8 Things CFOs Must Know About Health Reform

Whether a Chief Financial Officer is running the fiscal operations of a hospital system, an insurance company or a company that simply employs individuals with health coverage, the decision-making process for sustainability is changing at a rapid pace. However, after years of hearing about reformation in the health system, broad, sweeping and revolutionary changes are finally happening. Major shifts are also occurring in the population, as well as technological advances that will disrupt the entire premise of a four-walled institution for care and the very model we use for health delivery.

Health care in the US is a business – a multi-billion dollar business – and understanding the financial implications of health reform will make or break every CFO. Knowing that health access, demand, quality and payment changes are inevitable there is an immediate need for CFOs across the ecosystems to embrace and plan for transformation.

1. You have too many beds.
   While many hospital leaders won’t accept this at face value due to lengthy wait times, surgical demands and desire to shift beds, the truth is there are too many beds in a lot of hospitals. Between transferals to the outpatient setting and telemedicine, the need for expensive inpatient beds is declining. Additionally, hospital leadership are increasingly finding that they face problems with state authorities when they apply to move beds. Most recently at the University of Chicago, where 338 beds were being used for a 304-person utilization pattern, the state rejected a University application to move surgical beds.
2. Food, housing and transportation of patients is your problem.
   As Americans begin to define and attempt to tackle community and population-based care, the access individuals have to quality food, affordable housing and efficient transit matter.  No one living in a food desert will have the same health outcomes as someone living next door to a Whole Foods, just as an individual with a new car will always be more consistent in making appointments and picking up prescriptions than someone who has to access three public transit buses for the same activities. Real patient engagement and activation begins with understanding the environment of each patient.
3. Your patient demographics are shifting, and so too should your leaderships. As the US continues to brown, hospital leadership must be representative of the population to understand and meet need. At a recent Modern Healthcare Top 25 Minority Executives session, an awardee remarked that the United States is now a country of minorities, and “our leadership as minorities is our future for health outcomes.” With this in mind, it is inevitable and paramount to success that the leadership of any organization resembles and represents those it serves, so it makes the financial investments and decisions that influence the community.
4. More bodies in beds will never work again.
   Value-based purchasing means that a warm body in a bed not only drives costs higher for the payer, but that the longer a patient remains in the hospital – or the more often they return – the more penalties that accrue. Therefore, the goal should not be for more bodies, but for cost-effective bodies. Depending on the community serviced, this can mean desire for more Masters Athletes, specialized services or elective services. Additionally, as we shift to a world where technology enables more clinical procedures and recovery to be done in the outpatient setting, or at home, and expensive inpatient procedures decrease in volume and reimbursements, hoping to fill beds is futile.
5. Alignment with physicians is nonnegotiable.
   No leader can effectively attain a goal without buy in from those who carry out the work.  However, it is important to be aware that “physician alignment” is a term that causes almost all physicians to turn and walk the other direction out of fear that this indicates buying their autonomy and dictating their day-to-day, moment-to-moment ability to practice. According to Healthcare Financial News the implications of physician behavior are so important in 2014 that more revenue than ever will be spent recruiting physicians who see the world the same way you do, which is not very different from how corporation CFOs think about their employee hires.
6. As consumers take on more and more pay responsibility, unexpected payment shifts will keep occurring.
   Many experts estimate that defined contribution, health insurance exchanges and the growing individual health insurance market means that patients will become more informed about spending their health care dollars, and therefore, more unwilling to spend. The future of reimbursements and pricing strategies is presently a puzzle wrapped in an enigma because of extreme uncertainty. However, it is general knowledge that Medicare and Medicaid reimbursements are going to continue decreasing, with the American Hospital Association and Moody’s already estimating an, “unequivocally negative” outlook for hospitals on the reimbursement fronts.
7. Technology and data utilization can save you money.
   While the learning curve with new technology can be excruciating and the meaningful utilization of collected information seems daunting, everything from workflow to health activities and employee/patient engagement can be monitored – and altered in real time – using new technology. Moreover, the more information that is known today, the better predictive analytics and behavioral change that can be made tomorrow. However, as the amount of technology available to leadership continues to grow exponentially, the purchasing of new tech will be a balancing act between what is a passing fad versus what is sustainable and transferable.
8. Your EHR is going to cost you. Big time.
   Now this seems obvious to most hospital CFOs, as they have already seen the initial price tags that come with implementing a “holistic” electronic system. However, the most costly elements may not yet be realized. As mergers and acquisitions continue, technology advances and EHR capabilities increase, the need to refresh systems will continue.  At present there is not one system that meets end-to-end patient or provider needs, leaving the ecosystem open for further disruption, which inherently includes more interoperability, more upgrades, more plugins and more costs.

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Health Insurance Benefits – Can You Have It Your Way?

As the percentage of large employers that consider a shift to defined contribution and/or private exchange increases, the number of options – and flexibility in those options – must also increase. Consideration for those options rose last year from 14% to 18% among large employers (500+ employees). Further, those who are considering the move to a private exchange want to because of their desire to offer more and better plan options, as well as realize cost-savings. Shifting to the defined contribution framework allows employers to moderate their subsidies to employees, and employees to make better trade-offs among plan options. Additionally, by increasing choices, defined contribution makes it easier for employers to integrate their health incentive and wellness programs by layering them “on top” of the defined contribution.

With this economic opportunity in the market, it is imperative that health plans and enrollment become more tailored to individual and company needs, in addition to the one-size-fits-all solutions of the past and present.

Private health exchanges, according to bswift, like their new Springboard Marketplace, could be the platform to give consumers that greater choice and increase individual decision-making. Given that most large employers who are considering a defined contribution will remain self-insured, bswift is taking a calculated gamble that employers will continue to invest in cost management solutions such as incentives, wellness programs, consumerism as opposed to simply shifting costs to employees under the “fix it and forget it” cost sharing approach suggested by some competitors.

Customize Your Cart

The Springboard Marketplace that bswift has created has the online functionality healthcare.gov could only have dreamed of, and the choice construction of a grocery store.  In fact, the terminology the company uses alludes to “Stocking the Shelves” with your benefit choices and “Shopping” for your ideal group of benefits. This is all done through the interactive benefits advisor, Emma, who walks employees through an online step-by-step process to fill their cart with health care options.

For those aware of bswift’s background as a tech company it may not be a surprise that the software and services offered are aimed at streamlining a very sophisticated system, and making the user experience easy. And for those that know the company’s Executive Director of Exchange Solutions Brad Wolfsen, the shopping experience and ease of transition into a new set of consumer options will easily resonate. Mr. Wolfsen, before joining the team, built and led Safeway’s wellness and retail strategy programs, and was the President of Safeway Health.

According to Mr. Wolfsen, the real benefit he sees to bswift’s products are that they, “allow employers to focus on equity for employees and shift to a retail view on providing health benefits.”  Or, as the Society for Human Resource Management labels it, From Parenting To Partnering.

New Plans Equal New Decisions

With a growing demand for health benefit options that resemble a choose your own adventure book, but with a set amount of money to spend, the development of software must also be functional for employers and employees. The Springboard Marketplace has been constructed so that functionality can simply be turned on and off, so that choices are simplified. Additionally, since there is not a standard approach to benefit choices and many legacy systems that have to be revamped due to mergers, acquisitions and partnerships, greater automation for employers means less paperwork for HR departments. By making workflow, reporting and administrative work more efficient through automation, cost-savings increase even further.

“The best and brightest clients are currently driving what is in the bswift system now,” says Mr. Wolfsen. “As we move towards expanding the suite of benefit options and meeting compliance standards, we are also investing in the shoppers experience.”

He, along with his colleagues at bswift, believe that their tech company is nimble in ways that others are not, and that with the help of their platform and Emma, more and more employers will begin the migration to defined contribution and private exchanges. If true, that growing shift could redefine how health benefit decision-making is done by employees in the future.

 

American Heart Association Launches Accelerator To Find Internal Game Changers

Accelerator programs and incubators are growing rapidly in number within the health care industry, with most replicating standard tech incubator models. But one organization has worked to redefine what an accelerator program can look like in the health space by joining one of the country’s largest and most influential associations in its landmark effort to court healthcare innovation. Dr. Ross Tonkens, a cardiologist and Chief Medical Officer in Cary, North Carolina has directed the creation of the Science and Technology Accelerator Program inside the American Heart Association (AHA), that targets and supports ground-breaking ideas from residents to senior clinicians.

Breaking The Mold

Although the AHA is most well known for its Heart Walks, Heart Ball and various awareness efforts such as the Go Red campaign, with a growing accelerator program, the Association could soon be known for changing how health associations and organizations think about growing overall impact. Not only do new ideas, technologies, and products improve the branding and public relations of an association, but it also leads to innovation that improves cost-effective practices, patient experience and standards of care.

According to Dr. Donald Lloyd-Jones, Senior Associate Dean for Clinical and Translational Research at Northwestern University, “When the prevalence of atrial fibrillation is presently estimated between 2.5-6 million Americans, but also estimated to be 6-16 million by the end of 2015, we know invention and innovation are needed.”

The AHA’s 2020 Impact Goals are to reduce deaths from cardiovascular disease and stroke by 20% as well as improve cardiovascular health of all American’s by 20%. Lloyd-Jones said the kind of disruption and change necessary to make these goals achievable will have to come from newer and more effective ideas and products through the Accelerator program in addition to continued research funding.

Dr. Lloyd-Jones set the tone of the AHA’s “Get Pumped” efforts by highlighting that, “continuing to fund research efforts will ensure tomorrow’s health and science discoveries make it from bench to bedside.”

Dr. Tonkens adds that investments through the Accelerator program can encourage industry and venture capital interests to “pick up the baton and carry it to the finish line after we fund proof of concept clinical research.”

Funding

Presently, the AHA is the second largest funder of cardiovascular research after the federal government. AHA has spent over $3.5 billion in supporting basic science research, and continues to do so. The Accelerator on the other hand is focused on identifying the game changers that can be propelled to market as quickly as possible, and helping the industry and investors feel confident in having a lower amount of risk on innovative products.

While AHA gave an estimated  $134 million last fiscal year in research, the AHA Science and Technology Accelerator Program is independent. To date it has not collected money directly from AHA, but instead, relies solely on donations directed to the Accelerator through awareness and fundraising efforts.

While this can make funding difficult, it also means any return on investment by the Accelerator is used to drive game changers into the market faster; the gift that keeps on giving.

Challenging The Status Quo

The Accelerator program not only invests money, but also expertise in areas such as scientific research, regulatory issues, intellectual property and commercialization strategies. This is done to ensure that all ideas are solicited, vetted and implemented to the best of their abilities, even those from younger individuals in the AHA that may not have yet been granted government funding or published in journals.

At the Heart Innovation Forum in Chicago last October, Jill Seidman of Healthbox agreed. During a panel discussion on accelerating discovery to patient experience she examined to audience that it was ideal for Chicago to host the AHA Forum because it was on the forefront of young innovation. She explained that, “bridging academic medical centers (AMCs) with community centers and clinics is imperative to improving outcomes, and Chicago has more AMC and medical schools than any other region in the United States.”

Dr. Tonkens message was clear at that same Forum. He said that like Healthbox, the Science and Technology Accelerator within AHA could fund – and has – great ideas. As he put it, “small amounts of money can dramatically improve life expectancy and decrease death from heart attack and stroke when leveraged by the global expertise in science, medicine, IP, regulatory and commercialization strategies which AHA is uniquely capable of bringing to bear.

American Heart Month And Beyond

As February closes out National Heart Month it is important for American’s to think about the implications of the country’s most detrimental health condition, heart disease. As a nation we have a long way to go to improve overall outcomes as they pertain to cardiovascular health, and especially those of our minority populations.

Through initiatives that range from the new Get Pumped phone app to high-end fundraisers to advocacy campaigns, the AHA is working hard on its outreach, educational, and public policy efforts. “Funding research and encouraging technological innovation is critically important,” said AHA Illinois Government Relations Director Alex Meixner, “but we also work with stakeholders ranging from hospitals to local, state, and federal governments to ensure that today’s scientific breakthroughs become tomorrow’s universal standards of care.”

Further, the status quo must be disrupted, and must be met with acceptance by veteran clinicians. Although current best practices exist for a reason, there cannot be progress using older methods to care for our aging and changing population.

 

An Engineering Feat Gives Hearts Extra Life

With the release of their new HeartAssist5 heart pump, ReliantHeart is making real-time, personalized feedback possible for the millions of Americans suffering from heart failure. The new technology allows for real-time, remote monitoring of implantable devices, years of added life for patients, and flexibility to travel without a physician nearby. With a staggering projected 46% growth in heart failure by 2030, advances in heart failure innovation are on the forefront of changing medical treatment, policy, device research and physician reimbursements. Further, with heart failure and disease disproportionately affecting minorities in the US, advances in length and quality of life could be huge strides for medical equality.

Heart Failure In America

Approximately 7.5 million people in the United States currently suffer from heart failure, a figure that is increasing over time as more people survive heart attacks and various other heart conditions. According to the Heart Failure Society of America, an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year, with deaths averaging 250,000 annually, more than double since 1979. Even worse, an estimated one half of heart failure patients die within five years of diagnosis and 20% within the first year.

With a waiting list for heart transplants at an overwhelming 3,736 at publication, and less than 2,500 hearts donated annually, the need for a bridge between heart failure and transplant is literally life and death.

LVADs

Left ventricular assist devices (LVAD) are implantable heart pumps that were created to temporarily support patients with advanced heart failure as the bridge between diagnoses and transplant. However, with new scientific advancements, LVADs are becoming a long-term tool for improving heart function without transplant.

The right ventricle pumps blood to the lungs, but the left ventricle is responsible for pumping blood to the rest of the entire body, making it much more susceptible to failure. Therefore, LVADs have been the focus of most modern research to prolong and improve life saving implants.

Patient-Centered Care

Reliant’s system acts like your car’s dashboard. “If a patient’s pump has any sign of a challenge, like dehydration or low flow, the remote monitoring system signals the change to a data-collection center that notifies the transplant center as well as the individual,” ReliantHeart CEO Rodger Ford says. This is what makes the HeartAssist5 unique; at the first sign of a problem the right people are notified immediately.

Essentially, if the engine light goes on, the heart center and patient are notified to get the engine checked.

He also notes that the patients can set monitors to send text message notifications, thus making changes in blood flow, speed and power truly personalized. Individual blood flow is collected and transmitted every 5 minutes, making one’s own body the standard comparator.

The greatest importance to Founder and CTO Bryan Lynch is his ability to use his background as an engineer to, “Get involved in a project where you can actually see how you saved a life. While the docs and nurses are the real lifesavers, we give them the tool to make it possible.” He continues that it is vitally important for engineers and innovators to gain a patient-centered approach to get a real reduction in cost burden and improve quality of life.

Sailesh Saxena, CFO, continues highlighting the patient focus of the company by telling about the origination of the design of the VAD pack. “Bryan and I used to go to Schlotsky’s Deli ($BUNZ) for lunch,” he said, “and we used to see this man wearing a coat although it wasn’t cold out. Bryan noticed immediately that he was attempting to hide an LVAD controller and batteries. Well, this happened more than once, and we recognized that he was always concealing the VAD controller. So we decided that we needed to create a unique insert so that our LVAD control system could slip right into a Louis Vuitton ($LVMH) or Gucci ($GUC) bag unnoticed. It’s the small things that make the patient feel like we understand what they really want.”

Expanding The Geography Of Care

Remote monitoring, like other methods of telemedicine, is a key to expanding the geography of health care. “As technology matures, with the help of remote monitoring, the cardiologist and patient will feel safer with greater distances between them,” says Saxena.

This growth in telemedicine as a whole, and specifically in heart care, has major implications for the Centers for Medicare & Medicaid Services (CMS) as well as health care policy and reform. Because CMS is beginning to assign reimbursements and penalties based on patient outcomes instead of traditional fee-for-service metrics, it will become more and more important to have reimbursements reflect remote monitoring and its likely benefits.

Reimbursement codes also need to be reworked to genuinely target geographic discrepancies in care, which are fundamentally important for transplant centers. However, at present, CMS is slowly beginning to take growth rates of heart implants seriously based on the agency’s continued increases in payments, including their slight variations in geographic differences.

An Engineering Feat

In a recent study, researchers found that platelets flowing through the HeartAssist5 are exposed to significantly lower cumulative shear stress levels than in competitive devices tested. Ultimately, this means that the ReliantHeart product allows for what the CTO calls “a more physiologically normal cardiac output, including the pulse.”

What Bryan means is that people with failing hearts have low blood flow throughout the body, which is why they are so sick. When an LVAD is implanted, patients return to a more normal flow, but they also need blood flow that is as natural as possible. With the HeartAssist5, blood is not damaged and any pulse that the recovering heart produces is naturally transmitted to the body.

The LVAD and heart now work together to help the patient recover.

Although there are two other continuous flow LVADs on the market (THOR and HTRW), the ReliantHeart team claims their careful design capitalizes on working with the natural ventricle to the benefit of the patient, almost like a gym trainer for your heart.

Their “implantable flow probe” is also a revolutionary aspect of the HeartAssist5. This ultrasonic probe measures the blood flow from the LVAD in real-time providing critical feedback that is a one-of-a-kind technology providing data that makes the aforementioned remote monitoring so valuable. Ford says this ability to see patient-specific trends remotely in real time not only helps all patients improve quality of life, but the longevity of the HeartAssist5 creates a life support system, far beyond the “bridge” that the LVAD was originally created to be.

So this month, for American Heart Month, think about what innovation really is. It might be the ability to prolong and add quality of life for individuals and families across the nation, to share more time with loved ones.

 

President Obama Fails To Explain Tech Glitches And Solutions In ACA Speech

Monday at 11:30am EST, President Obama spoke in the Rose Garden about the recent troubles with health insurance exchange enrollment and websites. With a team of young people standing behind him and Janice Baker at his side, the first person in the state of Delaware to successfully enroll in the exchange, President Obama said he was speaking to every American wanting to get affordable health insurance. He claimed that in the last three weeks, despite the horrific technological problems with the websites, that “half a million consumers across the country have submitted application through federal and state marketplaces.” He further touted that the “federal site alone has been visited 20,000,000 times” in the last three weeks. Unfortunately for those American’s who are really interested in signing up on the exchange sites, he glossed over the depth and breadth of the current troubles, giving a speech that sounded more like a State of the Union address with small-business examples and reading letters written to the White House.

President Obama also alleged that no one wants to see the exchange sites improve more than the federal government, noting that, “the website has been to slow, and people have been getting stuck during the process.” He also said that it is the mission of the administration to make them “more better,” with visible cringing from the audience, but claimed failures were due to response rates. He said the public response was “overwhelming, which has aggravated the underlying problems.”

However, he failed to go any further to explain what those other underlying problems were or when specifically they will be fixed. He did say that while HHS and contractors such as CGI Federal are working out the “kinks,” American’s should be patient. He claimed that “if the product is good, [American people] are willing to be patient,” suggesting that there will not be a delay for the individual mandate.

Nevertheless, he followed this by assuring the public that unlike Black Friday sales, the insurance plans will not run out like purchasing a new PlayStation – adding to the list of items the administration has compared exchange sites to, including iPhones and travel websites.

Despite his promises of improvements and putting the “best and brightest” on the job, CNN and other sites have insisted that the inherent technological and platform problems with Healthcare.gov will not be resolved anytime soon. This begs the question, that if the federal government is now searching for the best and brightest to correct the estimated 5,000-5,000,000+ lines of coding that need to be fixed on the federal site alone, who was working on the original platforms?

As he continued his speech, the President reminded the American public that although the websites for enrollment are not as, “quick, consistent or efficient as we want,” that the exchange sites are far more than “just a website.” He noted that many pieces of the Affordable Care Act (ACA) are already in place and being utilized by millions of Americans. He addressed pre-existing conditions, youth under the age of 26 and several other provisions that are already being rolled out by federal law, and the successes they have seen there.

He noted more examples of ACA triumph in Oregon, where he maintained that the exchange, “has cut the number of uninsured people by 10% in three week,” which is about “56,000 more Americans” with health insurance coverage.

During the speech, President Obama also tried to clarify the exchanges or marketplaces by describing them to the public as becoming part of a “big group plan… that bargains on your behalf for the best deal in health care.” He said that by doing so, insurance companies have created new products and options that strengthen market forces, leading to better deals.

He went on to say that without a doubt, “prices have come down,” further claiming that “when you add the next tax credits (those not yet implemented)… then the prices come down even further.”

The President rounded out his talk by noting the Republican party’s opposition to the ACA and how willing they were to “shut down the global economy” to fight against the ACA. A move, he claimed, that shows just how unwilling Republicans are to negotiate on legislation intended to, “free families from the pervasive fear that one illness one injury will cost you everything.”

While that may be the goal of the Affordable Care Act, the underlying technological and coding problems may prove to make that impossible.

 

Closing Racial And Ethnic Disparity Gaps: Implications Of The Affordable Care Act

For all intents and purposes, the Affordable Care Act (ACA), the President’s signature piece of legislation, will provide more health care coverage to poor and underserved populations. Persistently disadvantaged communities have much further to go than those with insurance, and new means of accessing and paying for care will benefit them disproportionately. Nevertheless, with more than 20 percent of the nation’s Black population uninsured, more than 30 percent of Hispanics uninsured and a country still grappling with understanding and properly addressing disparities, just how far does the ACA take us?

By mandating individual health insurance coverage and expanding the list of covered preventative services, ACA legislation should, theoretically, improve the quality of health care for those populations at disproportionate risk of being uninsured and having low incomes. In advance of the January 2014 start of major health reform initiatives, some estimate that more than half of the uninsured will gain insurance coverage.

However, research has shown that having health insurance itself does not have a substantial impact if people cannot find a doctor to see them, do not have proper information about accessing resources, or are not treated in a culturally and environmentally competent manner. Moreover, when the number of uninsured could be decreased by more than half, but being uninsured is not equitable across racial and ethnic groups in the US, what happens to our countries most vulnerable?

It has been well documented that low-income individuals and those without employee-sponsored insurance (ESI) are more likely to be people of color. Kaiser and US Census estimates indicate that there are significant differences in insurance rates by race and ethnicity, with national averages approximating there are almost three times as many uninsured Hispanics as Whites. In Louisiana, for example, it is believed that more than 50% of the state’s Hispanics are uninsured, while only 18% of Whites are. In the same state, it is estimated that 30% of Blacks are uninsured, reiterating just how unbalanced our country remains and how terribly far we have to go to eliminate inequalities.

The oft-cited example of health reform success is Massachusetts, where Blue Cross Blue Shield 2013 estimates indicate that about 97 percent of the state’s population has health insurance thanks to health reform. While this is a grand feat for gaining an insurance card, insurance alone does not constitute affordable, quality care, or improved long-term health and equity. The real successes come from improved statistics on accessing care, preventative care and disease reduction.

For those looking to Massachusetts, data does support a slight improvement in overall access to care by showing that Whites, Blacks and Hispanics all had increases in the number of insured, and further that the percentage of the state’s population that had “any doctor visit in prior year” between 2006 and 2009 rose by more than five percent.

Unfortunately, as many have argued, those for and against health reform, Massachusetts is not necessarily a good representation of other US states or populations, as anyone who has been to Massachusetts knows that the state population looks and behaves very differently from places such as southern California or the Southside of Chicago. Furthermore, even in Massachusetts the number of Blacks and Hispanics that remain uninsured is two and three times that of Whites, respectively.

Many of those who will be left uninsured will be Blacks, immigrants and Hispanics, who will continue to use Emergency Departments for critical care or, worse, go untreated.

Additionally, there are those who are lower middle class (a growing group in this nation) who fall into the economic gap where they cannot afford the employer/exchange insurance offered to them, but earn too much to receive subsidies for offsetting the mandatory cost of insurance, which are often people of color.

Other groups of concern are those minorities who do not have the knowledge of where to access care, do not have the financial or transportation means to access care or still distrust the system due to systemic problems with culturally competent care.

Although the ACA takes us a step forward in giving many of the countries uninsured an insurance card, the US must address what to do about probable provider shortages that will result from a lack of primary care physicians and different utilization in care. We must be prepared to understand both to cultural differences in demand and pent-up demand of the previously uninsured, as well as start to really face how to deal with persistent racial and ethnic inequality in this nation that shows itself in our health care system every day.

In the coming weeks, months and years the US citizens have to do more than champion or attempt to repeal the ACA. Party lines and moderate attempts at change will never fix our broken health care system. We have to start addressing the real issues our country faces, those of injustice, unequal access and treatment and how we properly care for and address the needs of those who are not White and wealthy.

 

High-Risk Pools and Reinsurance: Potential Shock Waves to Insurers

Due to poorer health, higher cost services and pent up demand for health care, there are numerous concerns about high-risk and expensive individuals. These are people who were previously uninsured or enrolled in high-risk plans that will soon be covered by exchanges. Further, there is concern that premiums could skyrocket in 2014 if the unhealthy disproportionately move to exchanges for coverage while younger, healthier individuals slowly and cautiously join.

The Affordable Care Act was partially designed to mitigate these concerns. One method in particular is aimed at spreading the risk amongst the individual market for the first three years through “reinsurance”.

The initial description of reinsurance was that all insurers would be responsible for paying into the program.  Insurers were eligible to get funds in return, if a large portion of their enrollees were high-risk and expensive. The plan was designed to pay out $10 billion in year one, $6 billion in year two and $4 billion in year three to insurers of high-risk plans, incentivizing them to phase in their high-risk (and higher cost) individuals onto the exchanges.

The goal was to keep the individual market premiums low by balancing out costs in the exchanges, so that the young and healthy would equally participate. The gradual transition would give further funding to insurers to support their high-risk population, hopefully, mitigating the obvious discrimination of not allowing those high-risk persons equal, free market participation in the individual market.

Recent changes made by the federal government however, now have states and insurers concerned about the program they are required to pay into and get funding from, once the health care law takes effect.

The Department of Health and Human Services (HHS) has released regulation clarifying that state high-risk pools are no longer eligible for the return of funds, and that the government money will not be given for anyone with medical costs  around$60,000 per year. This shifting of incentive has many health policy analysts worried that states now have no reason not to dump their high-risk pools onto the exchanges on opening day.

Under the new regulations it actually makes sense for insurers to move high-risk enrollees as quickly as possible to get larger shares of the reinsurance funds. Therefore, insurers like the Blue Cross Blue Shields of the world will most likely have to ask HHS for more flexibility, and perhaps assistance during the transition period.

Reinsurance was anticipated to slowly maneuver high-risk people from the state’s pre-existing condition plans and high-risk pools plans onto the exchanges in a manner that prevented a substantial jolt to the individual market. However the recent clarification may actually have the opposite effect on its intended goal, forcing insurers to quickly move high-risk individuals en masse to the exchanges. This drastic shift in health care dollars may in fact destabilize the individual market, rather than slowly coaxing a change.

 

Direct Health Care Services for the Uninsured

Two weeks ago I wrote about some of the unintended, but positive, consequences that could result from employers dropping employer-sponsored health insurance (ESI). Following that post, many weighed in about various other consequences of such behavior from employers and what that means for health care coverage for millions of families in the US. One issue in particular caught my attention; not only because of the touching stories associated with the discussion, but because of the unique and inspiring methods some providers are utilizing to compensate for the lack of insurance coverage.

As Jodi Carroll of VoteFacts.org underscored, millions of women and men in the United States are reliant on their significant others employer to provide their family’s health insurance. Women, in particular, are disproportionately reliant on husband’s employers for coverage, with children who are also dependents.

Although there are positives that might ultimately develop in the individual market due to ESI, the current and near future are exceptionally frightening for many families and employers have started down that slippery slope by excluding many dependents from future insurance coverage.

Given the recent discussion in the media, spouses and children being dropped from employer coverage is a growing concern. In the context of a bloated and dysfunctional health care system, this significant and immediate alteration in health insurance coverage could be very difficult for many households to absorb financially, particularly if their income falls just above the threshold for federal subsidies to purchase policies in the upcoming health insurance exchanges.

But, what if these spouses and children had an option that could provide them with most of the services they need, and was easily accessible and affordable.

Throughout the nation, in response to shifts in health care, many small direct health care providers are opening shop. These direct providers are able to combat many concerns through price transparency, easy access and lower costs as they establish what is basically a menu of cash only services. Further, these one-on-one scenarios improve decision-making between patient and physician and take out the need for insurance and proof of citizenship.

While many services are not available through these direct providers, a bulk of what the majority of people need are. Chronic disease management, acute care services and preventative care are all available at a face value, affordable price.

Residents in North Carolina have embraced a shining example of this new system. Access HealthCare is a direct care provider in NC with results to be impressed by. One of their diabetic female patients, and her teenage son, had lost their health insurance when her husband them, taking his ESI with him. According to her KevinMD website interview, she was working two retail jobs to fund her diabetes treatment and medical, at a cost of $5,000 a year.

However, once she found Access Healthcare, her annual costs were reduced to $450 annually and her health care results improved.

Similarly, according to Dr. Brian Forrest, founder of Access Healthcare, “a patient who normally has an 80/20 plan (like Medicare Part B) might end up having to pay 20% of their fee to see a specialist for a stress echo. If the cardiologist I use gives them an 85% discount to just pay cash up front, then the patient actually spends less out of pocket by not using their insurance.”

Although not all medical care can be preventative or primary, Dr. Forrest contends that “only about 1% of the population gets hospitalized annually. Only about 5-10% of patients that seek care at a physician office cannot get the services they need in the outpatient setting.”

For now, most of what people need can be found in offices like those mentioned above. However, I would still encourage citizens to purchase, at minimum, catastrophic coverage for hospitalization.

Additionally, as we begin to see the intended and unintended consequences of the Affordable Care Act, it is vitally import that we are open to new ideas and creative methods for meeting the nations changing health care needs.

 

Dropping Employer-Sponsored Insurance Could Benefit Health Care System

Special thanks to Emily Egan for her thoughtful contributions, writing and ideas for this post. 

In 2010 President Obama told the American public that if they liked their health care coverage, they would be able to keep it. And, despite his signature health reform law, the Affordable Care Act (ACA), intending to expand the country’s employer-based health insurance system, many now estimate that the law will, in fact, do just the opposite. It is projected that a consequence of the coverage provisions implemented in 2014 will be for many companies to drop health care coverage for their employees.

To date, the majority of research studies, modeling estimates and employer surveys have predicted some level of employer insurance drop. While this is usually framed as a negative consequence of the law, moving away from our employer system may actually have positive implications for the health care system and individuals.

As a result of an expanded individual market, Americans participating in the health care system might see benefits in three specific areas: cost, transparency and portability.

The benefits would not manifest through Americans losing employer sponsored coverage, but in gaining new coverage from a choice of plans in a more robust individual market.

The individual market for health care insurance is historically underdeveloped compared to the employer-sponsored market due to high costs, individual underwriting, and the ability of insurers to deny applicants based on pre-existing conditions. This system began as a result of wage caps during World War II, and then expanded when preferential tax treatment for employer plans was codified into law. The dominance of employer-sponsored insurance (ESI) was solidified in an era of single income households where the breadwinner rarely changed jobs.

However, the individual market will soon experience substantial changes as a result of the ACA, and could become much more attractive to individuals as their choices increase. Further, knowing that employees will be able to find decent coverage elsewhere could become an incentive for employers to dump ESI.

In terms of improving cost, it is possible that when individuals have more consumer choice with regard to plans (rather than a single plan or a choice of several tied to one employer); most would be likely to choose lower-priced plans that require higher deductibles and out-of-pocket spending. This price sensitivity would not only reduce the aggregate amount spent on insurance, but may work to reduce unnecessary utilization of medical services and more price sensitivity when it comes to choosing providers, medications, and treatment plans. Which could, in turn, lead to an additional improvement: transparency.

Anyone who has attempted to navigate through the health care system can attest to the lack of transparency from providers and health systems. Most individuals do not ever see pricing information, as they are largely shielded from health care costs via their insurance providers. However, if individuals begin paying for treatment out of pocket up to a certain deductible, the demand for transparent and bundled prices should increase, and providers would be forced to respond or risk seeing patients walk away. We’ve already seen the popularity of retail clinics among those who are uninsured and use of high-deductible health plans by many Americans, in part, because of the clear pricing structure.

The third potential positive implication of significant ESI drop could be felt through an increase in the demand for portability of plans. Labor markets of 2013 look very different from those of the post- World War II era. Job transitions occur much more frequently, and with ACA implementation, health insurance providers are likely to alter their network of physicians. For patients with complex or chronic conditions, switching networks and losing access to a trusted physician as a result of a job transition, a job loss, or early retirement, can have harmful health consequences. However, with individual insurance coverage, loyalty to providers exists outside of ESI. Americans could soon have more flexibility to keep their coverage by not using ESI.

While it would certainly be preferable for major shifts in health care to be the result of thoughtful and well-researched strategy, there are potential unintended positive results of new ACA policies that align incentives such that it no longer makes sense for employers to purchase expensive insurance plans on behalf of employees.

Consequentially, the transition is unlikely to be a smooth one in the coming years, but the benefits of changes in individual market insurance coverage could outweigh the unavoidable growing pains of the changing market.

If a cycle of positive individual market results increases, more and more people could move to the individual market, by choice or force.  Only time will tell.

 

State-Federal “Partnership” Exchanges: The Rarely Discussed Alternative Option

Beginning in 2013, states will begin rolling out health care insurance exchanges as required by the Affordable Care Act (ACA). To this point most legislators, policymakers and health care experts have discussed the state-based and federal insurance exchange options at length. However, there is another form of insurance exchange that states are beginning to explore: the “partnership”.

In a state-federal partnership, states will divide obligations with the federal government. For this partnership model there is no requirement for a 50-50 split of labor, and the states are actually more of a facade whereby the consumers (individuals and employers) merely interact with the state. The federal government, on the other hand, will essentially perform all functions of the exchange management except customer service and plan management. Moreover, states have the choice to run either one or both of those functions. According to former head of insurance exchange planning at HHS Joel Ario, “States that choose this option are ceding the more technical aspects of exchange activity to the federal government but can retain control
of insurer oversight and consumer assistance.”

In the state-federal partnership model, the federal government will operate everything from consumer eligibility and enrollment to financial management and risk corridors. This essentially means that the federal government will take on most responsibility for the exchange, while granting states many of the perks they would receive if they had created a state-based exchange.

If the federal government is left to the heavy lifting, what exactly will the states portion of labor entail? The states can choose to be responsible for plan management, meaning they will be charge of qualified health insurance plan certification and reinsurance, data collection and basic supervision. The states can further choose to be in control of customer service functions such as in-person assistance. Nonetheless, even in this case, the federal government will oversee the websites and call centers where the heavy lifting will occur.

To date, only a few states have revealed that they intend to participate in a state-federal exchange. Illinois, whose Governor Pat Quinn announced its intention to run a partnership exchange in July of 2012, has already received $39 million for the state, and this sum does not even include Medicaid expansion. Arkansas has been making significant progress on their partnership since 2011. For its hard work, the federal government has given the state nearly $9 million in grants.

For more detail about the current responsibilities of the partnership, visit the PwC “Anatomy of an Exchange” chart created with data from the Robert Wood Johnson Foundation.