Advisor role in exchanges causes clash | LifeHealthPro

Advisor role in exchanges causes clash | LifeHealthPro.


CareFirst to give $8.5 million in grants to safety-net clinics

CareFirst to give $8.5 million in grants to safety-net clinics
By Lena H. Sun, Washington Post, February 28

CareFirst BlueCross Blue­Shield, the largest private insurer in the Washington region, plans to announce Tuesday that it will give $8.5 million to a dozen safety-net clinics to help them use a coordinated primary-care approach to treat their most vulnerable patients, executives said.

Over the next three years, the funded programs are expected to treat as many as 66,000 patients with costly chronic illnesses such as diabetes, heart disease and high blood pressure. The clinics are in Maryland, Virginia and the District.

The initiative expands on an approach known as the patient-centered medical home, which is being tested in dozens of public and private experiments across the country as part of the health-care overhaul. Federal policymakers are watching closely to see whether the strategy can improve care and reduce costs.

Instead of doctors waiting to see patients mostly when they have a specific problem, a team of doctors, nurses and other staff members aims to take care of the whole person on a continuing basis, with an emphasis on prevention and comprehensive care, often targeting the sickest patients. The strategy is expected to translate into better care and fewer emergency visits, hospital stays and trips to specialists, clinic officials said.

Many of the experiments are taking place in privately insured networks. CareFirst, with 3.4 million members, has been conducting one of the largest of its kind in the Washington area since January 2011. About 3,100 doctors, or 81 percent of the region’s actively practicing primary-care physicians, are participating in the program, according to Chet Burrell, CareFirst’s chief executive.

The program uses a team approach and relies on a host of financial incentives to encourage doctors to increase the emphasis on helping their sickest patients. Doctors who join the program receive a 12 percent increase in their insurance reimbursements, $200 for each detailed care plan they set up for a patient, and additional fees for improving quality and reducing overall cost.

In the initiative to be announced Tuesday, CareFirst will provide grants to the safety-net clinics to jump-start their own programs. CareFirst will also give technical support and guidance on electronic health record systems, clinic officials said.

Clinics were asked to submit proposals and were chosen based on how well they could coordinate care for the most needy patients.

“We’re not paying for the care, we’re paying for the coordination,” Burrell said.

One of the recipients is the Arlington Free Clinic, which provides free health care to about 1,600 low-income, uninsured residents. The clinic will receive about $350,000 over three years, roughly a third of the total cost of the program, said Nancy Sanger Palleson, the clinic’s chief executive.

The clinic will use the money to hire additional personnel and upgrade electronic medical records to allow the staff to better track the care of “the sickest of the sick” — about 160 people — she said.

For example, medical assistants could make sure the necessary bloodwork is completed before a patient’s appointment with a specialist, Palleson said. “Otherwise it would be a wasted trip for her and for the physician, who could be seeing someone else.”

With 140 affiliated doctors providing their services free, she said, “the more efficiently we can use them, the more people we will be able to see down the road.”

And the need appears to be growing. The clinic takes new patients through a monthly lottery system. Typically, about 120 show up for the lottery, and the clinic takes 25 of them, Palleson said — but last week, for the first time, 220 people showed up. “We could only take 25,” she said.

The other clinics include Mary’s Center and Unity Health Care in the District, the Spanish Catholic Center in D.C. and Maryland, and Community Clinic Inc. and partner Greater Baden Medical Services in Montgomery County and Prince George’s County.

Experts say the key will be whether the clinics can sustain the programs over time. “The kind of people who have complex medical problems as well as social and economic issues might be the people who would benefit most by this kind of initiative,” said Judy Feder, a health-care expert at the Urban Institute.

Those patients are most likely to “fall prey to the inappropriate use of health care, whether on the back end with preventable high-cost hospital admissions or on the front end with insufficient primary care,” she said.

Leveling the playing field will be even more important in the run-up to 2014, when primary-care doctors will be in greater demand as insurance coverage expands to millions more Americans, experts said.

Maryland hospitals to share patient data

Maryland hospitals to share patient data

By Lena H. Sun, Washington Post, Published: February 16

Maryland’s 46 acute-care hospitals will soon be able to share basic patient information among themselves and with credentialed doctors, a key step that health officials and clinicians say will improve patient care and cut costs.

The development, announced at a news conference Friday at Holy Cross Hospital in Silver Spring, is being led by the Maryland’s health information exchange, a statewide system that is working to promote the secure electronic sharing of health information among approved doctors’ offices, hospitals and other health organizations.

Maryland officials have been among the most aggressive in pushing for the sharing of health information, an important piece of the federal health-care overhaul. Patients have long been frustrated by the inability of doctors at one facility to access records about a visit to another hospital. But changing the process has been slow for a variety of reasons, including reluctance by hospitals and others to exchange information with competitors.

The goal is to “help ensure that providers have the right information about the right patient at the right time so we can reduce costs and improve care for all Marylanders,” Lt. Gov. Anthony G. Brown (D) said in a statement.

The level of data available for sharing is rolling out in stages.

All of Maryland’s acute-care hospitals are providing basic patient demographic information in real time to the exchange. But it will be 18 to 24 months before the hospitals’ users are fully trained to use the shared data. This includes when any patient in the state is admitted, discharged or transferred, officials said.

Eventually, all hospitals would share much more detailed clinical data, such as lab reports, radiology reports (but not images), and clinical documents such as hospital discharge summaries and specialist reports, said Scott Afzal, who heads the arm of the nonprofit Chesapeake Regional Information System for Our Patients (CRISP) that is in charge of running the state’s health information exchange.

Four of the five hospitals in Montgomery County already provide the most detailed clinical data to the exchange. But only two — Suburban and Holy Cross — have received the extensive training to allow their users to access patient data from other hospitals, he said.

At Suburban, emergency room doctors say the additional information has allowed doctors to improve care.

In an interview posted on the CRISP Web site, Barton Leonard, who heads Suburban’s emergency department, said doctors can even access the operation notes from a surgery that took place two hours earlier.

“No more waiting on faxes or sitting on the phone waiting to talk to someone in medical records,” Leonard said.

In one case in December, Leonard said he was treating a patient with a severe infection and was able to look up his previous blood and urine cultures at another hospital and quickly get him on the right antibiotic.

Efforts in the District and Northern Virginia have lagged farther behind that of Maryland. In the District, an effort to create a health information exchange by the D.C. Primary Care Association, a private group, was suspended because of a lack of funding. The District government is working to create another exchange. In Northern Virginia, a coordinating organization exists, but an exchange has not been set up.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

United Medical Center seeks $15 million from the D.C. government

United Medical Center seeks $15 million from the D.C. government

By Tim Craig, Washington Post, Thursday, February 16, 8:47 PM

United Medical Center is requesting an additional $15 million from D.C. taxpayers to help finance a turnaround, likely renewing debate about whether the city should own a cash-starved hospital.

After its previous owners defaulted on its obligations to the city, the District took over the Ward 8 hospital in December 2010 until a new operator could be found. But the city government is divided over whether the city should try to quickly unload the hospital to a private buyer or keep it to try to bolster its quality — and its price tag.

With the latter camp prevailing so far, the hospital’s board of directors wrote Mayor Vincent C. Gray (D), requesting additional funds to help United Medical rebrand its mission by shifting to “ambulatory and physician-centric care.’’ The hospital, formerly known as Greater Southeast Medical Center, specializes in traditional acute care.

The board is asking the District for an additional $9 million in direct funding, as well as to forgive a $6 million loan. The board will also seek $5 million in federal funds.

“The Board, hospital management, and [the Office of the Chief Financial Officer] leadership met to collaboratively determine the financial support needed to maintain hospital operations and fund the restructuring effort,” wrote Bishop C. Matthews Hudson, chairman of the board. “We came to a consensus that $15 million will be required.”

Gray said in a statement that he would “carefully review” the request “to determine the best response for the benefit of UMC, the District residents it services, and the city as a whole.”

Serving a limited number of clients with private insurance, the hospital has been plagued by financial problems for years. But as the only hospital east of the Anacostia River, D.C. Council member David A. Catania (I-At Large) and other city leaders have repeatedly stepped in to prevent it from closing.

The District invested $79 million in the hospital in 2007 as part of a deal to keep it from closing by selling it to Specialty Hospitals of America, a for-profit company. Specialty struggled to make it payments, citing low Medicare reimbursement rates. In 2010, the District took over the hospital after Specialty defaulted.

Catania, chairman of the health committee, has become a chief advocate for keeping the hospital under public control.

Chief Financial Officer Natwar M. Gandhi has suggested a quick sale. Although Gray agrees broadly with Gandhi’s concerns, he has signaled that he is willing to give the hospital time to stabilize its finances.

In October, a report by the Department of Health Care Finance recommended that the hospital readjust its mission so it can compete better. Citing the report, Gray then requested that the hospital focus more on ambulatory care before it is put up for sale.

Hudson said in his letter that additional money is needed to work toward Gray’s suggestion, including the hiring of a “turnaround consultant.”

“We are not just asking for money,” Hudson said in a brief interview. “There is a purpose to move the hospital forward.”

Hospital officials note that the facility’s finances have improved since the city takeover, including an estimated $2.5 million profit in the fiscal year that ended Sept. 30.

“If you want to make improvements, you have to invest in capital and . . . this proposal appears to do that,” Catania said through a spokesman, Brendan Williams-Kief.

But the hospital’s request could spark a fierce debate on the D.C. Council.

On Tuesday, Catania got into a profanity-laced shouting match with council member Marion Barry (D-Ward 8) when Barry tried to question Gandhi on the hospital’s finances.

Barry, however, endorsed the turnaround plan on Thursday. “We are not going to let the hospital fail,” he said.

Health insurance exchanges in limbo

Health insurance exchanges in limbo

By Sarah Kliff, Tuesday, February 14, 10:18 AM

Pablo Martinez Monsivais AP Of all the agencies to get spending boost in Monday’s budget, the Center for Medicare and Medicaid Services was among the very largest. The White House proposed a $1 billion bump for the agency, that actually had very little to do with Medicare or Medicaid. Instead, it was largely about health exchanges: the online, insurance marketplaces that are supposed to be the backbone to the Affordable Care Act.

More than $860 million of the proposed $1 billion would go to building a federal exchange, which the Obama administration will set up for states that don’t build marketplaces on their own. The agency needs more implementation funds, officials explained at a Monday press briefing, because the $1 billion appropriated within the law is probably going to run out by the end of the year.

Half “has already been obligated or committed for another purpose,” said CMS official Ellen Murray. “The rest will be used this year.”

There’s little expectation that Congress will actually appropriate the funds the White House has requested, especially when the ask is so big and would pretty much go directly toward health reform implementation. What happens to the federal exchange if Congress turns down the request? Center for Consumer Information and Insurance Oversight director Steve Larsen tells Bloomberg that the government “will work with existing, available funding sources.”

There’s a big question, though, about where those funds are – if they do, indeed, exist. Politico’s J. Lester Feder broke the news last year that while the law allows for “essentially unlimited” funding for states to set up exchanges, it did not appropriate funds for the federal government to do the same. All it provided was a general, $1 billion implementation fund – that’s the one that HHS expects to exhaust by the end of the year.

That federal marketplace will near certainly be needed, as large states like Florida and Louisiana have firmly decided not to set up their own exchanges. Even some states that want to move forward are running into trouble: Just Monday, state legislators in Oregon blocked its marketplace from moving forward.

The uncertainty of where federal exchange funding will come from underscores how much of the health reform law’s fate hangs on the upcoming election. There’s little doubt that the Obama administration will, somewhere, find funds to make sure a federal exchange comes online. The marketplace is, after all, essential to making the Affordable Care Act work. Under a President Romney, it’s pretty easy to see those funds not turning up, and throwing a big wrench into the health reform law’s future.

© The Washington Post Company

DC DISB Press Release on $1 Million Federal Rate Review Grant

DISB Awarded $1 Million Federal Grant

(Washington, DC) — Commissioner Gennet Purcell, Esq., of the DC Department of Insurance, Securities and Banking (DISB) announced that the District of Columbia will receive a $1 million federal grant from the US Department of Health and Human Services (HHS) to enhance DISB’s health insurance premium rate program.

The grant announcement, which was made recently by HHS Secretary Kathleen Sebelius, will be used to improve the oversight of proposed health insurance premium increases, take action against insurers seeking unreasonable rate hikes, and ensure consumers receive value for their premium dollars.

“The District of Columbia is extremely grateful to President Barack Obama and Secretary Sebelius for awarding the city with this grant that safeguards our residents from unreasonable health insurance premiums,” said Commissioner Purcell, adding that DISB had submitted the grant application in July. “With this grant, DISB will continue to create a financial-services market that protects residents from excessive rate increases, but also allows us to move forward in modernizing our approaches in reaching the goal of affordable and accessible care for District consumers.”

The Health Insurance Premium Review Grant is one element of a broad effort under the Patient Protection and Affordable Care Act (PPACA) to increase access to affordable health care. A total of $46 million was awarded to 45 states and the District of Columbia. PPACA includes a variety of provisions to promote a high-quality, high-value, health care system for all Americans, and to make the health insurance market more consumer-friendly and transparent. The grant underscored the federal administration’s commitment to work with state regulators; and it was awarded to DISB to make structural changes to its regulatory authority.

In seeking the grant, DISB proposed to use the funding to significantly enhance the agency’s process for the review and approval of rates of health insurers through the use of advanced technology and the hiring of specialized staff. Additionally, the grant will be used to create a uniformed rate filing procedure for all health providers operating in the District of Columbia. Finally, DISB will use the funding to develop procedures and a system to collect and report health insurance rates and trends in health insurance coverage to the HHS Secretary and the public.

“DISB is looking forward to having these tools to ensure the stability of the marketplace, keep costs low, and provide consumers with increased transparency; as well as offer the choices and quality they need to make the best health care decisions for their businesses and families,” Commissioner Purcell added.

For more details on health reform in the District of Columbia, please visit More information about PPACA may be found at

Kevin S. Wrege, Esq.


PULSE Issues & Advocacy LLC

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

Office: 202-625-1787

Mobile: 202-253-4929

AIS Health Business Daily Piece on Federal Rate Review Grants to States/DC

Featured Story, Sept. 1, 2010

Are Rate Review Grants to States a Strategy to Control Premiums or an HHS PR Maneuver?

Reprinted from HEALTH PLAN WEEK, the industry’s leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

By Steve Davis, Managing Editor

HHS on Aug. 16 awarded $46 million in grants to help state regulators police the insurance industry and crack down on unjustified rate hikes. State regulators tell HPW that the money is needed to upgrade infrastructure, enhance data collection systems, hire consultants and actuaries and post rate filings and other consumer information on their websites. But some industry observers, including two former insurance commissioners, contend the grants equate to little more than a publicity campaign to promote the health reform law. Moreover, they say, rising health coverage costs are the direct result of fees demanded by hospitals and other providers, and increased scrutiny of filings will have limited impact on rates.

Kansas Insurance Commissioner Sandy Praeger says her office will use some of the funding to hire a consultant to evaluate its current rate-review process. Her office now has 30 days to review and approve requested rates, but she typically only denies requests if she can demonstrate that they are excessive or discriminatory, she tells HPW. Praeger adds that the funding could provide her office with more resources with which to make such determinations.

“Those grants are going to be very helpful to states during difficult budget times and will give us the capacity to do what we need to do, whether that is providing consumer information and improving transparency, or going through the physical review process,” says Oklahoma Insurance Commissioner Kim Holland. She tells HPW that her office will use some of the funding to hire actuarial consultants to help it comply with the new rate review process and an anticipated increase in rate filing volume.

The District of Columbia and all but five states — Alaska, Georgia, Iowa, Minnesota and Wyoming — applied for and were awarded $1 million each. The grants are the first round of $250 million in funding called for by the health reform law to improve the way states review and approve insurance rate increases. Future grants will be awarded over the next five years. Each state that receives a grant is expected to require insurance companies to report more extensive information through a new, standardized process, which HHS says will help state regulators better evaluate proposed premium increases.

But the grants, which were touted during an HHS press conference, are politically motivated and will do little to protect consumers against rate hikes, says Paul Ginsburg, president of the Washington, D.C.-based Center for Studying Health System Change. The funding, he adds, is an attempt to convince the public that changes to the existing insurance system, as a result of the reform law, are already underway even though key provisions won’t take effect until 2014. He tells HPW that the funding will have little impact on health insurers or the rates they charge.

“The potential to lower rates significantly through rate review is not there, but it polls well to ‘put a cop on the beat.’ Part of it is pressure from those who preferred a single payer approach, who are highly suspicious that private insurers can bring value to health care,” he tells HPW.

Just 26 states have the authority to reject proposed rate increases, and many of them lack the resources to exercise that authority, which has contributed to “unjustified” premium increases in some states, according to HHS.

J. Robert Hunter, former Texas insurance commissioner, agrees that many states don’t have the authority to reject rate hikes, but says some of them simply lack the will to do so. Hunter, who now works with the Consumer Federation of America, warns that state regulators could lose some of their authority to HHS if they don’t get tough on rate hikes. “The only way for the federal folks to get [state regulators] to act is to threaten to take over” if they don’t conduct tougher reviews and keep coverage costs reasonable. “This $1 million carrot is vastly inadequate to do the job,” he adds.

Former Maryland Insurance Commissioner Al Redmer calls the grants a waste of money. “I don’t know of any state insurance administration that does not have some statutory authority to review rates already,” he tells HPW. “Typically state regulators can get what they need from the state legislature. [The grants are] just another attempt to spread federal dollars throughout state bureaucracies throughout the country. It is a [public relations] move.” Redmer is now president of Landmark Insurance and Financial Group and is running as a Republican for a state senate seat.

But Holland says turning to the state lawmakers for help might not be that easy. State legislatures are their “own unique animal” that deal with myriad issues. Moreover, rate review is a complex issue that some state legislatures might not want to tackle. Holland says she doesn’t now have rate approval authority, but says her office has asked health insurers in the state to begin filing rates “and they have been cooperating.” Ultimately the state legislature has to grant the insurance department the authority to conduct rate reviews.

States will be allowed to contribute $18,000 of their grant to the National Association of Insurance Commissioners, and nearly all of the grantees intend to do so, says Praeger. The funding will help NAIC add more capacity to its electronic rate and form filing system and standardize some of its data collection, she says.

Most states intend to use part of the funding to post details about the rate requests on their websites, according to their applications. While such information won’t impact rates, state regulators say it will give the public a better understanding of insurance costs.

Here’s a look at a few states and how they intend to use their funding:

  • Arizona: State regulators check filings in the individual market only for completeness. The additional funding will help the department of insurance improve its review process by hiring an actuarial consultant to review 95% of submissions for compliance, and to make recommendations regarding whether filings are unjustified or excessive.
  • Arkansas: The funding will help create and staff a “consumer-driven advisory council,” improve transparency and communications through an expanded website, and create a Rate Review Center for consumers and issuers.
  • Colorado: In its application, the state said it would use some of the funding to hold web-based town hall meetings and public rate hearings.
  • Illinois: Along with posting filings on its website and conducting public hearings on proposed rate requests, the state will translate web and print health insurance information into Spanish, Polish and Korean.
  • Massachusetts: The state insurance department says it will develop “new analytic tools” to evaluate rates. It also intends to require health insurers to separate claims and administrative data into “standardized buckets,” and develop new models to analyze rate data.
  • Oregon: The state, which now reviews only individual and small-group rate proposals, says it will use some of the federal funding to develop and implement a large-group market rate review process. Much of the grant will be used to examine rates requests and provide information to the public.
  • Wisconsin: Sean Dilweg, Wisconsin’s commissioner of insurance, says his office will use the grant money to improve transparency and consumer education around rate increases, and pay for additional “actuarial resources” that will help review proposed rate hikes and identify trends among health insurers. Some of the funding also might be used in the future to help the department make recommendations on whether a health plan can participate, or continue to participate, in the state’s insurance exchange, which must be operational by 2014 under the reform law.

Kevin S. Wrege, Esq.


PULSE Issues & Advocacy LLC

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

Office: 202-625-1787

Mobile: 202-253-4929