Article link: http://www.kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/?utm_campaign=KFF-2016-December-Pre-Existing-Condition-Data-Note&utm_content=60741450&utm_medium=social&utm_source=twitter
Wednesday, April 5, 2017
- Interstate sale of health insurance is unlikely to increase competition
- Insurers can already sell insurance across state lines and so far it hasn’t lower costs or improved care
In the wake of the failure of the legislative effort to repeal and replace the Affordable Care Act (ACA), the fate of another of the president’s health care priorities is unclear. In his first congressional address, President Trump articulated five principles for health care reform. His fifth and last called for giving “Americans the freedom to purchase health insurance across state lines,” a reform that, in his words, would create “a truly competitive national marketplace that will bring cost way down and provide far better care.” This concept was not in the House reconciliation bill (the “American Health Care Act” or AHCA) to repeal and replace key provisions of the ACA, but President Trump may be able to use his regulatory authority to promote the cross-border sales of health insurance.
The president has the authority to act on his own thanks in part to the ACA. That law includes a provision encouraging “health care choice compacts,” whereby an insurer could establish itself in one state and sell health insurance to consumers in multiple other states without having to follow those states’ laws and regulations. However, under President Obama, the U.S. Department of Health and Human Services (HHS) never published regulations enabling these cross-state sales.
While the ACA provision encourages states to enter into cross-state regulatory agreements in order to facilitate interstate sales, under Trump’s campaign and several congressional proposals, the federal government would effectively override states’ authority to regulate their markets. In the absence of legislative action, there is nothing preventing HHS Secretary Tom Price from issuing the required regulations and working with states to develop standards for interstate sales. In fact, several states already allow cross-state sales.
The Theory Behind Policies to Allow the Sale of Insurance “Across State Lines”
Health insurance has traditionally been regulated by states, which, until the ACA established a set of essential health benefits and other minimum consumer protections, meant that there was significant state variation in the rules governing insurance companies and the health plans that they sell. Some states have had numerous requirements mandating coverage of certain benefits, such as autism treatment, diabetes screening, or mammograms, while others have taken a hands-off approach to benefit design. Similarly, before the ACA prohibited charging women or people with preexisting conditions more for their coverage, some states limited insurers’ flexibility in setting premiums based on characteristics of enrollees while others did not.
The concept of selling insurance across state lines, which dates back to the 1990s, was borne out of frustration with the variation in state regulation. Proponents contend that if an insurance company were allowed to operate by the rules of just one state but sell plans in multiple states, they could lower the price of their plans, giving consumers new and more affordable choices.
When Theory Collides with Reality
While the frustration with the costs of our current health care system is well-founded, proposals to allow cross-state sales will do nothing to encourage greater competition or address the underlying drivers of health care costs. Just like politics, health insurance is local. Today’s health plans essentially provide enrollees with access to a local network of doctors and hospitals at a discounted price. According to many insurance experts, the primary barrier for an insurer looking to enter a new market is not the state’s regulations, it’s the cost of building up a provider network at discounted prices.
To date, six states have enacted laws to allow cross-state sales: Georgia, Kentucky, Maine, Rhode Island, Washington, and Wyoming. Yet none of these states has had a single new insurer enter its market because of its law. When asked about their laws, state officials and insurance industry experts in those states agreed that establishing a competitive provider network is the primary barrier to new market entrants. They also observed that the sheer complexity of how insurance products are developed, priced, and regulated makes it difficult to establish a single cross-state framework for consumer protection.
At the same time, there is a significant risk that if the ACA’s insurance reforms are repealed, and Congress enacts legislation to mandate cross-state sales, it could lead to adverse selection in many states. Without a federal minimum standard of protections, some multistate insurers with national or regional networks could take advantage of the exemption from a state’s standards for benefit design, premium rating, and other consumer protections. This would enable them to attract younger and healthier enrollees than local insurers who must comply with their state’s laws. This, in turn, could threaten the long-term viability of local insurers, increase premiums, and reduce consumers’ choices.
Across-state-lines legislation pending in Congress would effectively force states to allow interstate sales. However, if President Trump wishes to fulfill his campaign promise to encourage health insurance to be sold across state lines, he need look no further than current law and his own HHS Secretary. He is likely to find—as six states have already found—that cross-state sales will do nothing to improve consumers’ choices or lower premiums.
Article link: http://www.commonwealthfund.org/publications/blog/2017/apr/selling-health-insurance-across-state-lines#/utm_source=selling-health-insurance-across-state-lines&utm_medium=Twitter&utm_campaign=Health%20Coverage
To learn more, see our explainer Essential Facts About Health Reform Alternatives: Allowing Insurance Sales Across State Lines.
WASHINGTON, Sept. 28, 2017 — DoD leaders announced the Interim Final Rule that charts the way forward for transforming TRICARE, the military’s health care system.
The transition goes into effect Jan. 1, said Tom McCaffery, the acting assistant secretary of defense for health affairs.
“We are at a really important point in time for our beneficiaries and the overall military health system in terms of changes and reforms,” McCaffery said during a recent phone interview with reporters.
The changes grew out of the National Defense Authorization Act last year that mandated the transition to TRICARE managed care contracts. This, added to all the changes happening in general in the health care field, “makes for one of the most significant health care transitions for our beneficiaries in decades,” he said.
The changes make sense for the health care system’s 9.4 million beneficiaries, McCaffery said.
The rule implements TRICARE Select — the new preferred provider organization-style benefit established by congress that incorporates TRICARE standard and TRICARE extra, said Navy Vice Adm. (Dr.) Raquel Bono, the director of the Defense Health Agency.
“The rule also sets up an automatic enrollment process, so on January 1 beneficiaries in Prime will automatically be enrolled in Prime or automatically be enrolled in Select if they are enrolled in Standard or Extra,” she said.
The agency will establish an annual open season enrollment period that beneficiaries can participate in each year to choose their health care plans, Bono said. The open season will run much like the Federal Employee Health Benefit program works and will be held at the same time.
The rule also outlines the rules for qualifying “life events” that allow beneficiaries to make changes that need to occur outside the open season, Bono said. Qualifying life events trigger a 90-day opportunity to enroll in or change TRICARE purchased care coverage for the rest of the calendar year. These include changes to marital status, births, adoptions, changes in service status, and so on.
Bono said 2018 will be a transition year. “During that time, enrollment changes will be available throughout the year as beneficiaries adjust to the new process,” she said. “We will also be broadening access for beneficiaries by setting out the requirements that at least 85 percent of our beneficiaries have access to network providers in TRICARE Select.”
Switching Program Administration
The agency will switch administration of the program from the fiscal year to the calendar year to streamline the combined changes mandated by the National Defense Authorization Act and the new contracts for beneficiaries, Bono said.
Included in the rule for TRICARE Prime beneficiaries are new requirements for timely appointments and new access to care, Bono said. “For Select beneficiaries seeking care within our broader network, it offers access to no cost preventive services now available to Prime enrollees,” the admiral said.
The rule also means a conversion from the current cost share from a percentage to a fixed dollar amount, she said.
This is the start of the process, McCaffery said.
“We recognize that our work is not done,” he said. “The interim final rule is an important step in the whole process we will need to have continued, [with a] very intense focus until the formal transition takes place January 1, and for months afterward.”
Article link: https://www.defense.gov/News/Article/Article/1328573/dod-leaders-announce-tricare-interim-final-rule-changes/
(Follow Jim Garamone on Twitter: @GaramoneDoDNews)
New criteria for vendors are meant to ease burdens and ultimately pass cost-savings down to the hospitals and systems that buy electronic health record software, Donald Rucker says.
The Office of the National Coordinator for Health IT’s plans to change the ONC Health IT Certification Program has sparked some important questions. Wouldn’t allowing vendors to now simply say they’re in compliance, rather than prove it in an ONC-Authorized Testing Laboratory, pave the way for EHR vendors to essentially flout the rules? And what’s to prevent more certification problems such as the eClinicalWorks $155 million settlement?
Or as Andre Thenot tweeted Thursday, “ONC switches to pinky-swear instead of actual compliance testing. #whatcouldpossiblygowrong.”
But National Coordinator Donald Rucker, MD, said ONC wasn’t sacrificing any of its regulatory oversight but was simply doing what it could to reduce the hoop-jumping required of vendors so they could better allocate their resources to more usable and interoperable products.
“What we’re trying to do here is make things as smooth as possible in the regulatory process,” Rucker said Thursday during a call with reporters. “We’re not changing the certification requirements, per se. We’re doing a little bit of streamlining on the process. So that will hopefully, in part, reduce vendors costs – and in a market economy over time some of those savings come down to providers.”
With the new rules, compliance requirements remain the same as ever, according to ONC. But now, rather than vendors having to put in the work to demonstrate, for instance, a relatively simple functionality such as CPOE for medications to a test lab, they can simply affirm that their product does that task, while focusing more of their time and energy on innovation.
But didn’t the eClinicalWorks case show that sometimes a verbal promise isn’t good enough? And that sometimes more stringent testing – showing, not telling – is necessary?
Rucker doesn’t think so.
“The reality is that these are very public products,” he said. “They have user bases who immediately know if something is working or not working. If a CPOE doesn’t go through, these things are known almost instantaneously. So the vast bulk of the oversight is provided by those using the product. This has to be looked at in the broader context of use. That’s where the data was coming from in prior enforcement actions.”
Actually, he said the eClinicalWorks case is “a perfect example that what we have in place in fact does work.”
The discrepancies with eCW’s products were first “noted by end-users,” he said. That case was ultimately investigated further thanks to reactive surveillance – not the randomized surveillance that would be reduced as part of these new rules.
ONC still fully intends to take an aggressive approach to reactive surveillance. In fact, just this past month it updated its Health IT Feedback Form, making it easier and more intuitive for providers to approach the agency with complaints or concerns about their products.
“Our experience is that people will report if there are issues with their product,” said Rucker.
He emphasized that all certification criteria are still in place and enforceable. And he said he didn’t see much changing for ONC-Authorized Certification Bodies and ONC-Authorized Testing Laboratories.
The self-declarable criteria are all relatively basic functionalities, after all. Those that require conformance testing to interoperability standards are still being affirmed by ONC-ATLs.
“There are a lot of things that are still being tested,” he said. And even for those criteria that are now self-declarable, “you still have to know how to solve the equation. It doesn’t change what you have to learn.”
In other words, even with the new rules, when a product is certified, the vendor is attesting that it does what it’s supposed to do. If that’s later found out not to be the case, either by an ACB or through subsequent reactive surveillance, ONC will take action – correcting where there is a non-conformity or even decertifying a given product.
The bulk of certified technologies “do exactly what is asked of them from the certification criteria,” said Rucker. “Building medical software is a highly iterative process. And there are many inputs on this. Because these foundations tend to be so heavily used – minute in, minute out – things become obvious relatively rapidly.”
The aim here, said Rucker, is to “increase the operational efficiency of the vendors to the extent that we can. Because those (testing) costs are all eventually, sooner or later, borne by the providers purchasing the products.”
- The September Kaiser Health Tracking Poll, fielded largely prior to the most recent Republican effort to repeal the 2010 health care law, finds three-fourths of the public saying it is important for Congress to work on reauthorizing funding for the State Children’s Health Insurance Program (CHIP), which provides health care coverage for uninsured children. Democrats prioritize reauthorizing CHIP funding and stabilizing the ACA marketplaces, with at least eight in ten saying each is an important priority for Congress to work on now. These are also the highest-ranking priorities among independents, with about seven in ten saying the same about both reauthorizing CHIP and stabilizing the marketplaces. Republicans, on the other hand, are more likely to prioritize continuing efforts to repeal and replace the ACA, with 71 percent saying that is important for Congress to do now.
- In general, Republicans are more likely to want Republicans in Congress to focus on repeal efforts than on improving the way the Affordable Care Act (ACA) is working (66 percent v. 28 percent), while most Democrats want Democrats in Congress to focus on improving the way the ACA is working (52 percent) rather than trying to pass a national health care plan (43 percent). A majority of independents want Democrats and Republicans in Congress to focus their efforts on improving the way the ACA is working rather than focusing on either a national health care plan or repealing the ACA.
- Half of the public thinks the ACA marketplaces are “collapsing.” One proposed step Congress could take to stabilize the markets and control costs for people who purchase their own plans is to guarantee cost-sharing reduction (CSR) payments to insurance companies. The Trump Administration has said they may stop making these payments, which has led to insurance companies saying they may raise premiums or stop participating in the marketplaces. Two-thirds of the public – including majorities of Democrats and independents – say Congress should guarantee the CSR payments in order to help stabilize the insurance market while about three in ten of the overall public and about half of Republicans (53 percent) say these payments constitute bailouts to the insurance companies and should be stopped. Overall, about seven in ten Americans are not confident that President Trump and Congress will be able to work together to make improvements to the ACA marketplaces.
- Overall views of the ACA are once again divided, with 46 percent expressing a favorable view and 44 percent expressing an unfavorable view. While overall favorability increased over the past year, this month finds a return to a divided public that characterizes most of the last seven years.
- This month’s Kaiser Health Tracking Poll examines public support for a variety of competing health care policies aimed at improving or replacing the 2010 health care law, including plans to allow people to “buy in” to Medicaid or Medicare.
After the Senate failed to pass a bill to repeal parts of the 2010 Affordable Care Act (ACA) in late-July, some lawmakers have turned their attention to various competing national health policy issues, including efforts to stabilize the ACA marketplaces, proposals to create a single-payer health care system, and the reauthorization of funding for the State Children’s Health Insurance Program (CHIP), while some have continued to focus on repealing and replacing the ACA. This month’s Kaiser Health Tracking Poll examines how Americans are prioritizing the competing health care issues as well as their attitudes toward possible changes to the current health care system.
What Should Congress Work on Now?
Congress has a number of competing priorities for the month of September, and when asked about several of the issues they may address this month, a large majority of the public see reauthorizing funding for CHIP and passing legislation to stabilize the ACA marketplaces as important priorities for Congress to work on now. Specifically, three-fourths of the public (75 percent) say it is “extremely” or “very” important for Congress to work on reauthorizing funding for CHIP, the program which provides health care coverage for uninsured children. This is followed by seven in ten (69 percent) who say the same about passing legislation to stabilize the ACA marketplaces in order to minimize premium increases and encourage more insurers to offer health plans. Fewer, but still about half, say it is “extremely” or “very” important for Congress to work on reforming the tax code, which may cut taxes for some individuals (49 percent), or work on continuing efforts to repeal and replace the 2010 health care law (47 percent).
Link to full article: http://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-september-2017-whats-next-for-health-care/?utm_campaign=KFF-2017-September-Tracking-Poll&utm_content=60710675&utm_medium=social&utm_source=twitter
John D. Halamka, M.D., and Micky Tripathi, Ph.D.
At a high level, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 accomplished something miraculous: the vast majority of U.S. hospitals and physicians are now active users of electronic health record (EHR) systems. No other sector of the U.S. economy of similar size (one sixth of the gross domestic product) and complexity (more than 5000 hospitals and more than 500,000 physicians) has undergone such rapid computerization.
Along the way, however, we lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving. Burdensome requirements imposed costs on providers and vendors without offering sustained benefit. These deficiencies were manifested in five key areas: usability, workflow, innovation, interoperability, and patient engagement.
The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) set ambitious requirements for “meaningful use” of health information technology (IT) to ensure that Medicare and Medicaid would get value from their large investment on a fixed timeline. But in the absence of business and clinical drivers for change (HITECH predated the Affordable Care Act by more than a year), meaningful use came to be used as a de facto vehicle for transforming health care delivery — a purpose for which, as a technology investment program, it was not adequate.
This approach led to complex requirements that stressed processes more than outcomes, telling providers not only what they should do with their EHRs but also how they should use them. For example, quality measurement added data collection requirements that had a substantial negative effect on usability with little return; performance was not connected with payments. Providers bristled at externally imposed process-oriented requirements that dictated their user experience without a corresponding change in reimbursement policies or clinical best practices.
This challenging situation became untenable for daily practice workflow when meaningful use was added to other disconnected regulatory requirements, including the International Classification of Diseases, 10th Revision (ICD-10), the Omnibus Rule of the Health Information Portability and Accountability Act (HIPAA), and new payment models from commercial and government accountable care organization (ACO) programs.
Soon physicians were expected to provide high-quality and empathic care in a 12-minute visit while weaning themselves from paper based workflows, entering the numerous structured data elements required for meaningful use, rolling out new HIPAA privacy notices, implementing security protections for new electronic data, learning and incorporating new ICD-10 billing codes, and convincing their patients to use patient portals and secure e-mail, all while avoiding safety and malpractice issues. Instead of being a gift horse that reduced clinician burden, the EHR became an expensive Trojan horse loaded with an array of new regulatory requirements.
It wasn’t just the providers who suddenly faced an avalanche of requirements. EHR vendors seeking to innovate had to meet complex certification requirements, administered by ONC-authorized testing companies, that imposed not only direct costs, but large opportunity costs as well. Development resources had to be diverted to programming of complex certification requirements to meet the technical, functional, and workflow requirements of meaningful use, which left little available capacity for innovation and product development based on user experience.
Over time, providers and vendors began to perceive meaningful use as yet another check-the-box compliance program. Furthermore, meaningful use set unrealistic expectations for interoperability. Though it did not specify a nationwide patient matching strategy, create a nationwide directory of provider electronic addresses, forge a single set of consent or privacy guidelines, or define governance for deciding who could exchange what for various purposes, it set requirements with the assumption that interoperability could somehow skip over such essentials.
Instead of recognizing the work that needed to be done on these foundational items, some policymakers invented the myth of “information blocking” as the root cause for lack of data flow. Our 50-plus combined years in the health IT industry have taught us that when technology, policy, and business needs are aligned, data flow.
As health care organizations have moved to value-based purchasing, they are finding that data sharing is a business imperative. The needs of care management are now creating genuine demand for interoperability services, such as “pushing” data to support referrals and transitions and “pulling” data for unscheduled visits such as emergency care. The meaningful use program did not stress any outcome from data sharing. Instead, it required a specific technology and set a process goal: adopt secure e-mail and count the number of messages sent. Many organizations set up “dead letter boxes” to send secure e-mail and comply with the requirement without ensuring that any clinical benefit was provided.
Today, the private sector is meeting burgeoning demand for interoperability with nationwide, standards-based networks that solve key issues such as patient matching, provider directories, uniform consent and privacy policies, data governance, common contracts, and well-defined business cases. Such networks include Carequality, CommonWell, DirectTrust, Epic’s CareEverywhere, and Surescripts at the national level, as well as regionally focused health information exchange networks such as those in Indiana, Maine, Maryland, and Massachusetts.
They also now include record sharing with government entities such as the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the Social Security Administration (SSA). Standards obviously play a key role in interoperability, and meaningful use has done much to accelerate the implementation of vocabulary standards such as SNOMED-CT (Systematized Nomenclature of Medicine — Clinical Terms), LOINC (Logical Observation Identifiers Names and Codes), and RxNorm, which have been widely adopted. Emerging open standards such as FHIR (Fast Healthcare Interoperability Resources), based on modern Internet conventions, are being embraced by the industry and are attracting companies and developers from outside health care to build innovative business models and technology platforms that are already reshaping the industry.
In terms of patient engagement, early attempts such as Blue Button (allowing patients to download text files of parts of their records) were well-intended efforts that ultimately did little to engage patients. One success of meaningful use was creating an imperative, and mechanisms, for giving patients access to their medical records, albeit through unwieldy, EHR-tethered patient portals.
If we want patients to be engaged to help reduce the burden of care coordination, care plan tracking, and communication, we need modern tools that enable patients to interact with their providers using devices and workflows that are already part of their daily lives. Many companies are now offering such tools. HITECH has played an invaluable role in accelerating the adoption of EHRs throughout the country.
We believe that now is the time to step back and recalibrate the role of the federal government on the basis of lessons learned. First, requirements related to meaningful use and the MeritBased Incentive Payment System (MIPS) introduced by CMS could be dramatically simplified to focus on interoperability and a streamlined set of outcome-oriented quality measures.
Second, EHR certification could focus exclusively on interoperability capabilities by setting up a public test server and reporting on EHR vendors’ success in reading and writing medical records on it.
Third, interoperability could be encouraged by market action rather than by regulation. The ONC, CMS, DOD, VA, SSA, and other federal agencies could actively encourage private-sector networks to connect with each other using open industry standards, much as wireless and automated-teller networks have done.
Finally, we could offer incentives for the adoption of open industry application programming interface (API) standards, such as FHIR, for provider– patient, provider–provider, provider–payer, and payer–patient interactions. The HITECH era was an important catalyst for EHR adoption, and the industry benefited from government intervention. If the post-HITECH era can return control of the agenda to customers, developers, and multi-stakeholder collaborations, we should be able to recapture the hearts and minds of our clinicians.
Disclosure forms provided by the authors are available at NEJM.org.
From Beth Israel Deaconess Medical Center and Harvard Medical School, Boston (J.D.H.), and the Massachusetts eHealth Collaborative, Waltham (M.T.) — both in Massachusetts.
DOI: 10.1056/NEJMp1709851 Copyright © 2017 Massachusetts Medical Society.
Article link: http://www.nejm.org/doi/pdf/10.1056/NEJMp1709851