Most health insurers say they will take part in health insurance exchanges despite concerns about how the programs will function, technical barriers, and the health status of participants. Meanwhile, a federal study finds that premiums will cost less than originally expected and selection will be broad.
Nearly 70% of health insurance executives responding in a study released today say they will take part in health insurance exchanges despite widespread concerns about how the programs will function, stubborn technical barriers, and the health status of the people they will be covering.
The PwC study, titled Health Exchanges: Open for Business [PDF], found that the access to potentially millions of new customers on the individual market and a fear of being left behind if these exchanges succeed are overcoming the reservations that many health insurance executives have expressed.
The six-month enrollment period for the exchanges—a key component of the Patient Protection and Affordable Care Act—starts on Oct. 1, and coverage begins on Jan. 1, 2014.
"With open enrollment about to begin, large national insurers and new players, some from other industries, are jockeying for position in the new exchange market," Ceci Connolly, managing director of PwC's Health Research Institute, said in prepared remarks. "Investment in retention programs will be crucial to securing the loyalty of a new crop of technologically savvy buyers. Companies should think beyond initial implementation challenges and focus on building a meaningful customer experience, with an eye on cost reduction and personalized communication."
HRI surveyed more than 100 insurance executives about the exchanges and found that:
69% plan to offer coverage on the exchanges, suggesting the rising significance of this new business opportunity
10 of 18 national health insurer executives said they won't offer exchange coverage in all the states where they now have business, and 50% expected to enter additional states after 2014
63% said technology integration and 61% said coordination of subsidies were major barriers to implementation
34% of insurers said understanding newly eligible customers was a major barrier to implementation, suggesting they may not thoroughly understand the challenges associated with attracting and maintaining this new group of buyers armed with the ability to choose—a major shift from the wholesale approach many insurers are used to
91% expect that premium costs, followed by total out-of-pocket costs, will be what consumers care about most
Industry and consumer experts expect that personalized communication, tangible rewards, health management programs, and brand recognition will be factors in consumer choices
Robert Zirkelbach, spokesman for America's Health Insurance Plans, says health plans are entering the exchanges despites significant unknowns: mainly the prohibition against denying coverage to people with pre-existing conditions, and whether young and healthy people will sign up.
"Adverse selection is a huge issue," Zirkelbach told HealthLeaders Media. "The broad agreement is that for the new exchanges to work there needs to be broad participation among young healthy people to offset the cost of those who are older and have high healthcare costs. That is why our industry has been so focused on the issue of affordability. If it is not affordable and young healthy people decide not to purchase, these exchanges won't work."
Zirkelbach says the uncertainty will be mitigated somewhat by federal backstops such as a three-year reinsurance program that is designed to temporarily offset highest-cost enrollees and provide some stability for the plans in the start-up phase.
While there are bound to be glitches when the enrollment period begins, Zirkelbach says many of the plans that will participate in the exchanges have gained relevant experience with the launch of the Medicare Part B program.
"Obviously the exchanges are larger, but when the Medicare Part B program was implemented there were problems, and it was our members who stepped up and helped fix problems while at the same time helping seniors navigate the system to find the right kind of drug coverage," he says. "That is the role we are going to play in the open enrollment for new exchanges."
Also today, the Department of Health and Human Services released a report finding that consumers in most states will be able to choose from an average of 53 health plans in the exchanges, and that most will have a choice of at least two different insurers or more. Premiums nationwide will be around 16% lower than originally expected—with 95% of the eligible uninsured living in states with lower-than-expected premiums—even before taking into account financial assistance.
"We are excited to see that rates in the marketplace are even lower than originally projected," HHS Secretary Kathleen Sebelius said during a media call on Tuesday afternoon. "In the past, consumers were too often denied or priced out of quality health insurance options, but thanks to the Affordable Care Act, consumers will be able to choose from a number of new coverage options at a price that is affordable."
HHS says its report shows that people living in the 36 states where HHS will fully or partly run the health insurance Marketplace—which is HHS's term for the federally operated exchanges—will have an average of 53 qualified health plan choices. Plans in the Marketplace will be categorized as gold, silver, or bronze, depending on the share of costs covered. Young adults will also have the option of purchasing a "catastrophic" plan, increasing their number of choices to 57 on average. About 95% of consumers will have a choice of two or more health insurance issuers, often many more. About one in four of these insurance companies is offering health plans in the individual market for the first time in 2014.
The average premium nationally for the second-lowest cost silver plan will be $328 before tax credits, or 16% below projections based on Congressional Budget Office estimates. About 95% of uninsured people eligible for the Marketplace live in states where their average premiums are lower than projections. And states with the lowest premiums have more than twice the number of insurance companies offering plans than states with the highest premiums, HHS says.
The shift away from post-acute hospital-based procedures to ambulatory services, which lack high-cost infrastructures, is "the future of healthcare," according to one health system executive. Keys to revenue growth include economies of scale and joint ventures with physician groups and hospitals.
Ambulatory surgery centers will continue to record volume growth as hospital inpatient surgery volumes continue to shrink, a report from Moody's Investors Service shows.
Moody's senior analyst and vice president Ron Neysmith said in a new study this month that the lower costs for outpatient procedures in ambulatory settings are driving the transition away from hospital-centric care.
"Ambulatory service centers provide care without the high-cost infrastructures associated with hospitals," Neysmith said in prepared remarks. "More procedures can be done safely on an outpatient basis and outpatient facilities are reimbursed on average 57% of the hospital rate for similar procedures, so insurance payors, including Medicare, have increasingly been directing patients to lower-cost settings."
As a result, ambulatory service centers' same-store revenues have been growing in the low- to mid-single digits since 2007 while same-hospital inpatient surgeries have been flat (measured at a 0.22% annual decline) in the same period.
Rob Shelton, director of marketing and communications at SSM Health Care, says the St. Louis–based health system is part of the industry-wide transition into the outpatient setting for several service lines, including imaging, pain management, ambulatory surgery, and urgent care.
"The system is forcing us to move to an ambulatory environment. Medicare and other payers don't want to pay for inpatient stays. For the first time in SSM's history the scales have tipped and more of our business is actually on the outpatient side than on the inpatient side," Shelton says. SSM operates 18 hospitals and 150 outpatient sites across four states.
The shift towards outpatient settings may have been accelerated by the recession, which brought with it higher unemployment and reduced the number of insured people in the marketplace, the Moody's report says. At the same time, elective procedures have dropped owing to the economic uncertainty and because insurance plans have raised copays, deductibles, and other out-of-pocket expenses for patients.
SSM views the shift as "the future of healthcare: services delivered in more of an outpatient ambulatory setting and meeting the needs of our patients," Shelton says. '"When you look at it from a revenue perspective and a volume perspective, we are actually seeing more, and that is across the board on outpatient, and that includes a wealth of different services."
Shelton says SSM is not interested in opening another hospital in the St. Louis market. "We really have shifted focus to the outpatient side," he says. "Hospitals of course have larger overhead. An ambulatory network can have less overhead and give us more penetration into the market. We continue to look at where we need to be in our market across the St. Louis region, whether that is placing physician offices or urgent care centers, imaging centers, rehab centers, pain care centers, any number of things that are performed on an outpatient business."
Moody's Neysmith said the top financial performers among ambulatory service centers will be those that concentrate on higher revenue treatments such as orthopedics and pain management. At the same time, growth in ambulatory service centers could be tempered by reductions in reimbursements, the shift toward bundled payments and value-based care, and the continued acquisition of surgery centers by hospitals. Even with those caveats, Neysmith says ambulatory surgery centers are well positioned to take advantage of an aging population.
"In a highly fragmented market, the larger players with economies of scale and joint ventures with physician groups and hospitals will benefit from patient referrals," he said.
Witnesses representing payers and providers agree that healthcare industry consolidation predates the Patient Protection and Affordable Care Act by at least two decades, but blame each other for rising healthcare costs.
A U.S. House Subcommittee heard a range of perspectives on Thursday from a panel of lobbyists and policy wonks who were asked if the Patient Protection and Affordable Care Act is hurting competition in the healthcare marketplace. The consensus from the panel was maybe, maybe not, and we're not really sure yet.
There was a general agreement from the witnesses that healthcare industry consolidation predates the PPACA by at least two decades. The questions then became whether or not "Obamacare" was accelerating that consolidation and whether that consolidation is driving up healthcare costs.
For the most part, the testimony from lobbyists for the American Hospital Association and America's Health Insurance Plans, covered little new ground but reaffirmed each side's contention that the other was to blame for rising healthcare costs.
"Officials at the antitrust agencies have stated repeatedly that they have been and will remain focused on competition in the healthcare sector. Transactions that these authorities deem to be anticompetitive, in fact, have been challenged," AHA lobbyist Sharis A. Pozen told the Subcommittee on Regulatory Reform, Commercial and Antitrust Law.
"However, despite these activities hospitals' price growth is at a historic low and is not the main driver of higher health insurance premiums," Pozen said.
"The growth in health insurance premiums from 2010-2011 was more than double that of the underlying health costs, including the costs of hospital services. The antitrust authorities should continue to pay as much attention to the health insurance industry as it does to the hospital field and there is no question that the health insurance industry is highly concentrated and is now acquiring hospitals and providers in an effort to replicate the continuum that hospitals are now providing."
AHIP lobbyist Joseph Miller cited several studies showing that hospital consolidations mean higher costs for consumers. He called on the federal government to continue to review hospital mergers that have the potential to harm consumers by consolidating market power and diminishing competition.
"Through the ACA implementation process, AHIP has emphasized that affordability must be a central goal in health reform and that addressing provider market issues is an important part of achieving this goal," Miller said. "Promoting competition and halting harmful consolidation in provider markets are critically important steps toward increasing affordability."
The back-and-forth between the representatives of AHIP and AHA prompted another panelist, Duke University Law professor Barak D. Richman, to note that "both providers and insurers alike seek to exploit different loopholes in the reimbursement system."
"What's funny about the conversation you hear out of AHA and AHIP is sometimes you're hearing both sides of what is really the same coin," Richman told the subcommittee during the question-and-answer period.
"The insurers often lament consolidation among the providers and use that as a justification to consolidate themselves. Providers lament big insurance companies and use that as a justification for their own consolidation. This kabuki dance has gotten us to a large degree in this mess we are in."
Richmond also noted that the market model for providers is "one designed to capture a market and extract maximum dollars from payers."
"There is an alternative business model which really has not been pursued a whole lot among providers and that is to pursue efficiency or value-based models," he said. "It is one reason why business education is so critical to encourage both providers and administrators to really pursue. It involves a very different kind of economic model."
The subcommittee also heard from Thomas P. Miller, resident fellow at the American Enterprise Institute; Thomas L. Greaney, at law professor at St. Louis University School of Law; and consumer rights lobbyist David A. Balto, a former federal antitrust lawyer.
In an attempt to illustrate the impact of losing federal Medicaid funding, the Missouri Hospital Association is using data linking the effects of poverty, poor health, and life expectancy in the state and making comparisons to rates in Third World countries.
When elected officials in Missouri decided last year against expanding their Medicaid program under the Affordable Care Act, the Missouri Hospital Association commissioned a report detailing the economic impact of losing the estimated $1 billion each year in federal funding.
Unfortunately, using common sense to explain an obvious point didn't work.
Now the MHA is trying a new tactic: Shame.
Of course, MHA won't call it a shame campaign. They're much too smart to openly embarrass the state and federal lawmakers they're trying to win over. However, shame is clearly the theme that rings through in MHA's report linking the effects of poverty, poor health and life expectancy in Missouri and comparing them with those of Third World countries such as El Salvador, Vietnam, and Angola.
It would be hard to live in any state with these sorts of health statistics and not be embarrassed. For example, MHA reports that:
Eleven counties in southeast Missouri and the City of St. Louis have average life expectancies less than 74 years. By comparison, Missourians living in these areas can expect to live two years less than the residents of Vietnam and Venezuela, and one year less than Hondurans and Lebanese. On average, they will enjoy the same life span as the population of Iran.
At 71.3 years, Pemiscot County would have the 85th lowest life expectancy in the world if it were a country—just below El Salvador with an average life expectancy of 71.4 years.
In 2011, 75% of Missouri's uninsured adults were in the workforce. However, many low-income blue collar and service industry workers lack access to employer-sponsored insurance, while Medicaid coverage is limited.
In 2013 a single working parent of two can earn no more than $9.59 per day to qualify for Medicaid in Missouri. By contrast, the average daily income in Angola is $13.35. Because of these strict eligibility standards, a large number of Missouri's uninsured are low-income working adults in blue collar and service collar industries.
On average, an uninsured Missourian was treated in a hospital emergency department every minute of every day in 2012. Throughout the last eight years, ED visits by the uninsured have increased 83% in Missouri, from more than 300,000 in 2004 to nearly 560,000 in 2012.
"Sadly, depending on where you live, your community may be part of Missouri's downward spiral in health status," MHA President/CEO Herb B. Kuhn said in prepared remarks. "The gaps in life expectancy between communities with higher incomes and increased access to care, often separated by mere miles, are profound. That's bad for Missouri and the state's economy."
If it's any consolation, Missouri already ranks 42nd in health status according to America's Health Rankings – close enough to the bottom that it wouldn't be a long drop.
MHA spokesman David M. Dillon says the state's hospitals are hopeful that state legislators and the general public will be motivated to change the status quo once they understand that Missouri health statistics rival those of Third World countries.
"One of the important parts of this report versus a lot of the more academic stuff we have done in the past is that it shines a pretty bright light on comparatives and gives individuals an opportunity to understand it in a way they might not otherwise," he says.
"If you look at the state of the state, there is this preconception about what Medicaid covers and who it covers and you'd think we have two metros so it's an urban problem. Well, not so much. It is very much a rural problem."
Dillon is picking his words carefully. That's because Missouri's hospitals did not create this "preconception" that they now have to overcome. In coarser terms, the report shows that refusing Medicaid expansion dollars hurts rural whites as much if not more than it hurts urban blacks.
The data also show that most of these blacks and whites who could be served by the Medicaid expansion are holding down jobs that provide no health benefits. These people are not the "moochers" and "takers" that some would have us believe. Their common denominator is poverty.
"The low Medicaid eligibility level being $9.59 a day for income just tells you that even adults with children would have a very hard time being eligible," Dillon says.
There is some hope that Missouri elected officials are coming around. The Missouri House and Senate have each formed interim committees to examine the Medicaid expansion to see if they can find a compromise proposal during the 2014 session. Dillon says many lawmakers understand what is at stake.
"There are a lot of them in public who would say 'no' but there are also a lot who would acknowledge what the economic benefit of it is and the impact on their constituents. They want to say 'yes' but there has to be a program that is very Missouri-specific," he says. "That is what you are seeing in other states and last week and this week we have seen governors in other states talk about this issue and create plans that were very tailored to the politics and the needs of their states."
"We are hoping that reports like this help shape the public perception of the problem because frankly, as a community, we get really wrapped up in things like discussing the federal poverty level and most people don't have any connection to that term in their lives," Dillon says.
"That is why we were making an effort this time to talk about what those numbers means and make comparatives to what they might mean. Life expectancy was a good benchmark, so it was going to be easier to show comparatives on [that metric]. Talking about the negative health implications and what they mean is vital."
"It is one thing to talk about what happens in Jefferson City," he said. "It's another thing to put it into the context of how people live their lives."
While data shows there's been an uptick in hospital employment for physicians, more than half still work for themselves, an AMA survey finds. The number of physicians in solo practice, however, has dropped.
Conventional wisdom says physicians in private practice are a dying breed.
The narrative says physicians are flocking to employed arrangements with hospitals and larger physician practices as health reform and compensation models push the healthcare industry away from fee-for-service and toward economies of scale, quality outcomes and population health.
An American Medical Association report released this week, however, suggests that the demise of private practice physicians may be overstated [PDF]. "To paraphrase Mark Twain, the reports of the death of private practice medicine have been greatly exaggerated," AMA President Ardis Dee Hoven, MD, said in prepared remarks.
"This new data shows that while there has been an increase in hospital employment, more than half of physicians (53.2%) were self-employed in 2012, and 60% worked in practices wholly owned by physicians. Needed innovation in payment and delivery reform must recognize the wide range of practice types and sizes that exist today so all physicians can participate in the move to a more patient-centered system that rewards high-quality care and reduces costs."
Of course, the report also shows that conventional wisdom is not completely wrong. There has been a trend toward hospital employment over the past five years. In 2012, 29% of physicians worked either directly for a hospital (5.6%) or for a practice that was at least partially owned by a hospital (23.4%). The last AMA survey taken in 2007–2008 did not distinguish between direct hospital employment and employment in a hospital-owned practice, but found that 16.3% of physicians worked in one of the two settings.
Phil Miller, vice president of communications at Merritt Hawkins, says the AMA findings are consistent with what the Irving, TX-based physician recruiting specialists find in their annual recruiting assignments.
"I was a little surprised to see they indicated that a little over 50% of physicians are still self employed. That contradicts a little some of the other things I have seen out there," he said. "In the great majority of settings that we are recruiting into it's an employed setting, mostly hospital employed. But it could be a community health center or a larger medical group, with the doctor coming in as an employee and not a practice owner."
Miller says that in 2004 only 11% of the physician search assignments Merritt Hawkins conducted were hospital employed physicians. This year, that figure went up to 64%.
"Of the physicians who are being recruited and newly hired by various entities, they are overwhelmingly going to employed settings. If a doctor is coming out of residency for example, the ones who are switching practice locations and are being recruited by people like us they are going into employed settings," Miller says.
It is also becoming increasingly uncommon for independent physicians to be recruited into other independent practices. "We recruit that doctor not for another independent setting. They are going into an employed setting," Miller says.
"That gradually siphons off the numbers of independent doctors. Even in the AMA survey they're showing that the percentage of hospital employed doctors is growing. Today it's a little unusual for a doctor to go from one independent practice to another."
The AMA study also found that:
The percentage of physicians who were practice owners in 2012 decreased eight percentage points from 2007/2008.
18% of physicians were in solo practice, down 6% points over five years.
Single specialty practice was the most common practice type in 2012, accounting for 45.5% of physicians.
Miller says every trend is pointing towards the employed model.
"The number of solo settings that we recruit into 10 years ago was close to 20%. Last year it was 1%. It was the same thing with partnerships," he says. "Solo practices and partnerships were the classic independent settings and now we do next to none of those anymore. Pretty much 90% or more of the settings we recruit into now feature employment of one kind or another."
In an online event Monday, the nation's three largest hospital associations expressed their unified support for the Patient Protection and Affordable Care Act in the face of withering and relentless criticism that appears to be sapping public support.
Leaders from the nation's three largest hospital associations met on Monday to reaffirm their support for the Affordable Care Act and encourage hospitals to help patients understand their health insurance options when open enrollment begins on Oct. 1.
"This is going forward. This is going to happen. I don't think there is anything between now and the near future that I could imagine would derail it," Chip Kahn, president/CEO of the Federation of American Hospitals, said at the Monday afternoon webcast sponsored by the American Hospital Association.
"And over the next six months you are going to have the opportunity to work with your communities and your patients to help your patients get the health coverage they need."
Joining Kahn at the hour-long webcast were: AHA CEO/President Rich Umbdenstock; Sister Carol Keehan, president and CEO of the Catholic Health Association;Mandy Cohen, MD, senior advisor to the administrator of the Centers for Medicare & Medicaid Services; and Cynthia Taueg, vice president, ambulatory and community health services at Detroit-based St. John Providence Health System.
The event was open to anyone with online access, but billed as an opportunity for hospital leaders to submit questions about the looming six-month open enrollment period for individual coverage on the health insurance exchanges, or marketplaces, as they are known. Cohen and Taueg provided suggestions to help hospitals with the transition.
"One thing [hospitals] might want to do is think about the patients that they already serve that are perhaps uninsured and how they can reach out to give them some information, be that through a mailing or some sort of a drive or health fair on the campus. But reach out to them. Don't wait for them to call you," Taueg said.
"Secondly, don't forget about your employees or your associates. They too are ambassadors in your community. They need to be informed, and many of them have family members who need to go to the marketplace. So take the time to look at your own employees and work with them."
"The third thing is I can't emphasize the partnerships enough. They are very important. You need to know who the navigator grantees are in your area and build on the partnerships that you already have. While it is not necessarily innovative, these are things that work. We just have to make sure that we work them."
Cohen was asked by Umbdenstock if the exchanges would be operational on Oct. 1.
"We are going to be ready on Oct. 1," Cohen replied. "We are not moving that deadline. Oct. 1 is coming and we will be open for business. The important thing is the context. Oct. 1 being open for business [means] it is the first time that folks will largely be seeing a lot of the plans in their states, their rates, and they really need to think through those options and that is why this enrollment period is six months long. It is not Election Day on Oct. 1. It is just a beginning."
The webcast, however, clearly provided a public platform for the nation's three largest hospital associations to reaffirm their unified support for the Patient Protection and Affordable Care Act in the face of withering and relentless criticism that appears to be sapping public support.
A Pew Research poll released Monday found that 53% of Americans disapprove of the PPACA. The same poll also found that only 25% of respondents said they understood how the law will affect them.
"People will only enroll if they know that this coverage is available and if they understand how to access these new coverage options," Umbdenstock said. "That is where we can help. It is critical that community stakeholders, certainly hospitals, faith groups, civic organizations and others come together to help make the enrollment process straight forward and widely available."
Keehan called access to healthcare "a matter of human dignity" and said hospitals will play a vital role "as a credible source of information in our communities." Keehan encouraged hospital administrators to "watch closely what is happening in your state with regard to marketplaces and Medicaid expansion."
"While the Affordable Care Act is not perfect, it is a great step toward the healthcare system all Americans deserve. To make the coverage provisions of the law readily available we need to focus now on enrollment, educating the public, signing people up, learning what we as hospitals can to do contribute," Keehan said.
"No matter who does the study, 75% to 85% of the people that this Act is supposed to help in this open enrollment believe there is nothing in the Act for them and that is largely because of massive misinformation. A good number of people don't even believe the Affordable Care Act is still the law and that it offers assistance and helps them pay for coverage."
The CHA leader also sought to tamp down the apocalyptic predictions of ACA critics.
"Try to have a historical perspective," Keehan said. "Look at the beginnings of our Medicare program. There were lots and lots of ups and downs in that and today not having the Medicare program is unthinkable. There will be bumps in the road, unintended consequences, things we didn't think of. But they are all worth getting beyond. We have the talent and commitment at CMS and (Health and Human Services) and in the Administration and Congress and get beyond them and give us a healthcare system that is worthy of our nation."
Primary care is one of the top most strategic service lines in the next two to five years, according to HealthLeaders Media's Intelligence Unit. In this feature, Council members detail how they have improved the quality and coordination of care with primary care at the foundation of their provider systems.
How does primary care fit into your organization's overall service line strategy and what are the main goals for your primary care service line?
Xavier Sevilla, MD Vice President of Clinical Quality for Physician Services
Catholic Health Initiatives
Englewood, CO
On the healthcare landscape:We are focusing on clinical integration, to align physicians and hospitals to deliver coordinated, high-quality care. The foundation of this new care delivery system is primary care. There is overwhelming evidence that a high-performance primary care service line is critical in achieving the triple aim of improving the health of populations, improving the experience of care of our patients, and decreasing per capita healthcare costs. We firmly believe that our primary care service line will be the key to our future success in this new world and at the same time help us achieve our mission of creating healthy communities.
On the role of primary care:There needs to be total transformation in the way that we operate our primary care service line. In April we started a large initiative in our health system to transform our primary care offices across the enterprise into patient-centered medical homes. This involves implementing several high-leverage changes such as team-based care, enhanced access, practice-based population management, improved care coordination, and patient-centered care.
On the added benefits:We believe that by implementing high-performance primary care offices we will also improve the morale and job satisfaction of our primary care physicians and staff. Our goal of transforming primary care will allow us to build a health system that will deliver affordable, coordinated, and high-quality care for all our patients.
William B. Riley Jr., MD
Chief Medical Officer, Administration
Memorial Hermann Sugar Land (Texas) Hospital
Memorial Hermann Katy (Texas) Hospital
Primary care is at the top of our list throughout the system because we are into the accountable care organization and medical home business, and you have to have sound primary care base to do that. So, that is a central core of our system strategy going forward for the foreseeable future.
We've got a number of medical homes within the system that are already up and running. The ACO application has been approved so we are going full steam ahead with this, and our primary care recruiting strategy has been in full gear for well over two years now. We are about as far along as you can get.
Recruiting problems with primary care physicians haven't really happened to us yet. We expect that it will and I think we are going to have to look to the use of mid-levels, advanced practice nurses, and others going forward. The big iceberg is when the floodgates are opened by the Affordable Care Act: How many people are going to show up expecting primary care doctors? From what I have been able to read and hear, there is going to be an unmet demand for primary care. That demand will very likely have to be filled by others, notably mid-levels.
Ninfa Saunders
President and CEO
Central Georgia Health System
Macon, GA
Primary care is going to be a very critical and pivotal service line for us. As we begin to look at care coordination, the physician in the middle is the primary care physician. Getting the manpower together is very important. To that end, the Medical Center of Central Georgia and the Central Georgia Health System continue to look at connections in primary care and strengthening that.
We just developed a model in a medical mall. There are three primary care physicians surrounded by rotating specialties. They have in the building a diagnostic arm for both radiology and laboratory to ensure that the care is coordinated within that particular clinic, driven and coordinated by the primary care physician.
We have a partnership with Mercer University. We are the teaching hospital. Mercer University's mission is to prepare primary care physicians in the region, with particular focus on underserved areas. Embedded in our partnership with Mercer as a teaching hospital is the ability to train and develop a strong primary care base so we will have the connection that feeds into the specialty base, not only for care but also to prepare these medical students for the future.
Scott D. Hayworth, MD
President and CEO
Mount Kisco (N.Y.) Medical Group
I run a 300-physician multispecialty group. About 50% of our physicians are primary care and 50% specialty, depending upon where you put OB-GYNs. As you look at the Affordable Care Act and healthcare reform and the move to value, there is a real shift to primary care in the country. As a result, all organizations are trying to expand their capacity in primary care. That includes using physicians as well as mid-level providers, physicians' assistants, and nurse practitioners.
We all have to expand our capacity to handle the volume. Unfortunately there is a real shortage of primary care physicians in the country. It is much easier for us to recruit primary care physicians than if we were a one- or two-doctor practice. However, there is such a severe shortage that even a large group like ours has trouble. To recruit them, we offer higher salaries and recruiting bonuses. They know they're more valued now because they have so much more opportunity.
Under the world of value, five years from now you are going to need more and more primary care doctors to keep your specialists busy. Because as we drive down procedures, specialists will need more doctors to feed them. In order to keep our specialists busy we are going to need more primary care doctors to feed them.
Researchers say companies that have won an award for their employee health and safety cultures also outperform the Standard & Poor's 500, but they cannot yet say that causality has been identified.
What does a company's employee wellness program have to do with its stock price?
It found that companies that have won the Corporate Health Achievement Award for their employee health and safety cultures also outperform the Standard & Poor's 500 by 3.03% – 5.27%.
Study coauthor R. Dixon Thayer, CEO and co-founder of HealthNEXT consultants, concedes that the study cannot categorically link the higher stock performance with better wellness and safety programs. "What we cannot say from this research is that there is causality. What we can say is there is a high correlation between one and the other," he says.
"Maybe companies that invest highly in their workforce wellness also are just better run companies. And one of the reactions we have and we hope others will have to that is 'so what?' The point is that well-run companies that are achieving superior returns make these investments."
The study comes as a number of high-profile companies, including Walmart, pizza maker Papa John's, Trader Joe's, and Lands' End clothiers' have said they will re-examine business operations and would consider reducing employee hours or dropping healthcare coverage to contend with mandates in the Affordable Care Act.
Study lead author Raymond Fabius, MD, vice chairman of HealthNEXT,says an increasing amount of evidence is suggesting that for every dollar spent on healthcare costs, companies lose about $3 of productivity."So, what we are starting to see is that a lot of this intuitive understanding that we are seeing is now being much more significantly proven by metrics with a financial basis," he says.
Thayer says it's not earth-shattering news that companies that take better care of their employees generally have more productive employees who stay on the job longer, have fewer sick days, and are more productive.
"It is common sense, but it is amazing how many companies have had a hard time finding their way to the fact that a significant impact on their EBITDA [earnings before interest, taxes, depreciation and amortization] would then translate into earnings per share which translates into share price," Thayer says.
"While we're all in agreement that this is intuitive, the list of companies in the Fortune 500 who have made a significant commitment to building a culture of health which is well beyond providing health benefits is very small number. Our research at suggests that it may be as few as 25 out of the Fortune 500."
As a key deadline nears, "Obamacare" fraudsters, under the guise of helping with enrollment in health insurance exchanges, are trying to dupe unwitting consumers into giving up personal information.
As states and the federal government scramble to meet a fast-approaching deadline to establish health insurance exchanges under the Patient Protection and Affordable Care Act, scammers are hoping to cash in on consumer confusion about the plans, the National Association of Insurance Commissioners warns.
"There are folks taking advantage because they know people are hearing blurbs on TV and radio," says Kansas Insurance Commissioner Sandy Praeger, chair of the NAIC's Health Insurance and Managed Care Committee.
"Consumers are not paying a whole lot of attention to it, but just enough where somebody comes along and says 'you've heard about this new health insurance. I am here to make sure you get signed up.' Obviously there is no phone solicitation that is going to occur."
Open enrollment in the new marketplaces begins Oct. 1, but bogus websites that claim to be part of the exchanges have been sprouting online for more than a year. Oftentimes the scammers are looking to sell phony policies or obtain personal information from unwitting consumers, such as Social Security/Medicare ID, credit card, or bank account numbers.
>Bogus Health Plan Offers
Praeger says anecdotal reports have been surfacing about the scams, but it's hard to know how widespread they've become. "We know there are some phony websites that have been created so it's hard to tell because sign-up hasn't really started yet," she says. "But that is why an ounce of prevention is worth a pound of cure—the old medical adage. It is important that we at least get information out there and alert people."
NAIC has red-flagged a handful of the most common scams. One ploy involves unsolicited calls from vendors claiming to have the consumer's new "Obamacare" insurance card. But first personal and financial information must be verified before the card can be mailed. This is a variation of another scam that targets senior citizens on Medicare with claims that bank account and Social Security numbers are needed for them to continue receiving benefits.
There is no requirement to get a new insurance card or a new Medicare card under the PPACA, and NAIC notes that anyone claiming to represent the federal government already would have access to personal and financial data and would not ask the consumer to disclose it.
Act Now or Go to Jail
Another scam identified by the NAIC include: Salespersons claiming that the premium offer is only good for a limited time. In fact, enrollment in the exchanges will be open from Oct. 1 to March 31, and rates for plans in the exchanges will have been approved for the entire enrollment period.
And scammers are known to employ scare tactics such as warning that consumers will got to jail for not having health insurance.
So far, Praeger says, no scams have surfaced that would require new laws. "Our existing consumer protection laws are adequate," she says. "There might be some creative scam out there we haven't thought about, but in most cases a scam is a scam and anybody trying to misrepresent the sales process or encourage someone to buy something that is not appropriate, our laws are sufficient."
Praeger says providers can help by steering patients to federal and state insurance department websites. "We set up our own separate website just for information about the Affordable Care Act called InsureKS.org," she says. "Hospitals, I am sure, are going to have their staff trained to be enrollment counselors. Most physician offices don't do the wallet biopsy before they treat somebody. They treat and if the person can't pay, hopefully physician offices will at least encourage people to look into the Affordable Care Act provisions."
Several mechanisms "end up leading to minority and uninsured patients having a higher death rate after trauma and I think that the hospital that they go to certainly plays a major role," says the lead author of a study that analyzed records from the National Trauma Data Bank.
Adil H. Haider, MD, trauma surgeon and associate professor of surgery at the Johns Hopkins University School
More than 80% of trauma centers that treat mostly minority patients have higher death rates than do trauma centers that treat mostly white and insured patients, a Johns Hopkins study shows.
The same study also found, however, that trauma patients of all races are 40% less likely to die if they are treated at hospitals with lower mortality rates, regardless of the severity of their injuries.
"Disparity issues are never simple," says the study's lead author Adil H. Haider, MD, a trauma surgeon and associate professor of surgery at the Johns Hopkins University School of Medicine. "There are several mechanisms that end up leading to minority and uninsured patients having a higher death rate after trauma and I think that the hospital that they go to certainly plays a major role into it. Certainly what this data shows is that not all hospitals are equal."
The findings detailed in an article published in the October issue of Annals of Surgeryare based on an analysis of records from the National Trauma Data Bank. Haider and his team classified 181 trauma centers across the nation into three categories and found 86 hospitals with lower-than-expected death rates; six with average death rates; and 89 with higher-than-expected death rates.
Researchers found that 27 of the trauma centers serve a population that is more than 50% minority, while 154 have patients who are mostly white. Of the trauma centers that serve predominantly minority patients 81.5% were classified as high-mortality, and 64% of black patients in the study group were treated at these high-mortality centers compared to only 41% of white patients.
Haider says detailed attention was given to making risk adjustments for the trauma patients cited by the study. "We risk adjust patients on age, the injury severity score, their physiologic state when they got injured and when they got to us," he says. "Every way we cut this it makes sense because it is very sensitive stuff. Once you say it, you can't take it back so you have to be super right when you do it."
The analysis also showed that 45% of patients at high-mortality centers don't have insurance, compared to 21% at low-mortality hospitals.
"We did not study hospitals' bottom lines, so now I am speculating, but if you have a better bottom line because you have more insured patients then you are able to invest in more stuff and you are able to do a better job and keep getting better," Haider says.
"On the other hand if you are working under extreme pressure and you have to take care of a lot of patients and you are not getting paid to take care of these patients, then it is difficult to improve quality. I don't mean to give a pass to hospitals that are on the bottom of the ranking, but I totally understand why they are doing such a difficult job. I have seen myself hospitals that are working in difficult circumstances that are doing a fantastic job with what they have. If they had more resources they would be fantastic and would go right up the list."
While the findings in the study are troublesome, Haider says he takes some solace in knowing that the results did not show any treatment bias on the part of trauma teams.
"We talk about healthcare disparity all the time but the fact is that no matter your skin color, white, black, or Hispanic, they ended up with the same results based on what hospital you went to," Haider says. "If you went to a low-performing hospital and you were white, you [would] have the same results as a black guy at that hospital."
"Similarly," he says, "if you went to a high performing hospital whether you were black or white you all did good. That was very heartwarming to see and a very positive finding for the study because a lot of disparity studies keep on showing that minority patients are doing worse, but this one shows that trauma centers do a great job if they are able to do a good job they do it no matter who you are. But obviously not all trauma centers can do a good job."
