2017 Renewal of Individual and Family Medical Plans

Insurance companies are mailing renewal information for individual and family policies, both benefit and premium changes. Some of the benefit changes are positive, some are not but most of these changes are dictated by The Affordable Care Act (ACA) commonly referred to as Obamacare. In most cases the premium increases are very substantial. I do not have complete rates for all the insurance companies as of yet.

Changes for 2017 cannot be made until November 1st for an effective date of January 1, 2017.

The individual health insurance market is shrinking. I will be setting phone appointments to begin on November to review plans. I strongly encourage that you to contact me. If you want to set a phone appointment with me, please respond to this e mail now and I will send you dates and times as options beginning in November.

Before your phone appointment, I will need to know the exact spelling of the names of doctors you want to continue to see, including their zip code. I will also need the exact spelling of any medications you need and the dosage.

If you believe you may be eligible for a subsidy through Covered California, I need to know your Estimated Modified Adjusted Gross Income for 2017. If you do not report a 2017 amount, I cannot complete a Covered California application as it will not be accepted into their system. I would encourage you to have a discussion with your tax professional. I need this information at the time of a phone appointment.

Some Grandfathered plans will be discontinued in 2017, we need to discuss replacement of those plans.

Rate Increases for 2017 Medical Insurance Plans

There will be a significant rate increase for 2017 plans. The reasons given are the end of funding that was available in the first three years to offset rates, the rise in specialty medication and claims from those who enroll during Special Enrollment Periods.

In regard to the specialty medication, sometimes pharmaceutical companies are raising prices of medications when the need for a medication increases. Newer specialty medications can approach $100,000 per course of treatment and/or per year.

Below is the press release from Covered California on July 19, 2016

SACRAMENTO, Calif. — Covered California unveiled its rates for 2017 on Tuesday and announced that some health insurance plans will be expanding into new areas throughout the state to compete for consumers in California.

The statewide weighted average change will be 13.2 percent, up from approximately four percent in each of the last two years. However, most consumers will see a much smaller increase — or pay less next year — if they switch to another plan.

“Shopping is going to be more important this year than ever before,” Covered California Executive Director Peter V. Lee said. “Almost 80 percent of our consumers will either be able to pay less than they are paying now, or see their rates go up by no more than 5 percent, if they shop and buy the lowest-cost plan at their same benefit level. That’s the power of shopping.”

Lee said the opportunities to shop and save show that California has succeeded in building a competitive marketplace for health insurance, with rate increases that are still below trends in the individual market before the Affordable Care Act was passed.

“This is a new era of health care, where the consumer is in the driver’s seat with the power to look easily for a better deal, and where subsidies help absorb the impact of rate changes,” Lee said. “These options did not exist before the Affordable Care Act.”

Some consumers who choose to keep their plan will see a significant increase in their premium for 2017, while others will see a more modest increase, depending on where they live and what insurance plan they have. Consumers will begin receiving notices in October, when they will have an opportunity to review their new rates and change plans for their 2017 health coverage.

For many of those insured, the bulk of the premium increase will be absorbed by the subsidy paid by the government to help enrollees buy health insurance. Approximately 90 percent of Covered California enrollees get help to pay for their premiums. The average subsidy covers roughly 77 percent of the consumer’s monthly premium, and while premiums will rise, the subsidies will rise as well.

“Even though the average rate increase is larger this year than the last two years, the three-year average increase is 7 percent — substantially better than rate trends before the Affordable Care Act was enacted,” Lee said.

Lee said the average rate increase reflects the cost of medical care for consumers, not excessive profit.

“Under the new rules of the Affordable Care Act, insurers face strict limits on the amount of profit they can make selling health insurance,” Lee said. “So, while all plans are experiencing different cost pressures, we can be confident their rate increases are directly linked to health care costs, not administration or profit, which averaged 1.5 percent across our contracted plans.”

For consumers who get a tax credit to lower their costs — which is about 90 percent of those who sign up through Covered California — the amount they pay is impacted not only by the premium choice, but by changes in their tax credit. While the average rate increase is higher than past years, Covered California’s risk mix — the ratio of consumers who are healthy vs. sick — remains one of the best in the nation according to the Centers for Medicare and Medicaid Services (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html).

Other reasons for rate increases include:
A one-year adjustment due to the end of a funding mechanism in the Affordable Care Act known as reinsurance, which was designed to moderate rate increases during the first three years when exchanges were being established. The American Academy of Actuaries estimates this will add between 4 percent and 7 percent to premiums for 2017.
Special enrollment by some consumers who may be enrolling in health insurance only after they become sick or need care, which seems to have had a significant impact on rates for two insurance plans.
The rising cost of health care, especially specialty drugs.
Pent-up demand for health care now being accessed by those who were locked out of the health care system before the Affordable Care Act was enacted.
Lee said Covered California is working to address some of these issues on multiple fronts. The exchange is aggressively marketing to attract healthy consumers year-round, and it is working to ensure special enrollment is available only to those who meet qualifying circumstances. It is also sampling the special enrollment population to better understand how to make any further improvements needed.

“We work hard to build a robust exchange that drives competition by attracting as many consumers as possible,” Lee said. “Now, consistent with the vision of the Affordable Care Act, we will redouble our efforts to make sure our consumers and potential consumers understand the importance of signing up during open enrollment and remaining covered throughout the year.”

Lee said Covered California’s 11 health insurers are competing across the state for its 1.4 million members.

“The sheer number of enrollees and their overall health means consumers in the individual market are benefiting from competition,” Lee said.

Below is the complete list of the companies selected for the 2017 exchange:
Anthem Blue Cross of California
Blue Shield of California
Chinese Community Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare
Oscar Health Plan of California
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Rate details by pricing regions can be found in “Covered California’s Health Insurance Companies and Plan Rates for 2017,” posted online at:http://coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf

The preliminary rates are subject to a 60-day public comment period and regulatory review by the California Department of Managed Health Care. In addition, the California Department of Insurance will review Health Net’s EPO.

Some insurance carriers will be increasing their coverage areas in 2017:
Oscar will be entering the market in San Francisco, Santa Clara and San Mateo counties.
Molina will expand into Orange County.
Kaiser will be available in Santa Cruz County.
With the expansion of its current carriers, almost all consumers (92.6 percent) will be able to choose from three or more carriers, and all will have at least two to select from.

In addition, more than 93 percent of hospitals in California will be available through at least one Covered California health insurance company in 2017, and 74 percent will be available in three or more plans.

Covered California also is improving its patient-centered benefit designs by increasing a consumer’s access to care by reducing the number of services that are subject to a consumer’s deductible.

Starting in 2017, consumers in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. In addition, consumers in Silver, Gold and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible, which could save them thousands of dollars.

These improvements build on features already in place that ensure most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging. In addition, some Enhanced Silver plans have little or no deductible and very low copays, such as $3 for an office visit. Even consumers in Covered California’s most affordable Bronze plans are allowed to see their doctor or a specialist three times before the visits are subject to the deductible.

In addition, the contract with health insurers for 2017 ensures consumers select or are provisionally assigned a primary care physician within 60 days of effectuation so they have an established source of care.

“Health care reform isn’t just about making insurance affordable, it’s about doing things to make it easier for consumers to get the right care at the right time,” Lee said.

In May, the Centers for Disease Control and Prevention announced that California’s uninsured rate had fallen to 8.1 percent at the end of 2015, down from 17 percent at the end of 2013, right before the Affordable Care Act began offering coverage.

“We can all be very proud of the extraordinary gains we have made in reducing California’s uninsured rate to a historic low,” Lee said.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and the Legislature. For more information about Covered California, please visit www.CoveredCA.com.

This article is from the Los Angeles Times date July 20, 2016

California Obamacare rates to jump

Premiums are set to go up an average of 13.2% next year. Rising medical costs are one reason, officials say.

BY MELODY PETERSEN AND NOAM N. LEVEY

Premiums for Californians’ Obamacare health coverage will rise an average of 13.2% next year — more than three times the increase of the last two years and a jump that is bound to stir debate in an election year.

The big increases come after two years in which California officials had boasted that the program helped insure hundreds of thousands people in the state while keeping costs moderately in check.

Premiums in the insurance program called Covered California rose just 4% in 2016 after rising 4.2% in 2015 — the first year that exchange officials negotiated with insurers. The program insures 1.4 million Californians.

On Tuesday, officials blamed next year’s premium hikes in the program on rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare.

Two of the state’s biggest insurers — Blue Shield of California and Anthem Inc. — asked for the biggest hikes. Blue Shield’s premiums will jump an average of more than 19%, according to officials, and Anthem’s rates will rise more than 16%.

For consumers, the effect will depend on whether they get taxpayer-supported subsidies for their premiums and whether they are willing to switch to less-expensive plans that may come with higher co-pays and deductibles. Changing plans could also mean a new network of physicians, which could be disruptive to care for those with chronic conditions.

The rates vary significantly by region and insurer. Los Angeles and the rest of southwest Los Angeles County will see an average increase of almost 14%.

Blue Shield’s preferred provider organization rate in Los Angeles, chosen by 21% of those using the exchange, is increasing by an average of 19.5%. For a 40-year-old single person making $17,820 to $23,760, choosing a silver level plan, the monthly rate currently is $122, while the government pays Blue Shield $196. Next year that same person would pay $170, while the government would chip in $211 a month.

“We’re paying more for less,” said Jamie Court, president of Consumer Watchdog in Santa Monica. “Insurers are limiting access to doctors and hospitals while also demanding a higher price.”

Horacio Chavez, 34, of Boyle Heights said he made less than $25,000 last year as an education coordinator at a youth center. He currently pays a $100 premium for a Covered California plan that he uses for an annual checkup and a safety net in case of emergencies.

“I do want healthcare — I want the peace of mind that if anything happens to me that there’s some kind of coverage,” Chavez said. But “a 13% hike … that’s going to affect people.”

He said he’s already barely making ends meet trying to pay his rent, student loans from the University of Chicago, car payments and his health insurance premium.

“I’m already living check to check,” Chavez said.

Covered California officials defended the system Tuesday, saying that the competition among insurers offering coverage on the exchange was working to keep rates lower than they otherwise would be.

“California has a very competitive marketplace,” said Peter Lee, executive director of Covered California.

Obamacare has significantly reduced the number of uninsured Californians. Since the state’s health insurance exchange began offering coverage in 2014, the share of Californians without health insurance has fallen from 17% at the end of 2013 to 8.1% at the end of last year, according to officials.

Rates are expected to jump in other states too, although complete details won’t be available until later this year.

An analysis of 14 metro areas that have already announced their 2017 premiums found an average jump of 11%. The changes ranged from a decrease of 14% in Providence, R.I., to an increase of 26% in Portland, Ore., according to the analysis by the nonpartisan Kaiser Family Foundation.

The federal healthcare-  .gov   exchange provides insurance under the Affordable Care Act in 38 states. California and a few other states operate their own exchanges.

Around the country, several insurers, including giant UnitedHealth, have stopped selling health plans on the exchanges, and a number of new nonprofit health insurance co-ops have gone out of business.

Those decisions have fueled charges from the law’s critics that Obamacare isn’t working.

Former Secretary of State Hillary Clinton, the presumptive Democratic presidential nominee, is pushing a number of specific steps to ease price pressure on consumers, including allowing Americans ages 55 to 64 to buy into Medicare.

Republican presidential nominee Donald Trump has argued the health law should be repealed.

The health law’s next enrollment period begins a week before election day.

The state and federal health insurance exchanges provide coverage to about 12 million people nationally, representing just a fraction of the nation’s total insurance market. The vast majority of Americans — more than 250 million people — are in health plans purchased through an employer or provided by a government plan such as Medicare or Medicaid.

But the exchanges are a pillar of the Affordable Care Act’s program for guaranteeing Americans’ insurance coverage. And monthly premiums have become a closely watched barometer of how the law is performing.

Covered California’s Lee told the House Ways and Means Committee on July 12 that 2017 would be “a transitional year” for Obamacare, with rates seeing “significant adjustments” across the nation.

He said one reason for the increase was the end of a program designed to keep rates down during the insurance exchange’s first three years. The program had assessed a fee on all health insurers and then redistributed those funds among carriers whose members had the highest medical expenses, Lee said.

Lee added that some insurers had also not charged enough in the first two years because they didn’t have full data on the medical costs or health status of those signing up. Now they’re adjusting to account for those higher costs.

Mia Campitelli, a Blue Shield spokeswoman, said Tuesday that the insurer’s average 19.9% premium increase was “driven by our members using more healthcare services than we expected,” as well as the phaseout of the federal mechanism that had kept rates down in the law’s early years.

Anthem spokesman Darrel Ng said: “Factors such as increased use of medical services and added costs of drugs and medical therapies put upward pressure on rates and underscore the additional work that needs to be done to moderate the growth in healthcare costs.”

The financial pain for most Californians getting insurance through the exchange will be muted because 90% get taxpayer assistance to cover the premiums.

Americans making less than four times the federal poverty level — about $47,000 for a single adult or $97,000 for a family of four — qualify for the assistance.

Nonetheless, Americans who make too much to qualify for subsidies are likely to feel the brunt of the higher premiums. That will probably increase pressure on the new president — Democrat or Republican — to review the exchanges in 2017 for ways to make health plans more affordable.

A year ago, Lee wrote an op-ed in The Times saying that Covered California’s power in negotiating with insurers was allowing Obamacare to work in the state.

“We now have the full picture in California, where we are proving that health insurance exchanges can keep prices in check,” he wrote.

Though the Affordable Care Act has improved care for millions of Americans — for example, insurance companies can no longer set lifetime limits on care or exclude anyone because of a preexisting condition — the 6-year-old law contains few controls on overall costs.

Spending on the country’s medical system averages more than $10,000 for every American, according to statistics released by the Obama administration this month, far higher than any other nation. melody.petersen

@ latimes.com   noam.levey@latimes.com   Times staff writer Soumya Karlamangla contributed to this report.

RICH PEDRONCELLI Associated Press

“CALIFORNIA has a very competitive marketplace,” said Peter Lee, executive director of Covered California. Above, Lee discusses the program last year.

Drugs: Paying for firms’ gifts to doctors

This article appears in the Business Briefing of the Los Angeles Times dated June 21, 2016.

It discusses the harm caused to the patient when a physician accepts gifts from drug companies. This practice has been around for many years, hopefully with more scrutiny it will end.

DRUGS

Paying for firms’ gifts to doctors

As little as one free meal from a drug company can influence which drugs doctors prescribe for Medicare patients, according to a study using Medicare records and recently released data from the Affordable Care Act’s Open Payments program.

The study highlights subtle ways doctors may feel inclined to prescribe a drug after receiving just a small gift, even if the drug is more costly for patients and their insurance plans.

Researchers calculated that an estimated $73 billion a year could be saved if equivalent generics were prescribed instead of brand-name drugs, and patients pay for a third of that excess cost. The study was published Monday in the journal JAMA Internal Medicine.

Medicare Physician Reimbursement Proposal Could Reduce Number Of Practices.

Many doctors are leaving the Medicare system due to low reimbursements. Will additional costs drive more away?

Below is an article from Modern Health Care

Docs face stark choices under new Medicare pay proposal

By Beth Kutscher  | April 30, 2016

The new draft regulations designed to change how Medicare pays clinicians represent the most sweeping overhaul the CMS has made in a long time to the business of running a physician practice.

The goal is to have the vast majority of CMS funding flow through payment models that reward doctors for the quality of care they deliver, not just how many patients they see.

The changes have the potential to upend the way medicine is practiced today, accelerating the move toward hospital employment and making the small group practice a thing of the past. At the very least, the rule, once finalized, will inspire closer collaboration between doctors and hospitals, since physicians will have more incentives than ever to steer patients away from high-cost medical centers.
The CMS’ 962-page proposed rule is the first major step in hashing out the details of physician payment that Congress outlined in the Medicare Access and CHIP Reauthorization Act, the 2015 legislation that replaced the controversial sustainable growth-rate formula.

RELATED STORIESSidebar: Medicare’s new quality program targets measurement fatigue

Sidebar: How Medicare’s new payment overhaul tries to change how docs use tech

In its attempt to move more physician payments through value-based arrangements, the CMS is combining three existing programs into a new Quality Payment Program.

Clinicians will have to choose one of two paths: submit to the Merit-based Incentive Payment System (MIPS), or put a significant portion of their business into a qualifying Alternative Payment Model (APM).

Both carry financial risk for failing to meet program goals. The potential impact on physicians’ Medicare revenue under MIPS—which will apply to the vast majority of clinicians—would be as high as 4% in the first year, rising to 9% in subsequent years. The program goes into effect in 2019, but the first performance period begins on Jan. 1, 2017.

“This really is a defining piece of legislation for how we pay for healthcare in America,” said David Muhlestein, senior director of research and development at consulting firm Leavitt Partners. “It changes the expectation of what practicing medicine is. It’s increasing the scope of responsibility for physicians.”

Even though Medicare spending on inpatient services was nearly double the amount spent on physicians, according to 2014 data, the rule makes it clear that physicians will increasingly be the ones held accountable for keeping hospital expenditures in check.

That contrasts with the old way of paying for medical services, in which the person or entity performing a service also controlled the revenue.

“What’s important is not just what the costs are, but who is responsible for those costs,” Muhlestein said. Clinicians “now have all sorts of incentives to steer people away from the hospital.”

Physicians are likely to respond by fleeing to hospital employment, large independent group practices or joint ventures with hospitals. “This will hasten the demise of the very small physician practice,” Muhlestein said.

Another element of the rule that puts pressure on physicians is the transition from the current incentive program for meeting meaningful use of electronic health records to the CMS’ broader Advancing Care Information program. The new requirements emphasize interoperability, information exchange and data security, creating some concern that doctors will need to invest in sophisticated information technology and analytics systems.

“It’s really an infrastructure question,” explained Eric Zimmerman, a principal at McDermott+Consulting. “What you might find with some of these small groups is sort of a downward spiral.”

The rule also came under criticism from the American Hospital Association for its narrow definition of an alternative payment model. The CMS exempted many of its current value-based payment models from qualifying as advanced APMs for the purposes of their exemption from MIPS. For instance, the rule excludes the Bundled Payments for Care Improvement initiative, as well as Track 1 of the Medicare Shared Savings Program, which delivers bonuses for meeting cost and quality targets but carries no downside risk.
MH TAKEAWAYS Physicians have traded the perennial threat of Medicare pay cuts for a framework that gives them little choice but to adapt their practices to value-based care.

Ninety-five percent of the 433 accountable care organizations in the Shared Savings Program this year are in that track.

APMs, the CMS said, must bear “more than nominal financial risk” in order to qualify.

The incentive payment system, meanwhile, is designed to be budget-neutral, which means there will be winners and losers when it comes time to dole out payments. The CMS is forecasting that there could be $833 million in negative payment adjustments and $1.3 billion in positive payment adjustments, which includes $500 million in “exceptional performance” payments for the highest-scoring physicians.

Under the framework the CMS laid out, it will be harder for physicians to tread the neutral middle ground.

“MIPS is essentially a linear performance score,” said Tom Lee, CEO of SA Ignite, a technology firm helping providers prepare for MIPS. “Every point counts. That’s going to increase the need for people to get educated that the game has changed.”

MIPS consolidates the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier and the EHR meaningful-use program—none of which was particularly popular.

Under those programs, huge numbers of physicians swallowed Medicare pay cuts rather than submit the quality data necessary to avoid the cuts and possibly earn a bonus. For example, about 5,400 out of 13,800 physician groups eligible for the value-based payment modifier in 2016 took a 2% pay reduction because they failed to meet the reporting requirements.

“No one liked PQRS and no one is going to really want to participate in MIPS,” said Sheila Madhani, a director at McDermott+Consulting. “So there’s going to be this push to get into APMs.”

APMs also provide more flexibility for physicians who want to make investments that otherwise would not be covered, such as hiring care coordinators.

But the CMS’ strict eligibility standards for APMs mean that the only way for many practices to avoid MIPS would be through an accountable care organization. “An ACO is basically the approach that most providers are going to end up with,” Muhlestein said.

Yet many of the APM deadlines are fast approaching. Applications for the Shared Savings Program, for instance, are due as soon as May 31. That doesn’t give providers much lead time to prepare, Lee said.

At the same time, a game of musical chairs will play out as physicians rush to find partners, either as a “virtual group”—a mechanism in the statute that allows small, independent groups to spread performance evaluation across a larger number of physicians—or through a more formal relationship.

“If I’m a practice manager, I’m probably getting pitched a lot,” Lee said. “The big underlying question is ‘What is the minimum amount of resources and support you need in order to play the value-based game?’ ”

Anthem Blue Cross Individual Grandfathered Plans

Over the next several months, Anthem Blue Cross will be increasing rates on their individual Grandfathered Plans. As a result of this increase, Anthem Blue Cross will allow for a temporary Special Enrollment Period to change to Affordable Care Act or Obamacare plans. Once a change is made, your Grandfathered status will cease and is no longer available.

The main advantages of a Grandfathered Plan is a larger provider network and a larger drug formulary. The advantages of an Affordable Care Act or Obamacare plan is the benefits may be better and the premium may be lower.

If you would like to discuss a change in plan, please let me know. I will need the following information:

Full name, address and phone number of any doctors you wish to keep.

Name of all prescription medication taken.

 

Californians are at Risk for Diabetes

an article from the Los Angeles Times, dated March 10, 2016 confirms that everyone needs to adopt a healthy lifestyle.

Almost half in state at risk for diabetes
Yet most pre-diabetic adults are unaware of their condition and don’t get treated, experts say.
BY SOUMYA KARLAMANGLA
For decades, more and more Californians have put on weight and fallen sick with diabetes, prompting warnings that the disease was spiraling out of control.
Now experts have data showing just how bleak the situation is.
Researchers from UCLA determined that 55% of California adults have either diabetes or pre-diabetes, a condition in which blood glucose levels are higher than normal but not high enough to be considered diabetic, according to a study published Thursday.
Experts already knew that about 9% of people in the state have diabetes. But previous estimates had put the rate of pre-diabetes at about 33%, lower than the 46% calculated by UCLA researchers.
“Our genes and our environment are kind of on a collision course,” said Dr. Francine Kaufman, the former head of the American Diabetes Assn., who was not involved with the research. “It’s not stopping.”
Rates of diabetes have increased more than 175% nationally since1980, according to federal data. It’s now the seventh-leading cause of death in California.
The UCLA researchers used data from the National Health and Nutrition Examination Survey to create a model that predicts pre-diabetes, based on factors such as race, height and weight. That model was then applied to data from the California Health Interview Survey, determining that 13 million adults in the state have either pre-diabetes or undiagnosed diabetes.
Up to 70% of those with pre-diabetes develop diabetes in their lifetime.
“This study is a barometer that’s telling us that the storm is coming,” said Harold Goldstein, head of the California Center for Public Health Advocacy, a nonprofit that supports public health initiatives and funded the study.
Already, 2.5 million Californians have been diagnosed with diabetes, which can cause kidney failure, amputation and premature death. More than 100 diabetic Californians lose a leg, foot or toe every week because of the disease, according to state data.
But experts say there’s hope of curbing the disease’s spread. The vast majority of diabetes cases in California — upward of 90% — are Type 2, which is preventable. People can stave off developing diabetes by adopting a healthier diet and increasing physical activity, experts say.
The difficulty is that most people don’t take action until it’s too late.
“One of the biggest problems with pre-diabetes is that most people don’t know they have it,” said Dr. Susan Babey, the paper’s lead researcher and a co-director of the Chronic Disease Program at the UCLA Center for Health Policy Research.
About 90% of people with pre-diabetes are unaware of their condition, so most don’t get any treatment, said Matt Petersen, managing director of medical information for the American Diabetes Assn. There are no symptoms of pre-diabetes, which can be detected only through blood tests.
“If you do intervene, you have a successful outcome,” he said. “We just have to have people know they’re at risk and get screened.”
An often-cited clinical research study found that people with pre-diabetes who were overweight and improved their diet and worked out reduced their diabetes risk 58%. Those who instead took a medicine to treat diabetes reduced their risk only 31%.
The UCLA researchers found that pre-diabetes in California increases with age, from 33% of adults ages 18 to 39 having the condition to 60% in those 55 to 69.
They also found racial and ethnic variation in the rates. About 42% of Asian adults have pre-diabetes, 44% of Latino adults, 48% of white adults, 50% of African American adults and 55% of Pacific Islander adults.
Goldstein says he thinks the high rates of pre-diabetes, especially among younger generations, arise from sedentary lifestyles and unhealthy eating habits. “They’ve grown up in a world that’s designed for the disease,” he said.
He wants to increase access to healthy, fresh foods, and reduce junk food advertising. On Tuesday, California state legislators proposed a “health impact fee,” which would tax sugar-sweetened beverages by 2 cents an ounce. Bob Achermann, executive director of the California Beverage Assn., on Wednesday called the measure the latest in a series of “misguided tax proposals on sugar-sweetened beverages,” and urged leaders to “find real solutions to obesity and diabetes.”
In 2014, Berkeley voters approved the nation’s first citywide tax on sodas and other sugary beverages.
Kaufman, a pediatrician and endocrinologist, agreed that soda and fast food are a problem.
When she began her medical training at Children’s Hospital Los Angeles in 1975, she almost never had young patients with diabetes. Now she sees children with the disease regularly.
The work that’s been done in California so far hasn’t done much to stop the increase in diabetes cases, she said. “It just isn’t enough to make any kind of dent,” she said. soumya.karlamangla
@ latimes.com

JUSTIN SULLIVAN Getty Images
HIGH RATES of pre-diabetes, especially in younger generations, arise from sedentary lifestyles and unhealthy eating habits, the head of a health nonprofit says.

Eliminating Confusing Health Plans

It has been my experience as an insurance broker that some insurance companies have far too many plan designs which are very confusing for the consumer. Hopefully changes will be adopted to make the process of choosing a plan more consumer friendly.
Below is a partial excerpt from Covered California’s Daily News, dated March 9, 2016 which discusses the issue.
________________________________________
New Analysis Urges Shift to Patient-Centered Benefit Designs to Cut Costs and Help Consumers Get Care
Posted: 09 Mar 2016 02:52 PM PST
Lessons Learned in California Can Help Avert a Collision Between Conflicting Reform Initiatives

SACRAMENTO, Calif. — A new analysis urges state-based marketplaces, the employer-sponsored insurance market and health insurance plans to take action and move toward plan benefit designs that put consumers first, and remove existing barriers to getting needed health care.
In an article written in the New England Journal of Medicine by Dr. Elliott Fisher, Director of The Dartmouth Institute for Health Policy and Clinical Practice, and Covered California Executive Director Peter V. Lee, both stress the importance of patient-centered benefit designs to reach the next level of health care reform.

“Health plans, states and employers should take to heart the lesson that offering a lot of different designs does not serve consumers well,” Fisher said. “Too many health plans, in exchanges and the employer sector, offer confusing benefit designs with out-of-pocket costs that prevent people from seeing their doctor.”

Lee said Covered California has a model that has worked for its consumers since the agency opened its doors in 2014.

“Covered California has led the way in the fight for consumers by shaping benefit designs that help consumers make apples-to-apples comparisons and to get the health care they need,” Lee said. “A good patient-centered benefit design is critical to making sure consumers get the right care at the right time.”

Fisher and Lee noted that the current health care system seeks to improve care and cut costs through provider-focused and consumer-focused reform initiatives that directly conflict with one another.
For example, provider-focused initiatives encourage physicians, hospitals and other providers to coordinate and improve care to lower costs. However, the consumer-focused approach discourages people from seeing their provider because of increased cost-sharing.

Studies show the proportion of Americans with employer-sponsored coverage involving deductibles of more than $1,000 has increased from 10 percent to 46 percent since 2006, with many plans requiring people to fully meet their deductible before receiving any coverage for primary care. A 2015 National Bureau of Economic Research study showed the adoption of a high-deductible health plan in a relatively high-income population led to a 10 percent reduction in the use of preventative services and an 18 percent drop in physician visits, with the greatest reductions occurring in the sickest patients.

“We want consumers to be able to see their doctor when necessary, so their health care needs can be met in the most effective and efficient way possible,” Fisher said.

The authors cite California’s approach as an example of how it might be possible to avoid this collision between provider- and consumer-focused efforts. Covered California, the state’s insurance exchange, requires plans to adopt patient-centered benefit designs that allow consumers at every metal tier (cost-sharing split between insurer and enrollee) to visit their primary care physician without the cost being subject to a deductible. “When a consumer is able to get the right care at the right time, it cuts down health care costs for everyone,” Lee said.

The Centers for Medicare and Medicaid Services recently announced it would allow health insurance companies to offer patient-centered benefit designs on the federal exchange.
“This is a good step for consumers,” Lee said. “However, more needs to be done if we are going to reach the next level in health care reform.”

The article, “Toward Lower Costs and Better Care – Averting a Collision between Consumer- and Provider-Focused Reforms,” is available atwww.nejm.org/doi/full/10.1056/NEJMp1514921.

About The Dartmouth Institute
Since 1988, The Dartmouth Institute for Health Policy and Clinical Practice has been working to find solutions to some of the most challenging problems in health care delivery. Our goal is to help create an affordable, high-performing health system for everyone.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, was charged with creating a new health insurance marketplace in which individuals and small businesses can get access to affordable health insurance plans. Covered California helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the governor and the Legislature.

Health Law Insurance Plans to be Rated by Network Size

Below is an article from the New York Times date March 6, 2016 which also discusses the increase in out of pocket costs for 2017.

WASHINGTON — The Obama administration, responding to consumer complaints, says it will begin rating health insurance plans based on how many doctors and hospitals they include in their network.

At the same time, the maximum out-of-pocket costs for consumers under the Affordable Care Act will increase next year to $7,150 for an individual and $14,300 for a family, the administration said. Consumer advocates said those costs could be a significant burden for middle-income people who need a substantial amount of care.
Under new rules to be published Tuesday in the Federal Register, insurers will still be allowed to sell health plans with narrow networks of providers. But consumers will know in advance what they are getting because the government will attach a label indicating the breadth of the network for each plan sold on HealthCare.gov.
About 12.7 million people signed up or had their coverage automatically renewed in the third annual open enrollment season, which ended on Jan. 31.

Many health plans offered in the public marketplaces provide a limited choice of doctors and hospitals, and some insurers narrowed their networks this year by excluding some doctors and dropping popular teaching hospitals.
Consumers have grumbled about the changes, and some say they have had difficulty finding medical specialists. But cost-conscious consumers have gravitated to these plans because they tend to offer lower premiums than health plans providing a greater choice of doctors and hospitals.
Consumers can already find out which health plans include a specific doctor. But until now they had no reliable way to determine if a health plan had a large or small network of providers. The new ratings will indicate how the breadth of a health plan’s network compares with that of other plans in the same geographic area.
“This could be really helpful for a lot of consumers,” said Sabrina Corlette, a consumer advocate and professor at the Health Policy Institute of Georgetown University.
Consumers have also complained about the out-of-pocket costs for many health plans under the Affordable Care Act.
“For many people, $7,000 of costs can be a huge impediment to actually receiving care,” especially if patients incur those costs in a month or two at the start of a year, said Marc M. Boutin, the chief executive of the National Health Council, a coalition of advocacy groups for people with chronic diseases.
Out-of-pocket costs, as defined by the government, include deductibles and co-payments, but not the premiums that people pay for insurance. Each insurer sets limits on out-of-pocket costs for its health plans, and the limit cannot be higher than the maximum specified by the government. The maximum for an individual will exceed $7,000 next year for the first time. It will go up by $300 in 2017, after an increase of $250 this year.
Consumer groups say this rate of increase is unsustainable. Moreover, they say, high out-of-pocket costs have deterred some people with insurance from using expensive prescription drugs.
Ben Wakana, a spokesman for the Department of Health and Human Services, said that in setting the new ceiling on out-of-pocket costs, the administration had used a formula laid out in the Affordable Care Act. Before the law was adopted, he said, people with cancer or other serious illnesses could be bankrupted by hundreds of thousands of dollars in medical bills, and the law provides new protections.
People with low incomes can obtain discounts that reduce their deductibles and other out-of-pocket costs if they choose midlevel silver plans. Slightly more than half of the people with marketplace coverage received such “cost-sharing reductions” last year.
Ms. Corlette, the Georgetown University professor, said that in writing the new rules, “the administration was walking a very delicate line, pushing forward with consumer protections while trying to keep insurers onboard and participating in the marketplaces.”
In some markets, consumers can choose from dozens of health plans. In a move intended to simplify the shopping experience, the Obama administration has devised six model health plans that it describes as standardized options. Federal officials specify the amount of deductibles, co-payments and other charges for doctors’ services, hospital care, X-rays, laboratory tests and prescription drugs.
The standard features will make it easier for consumers to compare plans, officials said, and the government will highlight these plans in some way on HealthCare.gov. But the government is not requiring insurers to offer the standardized options or limiting their ability to offer other plans in 2017.
Another new requirement is meant to guarantee “continuity of care” for certain patients. If a health plan drops a doctor from its network without cause, the insurer must allow patients in “an active course of treatment” to continue seeing the doctor for up to 90 days. This protection would apply, for example, to patients receiving chemotherapy or radiation therapy for cancer and to women in the second or third trimester of pregnancy.
Under the new rules, consumers using the federal marketplace will be able to get help year-round from insurance counselors financed by the government. The counselors, known as navigators, help people sign up in the annual open enrollment period. The administration is expanding their duties to include teaching people how to use insurance, appeal denials of coverage and obtain exemptions.

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