and others who work in the nation’s healthcare system are growing increasingly alarmed at the Republican tax bill, warning that it threatens care for millions of sick Americans.

The legislation – which GOP leaders are rushing to pass this week – will eliminate beginning in 2019 the Affordable Care Act penalty on consumers without health coverage, a move many experts warn will weaken insurance markets in parts of the country.

The tax bill, which includes huge tax cuts for corporations, may also force tens of millions of dollars in cuts to the Medicare program under federal budget rules, though congressional leaders say they are confident they can waive the rules as they have in the past.

Most worrisome to many, the bill will open a $1.5-trillion hole in the federal deficit over the next decade. That will put substantial new pressure on government healthcare programs such as Medicare and Medicaid and has already ignited a renewed Republican campaign to cut them back.

“This is a horrid bill,” said John Baackes, chief executive of L.A. Care, a public insurance plan that covers more than 2 million mostly low-income residents of Los Angeles County.

“They haven’t been able to repeal and replace [the healthcare law], so they’ll attack it through the budget by looking for ways knock down the money that’s needed to cover people.”

The GOP tax package – which would reduce the corporate tax rate from 35% to 21% – may mean more money for drug makers and for-profit insurance companies and hospital systems.

But across the country, dozens of healthcare groups, including every major physician association and patient advocacy organization, have urged GOP lawmakers to slow down and at least preserve the insurance requirement.

“This bill leaves too many patients behind and saddles millions more with higher premiums,” said Harold P. Wimmer, chief executive of the American Lung Assn., which was among 16 patient organizations that sent a letter to congressional leaders this month warning that the tax bill could erode sick patients’ access to medical care.

The groups include the American Diabetes Assn., the American Heart Assn., the Cystic Fibrosis Foundation, the Arthritis Foundation, the March of Dimes, the National Multiple Sclerosis Society and the advocacy arm of the American Cancer Society.

Last week, the American Academy of Actuaries sent congressional leaders a similar warning that if the mandate is eliminated, “premiums would increase as a result, reducing affordability and eroding preexisting condition protections.”

At highest risk may be consumers in regions of the country where there are few insurers selling plans now and where premiums are already very high.

Republican leaders have dismissed the objections of healthcare groups and others, arguing that eliminating the penalty on people who don’t get health insurance will remove an unfair government requirement.

“Obamacare’s coercive individual mandate represents perhaps the worst example of the federal government violating individual freedom and liberty,” Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee.

GOP lawmakers have also rejected analyses by the nonpartisan Congressional Budget Office, independent economists and others that the massive tax cuts in the legislation will drive up the federal deficit. President Trump and his congressional allies say the cuts will fuel economic growth.

But senior Republicans have made no secret of their interest in renewing a push to cut government healthcare programs next year to control the ballooning government debt.

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” House Speaker Paul D. Ryan (R-Wis.) said during a recent appearance on “The Ross Kaminsky Show,” a conservative talk radio program in Denver.

“Frankly, it’s the healthcare entitlements that are the big drivers of our debt, so we spend more time on the healthcare entitlements, because that’s really where the problem lies, fiscally speaking,” Ryan said.

Ryan has long advocated major changes to the federal Medicare program.

And each of this year’s leading Republican bills to roll back the Affordable Care Act – commonly called Obamacare – would have slashed hundreds of billions of dollars of federal healthcare aid to low- and middle-income Americans.

That would have left some 20 million more Americans without health coverage, according to independent analyses of the GOP repeal bills.

A new push to slash federal support for Medicare, Medicaid and other health programs risks a similar erosion in health protections, warned Dr. Ashok Rai, president of Prevea Health, a medical system in northern Wisconsin.

“We should be looking for ways to control healthcare spending,” said Rai, incoming chairman of the American Medical Group Assn., a leading advocate for making healthcare more efficient. “But when you are talking about blanket cost reductions, that affects a lot of needy people. … The consequences for the health of America would be serious.”

State leaders and healthcare officials in California and other states that rely heavily on state taxes to support their healthcare safety nets worry they will face even more pressure under the tax legislation.

The GOP bill would cap how much taxpayers can deduct in state and local taxes from their federal tax returns, effectively penalizing many taxpayers in states such as California, which has among the highest state income taxes in the country.

Although about 14 million California taxpayers are expected to see a tax cut in 2019 — most of less than $2,000 — nearly 2 million taxpayers will see their taxes increase, driven largely by this new cap, according to an analysis by the Washington-based Institute on Taxation and Economic Policy.

“The fact that Californians would be paying more in federal taxes would inevitably put new pressure on our state and municipal governments to reduce their taxes,” California Health Care Foundation president Sandra R. Hernández noted in a recent blog post.

“Under that scenario, it is not hard to imagine a new wave of painful state and local budget cuts.”

No Progress on Negotiations to Fund Children’s Health Insurance Program

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Source: The Hill

Negotiations on a bipartisan bill to fund the popular Children’s Health Insurance Program (CHIP) have made little progress, a top House Republican said Monday.

Energy and Commerce Committee Chairman Greg Walden (R-Ore.) said Democrats have not made a counteroffer on paying for an extension of the program.

“Despite Ranking Member [Frank Pallone Jr.’s (D-N.J.)] statement calling for renewed bipartisan negotiations nearly two weeks ago, we have yet to receive a single counteroffer from our Democratic colleagues,” Walden said in a statement.

“If Democrats are serious about funding these important programs, I call on them to follow through on their offer for renewed negotiations. There is too much at stake for partisan games and gridlock.”

The Energy and Commerce Committee passed a bill extending funding for the program earlier this month with no Democratic support.

Democrats, however, took issue with offsets that would cut an ObamaCare public health fund and increase Medicare premiums for those with incomes of more than $500,000 a year.

Walden agreed last week to reopen negotiations with Democrats on ways to pay for the program but said Monday there hasn’t been any progress.

He said if the two sides can’t come to an agreement, the full House will vote on the bill passed by the committee once it returns from recess next week.

Pallone, meanwhile, released a statement last Friday suggesting that Republicans have refused to budge on the offsets.

“It’s clear that House Republicans want to use reauthorization of children’s health insurance and Community Health Centers as a way to further undermine the Affordable Care Act and weaken Medicare,” Pallone said.

“Republicans remain fixated on sabotaging the ACA anyway they can. I reject the premise that we can only offer health care to children by taking it away from others, and, to date, Republicans refuse to budge in that regard.”

Funding for the program technically expired Sept. 30, but states have enough funding to last at least for the next few months.

Without any action from Congress, Arizona could be the first state to run out of funding by the end of November.

California Hits Nerve By Singling Out Cardiac Surgeons With Higher Patient Death Rates

Image result for Cardiac Surgeons photos

Source: California Healthline

Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.

Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.

“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized,” said Koumjian, whose risk-adjusted death rate was 7.5 per 100 surgeries in 2014-15. “The surgeons that worry about their stats just don’t take those cases.”

Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon.

California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft.” The practice is controversial: Proponents argue transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.

“This is a hotly debated issue,” said Ralph Brindis, a cardiologist and professor at UC-San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information.”

Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.

California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure. State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.

“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody,” said Holly Hoegh, manager of the clinical data unit at the state’s health planning and development office.

Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged from six to 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.

In this year’s report, the seven surgeons with above-average death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica. Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“For the lion’s share of my career, my numbers were good and I’m very proud of them,” said Pellegrini. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases.”

During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.

Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.

Robertson said in a written statement that he had three very “complex and challenging” cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions.” They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.

“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results,” Robertson said. “Every single patient is different.”

The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.

State officials said that providing surgeons’ names can help consumers make choices about who they want to operate on them, assuming it’s not an emergency.

“It is important for patients to be involved in their own health care, and we are trying to work more and more on getting this information in an easy-to-use format for the man on the street,” said Hoegh, of the state’s health planning and development office.

No minimum number of surgeries is needed to calculate a rate, but the results must be statistically significant and are risk-adjusted to account for varying levels of illness or frailty among patients, Hoegh said.

She acknowledged that “a risk model can never capture all the risk” and said her office is always trying to improve its approach.

Surgeons sometimes file appeals — arguing, for example, that the risk was improperly calculated or that the death was unrelated to the surgery. The appeals can result in adjustments to a rate, Hoegh said.

Despite the controversy it generates, the public reporting is supported by the California Society of Thoracic Surgeons, the professional association representing the surgeons. No one wants to be on the list, but “transparency is always a good thing,” said Junaid Khan, president of the society and director of cardiovascular surgery at Alta Bates Summit Medical Center in the Bay Area.

“The purpose of the list is not to be punitive,” said Khan. “It’s not to embarrass anybody. It is to help improve quality.”

Khan added that he believes outcomes of other heart procedures, such as angioplasty, should also be publicly reported.

Consumers Union, which sponsored the bill that led to the cardiac surgeon reports, supports expanding doctor-specific reporting to include a variety of other procedures — for example, birth outcomes, which could be valuable for expectant parents as they look for a doctor.

“Consumers are really hungry for physician-specific information,” said Betsy Imholz, the advocacy group’s special projects director. And, she added, “care that people receive actually improves once the data is made public.”

But efforts to expand reporting by name are likely to hit opposition. Officials in Massachusetts, who had been reporting bypass outcomes for individual doctors, stopped doing it in 2013. Surgeons supported reporting to improve outcomes but were concerned about doctors being singled out for worse rates when they were just taking on difficult cases, said Daniel Engelman, president of the Massachusetts Society of Thoracic Surgeons.

“Cardiac surgeons said, ‘Enough is enough. We can’t risk being in the papers as outliers,’” Engelman said.

Engelman said the surgeons cited research from New York showing that public reporting may have led surgeons to turn away high-risk patients. Hoegh said research has not uncovered any such evidence in California.

In addition to Koumjian, Robertson and Pellegrini, the physicians in California with higher-than-average rates were Philip Faraci, Eli R. Capouya, Alexander R. Marmureanu, Yousef M. Odeh. Capouya declined to comment.

Faraci, 75, said his rate (8.34 per 100) was based on four deaths out of 33 surgeries, not enough to calculate death rates, he said. Faraci, who is semi-retired, said he wasn’t too worried about the rating, though. “I have been in practice for over 30 years and I have never been published as a below-average surgeon before,” he said.

Odeh, 45, performed 10 surgeries and had two deaths while at Presbyterian Intercommunity Hospital in Whittier, resulting in a mortality rate of 26.17 per 100. “It was my first job out of residency, and I didn’t have much guidance,” Odeh said. “That’s a recipe for disaster.”

Odeh said those two years don’t reflect his skills as a surgeon, adding that he has done hundreds of surgeries since then without incident.

Marmureanu, who operates at several Los Angeles-area hospitals, had a mortality rate of 18.04 based on three deaths among 22 cases. “I do the most complicated cases in town,” he said, adding that one of the patients died later after being hit by a car.

“Hospital patients don’t care” about the report. he said. “Nobody pays attention to this data other than journalists.”

Why Doctors’ Offices Could Become Obsolete

Image result for self driving car photosSource: San Francisco Chronicle

A man showing early signs of a heart attack — detected by a bot tracking his heart activity from a sensor on his wrist — is picked up by a self-driving car that checks his vital signs on the way to the hospital. There, his doctors video-conference with a specialist, who assesses his symptoms through a Skype-like screen and recommends a treatment plan.

The scenario, inconceivable a generation ago, is closer than you might think. Technological advancements are ushering in a new era of health care, eroding the long-held model of hospitals and doctors’ offices as the physical center of the health system. The change is unfolding on many fronts, and experts say we are on the cusp of a revolution that could come within the next decade.

The growth of telemedicine (video chats with your doctor) and tools to track chronic diseases (wearable glucose-monitoring devices for diabetics) is inching us toward a time when medical care and diagnoses can be accessed from afar, and often without having to see a physician in person.

The explosion of relatively inexpensive direct-to-consumer genetic tests is allowing millions of people to learn potentially life-changing medical information about themselves without ever stepping foot in a doctor’s office.

And cutting-edge research in gene therapy is opening the door to the possibility of people with genetic diseases being treated much earlier in life, and being “cured” for longer periods of time — potentially improving the quality of life for millions.

This rapidly changing landscape raises the question: Will there come a day when we won’t need to go to the doctor’s office anymore? Will we be able to navigate the health system without coming into contact with a medical professional? And would that be good or bad?

Developers of self-driving cars are already considering including some basic inward-facing sensors that can be used for medical applications — such as those that can measure temperature or cameras that can visually assess the health of a passenger — to aid the elderly and people with disabilities, according to Nidhi Kalra, senior information scientist at the think tank Rand Corp. who researches autonomous car policy.

Some people “may have health complaints or challenges that the car needs to be aware of as it’s taking them to the mall,” she said.

Kaiser Permanente, one of the largest health systems in Northern California, recently set up a futuristic mock exam room where patients can sit in front of a computer screen to talk to a doctor remotely while using a stethoscope, digital thermometer and otoscope to check their own symptoms under the guidance of the physician. Kaiser CEO Bernard Tyson has personally participated in the experiment.

“That is the future — being able to provide a great health care service without someone having to get up and go all the way across town for that kind of medical visit,” Tyson said. “All these things represent the moving away from the hospital being the centerpiece of health care.”

Last year, 70 million interactions between Kaiser patients and their primary care doctor were done by secure email, video conference and other remote tools.

Worldwide revenue for telehealth devices and services is expected to hit $4.5 billion next year, compared to $441 million in 2013, according to the business analytics firm IHS Technology. During the same period, the number of people using telehealth services each year is projected to grow from 350,000 to 7 million.

“I don’t think we’ll get to a point where we’ll never see a doctor, but a large percentage (of doctors) will be seeing patients remotely” in the future, said Dr. David Tong, director of the telestroke program at California Pacific Medical Center in San Francisco. His program connects his vascular neurology practice with 20 other hospitals from the Oregon border to Visalia, so hospital physicians can seek his help in treating a stroke patient. Tong does a visual assessment of the patients using technology similar to Skype.

Tong has led the program since its inception a decade ago, when just two hospitals were in the telestroke network, and the concept of talking to a doctor through a screen seemed foreign to many patients. Today, it’s commonplace — “People think, ‘If I do this all the time with my friends, I’ll do it with my doctors too. What’s the difference?’” Tong said.

Despite the promise of remote medical care, though, many traditional barriers to health care remain. Wealth, geography and access to insurance are privileges that no app or technological advancement can replace.

“The major stumbling block right now is financial,” said Tong. “Right now, most insurance doesn’t pay for telemedicine in a very efficient way. That blocks some people from doing it.”

Medicare and Medi-Cal, for example, limit their reimbursement for telemedicine services to psychiatry and to patients who live in rural areas, Tong said.

There may also be drawbacks to receiving care remotely, which reduces the need for physical interaction. Studies have shown that human touch reduces stress, helps premature babies grow faster and improves the lives of nursing home residents.

But in another promising development, medicine is also moving in the direction of preventing diseases before they even cause any symptoms. Efforts by genetic testing firms to screen large populations — coupled with research in gene therapy and gene editing — will give people more information than ever before on their genetic makeup.

As soon as five years from now, “everyone who wants to be sequenced will have been sequenced,” said Dr. Jill Hagenkord, chief medical officer at Color Genomics, a Burlingame company that sells a $249 test that analyzes 30 genes associated with common hereditary cancers including breast, ovarian and pancreatic cancer. People can buy the test directly from Color or on Amazon, but they must submit their health information and have a physician review it and order the test before Color will analyze the sample.

“Whether that’s newborn screening in the hospital system or in a research setting … sequencing data will just exist,” Hagenkord said.

Color is already taking steps toward population screening, working with 40 large self-insured employers including Visa and Salesforce — which collectively cover tens of thousands of people — that subsidize or pay for the test for employees and spouses.

Using gene testing as a preventive tool “doesn’t take the medical professional out of the equation, but maybe you’ll just have a conversation earlier with your doctor,” about getting a colonoscopy sooner or making choices that may reduce your risk of certain cancers, Hagenkord said.

Meanwhile, researchers are working to bring gene therapy from the clinical trial stage to the real world to treat retinal disease and hemophilia — though treatments are not yet available commercially, said Dr. Chris Haskell, who leads Bayer Corp.’s West Coast Innovation Center. Bayer has a joint venture with CRISPR Therapeutics — which uses the gene-editing tool known as CRISPR — to develop and market therapeutics for blood disorders, blindness and congenital heart disease.

“With gene therapies, the industry is moving ahead very rapidly in clinical development toward bringing these to patients very soon,” Haskell said. “Gene editing is still a number of years away behind gene therapy, but has promise for being able to treat many more diseases.”

Gene editing is considered a subset of gene therapy. Gene therapy consists of adding a “missing” part of a person’s DNA, typically through an injection of an engineered virus that carries the replacement gene. With the blood-clotting disorder hemophilia A, patients are missing a blood-clotting protein called factor VIII. This protein is injected and, over the course of the next several days or weeks, the cells start producing the clotting factor and allow the circulatory system to clot normally.

“The trailblazing is happening with hemophilia because we understand the disease,” Haskell said. “But there’s a huge promise for bringing therapies to patients around the world, especially kids with metabolic disorders who have no good therapy.”

Gene editing makes it possible to modify the genetic code — and the applications seem limitless.

“This opens up a whole new realm of ways to treat diseases in that we can turn things on and off, take things out,” Haskell said. “With gene therapy, we have the hammer. Now we have the whole toolbox. However, we’re still learning how to use all these tools.”

And the workshop for those tools? It will be anywhere but your old, familiar doctor’s office.

Do High-Risk Pools Work? It Depends

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Source: The Washington Post

If the American Health Care Act ultimately becomes law, states will have the option to once again let insurers on the individual market charge those with preexisting conditions more than healthy people. Among the more contentious pieces of the AHCA, which the House of Representatives passed narrowly on Thursday, is a provision allowing states to request waivers to rules otherwise forbidding higher premiums based on a person’s health status. To get a waiver, states would have to explain how their approach would reduce premium growth and increase enrollment or competition; a late amendment to the bill added $8 billion to help defray higher costs to individuals with health conditions.

I have helped manage one federal and two state “high-risk pools” of the kind that could be re-created under this provision of the AHCA. Before the full implementation of the Affordable Care Act, states had significant discretion over their individual insurance markets, and most allowed plans to place a surcharge on individuals with preexisting conditions. Such “risk rating” was allowed because, before the ACA’s coverage mandate, those who didn’t get health insurance through their employer, Medicare or Medicaid could simply go without until they needed it, with no tax penalty. As a result, those who chose to buy insurance on the individual insurance market were more likely to have preexisting conditions and to incur higher health-care costs.

In 35 states, surcharges were applied to those with health conditions through the mechanism of high-risk pools — or plans that segregated these individuals from the rest of the commercial market. High-risk pools insulated healthier customers from higher costs to encourage people to buy coverage before they needed to use it. With adequate funding and affordable pricing, some state high-risk pools worked well.

I was the executive director — and the first employee — of Maryland’s high-risk pool when it opened in 2003. The state provided $120 million a year in subsidies for the plan, and people were eligible to join if they had been turned away by commercial carriers because of conditions ranging from cancer to hypertension, obesity, depression and even acne. Because commercial insurers denied 14 percent of applicants, Maryland’s pool grew to cover 21,000 enrollees — or approximately 20 percent of the market, a good take-up rate. While premiums were approximately 30 percent above what healthy individuals paid, pool members received more extensive coverage. And lower-income members had access to subsidies — this was well before Obamacare’s became available — that cut their premiums up to half what healthy individuals paid.

Inadequate funding produced different results elsewhere, however. Before Maryland, I helped manage California’s high-risk pool, which received $40 million a year in subsidies from tobacco taxes — one-third of what Maryland provided for a state six times more populous. California’s pool enrollment reached a peak of 21,000 in 1999, but it gradually declined as funding remained stagnant, resulting in a waiting list of up to a year. Premiums were 20 to 37 percent above what healthy individuals paid, with no low-income subsidies. Furthermore, California’s pool capped individual coverage at $75,000 annually — a limit hit by 3 percent of members with catastrophic levels of claims.

Another inadequately funded high-risk pool was actually created under the ACA. Because the Obamacare marketplace took nearly four years to launch, the bill established a temporary federal high-risk pool, which I helped set up. Four months after President Barack Obama signed the bill in 2010, the federal Pre-Existing Condition Insurance Plan began covering individuals who had been rejected by commercial carriers. The plan imposed no premium surcharge and was funded through a one-time, $5 billion appropriation. Enrollment peaked at 115,000 before we had to close it to new enrollees, nine months before the Obamacare exchanges opened, to stay within the $5 billion appropriation.

As these experiences show, funding mattered greatly to whether states took a somewhat benevolent (Maryland) or more neglectful (California) approach to high-risk pools. Is the money in the AHCA sufficient to subsidize premium surcharges for those with health conditions? The answer depends on many factors: How would insurers adjust their premiums in the new market? How would consumers respond to the end of the tax penalty, restructured tax credits and a 30 percent premium penalty on those who don’t maintain coverage? Would the elimination of Medicaid expansion coverage affect demand on commercial markets? How many states would request waivers? How well would programs and subsidies be promoted to those with preexisting health conditions?

The AHCA would also provide $130 billion over 10 years — a significant amount — to stabilize the individual and small-employer insurance markets, and states would be required to add tens of billions for market stabilization in the 2020s. How would those funds be applied? How much difference would they make?

If well-administered, the American Health Care Act could allow premiums to stabilize and help those with health conditions acquire affordable coverage. But if not, uninsured individuals with health conditions could end up longing for the good old days of the ACA.

Obamacare Premiums Rise as Insurers Fret Over Law’s Shaky Future

Image result for health premiums rising photos

Source: Bloomberg

Health insurers are asking for sharp increases in the cost of their Obamacare plans next year, thanks to instability in the law’s coverage markets that’s been compounded by the Trump administration.

In Maryland, Virginia and Connecticut — the first states to make filings public — premiums for Affordable Care Act plans will rise more than 20 percent on average, according to data compiled by ACASignups.net and Bloomberg. The increases follow years of rising premiums under ex-President Barack Obama.

The increases can be blamed in part on uncertainty among insurers about the strength of the law’s requirement that people carry insurance. The Trump administration has raised doubts about whether it will enforce what is considered by some insurers to be an already insufficient penalty.

“Failure to enforce the individual mandate makes it far more likely that healthier, younger individuals will drop coverage and drive up the cost for everyone,” Chet Burrell, chief executive officer of CareFirst, said in a statement. The insurer is asking for an at least 50 percent increase in premiums in Maryland. Burrell said uncertainty over the mandate played a “significant role” in the insurer’s rate requests.

The Affordable Care Act is at a critical juncture. Republicans and Trump want to repeal much of the law, and say the rising premiums are proof it isn’t working. At the same time, many insurers point to a lack of support for Obamacare’s programs as a reason for the increases, and have asked for help.

Rising Premiums

“It would be good to have some more aggressive stabilization efforts going on,” said Joel Ario, a managing director at Manatt Health who previously worked on the Affordable Care Act at the Department of Health and Human Services. “Uncertainty equals higher premiums.”

Health and Human Services Secretary Tom Price has said the administration will do what it can administratively to “support the reform effort by reviewing and initiating administrative actions to put patients, families and doctors in charge of medical decisions, bring down costs, and increase choices.”

Insurers are quitting Obamacare’s markets because the health law is “fundamentally flawed,” Alleigh Marre, an HHS spokeswoman, said in an emailed statement. “Repealing and replacing Obamacare remains the best option.”

The New Republican Strategy to Replace Obamacare: QuickTake Q&A

Politics and Policy

There are several other factors to blame for rising premiums, including underlying medical costs.

“We are seeing claims experience that reflects increased medical and prescription drug costs along with higher utilization,” Connecticut Insurance Commissioner Katharine Wade said in a statement.

That’s true in Maryland, too, said Insurance Commissioner Al Redmer. There, carriers are requesting average rate increases from 18 percent to 59 percent. That means in the Baltimore area next year, a 40-year-old could buy a basic “silver” plan for $714.95 a month from CareFirst, or one from Kaiser Permanente for $359.25 with a more limited network of doctors.

Medical Costs

“If carriers in Maryland are losing just on medical claims you can’t point to the current political climate and say, ‘Now things are worse,’” he said.

The rates are preliminary, and regulators often have the power to change them. Most other states will report their rates over the next several months.

CareFirst is a major insurer in Maryland, Virginia and Washington, D.C., and sells coverage under the Blue Cross and Blue Shield brand. The company said its premiums still fall short of covering its customers’ medical costs. It projects its accumulated Obamacare losses from the start of the program through the end of 2017 will reach $600 million.

Trump has cheered on some of Obamacare’s troubles, using them to justify his party’s efforts to repeal the law.

“Insurance companies are fleeing ObamaCare – it is dead. Our healthcare plan will lower premiums & deductibles – and be great healthcare!” Trump tweeted on May 4, the day House Republicans narrowly passed a bill to repeal much of the ACA. While the legislation faces a difficult time in the Senate, the premium increases are likely to remain a part of the debate.

Positive Signs?

It’s too early to say whether the results from the three states are indicative of broader trends. An analysis of Blue Cross and Blue Shield plans by S&P Global Ratings showed that insurers’ results were generally improving and the market stabilizing in the law’s third year.

BlueCross BlueShield of Tennessee will expand in the state next year, entering counties around Knoxville that would otherwise have no Obamacare plans after Humana Inc. said it would exit. After recording more than $400 million in losses from 2014 through 2016, BCBS Tennessee’s financial performance this year is improving, according to a letter the insurer sent to state regulators Tuesday.

Still, its premiums will include additional costs because of “the potential negative effects of federal legislative and/or regulatory changes,” CEO JD Hickey said in the letter. “These risks include but are not limited to the elimination of Cost Sharing Reduction subsidies (CSRs), the removal of the individual mandate and the collection of the health insurer tax.”

Scaling Back

Anthem Inc., which sells insurance under the Blue Cross and Blue Shield brand in 14 states, has said it may scale back that footprint. In Virginia, where it has 165,000 customers in the individual market, Anthem is raising rates about 38 percent. In Connecticut, the insurer has 35,000 customers and is raising rates 34 percent.

“We are forecasting that the individual market will continue to shrink, and that those individuals with greater health-care needs will be the most likely to purchase and retain their coverage,” Anthem told Connecticut regulators.

In some cases, rather than raising rates insurers are dropping out. Humana is withdrawing from Obamacare’s individual market entirely. Aetna Inc. has quit Virginia and Iowa has experienced broad pullouts. In an interview on ABC’s This Week with George Stephanopoulos, House Speaker Paul Ryan said the withdrawals showed the law is failing.

“What we’re trying to do here,” Ryan said, “is step in front of this collapsing law and make sure that we can have a system that works, a system with choice and competition and affordable premiums.”

Could GOP Bill Affect Employer Health Coverage, Too

Image result for employer health coverage photosSource: The New York Times

If it becomes law, the American Health Care Act will have the biggest effects on people who buy their own insurance or get coverage through Medicaid. But it also means changes for the far larger employer health system.

About half of all Americans get health coverage through work. The bill would make it easier for employers to increase the amount that employees could be asked to pay in premiums, or to stop offering coverage entirely. It also has the potential to weaken rules against capping worker’s benefits or limiting how much employees can be asked to pay in deductibles or co-payments.

Whether those changes happen depends on how the Trump administration, states and employers act. The possible effects on the employer health system got little attention during congressional debate.

The employer health benefit system existed long before the Affordable Care Act and was little changed by that law, which focused on expanding coverage for people who did not get their insurance from work. But Obamacare did expand some consumer protections for employer coverage. It also included a controversial “employer mandate,” which required large employers to offer affordable, comprehensive coverage to their workers or face a fine.

The Republican health bill, which passed the House last week and faces changes in the Senate, would weaken or eliminate those protections.

Employers who do not offer insurance to their full-time workers would no longer be fined. Under a Republican health law, benefits consultants predict that most employers would keep offering insurance so as to retain workers. But smaller employers, particularly in certain industries, may choose to cut back.

In its estimate of the effects of an earlier version of the bill, the Congressional Budget Office said that about seven million fewer Americanswould have insurance through work if the Republican health bill became law, compared with what would happen under current law. (Many of those people would still get coverage, the office said — they would just need to buy it themselves — but some would become uninsured.)

Employers would also be freed from penalties if their insurance did not meet a certain affordability standard for their workers; that could mean charging workers a larger share of insurance premiums.

Changes to Obamacare’s consumer protection rules are harder to predict. But it is possible, through the interaction between the health bill and current regulations, that employers would be able to skirt rules that forbid them from limiting the total amount of health care they will pay for in a year or a worker’s lifetime. A rule capping the amount that a worker can be asked to pay in deductibles and co-payments each year could be similarly vulnerable. That possibility was covered last week in The Wall Street Journal.

Matthew Fiedler, a fellow in economic studies at the Brookings Institution and a former Obama administration official, explained in a recent blog posthow the bill could bring back coverage limits. He said that the Trump administration could prevent employers from rolling back the rules through regulation. But he noted that a permissive regulatory approach, which could allow employers to impose limits on coverage, seemed consistent with the administration’s policy preferences. “I think it’s the most likely outcome, but it’s not a guaranteed outcome.”

Zach Hunter, a spokesman for the House Energy and Commerce Committee, which helped draft the bill, said that legislators did not intend for waivers to have any effect on the employer market. “Any ambiguity caused by previous administrations’ guidance from H.H.S. could be resolved by Secretary Price,” he said, referring to Tom Price. Alleigh Marré, a spokeswoman for the Department of Health and Human Services, told The Journal that the department would write regulations in line with the legislation’s intent.

Before the Affordable Care Act, limits on overall coverage were quite common. A Kaiser Family Foundation study found that 59 percent of American workers with employer health plans were covered by plans with a lifetime limit in 2009. A 2009 study from the benefits consulting firm Mercer reached a similar conclusion. It is not clear whether such caps would become as widespread in the future, but, if allowed, may become appealing for some employers looking to reduce costs.

“Lifetime limits affect very few people,” said Larry Levitt, a co-author of the Kaiser study, explaining employers’ thinking. “It allows you to lower your costs without affecting very many people.” But, he noted, such limits can be devastating to those with very costly health conditions.

Obamacare rules limiting the total amount patients with catastrophic illnesses could be asked to pay through deductibles and co-payments may also be weakened by the health bill. Currently, individuals can’t be asked to pay more than $7,150 annually for essential care. The limit for families is $14,300.

A recent survey of 666 employers from the benefits consulting firm Willis Towers Watson found that 15 percent of the employers would consider imposing lifetime coverage limits if it were allowed. The survey did not ask about raising out-of-pocket maximums.

James Gelfand, a senior vice president for the ERISA Industry Committee, a trade group that works with large employers on health benefits, said he thought the return of lifetime limits was extremely unlikely, even if the American Health Care Act became law. He spoke with some members in April about the issue. “That was an eye roll,” he said.

Changes are most likely among employers with fewer workers, or those that tend to pay hourly wages. Those were the types of businesses least likely to offer comprehensive coverage in the years before the Affordable Care Act. The Mercer study found that about 22 percent of wholesale and retail companies offered their workers so-called “mini-med” insurance plans, made illegal by Obamacare, with sharply limited medical benefits.

The Republican bill would not allow employers to charge higher insurance prices to those with pre-existing health conditions. That practice was barred by the Health Insurance Portability and Accountability Act in 1996, and was not changed by the Affordable Care Act. Some people who buy their own insurance might face a return of such health-based pricing under the Republican bill.

The bill would also ease a current pressure on employers to lower the cost of their health plans. Enactment of the so-called Cadillac tax on expensive insurance plans will be postponed until 2026 under the American Health Care Act.

Even if the law changes, coverage by most large employers is likely to remain widespread and robust, particularly if a strong economy prompts them to compete to attract workers. But even in past downturns, health benefits have proved tricky to take away. In the years before the Affordable Care Act, employers had no requirement to offer coverage and few rules about what benefits they should include. Still, in those years, generous employer coverage was the norm for large companies. “It’s not likely they would abandon that approach in a post-A.C.A. environment,” said Tracy Watts, the United States health reform leader at Mercer.

Last Updated 02/21/2018

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