A national organization representing medical practice leaders say they are increasingly frustrated by what it terms the "unnecessarily arduous process" for reporting data to Medicare's Physician Quality Reporting Initiative (PQRI). Once the reports are filed, there is an "unreasonable lag time" for results, the group states.
The Medical Group Management Association (MGMA), which includes more than 22,000 members, who are professional administrators and leaders of medical group practices, on Wednesday released a sharply critical research survey about PQRI at a time Congress is considering how to continue the program. A bill proposed in the Senate imposes penalties on physicians who fail to participate in the PQRI, but the House bill does not. The program is currently voluntary.
The medical practice leaders cited "multiple, continued administrative challenges" in reporting data for the PQRI. The organization stated in its survey "respondents took issue with the unnecessarily arduous process for accessing feedback reports and expressed little to no satisfaction with feedback reports."
The PQRI was established under the 2006 Tax Relief and Health Care Act (TRHCA) to provide an incentive payment for eligible professionals, who satisfactorily report data on quality measures for professional services furnished to Medicare beneficiaries. In 2009, physicians could earn a PQRI incentive payment equal to 2% of their billed Medicare charges. In 2007, a much lower payout was reported, with $630 the average amount, according to the American Medical Association.
"Though MGMA and its members remain committed to supporting clinical quality improvement initiatives, data from this research shines a bright spotlight on the underlying administrative difficulties with this program," said MGMA President and CEO William F. Jessee, MD, in a statement.
Of survey respondents who attempted to participate in the 2008 PQRI, fewer than half—48%—were able to successfully access their PQRI feedback report, a decline from 2007 when 51% were able to retrieve their 2007 report, the MGMA stated.
As officials of the MGMA see it, the PQRI is so complicated it takes almost nine hours on average for physicians or their staff to successfully download the 2008 PQRI feedback reports.
"It's a very onerous report for some, and we have some very sophisticated members, " says Robert Bennett, government affairs specialist for the MGMA, referring to the PQRI program. "We're not against PQRI, we want to improve patient outcomes. But it has to be something that doesn't take hours to download; you don't want a physician's office spending hours everyday trying to figure out how to put in tax ID numbers into a database."
According to MGMA officials, in 2009, only an estimated 32% of physicians even attempted to log into the program, while a mere 16% succeeded. "You have physicians who want that gold standard, [the PQRI], it's good for marketing, but it takes up to six months to get a response from the [Centers for Medicare and Medicaid Services]," Bennett says.
The survey also found:
60% of medical practices assessed their 2008 feedback reports and were "dissatisfied or very dissatisfied" with the report's presentation of information.
67% were dissatisfied or very dissatisfied with the 2008 PQRI reports' effectiveness in providing guidance to improve patient care outcomes.
While it took five hours "on average collectively" for medical practices to access their 2007 PQRI feedback reports, it took almost nine hours by practice staff and physicians to download the 2008 PQRI feedback reports.
Even if physicians get into the PQRI, there's still a question of being eligible for bonuses. About 109,000 physicians who reported their data nationwide in 2007, only slightly more than half qualified for bonus payments, according to an American Medical Association study.
Success in qualifying for the bonus varied greatly from state to state, the AMA stated in a 2008 report. "Although not a pay for performance program, this pay for reporting program provides incentives for merely reporting data," the AMA stated. "Many physicians feel the monetary returns for the amount of work expended in reporting is insufficient to warrant participation.
The AMA has stated that the "CMS should perform an analysis of why the success rate in this program was so low and so varied. Additional educational programs should be enacted to address deficiencies."
Jessee said in a statement he hoped CMS and Congress would "take note of our members' feedback and implement much needed improvements" in the program. Officials of the CMS said they could not comment immediately about the MGMA study.
There's a buzz in healthcare plans that may be just beginning and the year is barely seven weeks old. Buzz, heck. It's going to get a lot noisier.
The controversy is inadvertently wrapped around HealthLeaders Media Industry Survey 2010 questions about investment in individual markets. It also centers on the still unfolding drama over insurer Anthem Blue Cross's proposed 39% rate hikes in California.
In the HealthLeaders Media survey, 36% of health plan leaders said they planned to invest in individual markets, as a way to deal with the erosion of employee-based health insurance. At the same time, however, more than 62% also said that their company was not investing more resources into the individual market—at this time. [See Questions 24 and 25 in the Health Plans survey.]
We can certainly see more reticence now in the wake of the Anthem Blue Cross debacle. The company's proposals affecting its individual markets have become caught in a maelstrom of bad publicity and churning politics. As Bob Stone, co-founder and executive vice president of Healthways, a Franklin, TN-based population health management company says: "The individual market is actuarially tricky and fraught with PR and political landmines."
Anthem Blue Cross and its parent, WellPoint, have just stepped on the landmine. Anthem Blue Cross's decision to seek a rate hike was greeted by two denunciations by HHS Secretary Kathleen Sebelius, and announcements of investigations in Congress and the California Assembly. The potentially lengthy congressional hearings are slated for next week.
Anthem Blue Cross's announcement was poorly timed because it occurred in the midst of a recession and a stalled healthcare reform debate. As the HealthLeaders Media survey shows, there has been much uncertainty among insurers whether to pursue the independent markets. With the Anthem controversy, the hesitation may continue, although the individual market is seen as one of the few areas of growth in health insurance.
"Given the political backlash with respect to the rate increase in California, it would not surprise me to see a cooling of plans' interest in aggressively pursuing this market," says Stone.
The individual market, as WellPoint execs pointed out, is the "market of last resort" for people who do not have access to employer market or government-subsidized public programs. Individual markets represent a means to sell plans to a larger population base. But there is narrow room for error, as Stone sees it.
"For that business to be successful, the relationship between premiums charged and coverage expense must be actuarially sound," Stone says. "Since coverage is by definition sold individually, the underwriting risk can be easily pooled and it is easy to understand how the premium/expense ratio can get out of whack, which, in turn, leads to the plan's raising premiums."
WellPoint brass said repeatedly that increased medical costs have led to the increased rate hike request. Brian A. Sass, president of Wellpoint's consumer business unit, tried to support WellPoint's arguments with the facts as he saw fit. While much of the media has focused on the possible 39% increase, Sass wrote in a letter to Sebelius, the rate exchanges range from a 20.4 % increase to a 34.9% increase.
Almost as a tip to any health leader interested in exploring the individual health insurance market, Sass said there is much "volatility" in those markets. That's because of a quick and high turnover of members. The result is "the overall risk of the members can increase quickly," Sass wrote, noting a high "churn" rate.
For insurance regulators, Anthem Blue Cross' position is unconscionable. But actually, on the basis of numbers, the company may be justified in seeking the rate hike.
"The rate increase is probably ‘defensible at least actuarially, based upon the actual experience," wrote Bob Laszewski, author of the blog "Health Care Policy and Marketplace Review."
But this isn't about numbers. When Anthem Blue Cross executives dribbled out a response to Sebelius, who slapped it down, the company later agreed with insurance officials in California to postpone the rate hikes from March 1 to May 1 until the investigations are finished.
Not once have I seen this much negative publicity end up with a government agency telling a business in the aftermath: OK, raise the rates. The first mistake that Anthem Blue Cross made was not immediately and dramatically acknowledging the recession, its 800,000 individual customers, the importance of its individual market plan, and make clear the reasons behind this proposed insurance hike in a clear, emphatic, empathetic manner. Instead, it paid PR ping-pong with Sebelius.
Anytime I see a big company make a major PR mistake, I think back to New Brunswick, NJ, where I worked as a young reporter in the 1980s. At that time, healthcare giant Johnson & Johnson performed one of the smoothest, upfront, and certainly difficult PR moves, after the giant pharmaceutical firm discovered Tylenol capsules were found contaminated. Instead of floundering for days wondering what to say or not to say, J & J worked immediately to let people know what went wrong, and what they were going to do about the damage done to their drug. Quickly and honestly. The Tylenol brand was left intact.
As for the individual healthcare market, health planners may wait to see what's ahead for Anthem Blue Cross before they decide to venture into the market, or even consider their own rate hikes. It's one big headache. Take a couple of Tylenols and let's talk in the morning.
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More than two dozen states have launched healthcare reform initiatives, but most are strapped financially and are unlikely to undertake major reform while federal legislation is stalled on Capitol Hill, says a top health official for the National Conference of State Legislatures.
"A majority of states are clearly going to wait and see what the federal government is going to do," says Richard Cauchi, health program director for the NCSL.
That doesn't mean the states have been inactive, Cauchi adds. At least 26 states are considering healthcare regulations ranging from management of chronic disease to healthcare quality improvements, as well as insurance programs for children, he says.
Other programs considered are special grants for needy individuals, a special insurance program for state employees, Medicaid expansion and Medicaid buy-in plans, and changing to a single-payer system.
"States are very active in health changes and innovation in one sense–that there is legislation being considered to do all manner of things with health reform, but it's not comprehensive or universal," he says. Comprehensive reform entails achieving near universal coverage of state residents.
Missouri is one state that is considering comprehensive coverage. State lawmakers in January introduced comprehensive legislation that would establish the Missouri Universal Health Insurance Act to provide "comprehensive and necessary healthcare services" for Missouri residents.
Legislation would provide comprehensive health, mental health, and dental care for residents, according to the state legislation. In Maryland, a bill was introduced that would require the health system to provide healthcare services "to all residents of the state under a single system that is not dependent on employment."
However, states are also facing time and fiscal barriers. Budget constraints and limited days in which state lawmakers are in legislative session have contributed to the lack of widespread action, he says.
"The recession has made it harder for states to finance programs to cover the uninsured," the states' organization said.
In November 2009, states closed a cumulative budget gap of $145.9 billion with new gaps reported and predicted to continue through 2012. For some states, however, there is a feeling "why should we wait and they are not shy about trying something," according to Cauchi.
Within the past week, Cauchi says Colorado officials announced a major package to strengthen the state's healthcare system. State officials said they were focusing on cost-savings, improvements to public and private insurance programs, and better care for women.
"The demands on our healthcare system and the costs of providing care continue to increase for Colorado families, businesses, and providers, " said Gov. Bill Ritter Jr. in a speech before the Colorado Health Foundation on Feb. 11. "We can't wait for Washington to act and we aren't."
States, such as Colorado, may be moving ahead with some healthcare reform, but most are still far from Massachusetts, which has an individual mandate. Maine and Vermont are the exceptions. They have their own versions of comprehensive health reform, Cauchi said.
Other states have adopted expanded—though not comprehensive—healthcare reform, such as Connecticut, Florida, Illinois, Iowa, Minnesota, New Jersey, Utah, and Washington. Some states have enacted healthcare changes, such as insurance exchanges, pre-existing condition legislation, and other actions now considered in the federal reform bills.
States that have legislation introduced for some aspect of healthcare reform or build on what they already have, include: Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Mississippi, Missouri, New Hampshire, New Jersey, New Mexico, Oklahoma, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, and Wyoming.
About 46 million Americans lacked health insurance in 2008, as the number of uninsured increased during the recession as people lost jobs and employer-sponsored health insurance. At least 10 states have passed laws to achieve universal coverage for children, and "others are working toward that goal with many more states incrementally expanding eligibility for children in Medicaid/SCHIP (State Children's Health Insurance Program) in the past three years, according to Cauchi.
While the states contemplate their own healthcare plans, there has been much debate about whether the state approach to healthcare reform should take the lead in health reform.
Henry J. Aaron, a senior fellow for economic studies at the Brookings Institution, says he once supported state reforms, but he now favors a national approach to revamp the healthcare system, in part, because of the states' fiscal problems.
"There is not yet disposition in the states to do anything that would entail a financial commitment" to make significant healthcare changes, Aaron says. "They are still fiscally flattened by the recession. Even if Congress acted, the states could do nothing that would entail any financial commitment."
Minority patients in New York were less likely than whites to have surgeries at hospitals with a large number of procedures, according to a study published in the Archives of Surgery.
The study focused on 134,000 people who had 20 different types of surgery between 2001 and 2004 in hospitals in New York City, as well as nearby Nassau and Westchester counties. The study involved mostly whites, and fewer numbers of blacks, Asians, and Hispanics.
Compared with white patients, "treatment at high-volume hospitals by high-volume surgeons was lower by 11.8 % for black patients; 8% for Asian patients, and 7% for Hispanic patients," wrote Andrew J. Epstein of Yale's School of Public Health, the lead author of the study, "Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons."
In effect, the minority patients were "doubly-disadvantaged," the authors noted.
The researchers concluded that quality care improvements are needed for minority patients to assist them in choosing hospitals and physicians because studies have shown the effectiveness of high-volume hospitals.
"In addition to efforts to improve the quality of care among providers serving minority patients, policymakers and clinicians may be able to improve outcomes by encouraging minority patients and their surrogates to consider comparative performance information when choosing hospitals and surgeons," the researchers stated.
The study focused on 10 procedures and used state hospital discharge data. The procedures involved cancer treatment, coronary, and other conditions.
"Better information is needed about which providers minority patients have access to and how they select them," the study said.
Nearly half of U.S. physicians say language or other cultural barriers are obstacles to providing high-quality patient care, according to a study released by the Center for Studying Health System Change.
Forty-eight percent of all physicians in 2008 reported difficulties communicating with patients because of language or cultural barriers, and said they considered the situation at least a minor problem affecting their ability to provide high-quality care.
Less than 5%, however, viewed those barriers as a major problem that could result in a disparity of care across ethnic and racial populations, the study reported. Efforts to overcome the obstacles were considered modest or uneven.
The study, HSC Issue Brief–Modest and Uneven: Physician Efforts to Reduce Racial and Ethnic Disparities shows there is a great need to address the problem of language and cultural communication as the U.S. becomes more diversified, says James D. Reschovsky, PhD, senior health researcher for the Center for Studying Health System Change and co-author of the study. The study, sponsored by the Robert Wood Johnson Foundation, includes responses from more than 4,700 physicians and the response rate was 62%.
The issue takes on more urgency in the U.S. because an ever-increasing number of people speak a language other than English at home, according to Reschovsky.
"The challenges physicians face in providing quality healthcare to all of their patients will keep mounting as the U.S. population continues to diversify and the minority population grows," according to the study.
Efforts to reduce the language and cultural disparities face cost and reimbursement issues. "The tools most commonly adopted tend to be the least expensive to implement," the study said. "On the other hand, IT systems that can support reporting on patient care by race, ethnicity or language, as well as interpreter services, are expensive and less common."
Physicians may overstate their own ability in handling foreign languages. Physician interaction may involve a foreign language spoken by the patient, but the level of understanding on the part of the doctor may not be enough to carry out high-quality patient care, says Reschovsky.
"If a clinician is using high school Spanish to interpret for his Latino patients, it may not provide the level of communication you want in a clinical encounter," Reschovsky says. "There are also lots of patients who don't have an interpreter. Occasionally interpretation is provided by a family member and that is not necessarily the most optimum arrangement."
Levels of interpreter services among practioners should be drastically improved, according to Reschovsky. The study found that while nearly 97% of physicians have at least some non-English speaking patients, only 56% were in practices that provided interpreter services in 2008.
Mai Pham, MD, who works in Bread for the City, a Washington, DC-based clinic, says many physicians and patients face difficulties in overcoming language and cultural barriers, but often these problems aren't articulated—or can't be properly communicated. "Many patients are already feeling vulnerable because they have less information, less expertise, and less control. People can become afraid and insecure, " says Pham, who is also a senior health researcher at the Center for Studying Health Systems Change.
Healthcare providers have legal obligations to provide needed interpreter services, at least for patients with public insurance. However, physicians in solo and group practices were less likely to adopt measures to address disparities than those in institutional practices, such as hospitals, health insurers, and medical schools, according to the study.
Under pressure from state and federal officials, Anthem Blue Cross on Saturday agreed to postpone a proposed rate increase in California for at least two months, while the state insurance department examines the legality of the proposal.
Anthem will delay the rate increase, which was expected to begin March 1 and will mean a 39% hike for some individual insurance members, until at least May 1, according to Insurance Commissioner Steve Poizner of California.
Poizner said state officials will review with a "fine toothed-comb" the proposed rate hike for an estimated 800,000 members to ensure that most of the planned increase is allotted toward medical expenses as required by law. Anthem officials said they agreed to the request for a delay to "allow the department additional time for review." Anthem officials stated they welcome the "regulatory review and are confident that our rates reflected anticipated medical costs."
"Our decision to agree to postpone the rate adjustment does not change the underlying issue. All health plans are in the same situation in trying to deal with the steadily increasing medical costs in the delivery system, which are not sustainable," Anthem officials said in a statement. "We are also experiencing a higher proportion of healthy individuals choosing not to enroll, leaving an insured pool that utilizes significantly more services. We need to refocus the healthcare reform debate toward steps that will improve quality and control the underlying medical costs, which is driving the high cost of coverage."
Anthem officials said they understand the impact any rate adjustment would have on their members, and their members' ability to continue to carry health insurance. The company officials said they are "committed to driving quality and reducing costs in the healthcare system and improving the lives of Californians we serve and the health of communities across the state."
Poizner has stated that officials have "instructed the actuaries to review the rates with a fine-toothed comb to ensure they comply with state law that requires that 70 cents of every dollar in premiums is spent on medical benefits."
"Should they find that these rate increases were unwarranted, I will immediately take action to get Anthem Blue Cross to follow the law and lower their rates."
Anthem's proposed rate hike has come under criticism by the Obama Administration, with HHS Secretary Kathleen Sebelius accusing the company of leaving its customers with potentially "bad options: pay more for coverage, cut back on benefits or join the ranks of the uninsured. " Sebelius said she could not understand why the company would need a "massive increase" after its parent company, WellPoint, made $27 billion in the last quarter of 2009.
Anthem's proposed premium increases have also prompted an inquiry on Capitol Hill. The House Committee on Energy and Commerce and its subcommittee on oversight and investigations said they would examine the proposed rate hike increases affecting California's largest for-profit insurer. The subcommittee has scheduled a Feb. 24 hearing in Washington about the proposed increases. Angela Braly, the president and CEO of WellPoint Inc., the parent company of Anthem—was called to testify.
In California, state Assemblyman Dave Jones, D-Sacramento, chairman of the Assembly's Health Committee, announced plans to hold a Feb. 23 hearing on the topic.
The White House today announced nearly $1 billion in Recovery Act funds designed to help healthcare providers advance health information technology (IT) and train thousands of workers for future healthcare jobs.
The awards will help make health IT available to more than 100,000 hospitals and primary care physicians by 2014 and train thousands of people for careers in healthcare an information technology, according to a joint statement by HHS Secretary Kathleen Sebelius and Labor Secretary Hilda Solis.
The funds include $750 million in grant awards that Sebelius said are part of a federal initiative to build capacity to enable widespread use of health IT. She said the assistance would facilitate healthcare providers' efforts to adopt and use electronic health records in a meaningful way to improve the quality and efficiency of healthcare.
The $750 million includes:
$386 million is slated for 40 states and qualified state designated entities to facilitate health information exchange at the state level.
$375 million is for 32 nonprofit organizations to support the development of regional extension centers that officials say will aid health professionals as they implement and use health IT. Additional awards will be announced in the future.
Regional extension centers are expected to provide outreach and support services to at least 100,000 primary care providers and hospitals within two years.
"Health information technology can make our healthcare system more efficient and improve the quality of care we all receive," Sebelius said in a statement. "These grant awards, the first of their kind, will help develop our electronic infrastructure and give doctors and other healthcare providers the support they need as they adopt this powerful technology."
Labor Secretary Solis said that $225 million in Department of Labor grant awards will be used to train 15,000 people in job skills needed to access careers in healthcare, IT, and other high-growth fields. Through existing partnerships with local employers, the recipients of the grants have identified 100,000 job openings for skilled workers that likely will become available in the next two years in areas like nursing, pharmacy technology, and information technology.
The grants will fund 55 separate training programs in 30 states to help train people for health jobs.
In a back-and-forth with officials of Anthem Blue Cross's parent company WellPoint over the company's proposed rate hikes in California, HHS Secretary Kathleen Sebelius on Thursday said the company's proposals remain perplexing. She added it leaves customers "with nothing but bad options: pay more for coverage, cut back on benefits or join the ranks of the uninsured."
Reacting to a letter from WellPoint, Sebelius said the company's proposal to raise individual health insurance premiums by as much as 39% in California also demonstrates "the urgent need for real reforms that fix our broken heath insurance system."
Sebelius issued a statement after receiving a letter from WellPoint, which said the proposed rate hikes affecting 800,000 individual health insurance members were needed because of increased medical costs. The company said it did "regret the impact this has on our members." The company also said that individual medical insurance premiums do not reflect an individual member's personal claims experiences, but take into account other expenses, such as the medical costs.
Sebelius said she is perplexed that the company is seeking a huge rate hike. "It remains difficult to understand how a company that made $27 billion in the last quarter of 2009 alone can justify massive increases that will leave consumers with nothing but bad options pay more for coverage, cut back on benefits or join the ranks of the uninsured," she said.
"High health costs alone cannot account for a premium increase that is 10 times higher than national health spending growth," Sebelius added. "Without comprehensive reform, fewer people will be able to afford health insurance and Anthem's decision to raise their rates only demonstrates the urgent need for real reforms that fix our broken health insurance system."
"Reform will end the worst insurance company practices and put doctors and patients—not insurance companies—in charge of medical decisions. If we fail to implement reform, insurance companies will continue to prosper while families will continue to struggle," Sebelius said.
Sebelius made her pitch for health reform as the Senate and House continue to wrangle over stalled reform bills.
In addition, Anthem's proposed premium increases have prompted an inquiry on Capitol Hill. The House Committee on Energy and Commerce and its subcommittee on oversight and investigations said they would examine the proposed rate hike increases affecting California's largest for-profit insurer. The subcommittee has scheduled a Feb. 24 hearing in Washington about the proposed increases, scheduled to take effect March 1.
Saying the proposed increases are "deeply troubling," Energy and Commerce Committee Chairman Rep. Henry A. Waxman, D-CA, said, "We need to know what possible justification there could be for increases of this magnitude."
In California, state Assemblyman Dave Jones, D-Sacramento, chairman of the Assembly's Health Committee, announced plans to hold a Feb. 23 hearing to examine Anthem Blue Cross, based in Woodland Hills, as well as other California health insurers. The state's insurance commissioner, Steve Poizner, has said he would take "regulatory and legal action" against Anthem Blue Cross if the health insurer does not agree to delay the rate hikes.
New Jersey health plans have joined in the fight to overcome the costly paperwork morass choking the healthcare system.
Health plans launched an initiative in the Garden State on Thursday, in which Web portals will be used in a pilot program that officials say will make health delivery easier for patients and physicians by reducing paperwork for each patient visit.
The effort is similar to a pilot program that physicians, hospitals, and providers initiated in Ohio last October..
Both initiatives are sponsored by America's Health Insurance Plans (AHIP), and the Blue Cross and Blue Shield Association (BCBSA).
The plan is to replace an onerous system in which physician and hospital staff spend time and expense getting information needed to complete basic requirements for confirming eligibility, billing, and referrals for insurance, while sorting through a number of insurers. With the Web portal process, however, doctors and hospitals can interact with multiple insurers, and quickly access information in "real time."
Project proponents say reducing paperwork and administrative headaches could save the healthcare system billions over time. It would also simplify the information flow between health plans and doctors offices' and between health plans and hospitals, according to AHIP and BCBSA officials.
Officials say the programs are a "one-stop" part of electronic transactions that physicians have strongly advocated for years and could eventually be as useful as an ATM machine for banks. The New Jersey health plans participating are Aetna, AmeriHealth New Jersey, CIGNA, Horizon Blue Cross Blue Shield of New Jersey, and UnitedHealthcare.
The physician organizations involved include the Medical Society of New Jersey, New Jersey Academy of Family Physicians, the New Jersey Association of Osteopathic Physicians and Surgeons, the New Jersey Medical Group Management Association, and Partners in Care Corp.
"Streamlining the administrative process for providers will result in tremendous savings, both in time and resources, and ultimately lead to improved consumer experience," said Scott P. Serota, president and CEO of the Blue Cross and Blue Shield Association.
The New Jersey and Ohio initiatives are designed to be permanent, but during the first-year they are considered pilots to obtain feedback from users and make any adjustments. "We will see if any tweaks are needed," said Susan Pisano, a spokeswoman for AHIP.
Specifically, the Web portal process will:
Allow office staff to quickly determine eligibility and benefit information (e.g., copays, co-insurance, and deductibles, and differences in coverage for services provided in- versus out-of-network)
Give physicians access to current and accurate information on the status of claims submitted by offices for payment by insurers. As a result, there will be less need for follow up by office staff or submission of duplicate claims that mostly delay rather than expedite the process
Tests real-time referrals and timely pre-authorization of services
Provide for the online submission of healthcare claims
Congress is asking for Anthem Blue Cross's corporate e-mails and other internal documents and wants the top executive of Anthem's parent company, WellPoint, to testify as to why the insurer is raising individual health insurance premiums by as much as 39% in California.
WellPoint released a statement Wednesday, referring to the proposed rate hikes for the first time, saying it does "regret the impact this has on our members," but suggested they were related to increased medical costs. The company did not mention specific numbers.
"It is important to note that individual medical insurance premiums do not reflect an individual member's personal claims experience," the company said in a statement. "As medical costs increase across our member population, our member population premium increases to the membership pool is the result.''
"Unfortunately, in the weak economy, many people who do have health conditions are foregoing buying insurance," the company statement added. "This leaves fewer people, often with significantly greater medical needs, in the insured pool. We regret the impact this has on our members."
The situation involving Congress "highlights why we need sustainable healthcare reform to manage the steadily rising costs," WellPoint said in a statement.
The proposed increases in individual health insurance has set off a furor on Capitol Hill where the House Committee on Energy and Commerce and its subcommittee on oversight and investigations said they would examine the proposed rate hike increases affecting California's largest for-profit insurer. The subcommittee has scheduled a Feb. 24 hearing in Washington about the proposed increases, scheduled to take effect March 1.
Saying the proposed increases are "deeply troubling," the Energy and Commerce Committee Chairman Rep. Henry A. Waxman, D-CA, said, "We need to know what possible justification there could be for increases of this magnitude."
In California, state Assemblyman Dave Jones, D-Sacramento, chairman of the Assembly's Health Committee, announced plans to hold a Feb. 23 hearing to examine Anthem Blue Cross, based in Woodland Hills, as well as other California health insurers. The state's insurance commissioner, Steve Poizner, has said he would take "regulatory and legal action" against Anthem Blue Cross if the health insurer does not agree to delay the rate hikes.
The California officials are the latest to attack Anthem's decision. President Obama referred to it when he discussed national healthcare legislation and Health and Human Services Secretary Kathleen Sebelius sent a letter to Anthem Blue Cross, saying she wanted the company to justify the rates. "These extraordinary increases are up to 15 times faster than inflation and threaten to make healthcare unaffordable for hundreds of thousands of Californians, many of whom are already struggling to make ends meet," Sebelius wrote to Anthem Blue Cross.
Sebelius said the proposed increase was "difficult to understand" given WellPoint's $2.7 billion profit in the fourth quarter of 2009.
In launching its inquiry, the congressional committees requested the testimony of Angela Braly, the president and CEO of Wellpoint. The committees said they wanted to hear from the company no later than Friday if she would agree to the request. The committee also sought in a letter to Braly:
Internal communications, including e-mail, to or from senior corporate management relating to the company's decision to increase premium rates in California. The committee referred to senior corporate management officials as levels of vice president and above for Anthem Blue Cross and WellPoint Inc.
All presentations to senior corporate management, or government agencies, relating to the increase in premium rates in the individual health insurance market.
A detailed explanation of the reasons for the proposed rate increase.
For each year from 2005 to 2008, a table listing, as appropriate, premium revenue, claims payments, sales expenses, and other general or administrative expenses, and profits for all individual health insurance products, including an explanation of the methodology used for these calculations.
A table listing all proposed premium increases from January 1, 2009 through December 31, 2010 in the individual health insurance market for all WellPoint subsidiaries, including the amount of the proposed premium increases, the subsidiary, the state affected, and a detailed explanation of the reasons for the increase.
WellPoint company spokesman Kristin Binnis says the insurer is "reviewing [the congressional request] at this time." The company also expects to reply to Sebelius's letter "promptly," she said.
