Posts Tagged ‘House Energy and Commerce Committee’

Primary Care Gets a Break

Tuesday, July 30th, 2013

There’s no question that primary-care physicians have long been spurned by the fee-for-service model that doesn’t recognize or reimburse fully the time spent with patients. Well, internists had a pretty good summer. Firstly , the CMS “proposed creating new evaluation-and-management codes for non face-to-face activities relating to the coordination of care for patients with two or more chronic conditions”.  And, now a bipartisan draft bill from the House Energy and Commerce Committee’s health subcommittee extends that to care coordination between multiple physicians and other suppliers and providers of services.The number of chronic patients is expected to rise to 171m by 2030.
The CMS proposal solicited public comment on whether general third-party designation of a practice as a medical home could be considered evidence that the practice was up to the task of providing care-coordination services. But the draft of the House bill specifically mentions the National Committee for Quality Assurance’s (NCQA) medical home and patient-centered specialty practice recognition programs.

Part of the solution is to recognize practices as medical homes so they qualify under the new payment model.  Thus far, the NCQA program has designated 5,770 practices as medical homes.

“We are particularly pleased the draft includes expedited recognition of patient-centered medical homes as an approved alternative payment model for medical practices,” Dr. Jeffrey Cain, AAFP president of The American Academy of Family Physicians, said. That said, Cain did add that family doctors are “disappointed that the subcommittee’s draft does not include a provision to specify a higher base-payment rate for those services provided by primary-care physicians,” Cain said.

Primary care has long been affected by dwindling reimbursements — In the 20th annual Modern Healthcare Physician Compensation Survey, family physicians finished last among the 23 specialties tracked – and a consequent migration of family physicians towards hospital employment. Medical students are increasingly avoiding family medicine (the number of students selecting careers in primary care has declined by 41% in the last decade), leading to an expected shortage of 44,000 primary care physicians by 2025.

Little-Known ACA Proviso Stirs Controversy

Wednesday, May 9th, 2012

There’s a largely unseen battle raging among consumer advocates, physician groups and some Democrats in Congress over a key benefit in the Patient Protection and Affordable Care Act (ACA) — tax credits that will help millions of people purchase insurance.

According to Kaiser Health News, “At issue is a section of the law that outlines when low- and moderate-income employees can opt out of their employer’s coverage and instead get federal subsidies to buy insurance through new state-based marketplaces, called exchanges.  The debate over who qualifies for subsidies has been overshadowed by more-polarizing issues such as the government’s authority to require most people to buy insurance.  But if the Supreme Court upholds the law — or even most of the law — the way the tax-credit dispute is resolved will help determine how many people can get subsidized coverage.  A proposed Treasury Department rule says workers and their families cannot qualify for those subsidies unless their employer’s plan is unaffordable because it exceeds 9.5 percent of their household income.”

Consumer advocates are steadfast in their opposition to the rule because it bases affordability on how much an employee might pay for individual coverage, rather than on the cost of covering their entire family.  As a result, many workers won’t be able to afford family coverage, yet their spouses and children will be ineligible to get help to buy insurance.  Approximately 3.9 million dependents might be impacted, according to one estimate.

“The proposed rule excludes people Congress intended to cover,” said Bruce Lesley, president of First Focus Campaign for Children, who sent a letter to Treasury signed by more than 100 advocacy groups, including the American Academy of Family Physicians, the Children’s Defense Fund, the March of Dimes and the National Council of La Raza.  The letter asks President Barack Obama and congressional leaders to take “administrative action or legislation” to spell out what Congress intended.

Treasury officials are drafting final rules, which are expected to be released soon.  “We are working with consumers, businesses and all interested parties to ensure women and families get the affordable care they need,” Treasury Department spokeswoman Sabrina Siddiqui said.

Supporters of the proposed rule, primarily employer groups and insurance brokers, say it is in keeping with the wording in the ACA that defines affordability in terms of the cost of “self-only coverage.”  Critics, including the National Partnership for Women and Families, say it allows for basing the affordability standard on the cost of family coverage. The group notes that Treasury officials plan to use the cost of a family plan as a basis for exempting some people from penalties for not buying insurance.  “It’s unlikely that Congress intended affordability to be determined one way” for penalty fines and another for subsidies, according to the groups.

Several Democratic lawmakers who played key roles in writing and passing the law say the proposed rule is not what Congress intended.  “The notion that Congress wrote the law in a manner that would exclude many families from access to more affordable coverage…is simply incongruent,” according to Representative Sander M. Levin (D-MI), the ranking Democrat on the Ways and Means Committee, and Representative Henry A. Waxman (D-CA), the ranking Democrat on the Energy and Commerce Committee.

Employers and taxpayers have a lot at stake in the way this rule is interpreted. For every worker who forgoes “unaffordable” job-based coverage in favor of subsidized insurance, the employer pays either a $3,000 per subsidized-worker penalty or $2,000 per employee.  The government’s stake will be less if more workers retain job-based coverage and fewer people seek subsidies.  At the same time, tax credits are the main way the law is expected to help low- and middle-income Americans buy insurance if they don’t have access affordable employer-based coverage.  By 2019, for example, the Congressional Budget Office (CBO) estimated that the government will spend $70 billion in tax credits to help 18 million people buy coverage through the exchanges.

Workers paid an average of $921 for an individual health insurance policy last year. That equals 18 percent of the total cost of the plan, according to an annual survey by the nonpartisan Kaiser Family Foundation and the Health Research & Educational Trust.  An employee’s share of a family plan averaged $4,129, or 28 percent of the total cost.

Based on those figures, a worker earning $40,000 will be ineligible to get subsidies because the $921 is less than 9.5 percent of income, even though the cost of the family plan exceeds that cap. In that scenario, the worker’s dependents will be ineligible to receive subsidies.  The policy is certain to impact women, who are 2.5 times as likely as men to be insured as a dependent, the hardest, according to the National Partnership.

“It will force more people into not having an affordable option,” said Dana Cope, executive director with the State Employees Association of North Carolina.  According to Cope, family coverage costs increased the ranks of the uninsured in North Carolina, where the state subsidizes employee coverage, but does not contribute toward family insurance.  “State employees…who earn on average $41,000…cannot afford to cover their dependents,” Cope said.

Battle About Medicaid Block Grants Brewing in Congress

Wednesday, May 11th, 2011

Mississippi Governor – and possible presidential hopeful — Haley Barbour and other Republican governors recently demanded that Medicaid, the state-federal health program that covers 50 million poor and disabled, be transformed into block grants.  House Republicans have vowed to tackle expensive programs like Medicaid to cut federal spending.  Any attempt to turn Medicaid into block grants – federal lump-sum payments to states – raises many questions.  Democrats argue that a move of this type could result in loss of healthcare coverage for millions who are poor, sick and old.

Representative Fred Upton (R-MI), chairman of the House Energy and Commerce Health Subcommittee said to expect House bills on the Medicaid program’s maintenance-of-effort requirement and block grant funding to states.  Because Medicaid is an entitlement program, all Americans who are eligible are guaranteed coverage.  The federal government, which foots the bill for approximately 60 percent of Medicaid’s cost, is committed to helping the  states cover costs; in return, it requires them to cover certain groups of people and provide specific benefits.  For example, children, pregnant women who meet explicit income criteria and parents with dependent children must be given coverage.

“The governors have requested flexibility in the way they serve Medicaid patients,” Representative Joseph Pitts (R-PA), the Health Subcommittee’s chairman said.  “They maintain they can provide the service better and cheaper, so we’re looking to give them that flexibility and change this maintenance-of-effort provision.  I won’t be specific on the block grants, but we’re having discussions with governors.”  Pitts’ comments followed a Health Subcommittee hearing in which HHS Secretary Kathleen Sebelius answered extensive questions about the Obama administration’s fiscal 2012 budget and the Patient Protection and Affordable Care Act.

Why are the block grants important?  When the new healthcare law goes into full effect in 2014, approximately 16 million additional people will become eligible for Medicaid.  The debate, which cuts to the heart of the social contract between the government and its citizens, has implications for the other large entitlement programs — Social Security and Medicare.  In 2010, the federal government spent $1.5 trillion on those programs, or approximately 43 percent of the federal budget, according to the Congressional Budget Office.  Speaker of the House John Boehner (R-OH) said House Republicans’ upcoming budget proposal would cut Social Security and Medicare, despite the political risk of taking on such popular programs.  Democrats are skeptical.  Changing Medicaid into a block grant means “you have no guarantee that people who are now covered will continue to be covered, or whether (the states) will simply cut back on their Medicaid program,” said Representative Henry Waxman, (D-CA), who is a primary defender of the program.

HHS Giving Waivers to Small Health Plans

Tuesday, March 22nd, 2011

The Department of Health and Human Services (HHS) has okayed 94 percent of requests – primarily from sponsors of “mini-med” and other limited healthcare plans – for waivers that excuse them from meeting a key requirement of the Patient Protection and Affordable Care Act (ACA). According to HHS Secretary Kathleen Sebelius, the waivers are needed because most mini-med plans do not meet federal rules mandated by the healthcare reform law, which establishes a minimum yearly dollar limit on essential benefits that plans must provide in 2011, 2012 and 2013. For 2011, the minimum is $750,000, rising to $1.25 million in 2012 and $2 million in 2013.  To date, 919 of 975 waiver applications have been approved by HHS, according to Representative Henry Waxman (D-CA), the ranking Democrat on the House Energy and Commerce Committee.

“We are committed to making the waiver process transparent to the public and to make sure workers with mini-med plans are informed about the limited nature of their coverage,” said Steve Larsen, director of oversight in HHS’s Office of Consumer Information and Insurance. “For example, we have required plans that receive waivers to inform their enrollees that their coverage is limited.  HHS also helps to ensure transparency by posting a list of the plans that have been granted waivers, so stakeholders understand how they are affected.”  To date, waivers have been granted in Florida, New Jersey, Ohio and Tennessee.  Members of Congress said that in several other states, insurers and employers will need similar exemptions from some of the law’s requirements.

Not surprisingly, House Republicans slammed HHS for granting the waivers, claiming that they are proof that the Affordable Care Act is deeply flawed. “I think it is an understatement to say that these waivers have been controversial,” said Representative Cliff Stearns (R-FL).  “Obamacare was sold as all benefit — no downside.”  Plans that were granted waivers represent about 2.4 million people, or about one percent of the employer-based coverage market overall, according to HHS.

Additionally, House Republicans expressed concern that power over public and private health insurance programs was concentrated in the Centers for Medicare and Medicaid Services, led by an official, Dr. Donald M. Berwick, who has not been confirmed by the Senate. “He is in charge of almost all insurance coverage in the United States,” said Representative Michael Burgess, (R-TX).

Pre-Existing Medical Conditions Impact As Many As Half of All Americans

Wednesday, February 9th, 2011

A Department of Health and Human Services (HHS) study reveals that as many as half of all Americans under the age of 65 have pre-existing medical conditions, which could mean rejection by insurance companies or having to pay more for coverage.  According to HHS Secretary Kathleen Sebelius, that totals approximately 169 million people.  The report says that, of those Americans who are uninsured, 17 to 46 percent have pre-existing medical conditions, depending on the definition used. Such health problems are particularly common among adults aged 55 to 64 – a group long recognized as a problem spot in the healthcare system, because people of that age tend to have higher medical expenses but are too young to qualify for Medicare.

A Democratic analysis, released last fall by Representative Henry A. Waxman (D-CA), then the chairman of the House Energy and Commerce Committee, said that between 2007 and 2009, the nation’s four largest private health insurers denied coverage to about 650,000 people based on their medical history.

“Not surprisingly, as people age, their likelihood of having – or having had – a health condition increases,” according to Sebelius.  “Looking only at pre-existing conditions used in determining eligibility for high-risk pools, the percentage of Americans with these health conditions ranges from five percent of children to 48 percent of people ages 55 to 64.  Adding in common conditions that major insurers generally use in medical underwriting raises the risk to 24 percent for children, increasing to 86 percent for people ages 55 to 64.”

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans (AHIP), the industry’s lobbying group, offers a different opinion, noting that “We’ve long supported reforming the individual insurance market so that everybody can have access to health-care coverage, regardless of their preexisting medical conditions.  But this report exaggerates the number of people who are impacted.”

Rick Ungar, who writes for Forbes, offers another perspective and asks if pre-existing conditions are an indication that the American Dream is dead.  According to Ungar — who is an attorney in Southern California, and a frequent writer, speaker and consultant on healthcare policy and politics – his initial reaction to the government report was “Yeah…it made me suspicious too.  Go figure that this extraordinary government revelation would surface on the very day the House is taking up debate on the repeal of healthcare reform.”

Ungar’s suspicion eased when he read this additional quote from Zirkelbach.  “Most of the Americans included in the figures currently have insurance. They would be at risk,” he said, “only if they needed to change coverage and buy it on their own.  People who get insurance through their jobs are guaranteed coverage.” Alter+Care Inspire notes that an additional reason might be people losing their jobs – something to consider at a time when the private sector has been so sluggish.

“And there it was,” according to Ungar.  “This spokesman for the nation’s pre-eminent health insurance lobby was not only acknowledging that there are millions upon millions of people with pre-existing conditions who could be denied healthcare coverage, he was actually telling us that we need not worry about them because – so long as they continue to get their insurance through their job – it’s all good.  But what if they want to leave their job to engage in some good, old-fashioned American entrepreneurialism?  Did Mr. Zirkelbach inadvertently direct our attention to the depressing reality that up to one-half of all Americans may not be free to pursue their futures and fortunes as they see fit because they are trapped in their jobs by their healthcare benefits?  You bet he did.”