Immigration Bill Has Healthcare Workforce Implications

A bipartisan Senate immigration bill could boost the nation's healthcare workforce, in addition to expanding coverage to millions of newly legal residents. If passed, the law is expected to increase both visas and green card access for a broad range of healthcare workers. Specifically, it would make it easier for foreign physicians who come to the U.S. for their medical residencies to stay on after their training (if they’ll serve three years in medically underserved areas).

According to American Medical Association President Jeremy Lazarus, MD, “The AMA strongly supports the permanent reauthorization of the J-1 visa waiver program outlined in the Senate immigration bill that will allow International Medical Graduates to continue providing much needed healthcare to people in communities across the country. “IMGs play an integral part in American medicine, often joining physicians in practices serving patients in rural and low-income urban areas.”

Read more about the immigration bill and the two kinds of visas that foreign doctors can get: an H-1B visa for specialty workers or a J-1, which is an educational or cultural visa in Modern HealthCare (free subscription required) or Politico.

ACA Meeting in Denver on April 27th

Affordable Care Act (ACA) meeting scheduled for April 27th. Come learn the myths from the facts about the ACA and get answers to your questions on Saturday, April 27th from 1:00 – 5:00 at Manual Auditorium in Denver. Get more details in the flyer or read the agenda here.

Mediator Coming to Help with Exchange Set Up

Sparring between Colorado Department of Health Care Policy and Financing (HCPF) and the Colorado Health Benefit Exchange Board (COHBE) prompted an outside analyst to recommend a third party to triage and manage the project.

Federal grants that Colorado received to launch its exchange require outside analysts to conduct independent reviews. According to a new report from outside analysts at First Data, squabbling between state and exchange managers over IT projects and other policy decisions has been slowing down progress on the exchange.Therefore, a mediator from the Robert Wood Johnson Foundation now will come to Colorado to help managers get the giant multi-million dollar project off the ground on time by October 1st when it’s slated to open to consumers.

Yen Pham, an analyst from First Data stated, “A number of policy decisions need to be resolved by both COHBE and HCPF; they include the approach to accommodate referrals, eligibility mixed households and life change events.” Read more in the Colorado blog, Health Policy Solutions. 

Response to Study Finding CAHs Had a Slightly Worse Mortality Rate Than Major Medical Centers

A recent research report in the Journal of American Medicine stated that Critical Access Hospitals (CAHs) had a slightly worse mortality rate than major medical centers. Dr. Wayne Myers, a retired pediatrician and rural medical educator, responds in The Daily Yonder stating that the report gave the wrong reasons for the small difference in survival between the rural CAHs and larger regional hospitals. Read Dr. Myers's insightful response here.

Report Says Experience of CHIP Hints at Impact of Medicaid Expansion on Providers

Enrollment in public health insurance coverage will expand significantly beginning in 2014. At this time there is only a limited understanding of what happens when an influx of newly insured patients encounters a relatively fixed supply of providers. Will they choose to work longer hours to accommodate the increase in demand? The experience of the Children’s Health Insurance Program (CHIP) offers a preview of how providers might respond to the expansion.

According to a report in the Medicare & Medicaid Research Review, researchers from the Government Accountability Office and the Washington-based Center for Studying Health System Change found that the creation of the Children's Health Insurance Program in 1997 did not create a deluge of patients that the nation's pediatricians couldn't handle. Read more here.

Policy Options to Cut Emergency Department Costs

For nearly 50 years, emergency rooms have been fingered as a major source of excessive healthcare costs. And while some newer research has challenged the idea that a large proportion of patients visit the emergency room for routine problems, many payers and policy makers continue to focus on these patients as a major source of wasteful spending.

For a new study published in The Journal of the American Medical Association, researchers reviewed the records from almost 35,000 patient visits to emergency departments across the country. In just 6 percent of cases, the patient was discharged and could have been treated in a healthcare provider’s office. 

History has shown that limiting payments based on discharge diagnoses has been largely unsuccessful. However, other policy options are being tested around the country. Beginning last summer, emergency departments in Washington state established programs to educate patients on how to access care, as well as other measures designed to improve care, including statewide guidelines on prescribing narcotics, shared electronic health and prescription information, and regularly updated reports on how emergency department resources are utilized. The policy has already resulted in significant changes and a projected savings of over $31 million by the end of the fiscal year. Read more here.

Interim Report Says There is Little Support for Medicare Payments That Vary

An interim report recently issued by the Institute of Medicine concluded Medicare should not adjust payments on a broad regional basis to reward hospitals and doctors that spend less to achieve high-quality care. 

The study was conducted at the request of the secretary of Health and Human Services, Kathleen Sebelius, in response to a push by some members of Congress to revisit how Medicare pays hospitals and doctors. The report’s authors were responding to the argument that Medicare should pay higher levels of reimbursement to areas of the country that deliver measurably good care at low cost and less to regions where costs are high and outcomes are poor. Read more about the study in the New York Times.

Colorado Health Report Card Released

Each spring, the Colorado Health Foundation releases a health report card for the state, measuring things like teen pregnancy, smoking, obesity and mental health. This year, Colorado received three Bs, a C and a D.

The analysis divides Coloradans into five age groups, prenatal to old age. Overall, the report said adolescents, adults and the elderly are doing pretty well; they earned Bs and B pluses. However, the score for Colorado’s children, was a D plus. According to Anne Warhover, president and CEO of the Colorado Health Foundation, “[W]e’re not growing our own healthy children. Our child obesity rate remains in the middle of the pack. That’s where the foundation is really going to emphasize more and more of our work in trying to prevent childhood obesity. It leads to so much cost in our system.”

Read more about the report card in Katie Kerwin McCrimmon's post in the Colorado blog, Health Policy Solutions.

Thank Senators Bennet and Udall for Their Efforts to Ensure Rural Healthcare Providers' Need are Addressed by the Senate

As part of the ongoing budget discussions, Colorado Senators Michael Bennet and Mark Udall, and New Mexico Senator Martin Heinrich, have put forward Amendment 612 to the proposed Senate budget to ensure that rural healthcare providers' needs are addressed by the Senate. The amendment, which can be viewed by clicking here, makes sure that the budget passed by the Senate has needed flexibility to extend rural health programs and create others. Voting on this and all other amendments to the proposed budget, is ongoing.  The Colorado Rural Health Center and the National Rural Health Association encourage you to thank Senators Bennet and Udall for their support of rural providers (click on the links to email your support).

Clarification Regarding the Colorado Health Insurance Cooperative

In a blog post dated March 15th, I erroneously reported that Colorado received a loan to create a CO-OP, and I would like to correct that information.  The Colorado Health Insurance Cooperative (CO-OP) was established in 2012 through a $69 million loan awarded by the Department of Health and Human Services (DHHS) under the Affordable Care Act (ACA).  The CO-OP is sponsored by the Rocky Mountain Farmers Union Educational and Charitable Foundation, and is a consumer governed and operated, nonprofit insurance company that aims to offer affordable, high quality health coverage to individuals and small businesses.  The CO-OP will primarily be made available through the Colorado Health Benefit Exchange and independent insurance brokers in 2013.

Study Says Medicaid Expansion for All States Would Pay Hospitals More By 2022

According to a study by the Urban Institute funded by the Robert Wood Johnson Foundation, states that expand Medicaid could see $2.59 gained in Medicaid revenue for every private insurance dollar lost. Under the Affordable Care Act (ACA), states have the option to raise the income eligibility mark for Medicaid to 133% of the federal poverty line starting in 2014 in exchange for full federal funding for the expansion for three years and not less than 90% of the added cost after that. Read about the study here, which examined current low-income patients who have private insurance but would be newly eligible for Medicaid coverage if the state expanded the program. In Colorado, Senate Bill 13-200 is making its way through the legislative process. If passed, Colorado will expand Medicaid eligibility to 133% beginning in 2014.

Improving Quality and Patient Safety for Vulnerable Populations

Dr. Bruce Siegel is the President and CEO of the National Association of Public Hospitals and Health Systems (NAPH), and is a contributor to the Learning Health System Commentary Series of the Institute of Medicine (IOM) Roundtable on Value & Science- Driven Health Care.  Authored commentaries in the IOM Series draw on the experience and expertise of field leaders to highlight health and healthcare innovations they feel have the potential, if engaged at scale, to foster transformative progress toward the continuously improving and learning health system envisioned by the IOM.  Statements are personal, and are not those of the IOM or the National Academies.

In this commentary, Dr. Siegel describes NAPH’s current efforts to improve the disproportionate burden of hospitalization and poor health outcomes for the nation’s safety-net patients. Read his discussion on several concepts central to continuously improving care, including the importance of integrated, coordinated patient care across various care delivery settings here.

Opinion Piece: The ACA is Pushing Physicians to Become Hospital Employees

It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association, shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that accelerated around the time that the Affordable Care Act (ACA) was enacted.  Read Scott Gottlieb's recent opinion piece in the Wall Street Journal about hospital-acquired medical practices.

Will Medicare Cost Slow Down Close the US Budget Gap?

New evidence that the slowdown in healthcare costs over the past five years is happening not only because of a weak economy comes from the Economic Report of the President report, recently released by the President’s Council of Economic Advisers.  The report found that if the slowdown were to continue in the future, Medicare spending would basically remain flat as a share of the economy. Read more here about the Economic Report of the President as it examines changes in healthcare spending and unemployment rates across states.

Application for Benefits Daunting

According to an article in BenefitsPro, applying for benefits under President Barack Obama's healthcare overhaul could be as daunting as doing your taxes.  The draft of the application was released, and it runs 15 pages for a family of three.  Families USA Executive Director, Ron Pollack, expressed concern for the uninsured; he said they may be overwhelmed with the process and simply give up.  The Department of Health and Human Services (HHS) estimates it will receive more than 4.3 million applications for financial assistance in 2014, with online applications accounting for about 80 percent of them.  Because families can apply together, the government estimates 16 million people will be served.

Read the full article here, which includes a list of pros and cons for how the reform is shaping up.

Osteopathic Doctors May Help Ease Provider Shortage in Rural Areas

Osteopathic physicians have been around for more than 100 years.  But the recent growth in the field of osteopathy, both training facilities and number of graduates, may help reverse a looming shortage of primary-care providers that will hit rural communities especially hard.  Osteopathy programs historically have attracted more older applicants and career changers than MD programs, and recruit applicants in rural locations.  Read more about osteopathic physicians and the role they play in the healthcare workforce. LINK

CO-OP Opportunity for Insurance Coverage

When policy-makers decided not to include a public health insurance option in the Affordable Care Act, they compromised by adding the Consumer Operated and Oriented Plan (CO-OP) program to the law. Sponsored by consumer groups and other nonprofits, CO-OPs aim to offer consumers more options in states where few health insurers cater to individuals and small businesses. Colorado received a loan to create a CO-OP. 

A new policy brief from Health Affairs and RWJF reviews the challenges facing CO-OPs as they prepare for open enrollment in October. Read the brief.

HCPF Hosting Stakeholder Meeting to Discuss Churn

Earlier this year, Governor Hickenlooper announced that Colorado will expand Medicaid for adults up to 133% of the federal poverty level as part of the Affordable Care Act. Colorado will also be running its own state health insurance exchange, where eligible individuals and families will be able to shop for subsidized health insurance coverage. In preparation for this expansion, the Department of Health Care Policy and Financing (HCPF) has been working with stakeholders, the Center for Health Care Strategies, SHADAC, and other states to understand the needs and characteristics of this newly eligible population. 

HCPF would like to invite you to join the conversation on Monday, March 18 from 11:00 am to 1:00 pm for a stakeholder meeting to discuss “churn” – the movement of individuals between Medicaid and the exchange. 

Stakeholders may join via webinar and phone. To register for the webinar, click this link. If you’ve never attended a GoToMeeting webinar before, you will need to click “run” when the program prompts you. The webinar will allow you to see the slides during the meeting, but to hear the facilitator, you will need to call into the conference line and enter the participant code below.  

Call-in: 877-820-7831
Participant code: 946029#

Nurse Practitioners Say How They're Paid Affects Care They Can Provide

According to a study from Kaiser Health News published last week by the National Institute for Health Care Reform, researchers found that while scope of practice laws did not appear to restrict the primary care services nurse practitioners can provide to patients, they do affect how the advanced nurses are paid. Read more here.

Sequester Digest

News outlets around the country are covering the sequester and its impacts.  A collection of news articles relative to sequestration can be found below.  

The Washington Post: Republican Goal To Balance Budget Could Mean Deep Cuts To Health Programs
Anxiety is rising among House Republicans about a strategy of appeasement toward fiscal hard-liners that could require them to embrace not only the sequester but also sharp new cuts to federal health and retirement programs. Letting the sequester hit was just the first step in a pact forged in January between conservative leaders and Speaker John A. Boehner (R-Ohio) to keep the government open and the nation out of default. Now comes step 2: adopting a budget plan that would wipe out deficits entirely by 2023 (Montgomery, 3/4).

Politico: Paul Ryan Floats Change To Medicare Plan
Paul Ryan's budget will show how Republicans can balance a budget that's trillions of dollars out of whack. But the most significant unresolved issue comes down to a minuscule number: one year. Ryan — the House Budget Committee chairman — has privately been floating the idea of allowing his changes to Medicare to kick in for Americans younger than 56. In previous budgets, those 55 and older were exempted from his plan to turn Medicare into a premium-support — or voucher — program (Sherman and Allen, 3/4).

The Hill: GOP Centrists Balk At Ryan Medicare Shift
House Republican centrists are furious that GOP leaders are considering abandoning their pledge not to change Medicare retirement benefits for people 55 years and older. According to several sources, a handful of centrist GOP lawmakers attending a recent Tuesday Group luncheon erupted when Budget Committee Chairman Paul Ryan (R-Wis.) and House Majority Whip Kevin McCarthy (R-Calif.) broke the news (Hooper, 3/5).

The Medicare NewsGroup: Distrust Of Government Is A Hard Hurdle To Jump In Medicare Reform
One reason that changes to the Medicare program will be hard to make is because people distrust the federal government yet cherish what it offers them. This is a hard conundrum to overcome. The latest polling makes this point with great vigor. And the discussions among experts within different parts of the political spectrum illustrate why President Obama and Congress have scant prospect of success in producing any alterations to Medicare. … Skepticism about government is the deepest since the Pew Foundation began polling in 1958, when it found that 73 percent of Americans trusted the government in Washington, D.C., "all the time or most of the time." Today, the level of trust has shrunk to a meager 26 percent, according to the latest polling, conducted last month (Rosenblatt, 3/4).

Impact of Medicare Cuts on Colorado Rural Hospitals

As federal employees are contemplating smaller paychecks this week, administrators at rural hospitals are struggling just to keep their balance sheets in the black, thanks to the sequester.

In 2011, Medicare payments to Colorado hospitals were $253 million less than in 2009, according to the Colorado Hospital Association.  Now those same institutions are facing another 2 percent decrease in reimbursement for Medicare services.  That one-two punch could knock some hospitals out of the ring, according to Russ Johnson, CEO of San Luis Valley Regional Medical Center in Alamosa, Colorado.  Read the full article from ABC news here.  

Commission on Doc Pay Urges End to FFS, SGR

The National Commission on Physician Payment Reform released a dozen recommendations to ultimately change how physicians are paid by public and private payers, starting with the premise that physician salary and expenses account for 20% of healthcare spending, but the decisions doctors make influence another 60% of that spending.

The Society of General Internal Medicine convened the commission a year ago to suggest new ways to pay the nation's physicians that could improve patient outcomes and lower healthcare costs.  In the report released Monday, the commission concluded that the problems of physician payment are based on systemic issues, such as the traditional fee-for-service payment model, and problems pertaining specifically to Medicare, including the sustainable growth-rate formula to pay physicians and the operation of the Relative Value Scale Update Committee (RUC), which makes recommendations to the CMS. Read more here (may need free subscription).

New Analysis of Colorado Children and Health Insurance

The Colorado Health Institute recently released its annual analysis of the number of eligible children in the state who are not enrolled in the Medicaid or Child Health Plan Plus (CHP+) public insurance programs.

According to the analysis, about 125,000 Colorado children, or 9.7 percent of all children, did not have health insurance in 2011. This was a decrease from the 132,000 uninsured children in 2010.

View the 2011 estimates from the Colorado Health Institute here in three new publications:

• A fact sheet that summarizes the high-level findings and maps county-level estimates. 
• A data supplement that includes detailed tables of county-level data. 
• A methodology document that outlines the assumptions and processes used to create the estimates.

Docs Brace for $11 Billion Hit from Sequester

Friday's Cliff: Nondefense Programs to be Slashed by Roughly 8% 

WASHINGTON -- Medicare providers stand to absorb $11 billion of the $85 billion in federal spending cuts that start Friday and last for the rest of the fiscal year unless Congress takes 11th-hour action.

Under the impending sequester, Medicare payments to providers will be cut by 2%, and most nondefense programs will be slashed by roughly 8% starting Friday.

The across-the-board method to limit federal spending has been criticized and deemed harmful by both political parties and nearly all interest groups.  But with little agreement on what to replace the spending cuts with, it's growing more likely they will actually take effect. Read More

Ways & Means Chairman Hopes To Move Medicare ‘Doc Fix’ Plan

If done smartly, this issue could reshape our 

entire health economy for the better

The chairman of the House Ways and Means Committee made clear Tuesday that finding a solution to the vexing issue of setting Medicare physician payment rates is on his to-do list this year, and he got some tepid support from a key Democrat.

Rep. Dave Camp, R-Mich., said that the effort could be helped by a recent reassessment of how much it would cost.  Earlier this month, the Congressional Budget Office lowered its cost estimate for fixing Medicare’s physician payment formula over the next decade to $138 billion due to lower Medicare spending on physician services during the past three years.  In January 2012, the CBO estimated the cost of the fix at $316 billion, which it reduced to $245 billion last August. Read More

States Can Cut Back on Medicaid Payments, Administration Says

The federal government is bending over backward 

to show flexibility 

WASHINGTON — The Obama administration said Monday that states could cut Medicaid payments to many doctors and other health care providers to hold down costs in the program, which insures 60 million low-income people and will soon cover many more under the new health care law.

The administration’s position, set forth in a federal appeals court in California, has broad national implications as it comes as the White House is trying to persuade states to expand Medicaid as part of the new law.

The statement of federal policy infuriated health care providers and advocates for low-income people. But it may encourage wavering Republican governors to go along with the expansion because it gives them a tool to help control costs. Read More

Rural Providers on Edge as Sequestration Deadline Gets Closer

Sequestration, the automatic and across-the-board federal spending cuts that were specifically designed to be so painful that they never would occur, are likely to take effect on March 1st. This is different than what we were hearing just a few weeks ago. The 2% mandated cuts to Medicare totaling more than $2.9 billion in 2013 will disproportionately ill-effect the small rural providers that rely on federal government funding to keep their doors open.

According to Maggie Elehwany, the National Rural Health Association's vice president of government affairs and policy, says all signs are pointing towards sequestration going into effect putting rural providers on edge. Read the article in HealthLeaders Media here.

Colorado to Receive $2 Million to Continue Work on a Comprehensive State Health Care Innovation Plan

The Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced Thursday the first recipients of the State Innovation Models initiative awards.  Twenty-five states received nearly $300 million in awards will support the development of models of care that will transform healthcare delivery throughout the states. 

Over $250 million in Model Testing awards will fund 6 states – Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont – in implementing their plans for healthcare delivery transformation.  These states will use these funds to test multi-payer payment and service delivery models on a broader scale within their state.  An additional 19 states will receive nearly $35 million to develop their State Health Care Innovation Plans that will guide for comprehensive health care transformation.

Colorado is one of three states that will receive pre-testing assistance to continue to work on a comprehensive State Health Care Innovation Plan.  States receiving pre-testing awards will have six months to submit their State Health Care Innovation Plans to CMS.

Learn more about the State Innovation Models initiative and view the 25 awardees here.

Final Rule on Essential Health Benefits Released

The Obama administration released the final rule on essential health benefits this week, which sets the parameters for the types of benefits that must be offered by insurers starting in 2014. Kaiser Health News is tracking the news coverage; read capsules from Politico and The Hill, as well as link to the proposed rule here.  A bill will be introduced in the Colorado legislature this session which will allow the Division of Insurance to promulgate rules around essential health benefits, as well as align state law with federal statutes for implementation of healthcare reform.

Report Says Medicaid Expansion Will Boost Colorado's Economy

A new study of Medicaid expansion commissioned by the Colorado Health Foundation, and conducted by legislative budget analyst Charlie Brown and a team of economists, says expanding Medicaid to an estimated 275,000 additional people will cost Colorado less than the price of not adding them.  Brown and his team found that expanding Medicaid would be similar to a stimulus program for Colorado because millions of federal dollars will flow into the state to pay for the new patients’ care (federal taxes will pay 100 percent of the costs of Medicaid expansion from 2014 to 2016, then taper to 90 percent by 2020).

Key findings from the report include:

• In FY 2025-26, the last year of the study period, a comparison of the "no expansion" and "full expansion" options shows that the following economic impacts will occur as a result of the decision to fully expand Medicaid:
• The economy, as measured by state gross domestic product (GDP), will be 0.74 percent larger than if Colorado does not expand its Medicaid program. Expansion will result in just less than $4.4 billion in additional state economic activity in 2025.
• Average annual household earnings will be $608 more with full Medicaid expansion compared to no expansion.
• Colorado will have 22,388 more jobs in 2025 if the state fully expands Medicaid.
• While Medicaid expansion is not free, the combination of federal support for expansion populations and state savings in programs makes full expansion less costly to the General Fund than no expansion until FY 2020-21.
• By FY 2025-2026, state General Fund appropriations would be a cumulative $133.8 million less for full Medicaid expansion than if the state chose not to expand.
• The larger economy that would result from Medicaid expansion will generate more state tax revenue without an increase in tax rates. In FY 2025-26, tax revenue is projected to be $128 million higher due to a decision to expand Medicaid. In each year, the combination of the additional revenue generated from the larger economy and savings in other General Fund programs is sufficient to fund the state's share of the cost of Medicaid expansion.
• Compared to no expansion, Medicaid expansion will add an additional 275,000 Coloradans to Medicaid enrollment by FY 2025-26. Those added to Medicaid insurance include 209,000 newly eligible adults without dependent children, 44,000 newly eligible parents and an additional 22,000 currently eligible but not enrolled children and parents.
• Medicaid expansion will reduce the number of uninsured non-elderly Coloradans by 189,000 by FY 2025-26 and reduce the percentage of uninsured in the non-elderly population from 11.1 percent to 7.7 percent compared with non-expansion.

Read the press release from the Colorado Health Foundation and link to the full report here.

Healthcare as an Economic Stabilizer

Princeton economics professor Uwe Reinhardt provided his perspective this week on the impact of healthcare on the economy.  Reinhardt says the healthcare sector has functioned for some time as the main economic locomotive pulling the economy along, and in the last two decades, it has created more jobs on a net basis than any other sector.  Read more of his perspectives and enjoy an economics lesson here.

Nurse Practitioners Push To Help Care For Health Law's Newly Insured

More than 27 million Americans will soon gain health coverage under the health law. But who will treat them all?

"With such a large coverage expansion, and with an anticipated shortage of primary care physicians available to serve them, some states have or are considering allowing so-called advanced practice nurses -- those with advanced degrees -- to treat more patients. David Hebert is at the issue’s center. Hebert, a veteran health care lobbyist and former CEO of the American College of Nurse Practitioners, is the first CEO of the American Association of Nurse Practitioners (AANP) -- a new group with 42,000 members recently formed from the merger of the American College of Nurse Practitioners and the American Academy of Nurse Practitioners."

KHN's Alvin Tran sat down recently with Hebert to discuss the changing role nurse practitioners may soon have, as well as some physicians' efforts to stop them.

Click here to read edited excerpts of that discussion:

New Medicaid Estimates

According to a new cost-benefit analysis from the Colorado Health Institute, expanding Medicaid would cost Colorado about $1 billion over 10 years and add an estimated 240,000 to the state’s Medicaid rolls, including as many as 73,000 people who could switch from private to public health insurance. 

Colorado lawmakers expect to introduce a bill in the coming weeks that will outline the state's plans for Medicaid expansion.  Read the informative blog post from Health Policy Solutions here.

Dueling Legislative Approaches to Fixing the Doc Pay Emerge

Dueling legislative approaches to overhaul the Medicare physician payment formula emerged this week. The new movement on the stubborn problem comes as the Congressional Budget Office revised the 10-year cost of fixing it down by more than 40%, to $138 billion from $245 billion, based on lower spending on physician services in recent years. 

There are some general similarities in the proposals, but there are also critical differences between an approach contained in bipartisan legislation introduced Wednesday by Rep. Allyson Schwartz (D-Pa.) and a Republican bill expected from Ways and Means Health subcommittee Chairman Kevin Brady (R-Texas) in the coming months.

Both the bills would replace the sustainable growth-rate formula with temporary increases while replacement methodologies were devised, but the bills differ on important points, including whether federal officials or physician groups would take the lead in developing new payment systems and the degree to which fee-for-service payments would be eliminated.

Read the article in Modern Affairs here (account may be needed), or link to the proposals from Rep. Schwartz or Rep. Brady.

Notice for Employers Re. Exchanges Requirement Delayed

The Department of Labor announced last week that the requirement that employers provide notice to their employees of the existence of Exchanges will not take effect on March 1st.  It is expected that the timing for distribution will be late summer or early fall of 2013. 

The Colorado Health Benefit Exchange (COHBE) is a public entity governed by a Board of Directors. The Exchange, scheduled to open for business in October of this year, will be a new marketplace where  individuals and small businesses in Colorado can shop for and buy health insurance based on quality and price.  

Read more about the Exchange here, or learn more by visiting the Frequently Asked Questions from the Department of Labor regarding the requirements for notice to employees. 

Lessons Learned from Early Adopters of Remote Patient Monitoring Technologies

Remote patient monitoring such as home teleheath and telemonitoring can help improve coordination, improve patients’ experience of care, and reduce hospital admissions and costs. These technologies remotely collect, track, and transmit health data from a patient’s home to a healthcare provider and can facilitate communication and help engage patients in the management of their own care. A new brief from The Commonwealth Fund offers findings from case studies of three early remote patient monitoring adopters: the Veterans Health Administration, Partners HealthCare, and Centura Health at Home. Read the case studies and lessons from early adopters here.

AHA Rural Chair Says Reimbursement Top Challenge

Alvin Hoover, CEO of King's Daughters Medical Center in Brookhaven, MS, chairs the American Hospital Association's Section for Small or Rural Hospitals. Read his interview in "Health Leaders" about the reimbursement challenges facing rural hospitals in the reform landscape. Hoover says the overarching challenge is going to be to helping the legislators understand that massive cuts to reimbursement to try to lower the deficit can't all be on the backs of hospitals.  Read the interview here. 

Congress Looks at SGR Repeal

Repealing the sustainable growth rate (SGR) formula for physician reimbursement under Medicare is a high priority for the new leader of the House Ways and Means Subcommittee. Rep. Kevin Brady (R-Texas), says he wants to work with the House Energy and Commerce Committee to craft legislation to permanently repeal the SGR and replace it with, "a reliable physician reimbursement formula that rewards quality." Read more about the idea of a SGR repeal here.

Anthem's Telemedicine Program Connects Members with Needed Services

Anthem Blue Cross’ telehealth network recently marked an important milestone. By providing over 50,000 specialty consults, they connected members in some of the state’s most rural underserved areas to needed healthcare services. Read about how they built their model from its original purpose as a vehicle to serve the growing Medi-Cal population, and how the program has grown over time to serve other Anthem members and even other health plans without a network of their own.

 

Medicaid Officials Release Rule Affecting Cost-Sharing and Coordination

The Centers for Medicaid and Medicare Services (CMS) released their 474-page proposed rule affecting cost-sharing and coordination with Exchanges earlier this month.  The proposed rule states officials would be able to charge Medicaid patients higher cost-sharing for some services than current regulations allow.

The proposed rule also affects a wide range of other Medicaid provisions, including appeals of eligibility determinations; coordination between Medicaid and the new healthcare law's insurance exchanges; the role of counselors to assist people with their coverage applications; procedures to verify employer-sponsored coverage; and the use of updated Medicaid eligibility categories.  You can read more in the Commonwealth Fund's blog. 

NE Study Shows Residents in Rural Counties are Less Likely to Have Health Insurance

A new health study says more uninsured people live in rural Nebraska, and experts say the implications for the future affect all of us. This is true for Colorado, as well as across the country. The rural economy is based on small business and self -employment. Small business owners face inherent challenges in providing coverage for themselves and their employees. Lower purchasing power, increased risk of adverse selection and higher marketing and administrative costs all contribute to insurers charging higher premium costs to smaller employers, a common practice in rural parts of the state. Read the article here, or read more about health disparities facing rural Coloradans in the Colorado Coalition for the Medically Underserved's most recent issue in their infographic series about access.

HHS Releases Long-awaited Privacy Rule

The US Department of Health and Human Services (HHS) released its highly anticipated and long-awaited privacy rule yesterday.  The rule expanded liability of business associates of hospitals, physicians and other Health Insurance Portability and Accountability Act (HIPAA) covered entities if they release data in ways that violate patient privacy.  Called the “omnibus” privacy and security rule because of its broad reach, it updates earlier HIPAA rules with more stringent privacy and security measures passed under the American Recovery and Reinvestment Act of 2009.

Read Secretary Kathleen Sebelius's news release here, or link to the 563 page rule in the Federal Register. 

Many of these changes will affect your current privacy and security policies and procedures. CRHC's Senior Advisor, David Ginsberg, will be reviewing the changes and providing summaries. Stay posted for further updates and resources.

Questions? Contact: David Ginsberg, Senior Advisor, Colorado Rural Health Center

Infographic on Healthcare Access in Rural Colorado Released

Joe Sammen, Community Partnership Coordinator for the Colorado Coalition for the Medically Underserved (CCMU), blogged this week about policy options to improve access for rural Coloradans. His opinion piece accompanied CCMU's lastest brief in their infographic series, a series that explores health from the perspectives of different populations. Developed using health survey data, the series demonstrates Coloradans’ varying experiences of health and healthcare. Read Joe's opinion piece here on rural healthcare reform and opportunities for coverage, and view CCMU's rural health infographic with data on access and coverage for rural Coloradans here.

Roughly 12,000 Jobs to be Added Statewide with Expansion of Medicaid

A proposal to expand Medicaid to cover 160,000 more Coloradans will add roughly 12,000 jobs statewide, according to a rough estimate by economic development leader Tom Clark.  Legislators will be debating whether to accept the federal offer this session, which as part of the Affordable Care Act, offers states the option to expand Medicaid to persons living below 133% of the federal poverty level. Gov. Hickenlooper recently gave the expansion his support and estimated it would bring $12.28 billion in federal funds back to Colorado taxpayers over 10 years. Read more here.

NBC Political Director Says Rural/Urban Divide “Stark”

NBC political director and chief White House correspondent, Chuck Todd, declared the “Rural-Urban political divide is as stark as it has ever been.” Speaking to a Washington, D.C. news radio station Monday, Todd said today’s divided nation is no longer “red state verses blue state, it’s rural verses urban.” He added that many of the politically divisive issues such as gun control and abortion stem from rural and urban differences that are “cultural.” Chuck Todd has been invited to speak during the National Rural Health Association's 24th annual Rural Health Policy Institute next month. Join other Coloradans in DC to continue the discussions about rural health and meet with Colorado's elected officials. Click here for more details on the Policy Institute. You can listen to Chuck Todd’s full interview here.

MedPAC Recommends 1% Pay Increase for Hospitals

Congress' primary Medicare advisory body recommended last week that HHS Secretary Kathleen Sebelius should limit hospital cuts she was required to make under a year-end fiscal cliff law to leave those facilities with a 1% payment increase next fiscal year.

The Medicare Payment Advisory Commission (MedPAC) unanimously recommended that Congress direct Sebelius to increase inpatient and outpatient prospective payments by the 1%, which is technically a reduction from the pre-existing legislative formula that said hospitals should receive a 1.8% increase starting next October.

Under the year-end American Taxpayer Relief Act of 2012, Sebelius was required to find $11 billion in savings from hospitals within four years through rate reductions. If the cut was evenly spread out over the four years—as the Congressional Budget Office assumed it would be—then it would reduce the fiscal 2013 update to a 0.6% cut.

However, if the MedPAC recommendation is followed, Medicare hospital spending would increase in the next fiscal year by up to $2 billion, according to the advisory body. Link to the full article here.

Health Cost Growth Slow But Showing Signs of Acceleration

A report recently released by the U.S. Centers for Medicare and Medicaid Services and published in Health Affairs, says U.S. healthcare spending rose at a historically low rate of 3.9 percent for the third consecutive year in 2011. But despite relatively low growth over the last few years, the figures showed signs of acceleration as the economy recovered from recession. Read the full article here.

Gov. Hickenlooper Announces Plans for Expansion of Medicaid in Colorado

Governor Hickenlooper announced this week his administration’s plans to expand Medicaid as part of federal healthcare reform.  This is a big win for rural Coloradans who typically earn lower wages than their urban counterparts and disproportionately experience unemployment. CRHC’s most recent policy survey shows members overwhelmingly support the expansion as a means to increase access to care for rural Coloradans, so this is exciting news for CRHC members and partners. 

The new eligibility standards will enable the state to cover an additional 160,000 adults. The federal government will cover 100% of the costs for the newly-eligible Medicaid population through 2016. After that, the federal match begins to taper down, and Colorado will be responsible for 10% beginning in 2020 (unless the law is changed).

The Governor’s press release can be found here.  Gov. Hickenlooper released a fact sheet and an FAQ with his announcement.  Click on the embedded links to read those documents. 

Rural Fiscal Cliff Averted

The rural fiscal cliff was averted this week when Congress came to an agreement at the 11th hour. David Lee of the National Rural Health Association released the following comments in regards to the legislation.

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Hundreds of millions of dollars in rural health cuts were prevented by Congress as part of the last-minute “fiscal cliff” legislation passed late in the night on New Year’s Day. While many were watching an underwhelming Orange Bowl, the President signed-into law legislation that reinstates critical Medicare reimbursement payments to over 850 rural hospitals, as well as prevented cuts to rural primary care physicians and rural ambulance providers.

The fiscal cliff bill, which included large tax provisions and an extension of unemployment compensation, also reinstated the Medicare Dependent Hospital program and the Low-Volume Hospital adjustment, which both expired October 1. Had Congress not restored these payments, many rural fiscally fragile facilities likely would be forced to close their doors.

This is a big win for rural providers and NRHA wishes to thank all of grassroots advocates who made their plea to Congress to prevent these harsh cuts. Stay tuned, we aren’t completely out of the woods. The 2% across-the-board sequestration cuts were delayed for two months, but the battle will begin again soon. Additionally, all rural payments were extended for only a one-year period and additional calls for cuts are surely just around the corner. This means, this year’s Policy Institute, where rural advocates appeal to their Members of Congress, significant than ever.

Below is a list of the rural Medicare provisions included in the fiscal cliff legislation:

Medicare Physician Payment Update. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013. Medicare physician payment rates are scheduled to be reduced by 26.5 percent on December 31, 2012. This provision would avoid that reduction and extend current Medicare payment rates through December 31, 2013. 

Work Geographic Adjustment. Under current law, the Medicare fee schedule is adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance. This provision extends the existing 1.0 floor on the “physician work” index through December 31, 2013. 

Payment for Outpatient Therapy Services. Current law places annual per beneficiary payment limits of $1,880 for all outpatient therapy services provided by non-hospital providers, but includes an exceptions process for cases in which the provision of additional therapy services is determined to be medically necessary. This provision extends the exception process through December 31, 2013. The provision also extends the cap to services received in hospital outpatient departments only through December 31, 2013. 

Ambulance Add-On Payments. Under current law, ground ambulance transports receive add-on to their base rate payments of 2% for urban providers, 3% for rural providers, and 22.6% for super-rural providers. The air ambulance temporary payment policy maintains rural designation for application of rural air ambulance add-on for areas reclassified as urban by OMB in 2006. This provision extends the add-on payment for ground including in super rural areas, through December 31, 2013, and the air ambulance add-on until June 30, 2013.

Extension of Medicare inpatient hospital payment adjustment for low-volume hospitals. Qualifying low-volume hospitals receive add-on payments based on the number of Medicare discharges. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment until December 31, 2013.

Extension of the Medicare-Dependent hospital (MDH) program. The Medicare Dependent Hospital (MDH) program provides enhanced reimbursement to support rural health infrastructure and to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This greater dependence on Medicare may make these hospitals more financially vulnerable to prospective payment, and the MDH designation is designed to reduce this risk. This provision extends the MDH program until October 1, 2013.

For a full copy of the legislation, click here.

Rural Hospitals Get Relief In Fiscal Cliff Deal

The New Year’s Day “fiscal cliff” deal means at least an extra $450,000 this year to tiny Jones Memorial Hospital in rural upstate New York. Click here to read the full article from Kaiser Health News.

AAFP Responds to New York Times Editorial, “When the Doctor is Not Needed.”

The American Academy of Family Physicians responded to a recent editorial posted in the New York Times (see blog post on December 17th).  The LTE can be found below. 

Letters to the Editor

The New York Times

Dear Editor,

In discussing the primary care shortage, let’s not lose sight of what is actually needed versus what is proposed in various solutions. The solutions in “When the Doctor is Not Needed” (NYT Editorial Dec. 15) are short-term answers to a long-term, systemic problem. We must differentiate between providing a service and utilizing expertise.

If we are to improve patients’ health and help restrain costs, we need to ensure patients get the right care from the right professional at the right time. Sometimes that means the expertise of the nurse practitioner is the best. Other times, a pharmacists’ patient education expertise is most appropriate. At all times, the expertise and deep clinical training of a primary care physician is the foundation.

Nurse practitioners, physician assistants, even patients themselves can implement health services —checking pulse and blood pressure, monitoring blood sugar levels, giving insulin injections, and managing chronic conditions. But they don’t necessarily have the expertise to know why the service is needed or how to respond to complications or lack of response. Limiting patients’ access to services provided only by a retail clinic, a nurse practitioner, pharmacist or other health professional restricts the patient’s access to the full panoply of available knowledge. Such solutions don’t ensure that the patient receives the most appropriate care, nor do they prevent unnecessary repetition of tests and procedures.

That’s why the American Academy of Family Physicians has called for patient-centered medical homes with team-based care from all health care professionals: physicians, nurse practitioners, pharmacists, or any necessary subspecialty physicians. Each professional has a crucial role to play, but they are not interchangeable. Only with such a team will patients have access to care that is comprehensive, accessible, preventive, efficient and, most importantly, effective.

 

Reid Blackwelder, MD
President-Elect
American Academy of Family Physicians