Republican Rep. Joe Wilson's shout of "You lie!" during President Obama's speech Sept. 9 brought renewed attention to questions about whether Democratic healthcare legislation would extend coverage to illegal immigrants. Although the answer is more complicated than reform proponents acknowledge, it also does not square with the dark warnings of opponents who say the proposals would bring waves of undocumented immigrants into taxpayer-funded plans, according to the Washington Post.
WellPoint, Inc. will resume marketing its Medicare Advantage and Medicare Part D health plans on Oct. 1 and begin enrolling new customers on Nov. 15 for the 2010 contract year after CMS lifted a nine-month ban on new enrollments this week.
In a letter to WellPoint sent yesterday, CMS Program Compliance and Oversight Director Brenda J. Tranchida noted, "WellPoint has made sufficient progress in correcting its deficiencies to merit lifting the marketing and enrollment sanctions." However, Tranchida also noted that "a recent CMS audit identified some continuing deficiencies in WellPoint's appeals and grievances processes."
As a result, Tranchida wrote, WellPoint will remain under its existing corrective action plans for its appeals and grievances processes. The insurer will also remain under its existing communications CAP, which requires WellPoint to disclose to CMS any new significant compliance issues. CMS will periodically ask WellPoint for specific data to assure that the deficiencies do not recur.
CMS also told WellPoint that it will not be automatically assigned new low-income subsidy members, although those low-income members can again choose WellPoint products during the upcoming Annual Enrollment Period.
CMS imposed the sanctions on Jan. 12 after a rash of consumer complaints about cost hikes and denied drug benefits. WellPoint blamed the snafus on a series of computer glitches, but CMS said at the time that it was suspending enrollment because the health insurer had failed to take corrective measures.
A CMS review of the insurer in January found "widespread and continued failures by WellPoint to properly administer their contracts in accordance with CMS requirements." CMS had identified WellPoint's noncompliance in several areas, including: enrollments and disenrollments; benefits administration—including determining premiums, and co-pays; grievances and appeals; marketing; claims processing; coordination of benefits; billing; and meeting call center and customer service requirements.
Indianapolis-based WellPoint is the nation's largest health benefits company, with more than 34 million members in its affiliated health plans. It owns Blue Cross and Blue Shield plans in 14 states. WellPoint has 1.2 million beneficiaries in its Part D plans, 462,000 in its Medicare plans, and 802,000 in Medicare Supplement plans for a total of about 2.5 million Medicare members.
The number of people in the United States without health insurance rose from 45.7 million in 2007 to 46.3 million in 2008, which represents 15.4% of the overall population, the U.S. Census Bureau announced today.
The Census Bureau report, Income, Poverty, and Health Insurance Coverage in the United States: 2008, also notes that real median household income in the United States fell 3.6% between 2007 and 2008, from $52,163 to $50,303, breaking a string of three years of annual income increases and coincides with the recession that started in December 2007.
The nation's official poverty rate in 2008 was 13.2%, up from 12.5% in 2007. There were 39.8 million people in poverty in 2008, up from 37.3 million in 2007.
The uninsured rates for the native-born and foreign-born populations were statistically unchanged at 12.9% and 33.5%, respectively, in 2008. Among the foreign-born population, the uninsured rates for both naturalized citizens (18%) and noncitizens (44.7%) were statistically unchanged.
The Northeast and the Midwest, each at 11.6% had lower uninsured rates in 2008 than the West (17.4%) and the South (18.2%), all of which were not statistically different from their respective 2007 rates. The uninsured rate for the West increased to 17.4% in 2008, up from 16.9% in 2007.
A further statistical breakdown of health insurance coverage found that:
The number of people with health insurance increased from 253.4 million in 2007 to 255.1 million in 2008
Between 2007 and 2008, the number of people covered by private health insurance decreased from 202 million to 201 million, while the number covered by government health insurance climbed from 83 million to 87.4 million. The number covered by employment-based health insurance declined from 177.4 million to 176.3 million.
The number of uninsured children declined from 8.1 million (11%) in 2007 to 7.3 million (9.9%) in 2008. Both the uninsured rate and number of uninsured children were the lowest since 1987, the first year that comparable health insurance data were collected.
Although the uninsured rate for children in poverty declined from 17.6% in 2007 to 15.7% in 2008, children in poverty were more likely to be uninsured than all children.
A further breakdown by race and ethnicity found that:
The uninsured rate and number of uninsured for non-Hispanic whites increased in 2008 to 10.8% and 21.3 million, from 10.4% and 20.5 million in 2007. The uninsured rate and number of uninsured for blacks in 2008, meanwhile, were not statistically different from 2007, at 19.1% and 7.3 million. The uninsured rate for Asians in 2008 rose to 17.6%, up from 16.8%.
The percentage of uninsured Hispanics decreased to 30.7% in 2008, from 32.1% in 2007. The number of uninsured Hispanics in 2008 was 14.6 million.
Based on a three-year average (2006-2008), 31.7% of people who reported American Indian and Alaska Native as their race were without coverage. The three-year average uninsured rate for Native Hawaiians and Other Pacific Islanders was 18.5%.
In the great debate over healthcare reform on Capitol Hill, one issue that intrigues legislators is the idea of a patient-centered medical home. With this model, patients would get to spend more time with a primary care provider—receiving more personalized care that could emphasize prevention and more patient involvement in medical decision-making.
New models are being tried out across the country, but one organization—Seattle-based Group Health Cooperative—recently revealed what the costs and benefits are to implement this model through a one-year pilot project at its Factoria Medical Center in Bellevue, WA. Based on the final results, GHC will be rolling out the model at its 26 other medical centers in Washington and Idaho beginning in 2010.
"We picked a clinic where we could pretty assuredly make the changes that we wanted to make and then observe to see what happened," said Robert Reid, MD, an investigator with the Group Health Research Institute. "The practice had good leadership . . . and it had a prior history of real successful practice change so that we knew the clinic could transform in a way we envisioned."
In the long term, "substantial transformation" was needed to make the switch to a successful medical home, Reid said. At the top of the list was reducing the number of patients in each primary care physician's panel from about 2,400 to 1,800. Reducing the number of patients would leave more time for coordination, outreach, and office visits, which were extended from 20 to 30 minutes per patient).
But on the flip side, that has meant more costs—or about $16 more per patient per year in those costs related to hiring more primary care providers plus other staff for the primary care team: 15% more for primary physicians, 72% more for clinical pharmacists, 44% more for physician assistants, 18% more for medical assistants, and 17% more for registered nurses. Overall, patients at the medical home used $37 more in specialty care—possibly because the enhanced primary care services detected previously hidden health problems.
However, on the flip side, because of fewer trips to the hospital emergency department (down by 29%) and fewer hospitalizations for conditions that primary care can prevent (down 11%), costs were reduced by $54 for each patient in the pilot clinic, which essentially "paid" for the staffing changes. More details are provided in this month's issue of the American Journal of Managed Care.
The clinic also emphasized use of both e mail and telephone encounters—as an alternative or complement to in person visits. This resulted in a 94% increase in e mail use, a 12% rise in more phone consultations—and 6% fewer in person visits.
For the patient experience, those in the pilot reported higher ratings than controls on six out of seven patient experience scales. For staff burnout, 10% of pilot's staff reported high emotional exhaustion at 12 months—compared with 30% of controls, despite similar rates at baseline.
So can this model work around the country? Reid noted that GHC is different than many organizations—for instance, its physicians are salaried. However, to make a model successful, it became apparent that the organization needed money up front to give its providers "breathing" room—time to meet with patients and generally open up time in their day.
"I think it's important to realize that there has to be investment up front," Reid said. But the payout—in terms of less hospitalizations and emergency visits—and even happier patients and providers—may work out in the end.
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CNN examines whether patients should connect with their physicians via social networking sites. While it can be a simple way to communicate with patients and build loyalty to the practice, it's important to protect the privacy of both the patient and the physician.
Among the many facets of the broad healthcare reform plan that President Obama offered during a speech before a joint session of Congress was tort reform. "I don't believe malpractice reform is a silver bullet, but I've talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs," said Obama.
Steve Arnold, MD, chair of the HIMSS Physician Community, talks about the progress being made toward a definition of "meaningful use" and whether it will set the bar at the right level for physician EHR adoption. [Sponsored by Emdeon]
Medical staffs today consist of a blend of four generations: the World War II Silent Generation (1925–1942), baby boomers (1943–1961), Generation X (1962–1981), and Generation Y (1982–1998).
Each generation brings with it a different work ethic, mode of communication, and definitions of professionalism and loyalty. If you're unaware of these generational differences or don't accept that they are sitting on your doorstep, they could stymie your recruitment efforts.
Differences include learning, teaching, and communication style, approach to clinical schedules, concept of work-life balance, academic and personal motivation, level of control of the work experience, and effective productivity incentives, according to "The Impact of New-Generation Physicians on the Function of Academic Anesthesiology Departments," which appeared in the December 2007 Current Opinion in Anesthesiology.
The first thing you need to know about generational and, therefore, cultural differences between older and younger physicians is that you can't change them.
"If you attempt to change someone else's culture, you are going to be in for a long fight," says Phillip Kibort, MD, MBA, vice president of medical affairs and chief medical officer at Children's Hospitals and Clinics of Minnesota in Minneapolis and St. Paul. "The best leaders are the ones who work with these differences as opposed to trying to change them."
Second, Generation X and Y are changing the definition of professionalism and loyalty. The Silent Generation and baby boomers generally consider medicine a calling and have dedicated their lives to their practice. Gen Xers and Yers, however, probably regard medicine as a career or job. They want to take time off for volunteer work, work 8 a.m.–5 p.m., and play an active role in their families.
"We now have two very discrepant ideas of what a professional is, and they are both right," says Tracy Sanson, MD, FACEP, associate professor at the University of South Florida in Tampa.
Gen Xers and Yers also grew up in the age of Sam's Club and eBay, and they're loyal to a brand as long as that brand delivers on their ever-increasing expectations. If a brand fails to satisfy, they look for a better deal, and that goes for jobs too.
And this is probably a good thing. Gen X and Y have forced the medical community to introduce creative recruitment and retention strategies, such as paternity leave, flex time, and part-time schedules, which Sanson says is desperately needed to attract future generations of physicians. This flexibility is also good for older generations, who are faced with the challenge of caring for ailing parents.
In addition, members of the Silent Generation and baby boomers entered into practice with the idea that they would move up the ladder and become a hospital leader in 20 years. "The Xers and Yers come in and want to know why they are not department director already," says Sanson.
The new definitions Gen Xers and Yers bring to professionalism and loyalty have thrown older physicians for a loop. Twenty years ago, medical staff leaders had the luxury of mulling over recruiting decisions for weeks, or even months.
"Now, if you are not texting them as they are getting in their car after an interview, they think you are not interested in them and they move on," says Sanson.
To leverage the strengths that all four generations bring to the workplace, she suggests developing a mentoring program that pairs members of the Silent Generation and baby boomers with Gen Xers and Yers.
"The Xers and Yers forget that the Silent Generation and baby boomers have institutional knowledge and a wealth of experience, so we need to tap into that," says Sanson. At the same time, Gen Xers and Yers bring the "why does it need to be done that way?" mentality to the table, which forces institutions to evolve.
Keep in mind that these mentoring relationships should not be created with the idea of one person denigrating the other for what he or she doesn't know. It's not about the younger physicians saying, "Here, let me teach you how to use e-mail," says Sanson.
If getting physicians onto the medical staff and keeping them there isn't difficult enough, finding younger physicians who are interested in becoming medical staff leaders certainly is. To help fulfill that need, Children's Hospitals and Clinics of Minnesota has developed a program that invites young physicians with leadership potential to undergo two years of leadership training at a local university.
"There is still a high percentage who aren't interested, but we get a good return on investment for the ones we do work with," says Kibort. "We hope those people will participate more in the hospital.
This article was adapted from one that originally appeared in the September 2009 issue of Health Governance Report, a HealthLeaders Media publication.
In July 1868, as the United States was reconstructing and reuniting after being torn apart by civil war, the nation came together to enshrine in a constitutional amendment the right of employment for every physician in the country.
Ok, that may not have been the original intent, but some California physicians are using the 14th Amendment to argue that the state's Medical Practice Act, which bans hospitals from employing doctors, is unconstitutional.
"No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States," the amendment reads, and some are arguing that targeted restrictions on how physicians can earn a living do just that.
But even more interesting, to me at least, than the legal validity of the case is the context in which it is being debated.
Those in favor of the ban on employing physicians, including the California Medical Association, have claimed the ban allows physicians to maintain their independence. They fear that an employed physician's decisions would be influenced by the hospital's profit motives, degrading the sacred physician-patient relationship.
But now it is opponents who argue that employment is nearly the only way for physicians to maintain their independence, because the financial climate has become so severe that physicians are struggling to make a living as independent practitioners.
Those who fear employment would lead to corporate control need only look to other states where employment is not only allowed, but is becoming much more common.
Employment does change the financial incentives physicians face, but rather than inject profit motives into medicine, it tends to diminish them. Look at organizations like Mayo and Cleveland Clinic that are being held up as examples of excellence in the healthcare reform debate. Both organizations employ their physicians, and it has helped them coordinate care to deliver quality, low-cost care.
Beyond financial incentives, though, employment seems to frequently come up as the answer to questions of how best to align hospitals and physicians.
Want to ease tensions with the medical staff over call coverage? Employ some physicians to handle emergencies. Having trouble getting buy-in for system-wide quality improvement initiatives? It's easier with employed doctors. Trying to recruit physicians just out of training? Many younger physicians actually prefer employment to independent practice.
It's certainly not the answer to all alignment problems. Many physicians have no interest in employment, and in many markets it simply isn't feasible.
But employment sits at the far end of an alignment continuum, and as collaboration between hospitals and physicians become more important to the success of both, employment is looking like an increasingly attractive arrangement for both.
We've already seen increased interest in many parts of the country, and it's no surprise that we're also seeing it in California. At some point, the ban will likely be lifted. If not because it is unconstitutional, because it is increasingly impractical.
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In an attempt to guide the healthcare debate that has veered off the tracks in recent weeks, President Barack Obama spoke to a joint session of Congress on Wednesday about a comprehensive health reform bill.
Obama discussed the need for cooperation and improving the current healthcare system rather than creating a new one, such as a single-payer system. The president's plan would include three "basic goals:"
More security and stability for those with health insurance
An insurance exchange for those without insurance
Slowing healthcare costs
Obama didn't touch upon one of the more controversial parts of the healthcare reform debate—the public insurance option—until 30 minutes into his speech. He described a public option as part of an insurance exchange.
Throughout his speech, Obama took aim at the health insurance industry, such as its costs to consumers and employers, insurers not providing coverage to those with preexisting conditions, and the "subsidies" given to private insurers that provide Medicare Advantage.
The 45-minute speech was Obama's first in-depth national speech about healthcare reform after spending the past few months on the sidelines as Congress worked on multiple reform proposals. So, after finally hearing directly from the president, what do health leaders think? Here are thoughts from nine health leaders:
Ken Graham
CEO
El Camino Hospital
"President Obama's message reminded us all that health reform is crucial to the economic health of America, and that the goal is not to reinvent the system, but to improve upon what is working and fix the inefficiencies that exist. As such, we embrace reform and the opportunities it presents for innovation, which not only leads to a higher quality of care and healthier lives, but also has the ability to decrease waste in the system. Closely tied to innovation is the adoption of evidence-based measures.
"This will allow us to identify the inefficiencies, correct them, and reduce variation in the system, thereby reaching a level of care that works for both providers and patients. Embracing innovation, I believe, will be essential to finding a solution that achieves the larger goals: Cutting costs, raising quality of care, and advancing healthcare delivery."
Doug Hawthorne President and chief executive officer
Texas Health Resources
"He did an excellent job of assessing the current landscape and acknowledged that fixing healthcare is central to fixing our economy He clarified for the audience his interest to build on what works with our system and fix only what is broken. He provided a clearer definition of a ‘public plan,' but is still not convincing. He attacked the insurance industry hard and clearly stated that they would have to comply to certain changes or they would be out of the picture.
"In summary, the President was determined in his words, but it is not definite what a plan would do and very unrealistic as to how it will be paid for. His most effective statement for me from a provider point of view was his desire to create safer care and a more coordinated and integrated model."
Tim Size
Executive Director
Rural Wisconsin Health Cooperative
"The President made it clear he stands on common ground for our country by ‘building on what works.' A new government-run plan that undermines the private sector now seems less likely. A major shift of patients into a plan paying Medicaid and Medicare type rates would harm rural patients' access to local healthcare. Reform affecting rural communities must and can be built on quality outcomes and efficiency while delivering care locally. As the President concluded, I ‘believe we can replace acrimony with civility, and gridlock with progress.'"
Karen Ignagni
President and CEO
America's Health Insurance Plans
"We agree the status quo is not sustainable. That is why health plans last year did something industries rarely do: Stepped up and offered solutions to address the healthcare concerns raised by the American people. We proposed health insurance reform to guarantee coverage to all Americans, eliminate pre-existing condition exclusions and rescissions, and no longer base premiums on a person's health status or gender. To keep coverage as affordable as possible, these reforms must be paired with an effective coverage requirement to get everyone into the healthcare system.
"New health insurance reforms and consumer protections will solve the problem without creating a new government-run plan that will disrupt the quality coverage that millions of Americans rely on today. We share the concerns that hospitals, doctors, employers, and patients have all raised about the significant unintended consequences of a government-run plan.
"Healthcare reform must also include a serious commitment to cost containment to ensure coverage is more affordable and to put our healthcare system on a sustainable and fiscally responsible path. New taxes on healthcare coverage will have the opposite effect by making coverage less affordable for families and small businesses across the country.
"Health plans will continue to work with policymakers and stakeholders to advance comprehensive, bipartisan healthcare reform. The nation cannot afford to let this historic opportunity pass us by."
Bruce McPherson
President and CEO
The Alliance for Advancing Nonprofit Health Care
"We are pleased that the President is seeking to exercise greater leadership in crafting healthcare reform legislation, and many of the principles he outlined, such as health insurance market reforms, are needed and appropriate. Clearly more details of his plan need to be unveiled, including medical malpractice tort reform, healthcare delivery reforms, and precisely how to pay for his $900 billion plan.
"Our one major disappointment in his speech was his apparent unwillingness at this point to remove from the table the public health plan option or similar ideas. Hopefully, he will drop this unnecessary and inappropriate concept in the weeks ahead, and in the process achieve bipartisan support and substantially enhance the odds of the passage of reform legislation this year.
"His claim and example in the speech of a lack of adequate private insurance competition in many states is not supported by the facts, nor common sense.
"If there are real competition problems that wouldn't already be resolved through the insurance market reforms he outlined, then there is an existing, appropriate government solution—referral of any allegations to federal or state anti-trust regulators for investigation."
Joseph Kvedar
Founder and Director
Center for Connected Health
"I have never heard President Obama give a poor address. He gave a fine address. It was, however, long on discussion of improving access. He gave great detail on access. When it came to the cost reduction part, the details were frighteningly lacking. For instance, there is credible data that screening tests that he referred to do not in fact reduce costs, but probably add to them.
"The other observation is that the whole speech was based on the construct that illness is the accident. I tend to be more concerned about the 50% of costs that are based on unhealthy behaviors or the part of healthcare that is less of an accident and more from irresponsibility. Any program that will truly impact cost must address this.
"So I'd say a very compelling case was made for health reform 1.0. These are important reforms and hard to get done, but should only be viewed as a first step."
Tracey Moorhead
President and CEO
DMAA: The Care Continuum Alliance
"We welcome the President's support tonight for expanded coverage of preventive care and his recognition of prevention and wellness as important tools for controlling the cost of chronic illness. But improving quality and reducing costs require broad-scale reform that moves our system from reactive care to promotion of health as a shared national resource. This will require payments and incentives aligned across all providers, purchasers, and consumers toward a goal of improved health."
Bob Stone
Co-founder and executive vice president
Healthways
"The President outlined a clear set of principles for what has now clearly been acknowledged as health insurance reform rather than healthcare reform. Arguably, a bill that included these provisions would go a long way toward addressing the issues of the uninsured, the under-insured, and those with insurance who have been treated less than scrupulously by bad actors among the insurance industry. It is less than clear, however, that this plan will do anything to lower healthcare costs.
"In fact, the absence of any reference to meaningful health promotion, prevention or chronic care management plans was disappointing given the years of evidence that 'supply side' and financial fixes—other than price controls—don't work (and even price controls didn't work long). Without a commitment to making America a healthier country—not just one where illness is more affordable to treat—it is unlikely that real cost savings or quality improvement will manifest. Unfortunately, that commitment was absent tonight.
"There are also clearly inappropriate and unnecessary costs in the current system and all should support the President's call to weed those out so that those dollars can be applied to the cost of his proposed plan. I am less than sanguine, however, that such an effort will have any great or sustained success. Even if it does, you can only capture those dollars once.
"While that may help defray some costs over the next decade, what happens after that if the plan doesn't actually reduce cost? And while we're on the financial points, if my math is right, the $1,000/year currently being paid by the insured to subsidize care for the uninsured totals about $1.5 billion a year (assuming 155 million commercially insured, which may be a little light), or about $1.4 trillion over the next decade. Are all the insured folks going to get that money back? If not, what's it going to be used for? Are the insurance companies going to pay it to the government to fund the new plan?"
Stan Nowak
CEO
Silverlink Communications, Inc.
"The President delivered a powerful speech last night on the critical need for healthcare reform. He's right to focus on the issue of access and the costs of doing nothing. But it's just as perilous to our country to do nothing about the true drivers of healthcare costs—the personal health decisions made daily by all Americans.
"By incenting individuals to make better health decisions, we can save our country millions of lives and billions of dollars—ultimately bending the cost curve to make real progress in healthcare reform."
