2017 Individual and Family Medical Plans Require a Primary Care Physician

Beginning January 1, 2017 all individual and family health plans in California will require that members select a Primary Care Physician (PCP) or have one recommended by their health plan.

The terminology used in this case is confusing. A PCP has historically been a physician who is associated with an HMO which limits your choice. This is not the case in this instance.

You must choose a general physician who is in the network of your insurance company. If you do not choose a physician the insurance company will assign one to you. I know that at least one company will review your claims history in order to assign a physician that you have seen in the past.

YOU DO NOT EVER NEED TO SEE THE PHYSICIAN CHOSEN

YOU CAN CHANGE THE PHYSICIAN AT ANY TIME

The thought behind this is that if one is attached to a name of a physician, it is less likely that one will go to Urgent Care or the Emergency Room. An office visit or a phone call supposedly will lower health care spending.

In Summary, choose a physician or have one chosen for you.

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.

Costs top healthcare concerns

This article from the Los Angeles Times, dated June 11, 2016 indicates that the cost of healthcare is a primary concern for our country. It also indicates that there is much confusion regarding Obamacare.

In my opinion the cost of healthcare will decrease significantly when physicians understand nutrition, exercise and psychological well being and will be able to effectively communicate this to patients. Everyone must be responsible for incorporating this in their lives.

USC DORNSIFE/LOS ANGELES TIMES POLL
Costs top healthcare concerns
A poll finds state residents more worried about rising prices than access.
BY DAVID LAUTER
WASHINGTON — Six years after President Obama signed the Affordable Care Act, the health reform law has gained acceptance from a majority of California voters, but the cost of getting healthcare remains a major concern, eclipsing worries about having insurance, according to a new USC Dornsife/Los Angeles Times poll.

The widespread worry about costs indicates a potential shift in the debate over healthcare, at least in this heavily Democratic state.

Nationally, the political debate has been stuck for most of the last six years on Republican efforts to block Obamacare, but that gridlock could lessen after the election.

In both parties, lawmakers increasingly have been hearing complaints from their constituents about the cost of care, and polls have found that prescription drug prices, surprise medical bills and other pocketbook issues concern voters more than the future of the health law.

Echoing that national trend, almost two-thirds of voters in the USC/Times survey say they worry “very much” about rising health costs, with only 10% saying that is not something they worry about.

Just slightly more than half say that lack of insurance is something they worry about a lot, and roughly three in 10 say they were not worried about it.

Latinos, however, were an exception, reporting equal levels of unease about cost and having insurance — three-quarters said they were very worried about each.

Cost concerns were most widespread among those in their 50s and early 60s. Indeed, that age group consistently showed the highest levels of anxiety on a series of healthcare concerns.

By contrast, those over age 65, most of whom are covered by Medicare, were the least likely to express worry about healthcare issues.

For a significant number of voters, the healthcare law itself takes blame for rising costs. Just over half of those surveyed said they believed that costs for average Americans have “gone up a lot” because of the law, compared with roughly one-third who said that the law had not caused that to happen.

As with many aspects of the healthcare debate, partisanship plays a big role in shaping beliefs about rising costs: Republicans by overwhelming margins blame the law, while Democrats were split closely on whether it’s responsible.

Most Americans have been forced to confront increased costs for health coverage for years — a trend that began long before the passage of the reform law.

Employers have continued to shift costs to their workers, mostly in the form of higher deductibles and co-payments. Although those higher costs may not have been caused by the new law, many blame it.

The law clearly has raised costs for one relatively small slice of Americans — mostly healthy, self-employed people with middle-class or higher incomes who were previously able to buy low-cost policies on the private market.

The new law requires those people to buy more comprehensive policies, which provide greater coverage, but at a higher price. Covering sicker customers who used to be denied insurance has also led insurers to raise some premiums.

Low- and middle-income Americans get subsidies under the law that lower their monthly premiums, but higher-income Americans do not.

More than three-quarters of California voters acknowledge the biggest effect the law has had — reducing the number of Americans who lack health coverage. By 77% to 15%, voters said that the law had achieved that goal.

Since the new law’s coverage expansion began in 2014, some 20 million previously uninsured Americans have gained coverage, and the share of American adults under age 65 who are uninsured has dropped from one in five to about one in eight, according to numerous private and government surveys.

But on that point, too, partisanship colors perceptions. Among Republicans, 28% in the current survey said that the new law had not led to more people having insurance. Among Republicans who identify with the tea party, 48% took that view, compared with 31% who said the law had reduced the number of uninsured.

The public’s view remains split on another of the law’s major accomplishments, as well — ending the ability of insurers to deny health coverage because of preexisting health conditions. The poll found 59% of voters saying that coverage could no longer be denied, while 21% said that had not happened.

On that question, the division did not appear primarily partisan. Instead, some of the groups whom the new law was designed to help most appeared least aware of one of its central elements.

Latinos, those younger than 30 and people with incomes under $30,000 were all less aware of the change regarding preexisting health conditions than whites and those who were older or more affluent. Among Latinos, for example, though 48% said the law had accomplished that goal, 30% said it had not.

That lack of awareness of one of the law’s main achievements marks a “messaging failure” by the law’s supporters, said Anna Greenberg, the Democratic pollster whose firm forms half of the bipartisan team that produced the survey for USC and The Times.

The White House and its allies have struggled at times to convey a message about the law, in part because for many Americans, it remains an abstraction.

Just over half of those surveyed said the law had no effect on themselves or their families. That’s by design: The law was written to cover the uninsured while minimizing the effect on people who get coverage through their jobs, as most working-age Americans do.

That has cost Obama politically. The views that most Americans have of the law have been shaped less by direct experience than by partisanship, according to Drew Altman, the president of the Kaiser Family Foundation, which has carefully tracked opinion about the health law.

Only about four in 10 of those who supported the law in the poll also said it had made their own families’ healthcare better.

Overall, 53% of the state’s voters favor the law, with 31% favoring it strongly. An additional 12% said they opposed it because it did not go far enough, while 27% said they opposed it because it went too far.

Those who said the law did not go far enough do not consistently back liberal views on how to replace it.

Only 40%, for example, supported a single-payer system — the sort of healthcare solution advocated by Sen. Bernie Sanders in his campaign for president.

By contrast, those who support the law backed the single-payer idea 69% to10%. Overall, just over half of the state’s voters supported it, with about one-quarter opposed.

The state’s voters divided evenly on the question of whether to repeal the law’s requirement that people have insurance.

Opinion on that question split along predictable partisan lines with one significant exception — Latinos, who generally back the law, also supported repeal of the mandate, by 57%-37%.

Most California voters have a positive view of their own healthcare and a somewhat positive view of healthcare in the state, the poll found. Seven in 10 rated their own healthcare as “excellent” or “good” while just under three in 10 called their care “fair” or “poor.”

Ratings were highest among those earning more than $100,000 a year and among those aged 65 and older, which reflects the generally positive view that Americans have of Medicare.

Asked about the state of healthcare in California, 44% called it excellent or good, while 34% said fair and 14% poor.

Ratings were gloomier about healthcare nationwide, with only 30% calling it either excellent or good, 39% fair and 25% poor.

The poll for the USC Dornsife College of Letters, Arts and Sciences and the Los Angeles Times was conducted jointly by the Democratic firm Greenberg Quinlan Rosner Research and the Republican firm American Viewpoint. It questioned 1,500 registered California voters from May 19-31. The margin of sampling error is 2.9 points in either direction for the full sample. david.lauter

@ latimes.com  .
DAVID BUTOW For The Times

 

Firm Accused of Bilking Medicare

From the Los Angeles Times Business Section, dated May 26, 2016

Firm bilked Medicare, U.S. says
Justice Department joins whistle-blower case accusing Prime Healthcare of overbilling.
BY PAUL SISSON
The U.S. Justice Department has joined a whistle-blower case against Prime Healthcare Services, adding significant weight to allegations of widespread Medicare overbilling at 14 of the company’s hospitals in California.

A Los Angeles magistrate judge granted the agency’s request to intervene in the case Tuesday, one day after the government declared in a court filing that its investigation of the Ontario- hospital operator has “yielded sufficient evidence” that the facilities “submitted or caused the submission of claims to Medicare for unnecessary inpatient stays.”

Prime finds itself under federal scrutiny because of a whistle-blower complaint submitted in 2011 by Karin Berntsen, a registered nurse and director of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more severe than they really were in order to justify billing for additional services and increasing hospital admissions.

Berntsen alleged that this practice occurred not only at Alvarado but also at 13 other Prime properties. Most of these hospitals are in Southern California, including Centinela Hospital Medical Center in Inglewood, Encino Hospital Medical Center, Sherman Oaks Hospital and Huntington Beach Hospital.

Berntsen’s litigation estimates the total amount of overbilling at $50 million, an amount that now could result in a significant financial payoff for her — and potentially large damages against the company.

Anti-fraud statutes allow fines of $5,500 to $11,000 — plus triple damages under certain circumstances — for each false or inaccurate bill submitted by hospitals and other healthcare companies . Whistle-blowers are entitled to 15% to 25% of the money recovered in cases involving the Justice Department.

In 2012, for example, pharmaceutical giant GlaxoSmithKline agreed to pay $2 billion to the federal government to resolve accusations that it overbilled for the prescription drugs Paxil, Wellbutrin and Avandia. In 2006, Tenet Healthcare was crippled after paying $900 million in a case involving alleged Medicare bill-padding, kickbacks and changing of billing codes to obtain higher reimbursements.    Prime has denied Berntsen’s allegations, calling them “speculative nonsense” after her complaint was unsealed in 2013.

In a new statement issued after the federal government’s intervention, the company was a bit more subdued. It said Medicare billing is complex and that there is a “lack of clarity between what federal regulators and physicians believe is necessary to adequately document medical necessity for hospital admissions.”

Prime also said its hospitals have successfully undergone Medicare billing audits conducted by an array of organizations, including the Joint Commission, the Healthcare Facilities Accreditation Program, the California Department of Public Health and government “recovery audit” contractors who are rewarded for spotting billing irregularities. The company currently owns 43 hospitals across14 states.

“Over 600 medical records that were appealed to the Administrative Law Judges and Medicare Appeals Council, all had rulings in Prime Healthcare’s favor, with no exception,” Prime’s statement said. “Given this precedence of successful appeals on thousands of claims, Prime Healthcare is confident it will prevail and ultimately be exonerated.”

But the Justice Department in a wide-ranging investigation referenced in its court filing this week cited “multiple witnesses who have worked at different Prime hospitals” who told the government that Dr. Prem Reddy, Prime’s chairman, president and chief executive, criticized emergency department physicians and demanded “their termination if he decided they were passing up opportunities to cause the admission of Medicare beneficiaries.”

The agency said those witnesses also accused Reddy of requesting “increased work schedules for [emergency department] doctors whose patients had a relatively high rate of admission,” of decreasing or discontinuing such shifts for physicians with low rates and of telling emergency department doctors “to find a way to admit all patients over 65 because they all have insurance.”

In contrast, the government said, Reddy allegedly worked to minimize hospital stays for uninsured patients — instructing that they should stay in the emergency department for only six to eight hours to get test results and then be discharged.

The Justice Department also cited the results of a Medicare contractor’s review of the company’s hospital admissions that “put Prime on notice of the same pattern of seemingly unnecessary inpatient admissions.”

Kathleen Clark, a Washington attorney who is an expert on the False Claims Act that governs whistle-blower cases, said the government’s involvement raises the stakes, given that federal regulators participate in only about one-quarter of such cases.

“It is actually quite significant when the government decides to intervene in one of these cases. The government brings to bear significant investigatory resources and leverage,” Clark said. “Intervention is seen not as a guarantee of a win, but it’s a very good sign for the whistle-blower and [his or her] lawyers.”

Marlan Wilbanks, an Atlanta attorney who is one of several lawyers representing Berntsen, said the government’s involvement could turn up additional evidence in the case disproving Prime’s assertion that previous audits proved the company’s billing practices are sound.

“Those entities were not designated to look for fraud,” he said. “Prime was given the benefit of the doubt. However, those entities did not have the evidence and the documents that the government and [Berntsen’s party] now possess.”

It’s unclear how long the legal discovery phase might take, especially because the Justice Department’s intervention will likely spur a series of procedural adjustments in the case. paul.sisson

@ sduniontribune.com

Medicare for More

The following article from the Atlantic states that lowering of the Medicare age from 65 to a younger age might infuse needed money into the Medicare system. Additionally, rates for those who are younger and not Medicare eligible might benefit if older sicker people enroll in Medicare. All will depend on the healthcare needs of those who are shifted around.

Hillary Clinton’s new proposal to expand coverage for middle-aged adults provides a glimpse at how she would make Obamacare her own.

VANN R. NEWKIRK II

MAY 23, 2016

What’s the next step for Obamacare? Much of the 2016 presidential race functions as a referendum on just what to do with the the six-year-old Affordable Care Act. Despite some mixed returns on costs and the stability of insurance markets, the health-reform law has brought the uninsured rate to its lowest point in American history. Reflecting that mixed legacy, most Americans now favor modifications to the ACA over continuing to implement it as it is or repealing it.

LATEST FROM POLITICS
That puts most Americans on the opposite side of whatever Donald Trump’s health care plan might be. But both Hillary Clinton and Bernie Sanders have plans to modify and expand Obamacare. Sanders’s plan of “Medicare for All,” a radical overhaul of the current system based on a single-payer system, has received most of the attention. Clinton’s more modest proposals to expand tax credits and allow undocumented immigrants access to health-insurance marketplaces have garnered less press. But recently, Clinton has made waves with a new idea to allow people over 50 or 55—the specifics have not yet been announced—to purchase Medicare plans.  At present, only those over 65 and a select few of their dependents are eligible for Medicare. This “Medicare for More” concept is a significant addition to the Clinton health plan, but what does it mean for the future of Obamacare?

A new report from Avalere extrapolates what it might mean for the future of 50-somethings. There are about 13 million people between the ages of 50 and 65 who are either uninsured or have purchased private insurance on the Obamacare marketplaces. This population represents most people in the age range without affordable employer- or group-insurance coverage and who don’t qualify for Medicaid. Assuming that this is the population that would be eligible for Clinton’s Medicare for More, Avalere reports that it is “unclear” if Medicare would automatically be a good deal for them.

With no knowledge of premiums or subsidies yet, a Medicare buy-in might just be too costly for those uninsured adults above 50 who have low incomes but are ineligible for Medicaid because of state rules. For those in private plans, Medicare has a distinct number of cost disadvantages, including a 20 percent cost-sharing requirement, no lifetime cap on out-of-pocket expenditures, and drug benefits that are generally less generous. Also, it is unclear if people under 65 could qualify for the Medicare Advantage plans that help fill in gaps in coverage. Sicker elderly adults regularly run up against the limits of Medicare, and it is hard to envision cases in which Medicare would make more financial sense for near-elderly adults with serious chronic illnesses than medium-cost marketplace plans.

Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy.

But Medicare has always been a good deal for those who don’t use many health-care services, and it might beat out low-cost marketplace plans for healthy adults between 50 and 65 with few health problems. Medicare provides access to one of the broadest networks of physicians, providers, and benefits possible, and consumers value continuity. A buy-in at 50 could allow people to remain on the same insurance coverage with the same providers for the rest of their lives. Also, while Medicare has not been shown to have a serious effect on health trajectories for uninsured adults who become enrollees at age 65, at age 50 it might provide services early enough to change outcomes. Medicare also provides protection against medical debts, and if premiums could be made affordable to uninsured adults over 50, it could have serious value as health issues mount with age.

Medicare for More might have more value to the Medicare program than to any individual beneficiary. People between 50 and 65 are healthier than those over 65, and many of the costs that penalize high utilization can be seen as offsets for having to cover the most expensive population in the country. Even for Medicare, which has broad power to affect prices and policy, covering services, visits, drugs, surgery, and hospital stays costs money, and as patients near costly end-of-life holding patterns, the cost curve skyrockets. Adding healthier, younger people to the risk pool might bring down the per-person costs of the program. If the subsidies are equivalent to marketplace subsidies, premiums and savings from the over-50 crowd could actually cut back net costs for the Medicare albatross. Removing more middle-aged adults from marketplace risk pools might actually make insurance cheaper for young adults as well.

The results of a Medicare buy-in for potential beneficiaries and the program will likely depend on specifics as detailed by the Clinton campaign, but its rhetorical value is much more readily assessed. Allowing private purchase of one of America’s two big public-insurance programs is an addition to Obamacare’s willingness to blur the lines between public and private insurance, risk, and public-health responsibility. The proposal gives Clinton ammunition both against Sanders in the primary and, should she win, Trump in the general.

But above all, Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy. Obamacare could very well be a platform for Clinton to achieve some of the goals that remain unfulfilled from the 1993 health plan that she spearheaded. Combined with some recent support from Clinton for the idea of a public option, a Medicare buy-in can be seen as a very Clinton-esque way of using the market to provide universal care. The free market solution to coverage, along with the major expansion of Medicare as a coverage pathway for non-elderly adults, is reminiscent of the ‘93 plan, and the population that it impacts is massive. Medicare for More would also cement Obamacare as the foundational law of all of American health policy, and establish a regime of incrementalism not unlike the coverage shifts seen in the decades between Medicare and Obamacare. The proposal might open the door for other shifts, such as allowing even younger people or government employees Medicare buy-ins.

For those further to Clinton’s left, however, Medicare for More might close the door for hopes of more radical overhauls while the figurative iron is still hot and while the ACA is still a hotly debated law. Sanders’s plan rests on frustrations about the compromising nature of the Affordable Care Act, which whittled down some of the more ambitious coverage plans in favor of  a market-based solution that still leaves millions uninsured. The current Obama-Clinton doctrine of health-care views zero uninsurance as a lofty and likely unreachable goal more than a first-order cause. Much of Sanders’s momentum with Medicare for All comes from the fact that the liberal benchmark––a universal public option supported by high, progressive taxes––has still not been reached. Clinton’s incrementalism would in all likelihood reset the clock on that dream.

Medicare for More isn’t Sanders’s Medicare for All, and it certainly isn’t what many Sanders supporters are looking for, but it is a step for Clinton and would be a significant addition to the massive impact of Obamacare. If Clinton does wind up in the White House, it could be the beginning of a piecemeal process to bring the ACA closer and closer to its originally intended ideal of universal coverage, as Obamacare is a perfect platform for incremental increases in coverage. Now, it is another sign that the work of providing coverage and making the health care system more affordable and better is not yet done.

Medicare Fraud is a Big Concern

Below is an article from the Los Angeles Times, dated Saturday May 7, 2016 which addresses the conviction of two doctors.

2 doctors found guilty of fraud

The pair tried to steal almost $9 million in hospice scheme, prosecutors say.

BY JASON SONG

Two Southern California doctors were found guilty this week of falsely certifying that their patients were terminally ill as part of a larger scheme to bilk Medicare and Medi-Cal out of $8.8 million in hospice-related services, according to federal prosecutors.

Sri “Dr. J” Wijegoonaratna, 61, of Anaheim was convicted of seven counts of healthcare fraud and Boyao Huang, 43, of Pasadena four counts after a two-week trial.

Prosecutors said the scheme involved Covinabased California Hospice Care, where employees paid so-called marketers to recruit Medicare and Medi-Cal beneficiaries. The patients were assessed by nurses to determine whether they were terminally ill, according to federal prosecutors.

Prosecutors argued that regardless of the assessments, Wijegoonaratna and Huang certified that the patients were dying, even though most were not. The certifications were then used to submit bills for unnecessary hospice-related services, prosecutors said.

“In fact, only a small percentage of patients died — notwithstanding the two doctors declaring they needed hospice care,” said Eileen M. Decker, the U.S. attorney for the Central District of California.

Prosecutors said also that Wijegoonaratna recruited some patients into the scheme and received tens of thousands of dollars in kickbacks. The California Medical Board has revoked his medical license.

The scheme was shut down in June 2013, according to prosecutors.

Wijegoonaratna and Huang will be sentenced Aug. 15 and face a maximum sentence of 10 years in prison for each count. Four other defendants have already pleaded guilty.

Jason.Song@latimes.com   Twitter: @byjsong

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.

 

Aid-In-Dying Law In Effect June 9

An article from the Los Angeles Times, dated March 11, 2016
Terminally ill patients should be consulting with physicians now if they want to end their lives, advocates say.
BY PATRICK MCGREEVY
SACRAMENTO — California’s terminally ill patients should begin talking to physicians now if they want to end their lives, advocates said Thursday after a legislative vote triggered a June 9 start date for the End of Life Option Act.
The law, which allows doctors in California to prescribe lethal doses of drugs to terminally ill people who want to hasten their deaths, includes a time-consuming approval process that could take several weeks, said Toni Broaddus, California campaign director for the group Compassion & Choices.
Gov. Jerry Brown signed the measure last year, but it wasn’t until the Legislature adjourned a special session in Sacramento on Thursday that June 9 was set for when it becomes legal for physicians to write lethal prescriptions without fear of criminal prosecution.
Broaddus said doctors can begin explaining options and considering requests. “We are telling people to start talking to their doctor now,” said Broaddus, whose group, formerly known as the Hemlock Society, helped pushed the bill to approval and has launched a bilingual education campaign on how to participate.
Sen. Bill Monning (D-Carmel), a co-author of the law, predicted discussions will begin before June 9 as patients make sure their doctors are up to speed on the law and physicians explain all options, including those not involving the legislation, such as hospice care.
“I certainly expect it’s going to provoke conversations within families and between terminally ill patients and physicians,” Monning said.
Senate leader Kevin de León (D-Los Angeles) said on the Senate floor just before the adjournment vote Thursday that the law “ensures Californians have access to humane and compassionate options to limit suffering at the end of life.”
The bill had failed to win needed support during the regular session, so supporters introduced it in special session, allowing it to bypass committees where opposition was strong.
The approval of the law through “controversial legislative tactics” was denounced again Thursday by Tim Rosales of Californians Against Assisted Suicide.
The group “remains strongly critical of this new law, and its lack of medical oversight and actual patient safeguards,” he said. “We will continue working with our partners, including doctors, patients and disability rights organizations, to educate those impacted and vulnerable, as well as working to limit the law’s harms and prevent any expansion.”
California will be one of six states to allow physicians to prescribe lethal drugs to the terminally ill.
The California Medical Assn. published guidelines on the law in January that spell out the requirements for terminally ill patients diagnosed with less than six months to live. The patients must make two oral requests at least 15 days apart and one written request that is signed, dated and witnessed by two adults. Patients must also fill out forms that were included in the legislation.
The process can be further delayed if the physician suspects mental illness requiring an evaluation by a mental health professional.
Even if some terminally ill patients begin the process now, Broaddus said she does not expect a large number of deaths June 9. In Oregon, which previously adopted the same law, patients on average wait 45 days to take the prescribed lethal dose.
The delays are often the result of patients wanting the medication in hand just in case but waiting until the last possible moment to take it, Broaddus said.
The California Medical Assn., which was neutral on the law, does not recommend whether patients and doctors should begin discussions now, according to spokeswoman Molly Weedn. “It’s up to those doctors and their patients and the individual situations” to determine what is best for their course of care, she said. patrick.mcgreevy
@ latimes.com
Twitter: @mcgreevy99

Kaiser Medical School to be in Pasadena

Kaiser’s medical school will add focus to more practical areas of medical care.

here is an article from the Los Angeles Times date, March 11, 2016
Site is near freeways, public transportation, affordable housing, medical provider says.
BY SAMANTHA MASUNAGA
Kaiser Permanente is moving forward with its ambitious plan to open a medical school that’s more in tune with new technologies and local communities.
The Oakland-based healthcare provider said Thursday its institution will be located in Pasadena. And it talked about how it will try to attract a more diverse student body.
Kaiser said it chose central Pasadena because the site is close to major freeways, public transportation options and affordable housing. Kaiser is also well-established in the surrounding area, with 14 hospitals in Southern California and medical office complexes in Pasadena and Glendale. The school will also be within several miles of facilities where students will be trained.
“We have major medical facilities and resources in that particular marketplace, so we feel really great about the extension of Kaiser Permanente beyond the four walls of that medical school,” said Kaiser Chairman and Chief Executive Bernard Tyson.
Pasadena’s diverse community was another driving factor, as Tyson said it was “essential” to the model of medical education Kaiser wants to establish. Kaiser officials have said it wants to recruit more minority students and teach doctors how to care for an increasingly diverse patient population.
There are no set plans yet for recruitment, but Kaiser is considering offering scholarships or tuition forgiveness to students who can help them “reach the communities that we wish to reach,” said Dr. Edward Ellison, executive medical director of the Southern California Permanente Medical Group.
“When you look at what’s happening in the country today, healthcare has never gone through as much change as it has today,” he said. “We believe that the way in which we deliver care has a lot of applicability for solving challenges of the future.”
Kaiser first announced plans in December to open a medical school.
The campus size in Pasadena, as well as the tuition, has yet to be determined.
The school will be built on land that Kaiser already owns. The property, located at 94 S. Los Robles Ave., currently houses an unoccupied building, which will be torn down and replaced with a larger building, Kaiser spokesman Marc Brown said. A Kaiser office building and the Kaiser Permanente Department of Research and Evaluation are on the same lot and will remain there, he said.
That part of Pasadena is already being revitalized, said Mayor Terry Tornek. A new residential building and hotel are set for construction nearby and other parts of the city are also seeing new developments.
“It’s a big deal,” he said of the medical school. “You bring in these students, you bring in their instructors, you bring in their support staff…. It has a multiplier effect.”
Kevin Trieu, owner of Beany’s Cafe, located a block away from the Kaiser school site, said he thought the institution could increase the foot traffic around his restaurant.
“Any time you get more people within walking distance to us, then that’s going to generate business for us, especially since we don’t have our own parking lot,” he said. “The fact they’re so close, I think it’s going to be wonderful.”
Groundbreaking for Kaiser’s medical school is planned for next year, and the first class of about 40 to 50 students is expected in 2019. In time, Tyson said he hoped the class size would increase to 200 to 300.
He said the plan for the medical school was an evolution of what Kaiser was already doing. The organization has more than 600 physicians in residency programs at its facilities and thousands of others do some training at Kaiser.
Kaiser has said that its approach to medical education will differ from that of many established medical schools. The curriculum and teaching methods will more closely align to the company’s commitment to quickly adopting new technology and adhering to the latest medical evidence in patient care. Kaiser has been a leader nationally at adopting electronic medical records and offering doctor visits online.
It also plans to integrate hands-on learning early on so that “what you’re learning, you’re going to immediately apply,” Ellison said.
For example, Kaiser plans to train students as emergency medical technicians when they arrive at the school to give them a practical grounding in healthcare. Students will also go into the community, visiting patients’ homes and learning how to better implement health behavioral changes, Ellison said.
“Not all innovation is about shiny new technology,” he said.
Analysts have said that a medical school teaching Kaiser’s method of healthcare might not appeal to all students. Critics have also worried that a Kaiser medical school would focus on cutting costs that could negatively affect patient care, since some patients have said Kaiser’s system limited their care.
Kaiser operates 38 hospitals nationwide, owns hundreds of clinics and has almost 18,000 salaried doctors at its affiliated medical groups. Nearly 80% of its 10.2 million members are in California, though the healthcare provider operates in eight states and the District of Columbia.
With the location settled, Ellison said Kaiser is now working to create a curriculum, forming a search committee for the school’s first dean and going through the accreditation process. samantha.masunaga
@ latimes.com
Twitter: @smasunaga

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