Alaska has enacted a telehealth bill that requires healthcare insurers offering fully-insured plans in the group and individual markets to cover telehealth services and stipulated that an insurer may not require an initial in-person visit before paying for covered services, reports State of Reform. The threat of COVID-19 prompted lawmakers to amend the legislation to make it effective immediately upon passage.
Arizona’s Supreme Court unanimously ruled that hospitals accepting payment from the state’s Medicaid program cannot try to collect additional payment by going after money owed to the patient, reports the Arizona Capitol Times. Specifically, the justices voided sections of state law that have allowed hospitals to impose financial liens on people who owed money to the hospital when Medicaid payments were lower than billed charges. This included a situation where a patient was in an automobile accident and the hospital attempted to collect money from the driver of the other vehicle.
California is joining several states in scrutinizing alternative health plans, programs that provide limited coverage and are not required to offer many of the protections provided by Affordable Care Act (ACA)-compliant plans, according to the New York Times. State officials ordered a major Christian group to stop offering the arrangement, which pools members’ contributions to cover their medical expenses, because they are not required to meet standards for traditional insurance plans.
Idaho legislators have established the Idaho Behavioral Health Council, a new three-branch approach to improve care for Idahoans with mental health and substance use disorders, reports the Office of the Governor. State legislators will work collaboratively with local government, educators, and community partners to develop a statewide strategic plan with action-oriented, time-bound recommendations that improve access to behavioral healthcare.
In a major victory for consumers, a federal judge in Kansas City, Kansas, is allowing a lawsuit over EpiPen price hikes to move ahead, according to KCUR. The lawsuit will determine whether drugmakers sought to monopolize the EpiPen market after they dramatically hiked the price of the device, triggering consumer fury and a congressional investigation. The judge’s ruling also allows consumers to sue for damages under state antitrust laws.
Michigan’s proposed budget contains $5 million in funding to create a five-employee office to transform how the state pays for healthcare through Medicaid, according to Modern Healthcare. The ultimate goal of the Medicaid transformation office in the Department of Health and Human Services is to come up with a variety of new or enhanced "value-based" reimbursement systems for health plans, hospitals, physicians, nursing homes and home and community-based providers. The office would evaluate best practices in other states, develop programs and offer recommendations.
SHADAC has released an update to Minnesota's Uninsured Profile Tool in partnership with the Blue Cross Blue Shield Foundation of Minnesota. The update enables users to view the rates and characteristics of the uninsured population by state, region, county, and ZIP code and by state legislative district. The profile, which is available for download on the SHADAC site, also includes an updated version of the companion interactive map.
A recent Commonwealth Fund case study reported on New Mexico’s community health workers (CHWs) who link vulnerable residents to organizations that address the need for stable housing, legal assistance and job training. The practice of embedding CHWs into medical settings in New Mexico began in earnest more than a decade ago with a pilot between University of New Mexico Hospital and a Medicaid managed care organization. The CHWs provided both navigation and social supports — connecting members to medical homes, making home visits and encouraging adherence to treatment recommendations. A study found these efforts reduced emergency department visits and hospital admissions as well as use of prescription drugs (including narcotics) and produced a fourfold return for the health plan that sponsored it.
Ohio’s Prescription Drug Transparency and Affordability Advisory Council, a panel of government, business and consumer advocates exploring ways to ensure that pharmaceutical drugs, has convened to discuss their recommendations for the state’s governor, according to the Times Reporter. Ohio currently spends about $3.5 billion a year on prescription drugs for state employees, injured workers, Medicaid beneficiaries, incarcerated prisoners and others. The Advisory Council is considering bulk purchasing and price transparency strategies..
Oregon state officials have requested a Medicaid waiver to delay all income verifications until after the state of emergency in response to COVID-19 is lifted, according to The Lund Report. Legislators are also considering options that would enact a grace period for non-payment of insurance premiums that lasts for the duration of the emergency declaration and put an “any willing provider” provision in place to eliminate out-of-network status for patients.
The Rhode Island Commission for Health Advocacy and Equity released a report that summarizes data collected through the state’s Health Equity Measures, a set of 15 measures that cover five domains, reports State Network. The report is intended to educate the General Assembly, state agencies, and partner organizations on health inequities in Rhode Island and includes examples of programs and policies in the state and across the country that are showing promise for reducing inequities.
VCU Health is halting seizure of patients’ wages and removing thousands of liens against patients’ homes, some dating to the 1990s, according to Kaiser Health News. The moves follow an investigation last year by Kaiser Health News that found VCU Health and Virginia’s other major teaching-hospital system, UVA Health, pursued tens of thousands of patients over the years for overdue bills, sending many into bankruptcy. Liens often reached thousands of dollars and Virginia allows creditors to garnish up to 25 percent of a patient’s earnings.
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Studies evaluating the individual mandate have found that the mandate increased individual-market enrollment, though at lower magnitudes than originally envisioned, and that that people with lower healthcare needs were more responsive to the mandate, compared to those with greater needs, according to a literature review published in Health Affairs. In its original form, the Affordable Care Act required people to obtain health insurance or pay a tax penalty—a provision that was effectively repealed starting in 2019. The individual mandate was created to expand insurance coverage and increase the pooling of healthcare spending across people in better and worse health.
Multiple studies over the last six years found that the Affordable Care Act’s Medicaid expansion has increased health coverage, affordability, and access to care while reducing uncompensated care costs for hospitals and clinics and potentially contributing to budget savings for states, according to a Kaiser Family Foundation review of more than 400 studies and policy reports. Moreover, research showed that Medicaid expansion is associated with decreased mortality overall and for certain specific conditions, reductions in rates of food insecurity, poverty, and home evictions and improvements in measures of self-reported health and healthy behaviors.
Some studies have shown that medical loss ratio requirements, which forced health insurers to spend a minimum percentage of money on medical care, have produced mixed results, according to Modern Healthcare. Since 2011, the ACA has required insurers in the individual and small group markets to spend at least 80 cents of every premium dollar on medical care and quality improvement and insurers in the fully insured large group market to spend 85 cents per dollar. Though intended to increase the value from each premium dollar, some studies show the rule may have resulted in higher medical spending and spurred mergers and acquisitions by companies trying to boost profits.
A review, published in Health Affairs, highlights areas where the ACA has affected healthcare spending, emphasizing the long-term impact on spending. The authors note that despite a large increase in the numbers of people with coverage, the annual expenditure growth rates in the years following the ACA’s implementation were generally lower than in the years before the ACA—average annual national health spending grew 4.3 percent between 2010-18, compared to 6.9 percent between 2000-09. Additionally, the ACA had both direct and indirect effects on prices and care utilization, and these varied by market sector.
COVID-19 has highlighted many gaps in our healthcare system. Numerous states are taking action to extend coverage and reduce cost-sharing for consumers. The Commonwealth Fund summarizes some of these state actions in a new publication. For example, some states that are limiting cost-sharing for treatments and vaccines, while others are expanding access to telehealth.
States are pursuing strategies to make healthcare prices more transparent after a RAND study revealed significant variation between private payer and Medicare prices, according to a review of state action published in JAMA. Seventeen states have developed mandatory all-payer claims databases (APCDs), or databases that house healthcare claims data from payers to monitor prices and quality, and three more states are implementing APCDs. Several states have also implemented right-to-shop laws that require health plans to offer consumers incentives to choose lower-cost, high-quality providers. A great deal of state activity has also been centered on protecting patients from surprise medical bills.
Medicare beneficiaries may still be paying more for the same drugs than they would through Walmart’s generic drug discount programs (GDDPs), according to a study in the American Journal of Managed Care. The study examined the differences in the out-of-pocket costs for common generic drugs for chronic illnesses when Medicare patients used their Medicare prescription drug plans (PDPs) or when they purchased through Walmart’s GDDPs. Around three-fifths of PDPs required consumers to pay out-of-pocket costs higher than those of Walmart’s GDDP in 2009, while just one-third did so in 2017. Opportunities for lower out-of-pocket costs still exist for Medicare beneficiaries, since a substantial proportion of plans still require higher costs than GDDP cash prices.
A universal healthcare program like ‘Medicare for All’ may not have profound effects on the total number of jobs in the U.S. economy—defying oft-repeated claims about rises in unemployment, according to an analysis from the Economic Policy Institute. Researchers assert that such reforms could boost wages and salaries, increase job quality, lessen the stress and economic shock of losing a job, support self-employment and small business development, and produce a net increase in jobs.
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At least three states are reopening their health insurance exchanges amid the coronavirus outbreak in an effort to boost coverage and expand treatment for the uninsured, reports Roll Call. Maryland, Massachusetts and Washington state all announced special enrollment periods for uninsured individuals this week as the outbreak worsens and governors declare emergencies. Twelve states and the District of Columbia operate their own health insurance exchanges, which give local leaders the authority to reopen enrollment on their own in the face of an emergency like the coronavirus.
To avert the potential public health risk that could result from barriers to care for the uninsured and underinsured, many have called for increasing the affordability of testing and treatment of symptoms, however consumer cost-sharing concerns remain. Waiving cost-sharing would make a difference in the individual and small group market, where exposure to out-of-pocket costs is considerable, according to the Robert Wood Johnson Foundation. Overall, 87 percent of individual market plans require the deductible be satisfied before there is any cost-sharing. With median deductibles ranging from $4,000 for silver plans and $6,000 for the small group market, a trip to the ED for testing may come at a steep cost for many.
Video “visits” through computers, tablets, and smartphones, also known as telemedicine or virtual healthcare, are being promoted by hospitals, health systems and federal agencies in response to the COVID-19 pandemic. However, with the absence of a physical exam and the absence of testing, all that telehealth can really offer patients right now is increased surveillance and an illusion of care that poses new risks for our future health and well-being, as well as the loss of privacy, according to STAT editorial. There are many limitations associated with telehealth, for example, swabbing to detect microbes or conducting advanced imaging. The biggest benefit of telehealth may be preventing people who have been exposed to the coronavirus from leaving their homes and spreading it to a physician’s practice or an entire emergency department.
Pharmacy benefit managers (PBMs) play an important role in our pharmaceutical supply chain and can create value by providing negotiation leverage as they amass scale by aggregating smaller buyers. However, consolidation has resulted in a situation where the 3 largest PBMs have approximately 80 percent market share, according to JAMA. One of the largest criticisms of PBMs is the lack of transparency surrounding the structure of payments from manufacturers—a situation that could lead to PBMs developing formularies to maximize payments to the PBM rather than maximize value to patients. Authors propose using this framework of competition, transparency, and agency to evaluate ways to intervene in the prescription drug market around PBMs.
The Patient-Centered Outcomes Research Institute (PCORI) has been reauthorized for another 10 years with bipartisan support, according to Modern Healthcare. PCORI funds comparative effectiveness research, which examines the benefits and risks of medical interventions to help patients and clinicians make better healthcare decisions.
The United States underinvests in community and public health programs compared with traditional healthcare services, despite research demonstrating that these interventions are cost-effective and, in some cases, cost-saving, according to JAMA. Recommendations for addressing community health include: focusing interventions not only on high-risk individuals, but also on high-risk neighborhoods; investing in community needs; implementing social impact bonds to bring local governments, social service organizations, and investors to improve a clearly defined social outcome; and providing vouchers to low-income families to relocate from high-poverty to low-poverty areas.
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