Rules that exclude patients from insurance coverage for a preexisting condition is one of the thorniest, and most reviled, parts of commercial health insurance. Ending it could make insurance more expensive but the country seems poised to make the change. President Obama told the nation that "healthcare reform cannot wait," and vowed "quality affordable healthcare for every American." A key to accomplishing this, Obama said repeatedly during his campaign, is eliminating preexisting-condition exclusions that deny coverage to countless Americans.
Harvard professor Thomas J. Lynch, MD, has been named director of the Yale Cancer Center and physician-in-chief of the new Smilow Cancer Hospital at Yale-New Haven (CT) Hospital, which will open in October. Lynch is currently professor of medicine at Harvard Medical School and chief of hematology/oncology at Massachusetts General Hospital Cancer Center. His appointment is effective April 1. Lynch says he is excited about the plans of the medical school and hospital to invest in new programs and infrastructure to improve the health and longevity of patients with cancer.
Tens of thousands of uninsured patients could qualify for up to $3.5 million in refunds on payments they made to eight Chicago and suburban hospitals under a class-action lawsuit settlement approved by a Cook County judge. Judge Sophia Hall accepted the settlement between patients and Oak Brook-based Advocate Health Care, the largest provider of medical care in the Chicago area. Advocate previously sent notices to 170,000 former patients about the settlement. Now it will mail claim forms to 40,000 of those patients it has determined are likely to be eligible, said an Advocate spokeswoman.
As the recession deepens, small businesses and those buying insurance on their own are struggling to maintain coverage amid double-digit rate increases. According to a new report by the Illinois Main Street Alliance, 12% of nearly 500 small businesses polled in a dozen states have dropped coverage for their workers within the past two years. In addition, 35% reported switching within the past two years to insurance that covers fewer services.
Fitness training for osteoporosis sufferers could be the latest program covered in a trend of health insurers providing benefits for wellness. Major insurance companies, including Blue Cross and Blue Shield of Illinois, Aetna Inc. and Cigna Corp., are covering therapeutic exercise services for men and women with osteoporosis.
Health insurers tend to be open to coverage of benefits that keep consumers out of the hospital, where medical care can be more costly. The Midwest Business Group on Health says three in five employers are providing or plan to provide cash and other incentives to motivate their workers to use preventive medical-care services to curb illness.
As the Obama administration tries to pull together a $634 billion down payment on achieving universal health coverage, it has made clear that it wants the health-insurance industry to foot a large part of the bill. President Barack Obama is expected to propose in his budget blueprint a mix of tax increases and healthcare spending cuts to fund a healthcare agenda. By far the biggest portion of proposed cuts, $177 billion over 10 years, would come from changing the way private-sector Medicare plans are paid by the government, according to a senior administration official.
Not only are healthcare costs growing, but a lot of the ideas to cut them may not result in savings for the federal government or the nation within a decade, Congressional Budget Office Director Douglas Elmendorf told the Senate Finance Committee. For example, disease management programs, "can improve health and may well be cost-effective," Elmendorf said. But the programs still might not result in overall spending reductions within 10 years because the number of the patients who participate is far larger than those who avoid expensive care as a result.
When you're planning a vacation and thinking of trying some pricey restaurant with a celebrity chef's name on the door while you're there, do you hop online to find some consumer reviews first? I do. Sure, you have to keep such reviews in perspective—no matter how good a restaurant might be, someone's not going to like it—but as long as most people offer a positive assessment, I figure the place must serve some decent grub. While I'm at it, I might search for reviews of my hotel, too. Or that museum I want to visit. Consumer reviews might have their limitations, but they also have their value, if you know how to use them.
At least when it comes to finding a golf course or a place to eat pancakes. But what about finding a physician? The health insurer WellPoint's deal with Zagat to have WellPoint members rate their doctors online has garnered a fair amount of press, but in case you need a primer: The reviews include WellPoint members' ratings of their physicians in four categories—trust, communication, availability, and cost. As with other Zagat guides, patients' ratings are summarized and displayed numerically; also included is the percentage of patients who recommend the doctor as well as contact information. A physician's ratings aren't posted until he or she has been rated by at least 10 people.
Now, a sizable number of physicians have been asking patients to offer online feedback in a variety of ways for some time. A sizable number of physicians also hate the idea, of course—at least in a casual form like this that seemingly likens finding good medical care to finding a good nightclub. The central theme of those who object is that while patients might report that they "like" doctors for any number of reasons, they simply aren't qualified to judge the quality of care—or as Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, put it in a New York Times piece I read, "There is no correlation between a doctor being an inept danger to the patient and his popularity."
I agree. Just because a physician is nice or friendly or accessible or whatever other generic adjective you want to apply doesn't mean he or she is actually, you know, good. WellPoint and Zagat contend the ratings are about patient experience, not care quality. Fair enough, but I'm not sure Joe Consumer reading reviews in search of a doctor will make that distinction.
If I knew that consumers would, in fact, make that distinction, then I actually think such ratings could have value—as long as the rating categories make sense. Communication, yes. Trust, maybe. Availability? I guess some docs make a stronger effort than others to squeeze in one more patient or return phone calls in a timely manner, but I don't know that a physician should get demerits for having tons of patients and thus being "unavailable." And cost? Physicians determine the cost of medical care? I didn't know that.
Smart remarks aside, this kind of feedback certainly has its place. At some companies, for instance, subordinates rate their supervisors. On college campuses, students rate their professors. Patients' observations on, say, the amount of time spent in the waiting room or a nurse's bedside manner do have value—particularly if multiple patients offer similar viewpoints and a genuine trend emerges. But to me, that value is limited. Talk to me about outcomes data or infection rates—then I'll pick my provider.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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American Hospital Association President Richard J. Umbdenstock told President Obama this week that U.S. hospitals will answer his call for "shared responsibility" to help the nation's fiscal future, as long as everybody else does, too.
"We believe we have to be part of the solution, but so do vendors, suppliers, other providers, employers, and consumers themselves. It's not going to be solved by any one approach or putting it on the shoulders of any one stakeholder," Umbdenstock says in an interview with HealthLeaders Media.
"Hospitals are the ones that hold this somewhat broken and disjointed system together on Main Street day in and day out for America's communities and patients in need," he says. "We are calling for reform, but not just in the form of short-term payment cuts and reductions, that will just force the system to get more out of kilter and out of balance than it already is."
Umbdenstock was among the several dozen people who met for more than three hours on Monday with Obama and key White House officials in what was billed as a fiscal responsibility summit. The meeting also included members of Congress, leaders of business and professional organizations, and advocacy groups.
No firm resolutions or action plans came out of the meeting. However, Umbdenstock says he was "pleased, as a representative of hospitals and other provider organizations, that the tone was one of solving a shared national problem."
"The president and his team set the context at the opening session," Umbdenstock says. "We as a nation have to start thinking about the long-term fiscal situation and fiscal stability of the country and they see the rising cost of healthcare as the major issue driving the challenge going forward as the population ages, as demand increases, as new procedures and technologies keep coming on line, and so on."
The Washington Post reports that Obama urged the group to "build off this afternoon's conversation and work together to forge a consensus." White House Budget Director Peter Orszag told the summit that slowing the growth rate in healthcare costs is "the single most important thing we can do to improve the long-term fiscal health of our nation. Let me be very clear: Healthcare reform is entitlement reform. The path of fiscal responsibility must run directly through healthcare," the Post quoted Orszag as saying.
Umbdenstock says he told the administration that America's hospitals appreciate the approximately $150 billion earmarked for healthcare spending in the stimulus plan, including the supplemental funding for Medicaid and COBRA, and $19 billion for healthcare information technology implementation incentives.
"Those are all positive steps that we thought were necessary at the moment and can be built upon in the future" he says. "Hospitals are right in the middle of this economic crisis, in some ways even more so than other enterprises. Like other enterprises, we are having our financial challenges, access to capital challenges, but we also have challenges in the form of more people losing coverage and turning to the hospitals as a safety net." Umbdenstock says he made it clear to the White House that hospitals are ready for responsible reforms.
"We believe you have to cover everybody in the system so they are getting the right care at the right time and in the right place and not just relying on emergency rooms or waiting until they are terribly advanced in their illness," Umbdenstock says. "We do need payment reform to address the government underpayment in the public programs and therefore the cost shift, but also to align incentives and drive some constructive changes in the delivery system. We also need administrative simplification. We have too many ways of billing and filing for reimbursement."
Umbdemstock says the Obama administration knows that AHA supports evidence-based medicine, but only if all of the parts are in place. "What we are worried about is that—at the moment—we don't have a significant portion of the services provided that have been validated. We don't have national agreement on the evidence," he says. "We've got a large research and consensus process ahead of us, and we are a little worried that some of the payment mechanisms will get out ahead of the evidence, which would be wrong and hard for us to support."
While he can't predict what the healthcare system will look like in the coming years, Umbdenstock says change is coming. "The future will be different. The delivery system will be different and the incentives will be different, and that's OK," he says. "The challenge will be getting from here to there through the period of change. That is where we can't afford to have crazy things done in the short-term that will jeopardize these community institutions or the services that patients need."
John Commins is the human resources and community and rural hospitals editor withHealthLeaders Media. He can be reached atjcommins@healthleadersmedia.com.
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Medicare Advantage is barely hanging on the ropes at the start of the 12th round. Challengers like Barack Obama, Harry Reid, and John Edwards have pummeled the fighter with sharp lefts and dizzying rights.
WellCare and Medicare Advantage were hurt by these blows, but this latest punch is the biggest shot yet.
CMS criticized WellCare for its enrollment and disenrollment operations, appeals and grievances, timely and proper responses to beneficiary complaints and requests for assistance, and marketing and agent/broker oversight activities. The news gives more fodder for those who would like to cut the private insurer program. During his campaign, President Barack Obama bashed the private Medicare program as a hand-out to big business that costs 13% more per beneficiary than traditional Medicare. He pledged to cut $50 billion in subsidies to the program.
After taking office last month, Obama recalled a draft of the 2009 Medicare Advantage and Part D call letter, so his administration could review and make changes. On Tuesday night in a televised speech to both houses of Congress, the president mentioned cutting waste and inefficiency out of Medicare. He didn't use the phrase "Medicare Advantage," but that is what Obama was talking about. Obama's aversion to Medicare Advantage is bad news for insurers involved in the program.
It's easy to understand why Obama and Democrats don't like Medicare Advantage. It's costing the country more than if those beneficiaries were in traditional Medicare, and earlier this month, Medicare Advantage insurers said they are increasing premiums by an average of 13% this year. This is in contrast to the 6% premium increase for commercial private insurer plans this year.
Medicare Advantage advocates argue that part of the reason for the difference is that Medicare Advantage plans offer more services than traditional Medicare, such as dental and vision. That argument isn't reaching Democratic policymakers, who may soon finish off the wounded fighter with one final hook.
Beaten and battered, Medicare Advantage is barely on its feet and Democrats are getting ready to throw the final blow that will send Medicare Advantage to the canvas for the last time.
Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com.Note: You can sign up to receiveHealth Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.
