Exchange Eligibility Regs: Massive and Visionary
Just as we were speculating Friday on timing for the Exchange eligibility and enrollment regs, out it came. The NPRM is a massive and visionary document that starts a discussion about how to revolutionize the way Americans select, enroll and pay for insurance.
States and the Federal government face a daunting task of preparing for a flood of millions of new consumers into Medicaid and subsidy programs in 2014. The ACA mandated a consumer-friendly, one-stop enrollment process with simpler eligibility rules and advanced technologies — referred to by one state official as "radical simplification". Most states couldn't be farther from the ACA's goals, having onerous cultures, manual paper-driven processes, and antiquated and disconnected systems. The Administration has released extensive guidance and unprecedented funding for states to revamp these processes and systems, and the timetable for planning and implementation is brutally tight.
Fact sheets from HHS are here. Tim Jost offered a nice overview at Health Affairs here. The GHG Public Policy team is reviewing the NPRMs and will have more perspectives this week on this page.
The Individual Mandate Will Get Settled by the Supremes
On Friday the 11th Circuit Court of Appeals in Atlanta found the ACA's individual mandate unconstitutional, ensuring the matter will be decided by the US Supreme Court in 2012. The only question among the DC chattering class is if the ruling will come in time to have an impact on the election, not whether the Court will uphold the law. Case law around the Federal government's right to tax interstate commerce -- and even inactivity like not buying health insurance -- is well-established, giving an edge to the Obama Administration that it will be upheld. Stay tuned.
Exchange Operations Regs Due Next
Recently at a Bipartisan Policy Center forum, CMS said the health insurance exchange regulations from HHS will cover enrollment and eligibility requirements. As we saw firsthand with the messy launch of Medicare Part D in 2006 -- one plagued by enrollment and eligibility SNAFUs for the first 6 months of the program, which kept thousands of beneficiaries from their needed medications -- the guidance can't come soon enough to ensure states and health plans have sufficient time and resources to get ready.
CMS said the forthcoming rule has a number of guiding principles:
- While it will be difficult given the intricacies of coordinating dozens of databases of healthcare consumer eligibility information, HHS is committed to flexibility for the states in figuring it out. The ACA requires the exchange to be a one-stop shop for determining eligibility in either the exchange, Medicaid, the Children's Health Insurance Program, or employer subsidies.
- There are wildly different eligibility rules for Medicaid, CHIP and the exchange subsidies, so streamlining those rules and procedures — such as for income verification — is key.
- ACA put emphasis on a simple enrollment process, for a simple reason: the vast majority of US citizens have never actually bought health insurance on their own. Most is provided through your employer, with the help of a friendly local broker. Exchanges need to be able to take a relatively small amount information from a consumer and be able to determine their eligibility for a range of healthcare subsidies, in near-real time. Simple for the consumer -- a monster for states and health plans to figure out. This is building the healthcare equivalent of Orbitz or Travelocity from a green field, to be presented to consumers who for the most part will have no idea what they're doing.
CMS said the eligibility and enrollment guidance will be coming "soon" but as is customary, wouldn't specify, though the draft reg has been submitted to OMB for approval, which means we can expect it in the next 60-90 days. And once that happens, the sluggish exchange planning process occurring in the states will get shot out of a cannon.
Help take the "salesguy" out of your sales force
With CMS sure to maintain their focus on agent conduct, plans must demonstrate adequate oversight of their ever-changing sales force.
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Watch a short demo video.
Learn more here. Feel free to leave comments, questions and feedback.
Medicare Sales Sentinel short demo video
Medicare Sales Sentinel fact sheet.
Why should physicians do prospective evaluations?
Most plans that have done prospective evaluations have taken one of two approaches: Using their existing physician network, or using mid-level practitioners who live in the same general area as the members to be evaluated.
Although they have been significantly more effective than network physicians in these programs, there is a better way.
It is possible to recruit physicians evaluators who can travel to the area of the project and devote their full day to the evaluations. They bring a number of advantages.
All in all, the traveling physician model works.
Obama is the Best Conservative President since Bill Clinton
An interesting article by noted wild-eyed liberal* Bruce Bartlett.
*Bartlett served on the staffs of Congressmen Ron Paul and Jack Kemp and Senator Roger Jepsen; as staff director of the Joint Economic Committee of Congress; senior policy analyst in the Reagan White House; and deputy assistant secretary for economic policy at the Treasury Department during the George H.W. Bush administration.
In Tough Times, the Elderly Make Easy Prey
Financial abuse of the elderly is up -- way up. It's a tragic sign of the times that seniors are being targeted for theft and abuse at record levels as the economy continues to sputter.
Further Evidence that Part D is Working
New data shows that seniors enrolled in Medicare Part D will pay about $30 in monthly premiums in 2012, 76 cents less than they do now and about 44 percent lower than originally projected in 2003. Indeed, since 2007, premium costs in Medicare's Part D program have increased by about $8, according to CMS.
The program continues to be a shining example of how the Federal government can create a new market for insurance from a green field, imbue it with fierce competition among private companies, and regulate the hell out of it to achieve a major public good. Part D has come in well over $100 billion cheaper than anyone thought it would on the Hill in 2003, and the vast majority of beneficiaries are happy with their choice of plan. The program has also been shown to reduce the incidence of unnecessary hospitalizations among those enrolled.
Sounds like a blueprint for health reform. Our government hasn't exactly demonstrated lately that it can learn from its mistakes; maybe we'll have more luck learning from our successes.
What Happened to the Crack-berry?
This amazing letter was written to RIM leadership by a ranking exec about the woes of their flagship product line, which you know and love as BlackBerry.
It's not often that a company* can appropriate a 1000-year-old word and completely change its meaning in the culture. It's a testament to the way RIM changed--one could say created--the smartphone category with its product. You always remember your first: mine was in 2003: the 6200, the last greenscreen model, which I promptly traded for the 7200 (color!) a year later. RIM's woes since then have been well documented and are fascinating. They go something like this: guessed wrong, got lazy, became out of touch with the market it created.
It's the last point I find most interesting. RIM defined the smartphone market by convincing businesspeople that responding to emails while on the toilet at 11pm was completely acceptable behavior. But they swiftly lost touch with this category by missing the implication of what they had created: that email and phone use were precursors to the real game, which was putting a computer in everyone's pocket. That was where the category was always headed--- it's easy to see now. But at the time, just the addition of a phone was so radical that when Blackberry first added it to its handheld--which was an overgrown two-way pager, they didn't even include a numbered keyboard.
Medicare Advantage is in a similar moment. While CMS gets credit for creating the category, seniors are now comfortable with managed Medicare. This coming generation even more so. But will the product be left behind by ACOs or other forms of integrated care? By MSAs? By something really cool that we don't even know about? Will MA learn how to integrate a phone? And will we forget to put the numbers on it?
*A CANADIAN company, at that!
A Way Out of the Healthcare Cost Explosion? Look North
According to a study by the University of Toronto in Health Affairs, US health care spending could be cut by billions a year if doctors spent the same amount of time and money dealing with insurance plans as their Canadian counterparts. Because Canada has a single-payer system -- essentially Medicare for all -- and because of our patchwork quilt of financing healthcare here, US doctors spend nearly $83,000 per physician per year dealing with insurance companies, compared to around $22,000 for doctors in Ontario, the study found. Staff in US doctors' offices also spend around 10 times longer per physician per week dealing with health plans than their Canadian counterparts.
The findings are similar to those found by a US Government Accountability Office study commissioned by my old boss, US Rep. John Conyers, back in 1991:
"If the universal coverage and single-payer features of the Canadian system were applied in the United States, the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured."
I acknowledge the political impossibility of enacting a single-payer system here in the US. But in our tough economic times, the financial death spiral we are in on healthcare costs, and watching the ongoing sumo match around the ACA, I do wish President Obama had stepped in front of the cameras a couple years ago and said "It's time all Americans had Medicare, with a choice of high-quality health plans."
This is also a family issue for me: my younger brother, one of the most brilliant physicians I have ever seen, actually fled to Canada 12 years ago in a fit of pique about the administrative burdens of medicine in the US, our litigious culture and the epidemic of drug-seeking patients. Today as an intensivist running the biggest ICU in Quebec, he's never been happier. Sure, there are plenty of affluent Canadians coming across the border for elective procedures they were stuck in a queue for back home, but at the end of the day, Canada kicks our ass in coverage, most major health indicators, and notably, physician satisfaction.
It's getting harder for the US to continue its jingoistic tune that we have the best healthcare in the world. We do -- but only if you can pay for it, and can find doctors who will see you.