health policy

Federal bill would link Medicare hospital pay to quality

Anne Zieger — Fri, 21 Nov 2008 09:14:55 -0500

Now here's a bill that would scare me a bit if I were a hospital administrator--even if it was inevitable (and it is) that such a measure would be written. Sens. Max Baucus (D-MT) and Chuck Grassley (R-IA) have drafted legislation that would link Medicare reimbursement for inpatient hospital care to the quality of that care rather than the number of services provided.

Yes, this is the way things have been going for some time, between the drive to bundle care--as Geisinger has done with some procedures--and quality incentives, but this definitely takes things a step further in the direction of so-called "value-based purchasing." (Value-based purchasing: now there's a concept that's a million times easier to talk about than to actually realize.)

The bill would kick off the new policy in fiscal 2012 and be phased in over four years through FY 2016. Medicare reimbursement levels would be based on quality standards from a list of measures from several groups, including the National Quality Forum.

To learn more about this bill:
- read this Kaiser Daily Health Policy Report article

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Group releases code for recruiting foreign nurses

Anne Zieger — Fri, 05 Sep 2008 10:21:57 -0400

Health policy group AcademyHealth has released a new voluntary code of ethics for use in recruiting internationally-based nurses, one designed to better protect their rights in the midst of a rapid growth in such hiring. According to the National Council of State Boards of Nursing, the annual percentage of newly-licensed, foreign-educated registered nurses in the country has risen to 16 percent, from a scant 5 percent in the 1990s. Today, meanwhile, AcademyHealth has identified nearly 300 U.S.-based international nurse recruitment firms, 10 times higher than the number of companies existing in the 1990s.

When researching the subject of such recruiting, AcademyHealth researchers found reports of unfair labor conditions, potentially inappropriate contract practices and even threats to a nurse's immigration status when things went badly. Meanwhile, they also heard about nurses who breached their contracts after getting financial and practice help with immigration and resettlement in the U.S.

The new voluntary code offers guidance on ways to make sure that recruitment is fair and doesn't cause harm in the nurses' home countries, AcademyHealth researchers said.

To learn more about the code:
- read this Healthcare Finance News piece

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Los Angeles sues Anthem for individual policy cancellations

Thu, 17 Apr 2008 06:59:58 -0400

The Los Angeles city attorney has sued Anthem Blue Cross for allegedly canceling coverage of thousands of members after they filed large medical claims. In doing so, it's following the lead of the state's Department of Managed Health Care, which has conducted an ongoing campaign against such practices. City attorney Rocky Delgadillo contends that Anthem, its parent company WellPoint, and another subsidiary unlawfully revoked the policies of as many as 6,000 members. What's more, he argues that the plans' 500,000 individual policyholders have been defrauded, because their policies won't actually help them if they get sick. Delgadillo is seeking $2,500 per violation, or $5,000 if the victim is disabled or a senior--numbers that could amount to costs of more than $1 billion if the city wins its suit.

To learn more about the suit:
- read this Los Angeles Times piece

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BCBS of MI promoting coverage pool for individuals

Fri, 29 Feb 2008 06:59:55 -0500

Blue Cross Blue Shield of Michigan has been spending big bucks to promote what it considers to be a perfectly reasonable proposal--to create a health insurance coverage fund for people who have been denied coverage elsewhere. The pool would be run by the Blue plan, which would cover its initial financing, but after two years all of the state's insurers serving the individual market would have to kick in as well. The pool would be created by legislation currently pending in the Michigan legislature. But other insurers aren't so happy with notion. They say that BCBS of Michigan, which already enjoys big financial advantages as not-for-profit, should stop complaining about its losses on the individual market and dig into its $2.8 billion in reserves.

A lot is at stake here, given that by some estimates, a full 25 percent of the state's residents may need individual policies in less than a decade. It will be interesting to see whether BCBS pulls this off; if so, it may provide a back-door solution for health plans across the U.S., who currently are under fire for aggressively dropping sick patients with individual coverage.

To learn more about the pending legislation:
- read this Chicago Tribune piece

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Health plan industry addressing policy cancellations

Thu, 28 Feb 2008 06:59:58 -0500

Hoping to get some control of a situation that is rapidly deteriorating into a series of regulatory fines, lawsuits and heinously bad PR, the health-insurance industry is mounting an initiative to deal with the issue of retroactive policy cancellations. Industry group America's Health Insurance Plans has begun pushing state regulators to adopt a draft bill giving consumers the right to appeal rescissions to an external panel. Decisions by the panel, which would be composed of independent healthcare professionals and lawyers, would be binding on all parties. Meanwhile, some individual insurance companies, such as Blue Cross of California, are preparing to roll out their own independent review programs.

The initiative comes in the wake of several legal actions that have slapped health plans engaging in these cancellations. Last week, for example, a California judge awarded $9.4 million to a hairdresser whose medical coverage was canceled by Health Net while she was being treated for breast cancer. Health Net also faces a suit filed against it by the Los Angeles city attorney, who contends that the plan engaged in a concerted campaign to cancel patients' policies when they became ill.

To learn more about the health insurance industry's plans:
- read this piece from The Wall Street Journal

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CA seeks $12.6 million fine for Blue Shield

Thu, 13 Dec 2007 06:59:57 -0500

The state of California's insurance chief is seeking a $12.6 million fine against Blue Shield of California, accusing it of 1,262 claims-handling law violations and regs and more than 200 improper policy cancellations. This follows a similar action earlier this year by the state's Department of Managed Health Care, which fined Blue Cross $1 million on similar allegations.

About half of the violations cited by the commissioner are for allegedly improper policy cancellation practices, under which the health plan retroactively rescinds individual policies (and refuses to pay filed claims) if it discovers what it considers misstatements on applications. The insurance authorities contend that rather than make these cancellations, Blue Shield must screen applications better before it issues the policies. The state also accuses Blue Shield of deliberately paying claims slowly, failing to pay interest owed on claims and mismanaging member appeals.

This issue, clearly, is not going away. Rather than changing their approach wholesale, plans like Blue Shield, Blue Cross and Health Net are digging in their heels and defending their (questionable) interpretation of cancellation rules. With so much at stake, and tensions mounting, expect some even higher drama on this topic in '08.

To find out more about this increasingly heated dispute:
- read this Los Angeles Times article

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CA court says retroactive policy cancellations "prohibited"

Fri, 07 Dec 2007 06:59:57 -0500

A new legal ruling has dealt a blow to some California health plans, who have contended until now that canceling policies for unintentional application mistakes is acceptable under California law. A state appeals court has ruled that health plans may not go over applications after medical claims have been submitted, an approach known as post-claims underwriting, calling the practice "flatly prohibited." The courts said that a class-action suit filed to challenge this practice will be allowed to proceed.

Blue Shield of California Life & Health Insurance Co.--and other health plans in the state-- have insisted that state law allowed it to cancel individual policyholders who make omissions or misstatements on applications, even after medical claims have been submitted. Observers say that the appeals court decision court should pressure some insurers into changing their business practices before they're forced to by the state. Still, to date California health plans have seemed quite determined to make such cancellations, despite taking considerable heat from regulators and consumers.

To find out more about the case:
- read this Los Angeles Times piece

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CA regulators plan limits to health policy cancellations

Wed, 24 Oct 2007 06:59:57 -0400

Two powerful state regulators have come together in California to propose rules limiting health plans' ability to retroactively cancel policies. The state's Department of Managed Health Care (DMHC) has come together with the Department of Insurance to issue rules which would forbid rescission of individual policies unless health plans could show that a policyholder made a "willful misrepresentation" (e.g, they lied) on their application. The rules would also require health insurers to do a medical underwriting investigation of potential beneficiaries rather than relying strictly on information provided in applications. The proposed regs will undergo a formal public comment period prior to approval.

The new rules are just the latest shots in the DMHC's battle with health plans over policy cancellations. In March of this year, for example, the DMHC fined Blue Cross of California $1 million after the agency concluded that it systematically and illegally canceled policies held by chronically ill and pregnant policyholders.

To learn more about the new proposed regs:
- read this Los Angeles Times article

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Study: Drug, devicemaker ties with academic ctrs common

Wed, 17 Oct 2007 06:59:57 -0400

A new study suggests that academic medical centers have tight relationships with pharmas and medical-device makers, perhaps tighter than previously thought. The study, which was done by researchers at the Massachusetts General Hospital Institute for Health Policy, found that 67 percent of teaching hospital departments and 60 percent of department heads had a compensated relationship with a drug or device maker. Meanwhile, about 65 percent of medical schools had such relationships.

The relationships between these companies and academic medical centers included consulting relationships, speaking opps, advisory board memberships and intellectual property partnerships--not to mention education program funding and support for residency and fellowship training.

To learn more about the study:
- read this Modern Healthcare article

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Medicaid managed care not equal to commercial plans

Wed, 10 Oct 2007 06:59:55 -0400

Ideally, Medicaid beneficiaries who enroll in a managed care plan would get the same care as anyone in a commercial plan. Unfortunately, however, that's not how it actually works today, according to a new study. The research, which appears in the Journal of the American Medical Association, found that standard commercial health plans performed substantially better on nearly all of 11 quality indicators. For example, 77.2 percent of commercial health plan beneficiaries got appropriate postpartum care, while only 52.7 percent of Medicaid managed care patients did.

This study suggests that despite great hopes to the contrary, managed care probably isn't the ticket for improving care for the Medicaid population, researchers said. At minimum, resources may need to be configured a different way to address these patients' needs, according to Dr. Bruce Landon, associate professor of health care policy and medicine at Harvard Medical School, who served as lead author of the study.

To learn more about the study:
- read this HealthDay News article

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