Enrollment in Federal Marketplace & 2014 Premium Tax Credits

By Claire Thayer, June 23, 2014

Last week, the Department of Health and Human Services published an in-depth research brief that examined 19,000 Marketplace plans for 2014 and analyzed data on the change in the premium cost associated with the tax credit for Marketplace plan selections made through the Federally-Facilitated Marketplace (FFM) during the initial open enrollment period.


Study highlights and selected charts are provided below:

For additional information, download the full research report, PREMIUM AFFORDABILITY, COMPETITION, AND CHOICE IN THE HEALTH INSURANCE MARKETPLACE, 2014. Interested in learning more about public and private health insurance exchanges? Health Policy Publishing’s Health Insurance Marketplace Newsmight be just what you’re looking for! Request a complimentary sample issue:


Goldman Exec: Economy is Growing, but…

By Cyndy Nayer, CEO, Center of Health Engagement, June 18, 2014

Goldman's top economist, Jan Hatzius, believes that the US economy is now growing at an above-trend pace. This is great news regarding economics and income security. For most.

But Hatzius calls out the high student debt and overall slow pace of job creation as a hindrance to the recovery and expansion of the marketplace.  

And there is still the issue of those without health care coverage or those with income insecurity--making less than the cost of living, managing multiple jobs, or at risk of losing their pensions.  

A video was recently published on the relationship of poverty to readmissions, featuring the Detroit Henry Ford health system. When there is low income, lack of access to pharmacies and healthy food, and poor public transportation, patients discharged from hospitals are often readmitted due to poor compliance in follow-up recommendations. They skip drugs, they eat poorly and they miss regularly scheduled physician checkups. Many are readmitted to emergency rooms and inpatient stays.

This, then, becomes not only a patient risk (for both increased costs and poorer outcomes) but also a health system risk (since CMS is penalizing health systems for avoidable readmissions). Costs go up for the patient (copays, deductibles, new prescriptions, more outpatient visits). Costs go up for payers (avoidable medical and drug costs, among others; absence management if the payer is the self-insured employer). Costs go up for the community (unreimbursed medical costs go up, tax dollars are used for some of these and needed infrastructure, education, and job creation are left behind).

A new study from Mannatt and Commonwealth Fund clearly lays out the advantages of clinicians helping patients to get the community services needed to overcome these inequities.

"Before physicians can substantially cut costs and improve outcomes, they must first address patients' social needs, including whether a patient has a home or heat or access to healthy food, according to findings from a new report," says the report.

This is another opportunity for value-based reimbursements to those entities that can coordinate care beyond clinical intervention. The study calls for patient-centered medical homes (PCMH) to onboard these tasks.  

But ACOs, public health and even business entities can become allies in this effort to identify resources to improve access to healthy food, needed pharmaceuticals, expanded consumer debt counseling and educational resources.

Using value-based reimbursement strategies, payers, health systems and public entities could benefit by providing clear increases to those clinical practices that use care coordination and document better health and health cost outcomes.

Sometimes, health is achieved through non-clinical, social determinants (influences) that are improved by using the trusted resources in a patient's life. The physician, nurse, and pharmacist are 3 of the most influential.



Stopping on Green 

By Laurie Gelb, June 9, 2014

The intersection greets you with a green light, but an accident blocks your lane. You brake instinctively, disregarding an official signal to proceed. Contradictory stimuli define our lives. 

Cut to health care’s adherence doctrine. “Ask your doctor. Take your medication as prescribed.” In what other subject area is it optimal for end-users to follow instructions without having internalized a rationale and therefore knowing when and how to ignore them? If you’re repairing something and the instructions say “use an inch of duck tape” and it takes two, do you stop working or use more tape?  You make a split-second decision in the moment. 

We expect to kludge. Every day, most people take action that is unprecedented for them, slightly different, under new circumstances or seen in a new light. When a wall-mounted sink falls off, most of us can imagine that we should use the main water shutoff even if we’ve never used it before. And if we came to a screeching halt at every choice about food, drink, OTC, rx, exercise, surgery, medical equipment, caregiving, parenting, safety, environmental controls, etc., we couldn’t function. Certainly, some health decisions merit more than a second for consideration, but that doesn’t mean they get it, whereas some receive more consideration than they deserve.

You might ask, why is understanding the rationale for and exceptions to instructions so important, considering that patients can consult a clinician that knows both well? But you know the answer: seldom is the clinician or the network next to patients as they make critical choices to act, avoid, deny, even everyday re-evaluation of instructions about meds, diet, exercise, procedures, lifestyle, rehab.The vast majority of decisions that drive health outcomes are unknown, unseen and uninfluenced by content and service providers. And our constituents, knowing their own context better than anyone while facing their own toppled sinks, must often take what is for them unprecedented action. 

As the green light illustrates, we haven’t abstracted information until we can act optimally when things go wrong, or when conditions differ from a perfect world. The necessity of lifelong learning applies to health care in spades, while the evidence base for preaching “follow” (along with paternalistic clinicians and arsenic cosmetics) reeks of mold.

Memorizing that 2x2=4 doesn’t mean that you understand arithmetic. When a toddler repeats words, she hasn’t yet learned the language. We should want health care choices made by reason, not rote. Since any ongoing regimen, including observation, should be re-evaluated periodically, the notion of “set it and forget it” doesn’t apply. 

Few life choices entail a greater emotional investment than your own and loved ones’ health, while typical messaging dispassionately informs you that following the rules offers the best odds.  Yet the “exceptions” are so ubiquitous as to be cliché. Long-distance runners drop dead of early MIs as grizzled sun-worshippers light up into their 80s.  The “what you get is what you follow” thesis merits growing skepticism as truisms (fats block arteries, calcium strengthens bones, exercise prolongs life) emerge as increasingly complex and non-curvilinear propositions. Moreover, today’s patients face competing risks and lifestyle choices that their ancestors never knew. 

Instead of preaching reliance on catechisms that may or may not apply to a given situation, how about skill-building in decision-making directly, including the rationale for caring at all, transcending health calculators and guidelines. Economic studies show lower costs for the “engaged.” It can’t be an innate urge to obsess about health care that engages them, since hypochondriacs entails higher costs. The truly engaged understand enough to add value to their care.

Let’s not seek “informed consumers” a la the cereal aisle, who can only consume the information and care we provide, but informed patients, caregivers, clinicians, administrators and payors, who can collectively lift all boats. Clinicians can ask better questions to optimize outcomes, while EHR designers find better ways to incorporate the answers. Payors can better align provider and patient incentives. Patients and caregivers can ask better questions as well, while acting optimally on the stimuli life presents. 

Our “best” patients are not necessarily the most compliant with our every word. Instead, they ask realistic questions and probe for the best kludges so they can best apply what they know to what they don’t. Indeed, exploring disease information on one’s own has been associated with greater adherence in the traditional sense, time and again. Our “best customers” and the caregivers that support them understand that intention is not action, there is no free ride in health care and sometimes they must preserve their own health and even lives by stopping on green. 

Last week’s Modern Healthcare piece on the Cleveland Clinic illustrates, hardly for the first time, that even marquee institutions mislay part of the achievable.  By the same token, the lives we can save or improve by helping decision-makers to do their best work are incremental to the followers who leave more to chance.

Next installment: what are quick wins for patient satisfaction [sic], disease management and e-health if/as we rethink the adherence doctrine?


athenahealth Annual PayerView Report Ranks Human Top Plan Again For Providersa

by Clive Riddle, June 6, 2014

athenahealth recently released their 2014 PayerView Report, which ranks “commercial and government health insurers according to specific measures of financial, administrative, and transactional performance. These measures provide an objective, comparative benchmark for assessing how easy or difficult it is for providers to work with payers.” For the second year in a row, athenahealth found Humana the top performing plan out of 148 plans analyzed.

Here are their rankings for local and national Commercial plans:

  1. Humana
  2. HealthPartners
  3. BCBS of MA
  4. Cigna
  5. Group Health Cooperative
  6. Capital Blue Cross - PA
  7. Care First BCBS - DC
  8. Unicare
  9. BCBS of NC
  10. Neighborhood Health Plan

Four major insights were provided by athenahealth regarding the report:

(1) “ Medicaid's Lackluster Performance Continues - For the 9th straight year, Medicaid performed worse than commercial plans and Medicare on key metrics such as Days in Accounts Receivable (DAR), Denial Rates, and Electronic Remittance Advice (ERA) transparency. “

(2)  “Providers' Burden to Collect on Claims Varies Widely - PayerView data indicates that provider collection burden (PCB), measured as the percent of charges transferred from the primary insurer to the next responsible party after the time of service, is increasing slightly. ..PayerView results reveal that Medicare and many Blue Cross Blue Shield plans require providers to collect large percentages of payments from patients, while Medicaids require minimal collection. “

(3) ”Blue Cross Blue Shield Plans Pay Providers the Fastest - As a category, Blue Cross Blue Shield plans reimburse providers most quickly, with an average of three fewer Days in Accounts Receivable compared to all other payers. On this measure, Blue Cross Blue Shield plans represent 20 of the top 25 performers.”

(4) “Commercial Payers Offer the Most Efficient Enrollments - While Medicaid enrollment proves particularly burdensome, national commercial payers' enrollment proves simplest. “

athenahealth notes that rankings from their report “are derived from athenahealth's athenaNet® database, which to date includes more than 52,000 providers across 50 states. The 2014 PayerView data set analyzes 108 million charge lines and $20 billion in health care services billed in 2013.”



RWJF Examines Current and Future Coverage Eligibility For the Uninsured – It’s a State by State Issue

By Clive Riddle, May 30, 2014

The Robert Wood Johnson Foundation, in conjunction with the Urban Institute, has just issued a nine-page Issue Brief: Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States.

The Urban Institute authors, Matthew Buettgens, Genevieve M. Kenney, and Hannah Recht found that:

  • This year, under the ACA, 56% of the uninsured became eligible for financial assistance with health insurance coverage through Medicaid, CHIP or subsidized private coverage through the new marketplaces.
  • In states that expanded Medicaid eligibility under the ACA, 68% of the uninsured became eligible for assistance, compared with 44% in states that have not expanded Medicaid.
  • If states that have not expanded Medicaid eligibility were to do so, 71% of their uninsured would be eligible for assistance.
  • Among states expanding Medicaid, the ACA is projected to reduce the number of uninsured people by 56%, compared with a 34% reduction among states not expanding Medicaid.
  • If the states that have not expanded eligibility were to do so, the number of uninsured in those states would decrease by 59% 

The authors note that the “Medicaid expansion states with the lowest share of uninsured eligible for assistance tend to be those in which Medicaid eligibility for adults had already been expanded above minimum required levels before the ACA.”

Given the state decisions are the determining factor, what is the range of eligible uninsureds in the non-Medicaid expansion states, and where is the low end based? Look South. The Authors state that “with the exception of Wisconsin, the share of the uninsured in nonexpanding states eligible for assistance ranges from 40 percent in Texas to 58 percent in Alaska and Maine. The states with the lowest shares eligible for assistance (Texas, Mississippi, Louisiana, and Georgia) have particularly large shares of residents below 100 percent of FPL. [What’s up with Wisconsin? The authors note that Wisconsin changed its Medicaid Waiver in 2014 and “therefore, Wisconsin resembles a Medicaid expansion state.”]

The top five states (all expansion states) by percentage eligible for any assistance, along with the projected percentage decrease in uninsured under the ACA:

1. West Virginia – 83% Eligible / 76% decrease in uninsureds

2. Kentucky – 82% Eligible / 63% decrease in uninsureds

3. Michigan – 81% Eligible /64% decrease in uninsureds

4. Ohio – 81% Eligible / 65% decrease in uninsureds

5. North Dakota – 80% Eligible / 64% decrease in uninsureds

Conversely, here’s the bottom five states (all non expansion states):

50. Texas – 40% Eligible / 31% decrease in uninsureds

49. Mississippi – 42% Eligible / 31% decrease in uninsureds

48. Louisiana -– 42% Eligible / 32% decrease in uninsureds

47. Georgia – 42% Eligible / 30% decrease in uninsureds

46. Alabama -– 43% Eligible / 28% decrease in uninsureds