Celebrate the 5th Annual Safety Net Clinic Week August 18th - 22nd!

The Colorado Rural Health Center and ClinicNET are celebrating the 5th annual Safety Net Clinic Week (SNCW) August 18th through the 22nd! In an effort to raise awareness about the diversity and impact of Colorado's healthcare safety net, this week is devoted to educating public officials and the community about these vitally important healthcare clinics - federally certified Rural Health Clinics (RHCs) and Community Safety Net Clinics (CSNCs).

RHCs and CSNCs provide access to primary care serves for individuals and families that are low-income, underinsured and uninsured and to those residing in rural and frontier communities. Patients who are uninsured and do not qualify for public insurance are often asked to pay for services as a flat fee or on a sliding fee scale based on their income level, and some clinics are free.

More information about SNCW 2014 will be coming soon. Think about hosting an open house or offering tours to your elected officials. It’s a great opportunity to showcase what you do to provide access to health in your community!

340B Drug Discount Program Under Scrutiny

The 340B drug pricing program lets thousands of hospitals, community health centers and family planning clinics buy outpatient prescription medications from manufacturers at an estimated 25 to 50 percent discount. Participants can then charge higher rates to insured patients and keep the additional revenue.

To qualify for the program, hospitals and clinics must meet federal requirements, such as non-profit status, serving a certain percentage of low-income or uninsured patients or receiving federal grants. The Affordable Care Act broadened the type of facilities that can qualify for the 20-plus year program, including Critical Access Hospitals, the smallest rural hospital.

Growth in the program is raising alarms among drug makers and some members of Congress who say that some facilities should not be eligible and that the money they receive from the discounts is not always being plowed back into patient care. The Health Resources and Services Administration (HRSA) runs they program, and Administration officials have promised to propose clearer rules for the program. Proposed regulations had been expected as early as this month, but a recent federal district court ruling has put into question whether HRSA has that authority.

Despite the ruling, HRSA says they plan to move forward with the proposed regulation, and it has been expected to touch on several areas, including eligibility and contracting. 

• Eligible patients: Patients who have a “relationship” with a 340B hospital or clinic are eligible to receive the discounted 340b drugs. But exactly what constitutes such a relationship isn’t clearly defined. “There’s always been a discussion about who truly is a patient of a covered entity and who truly can receive a 340B drug,” said David Ivill, a 340B expert with the law firm McDermott Will & Emery.
• Eligible facilities: Currently if a clinic is included in an eligible hospital’s Medicare cost report it can qualify for 340B drug pricing. Analysts expect a new regulation would provide more clarity on which facilities qualify and which ones don’t. While one part of a qualifying 340B hospital might serve large number of poorer patients, an affiliated clinic could see mostly insured patients. Under current rules both qualify to receive the discounted drugs.
• Contract pharmacies: Some providers in the 340B program can contract with outside pharmacies, like Walgreens, to give patients the flexibility of filling their prescriptions at locations that may be more convenient than a hospital pharmacy. A report released in February by the HHS Inspector General found inconsistencies in how some contract pharmacies determine who is eligible for the discounts and in how they conduct the oversight activities that HRSA recommends. In a statement, a HRSA spokesman said the agency has followed up individually with pharmacies identified in the report “to determine necessary next steps.”

Read the full article in Kaiser Health News here.

Missouri Bill Aims to Reduce Workforce Shortage by Allowing New Route to Become “Assistant Physicians”

Missouri may soon allow licensed medical school graduates to practice medicine and prescribe drugs without having completed a residency.

The proposal (Senate Bill 716), which has passed the state legislature and awaits the governor's signature, aims to address the issue of providing adequate healthcare in rural and other underserved areas of the state.

Under the bill, graduates of accredited medical schools could become “assistant physicians” and provide primary care services in rural or medically underserved areas if they haven't completed residency training. However, they must have completed the first two steps of their medical licensing exam. A collaborating physician would be responsible for all services rendered by the assistant physician.

Under rules from the Centers for Medicare and Medicaid Services, an assistant physician would also be considered a physician assistant. Read the article in Modern Healthcare here (requires a free subscription).  

Colorado Division of Insurance Releases First Look at Health Plans for 2015

The Colorado Division of Insurance released preliminary information this week from plans submitted by health insurers for Affordable Care Act (ACA) coverage in 2015. Rate and benefit information for the 2015 plan year was submitted to the Division of Insurance (DOI) on June 6th. Since that time, DOI staff has been conducting initial reviews to check the filings for completeness.

According to the preliminary study of rate filings provided by the DOI, Colorado residents and small businesses could face anywhere from a 10 percent increase in their health insurance premiums next year to a 10 percent drop in prices.

Commissioner of Insurance Marguerite Salazar commented, “We are pleased to see such a high number of carriers and plans. Rates seem to be holding relatively steady, which means we will continue to see a strong market in 2015 that will provide Colorado consumers with many options for health insurance.”

Over the summer, the Division of Insurance staff will examine each plan to make sure it is in compliance with the requirements of the Affordable Care Act and state and federal laws. The DOI will review the rates to ensure they are not excessive or inadequate. In addition, the DOI will also verify whether the plans meet the federally defined metal tier coverage levels: bronze (60% of medical expenses paid by the plan), silver (70%), gold (80%) and platinum (90%). These percentages are referred to as “actuarial value.” 

During the review period, Colorado consumers can submit public comments on the filings, which will be reviewed and considered by the Division of Insurance. The DOI will complete its review in September, then notify carriers and Connect for Health Colorado of the approved plans for 2015. Once approved, final plans will be posted on the DOI’s website. DOI will also provide summary information and charts detailing the number of approved carriers and plans for 2015, both on and off Connect for Health Colorado. Read the press release from the DOI here.  

AMA Calls to Give Veterans Access to Private Sector Health Providers

According to the American Medical Association (AMA), veterans facing long wait times for healthcare at government hospitals should have access to private doctors.

The AMA, the largest doctor’s group in the U.S., voted at its annual meeting yesterday to ask President Obama to give veterans access to private-sector health providers until a backlog at the Veterans Administration is reduced. More than 57,000 veterans waited longer than 90 days for an initial appointment at VA medical centers, according to an audit released yesterday. Read the article in in Bloomberg News here.

New Report About Narrow Networks Released by McKinsey Center

Roughly half of the products sold on exchanges in 2014 were narrow-network plans, according to a study by the McKinsey Center for US Health System Reform (read the study here). In the largest city in each state, that figure jumped to 60 percent.

The vast majority of exchange customers had a choice between broad- or narrow-network plans, the McKinsey study found. Broad network plans were available to 90 percent of potential customers, while narrow-network plans were an option for 92 percent of that population. Read the rest of the article in Modern Healthcare here (requires a free subscription). 

Creating rules around network adequacy are difficult for rural areas as a balance must be struck to create standards strong enough for meaningful access protections, but flexible enough to be achievable for the Qualified Health Plans. This discussion won't be over any time soon.

New Study From CHA Shows Impact of Medicaid Expansion on Hospital Volumes

A new study from the Colorado Hospital Association (CHA) shows the impact of Medicaid expansion on hospital volumes in the 26 states that chose to expand Medicaid eligibility under an option offered through the Affordable Care Act. The study shows that the Medicaid proportion of patient volume at hospitals in states that expanded Medicaid increased substantially in the first quarter of 2014. At the same time, the proportion of self-pay and overall charity care declined in expansion-state hospitals. You can listen to the article on Colorado Public Radio here, and read the study from CHA here.

Save the Date for Safety Net Clinic Week 2014!

Save the date for Safety Net Clinic Week 2014! SNCW 2014 will be celebrated August 18th through the 22nd. It is a week dedicated to raising awareness of all the various types of clinics with a commitment to serving patients who might otherwise have difficulty getting medical care.

Why is it important to celebrate Safety Net Clinic Week? Because while safety net clinics have some similarities, they also look very different from one another, and it is important to know where, why and how healthcare is currently being delivered. When it comes time for the federal, state, or even local government to make decisions regarding provider reimbursements, tobacco tax funds, Medicare or Medicaid payments, public coverage program eligibility, electronic health records (EHR) incentives, or other important policy choices, the people making those decisions need to understand how they affect safety net clinics like yours.

Therefore, the Colorado Rural Health Center and ClinicNET encourage you to celebrate Safety Net Clinic Week August 18th through the 22nd. Look for more information from CRHC and ClinicNET soon!

What Will Happen As Networks Continue to Narrow?

In the midst of all the turmoil in healthcare these days, one thing is becoming clear: No matter what kind of health plan consumers choose, they will find fewer doctors and hospitals in their network — or pay much more for the privilege of going to any provider they want.

These so-called narrow networks, featuring limited groups of providers, have made a big entrance on the newly created state insurance exchanges, where they are a common feature in many of the plans. While the sizes of the networks vary considerably, many plans now exclude at least some large hospitals or doctors’ groups. Smaller networks are also becoming more common in healthcare coverage offered by employers and in private Medicare Advantage plans.

Insurers, ranging from national behemoths like WellPoint, UnitedHealth and Aetna to much smaller local carriers, are fully embracing the idea, saying narrower networks are essential to controlling costs and managing care. Major players contend they can avoid the uproar that crippled a similar push in the 1990s. Read the article in the New York Times here.

Division of Insurance to Seek Shift on Geographic Rating Areas for 2015

Press Release from Colorado Division of Insurance (May 9, 2014)

The Colorado Division of Insurance (DOI) today announced it will ask the federal government for approval to change Colorado’s geographic rating areas for health insurance for 2015.

Geographic rating areas are geographical units made up of metropolitan statistical areas (MSAs), counties or three-digit zip codes, which are used by insurance carriers to price premiums.

The DOI seeks to reduce the number of rating areas from 11 to nine, combining four rural areas into two larger rating areas, while retaining the seven urban (or metropolitan statistical areas, or MSAs). Such a change will require approval from the U.S. Department of Health and Human Services.

“Consolidating the higher health cost regions into larger rating areas will spread the risks and the costs of providing health care more equitably over a larger population,” said Marguerite Salazar, Commissioner of Insurance. “We understand that people across the state are concerned about high health care costs and the impact on health insurance premiums. This is the fairest way of addressing the issue and working toward stable premiums in all regions of the state.”

The announcement comes after a meeting last week of the Health Care Cost Study Group. At that meeting, the DOI put forth three options for rating areas following presentation of an actuarial analysis commissioned by the DOI for the study group. The DOI invited comments through Wednesday, May 7.

The DOI received 306 comments of which 138 addressed the rating area options. Of those, 117 were supportive of the nine rating areas structure.

As part of this change, on Friday, May 9, DOI will formally request approval from the Department of Health and Human Services to change Colorado’s rating area structure. Due to this change, the DOI also will extend its deadline for insurance carriers to provide plans and rates for 2015 from May 15 to June 6, providing time for insurance carriers to adjust to the new areas.

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The Colorado Division of Insurance regulates the insurance industry and assists consumers and other stakeholders with insurance issues. DORA is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado.

Survey Says - Healthcare Executives Don't Trust Payers

A survey designed to measure the level of trust that hospital executives have in health insurance companies finds several factors that contribute to low scores, including the length of time it takes for claims to be paid, and the rates hospitals and physicians are paid.

Payers scored poorly on all three of the new trust questions in the annual National Payor Surveyconducted by ReviveHealth, a Nashville, TN based strategic communications firm and Catalyst Healthcare Research. The results from the final question, which asked providers whether a particular payer "balances its interests with ours and doesn't routinely take advantage of us," were particularly dire. Read the article in HealthLeaders Media here.

New Telemedicine Policy Draws Opposition

New guidelines issued by the Federation of State Medical Boards (FSMB) could have a chilling effect on the growth of telemedicine – especially in rural areas and among low-income patients, say some patient advocates, healthcare providers and healthcare companies. But the Federation says the updated guidance will safeguard patients’ privacy and ensure high-quality care in the current fast-changing healthcare delivery environment.

As part of a wide-reaching April 26 policy statement, FSMB changed the definition of telemedicine to care that “typically involves the application of secure videoconferencing… to provide or support healthcare delivery by replicating the interaction of a traditional encounter in person between provider and a patient.” It is not, according to the Federation, “an audio-only, telephone conversation, e-mail/instant messaging conversation or fax.”

The statement, which is not a legal document but is intended to help state medical boards’ develop professional policies and standards for their members, triggered a backlash from some stakeholders. Read the rest of the article in Kaiser Health News here. 

Telemedicine Still Facing Barriers In Most States

With more than 7 million people signing up for coverage under federal healthcare reform and millions more gaining coverage under Medicaid Expansion, providers now need to reach more rural patients than ever before. But providers and payers in many states are still struggling with outdated laws and other obstacles in their effort to reach patients in remote areas.

But experts say those barriers to care are slowly disappearing as more states pass laws to allow Medicaid to reimburse providers. That effort is also being helped by pilot programs launched by providers and insurers in an effort to improve care and generate savings by allowing rural residents to address health problems before they get worse. Read the article in Health Leaders Media.

Insurance Extension Decision Could Impact Many Coloradans

Insurance Commissioner Marguerite Salazar announced Friday that state residents who extended plans that do not meet minimum benefits required under federal healthcare reform before the end of last year may extend them again through the end of 2015 if their insurers continue to sell the plans.

It is unknown how many of the roughly 100,000 people currently covered by such plans in Colorado will have the opportunity to re-up and will choose to do so. But the people in such plans are viewed by many health analysts to be healthier than those who recently have purchased insurance for the first time. And keeping them out of the larger risk pool could cause prices for insurance policies to rise across the board.

Read more about how the extension decision could impact Coloradans in the Denver Business Journal or read about a national study on the impact of the canceled plans in Politico.

Is Rate Relief Coming to Colorado's Ski Towns?

Last Friday, Colorado Insurance Commissioner Marguerite Salazar said she wants to redraw the geographic rating boundaries which previously lumped together Garfield, Pitkin, Eagle and Summit Counties and created the most expensive insurance market in the U.S. Commissioner Salazar announced that by redrawing the boundaries, those counties will now be part of a 22 county region. 

Read more about the change in boundaries in Kaiser Health News or in Health News Colorado.

Study Says When Hospitals Buy Physician Practices, Costs Go Up

A new study gives ammunition to what health economists and health insurers have argued for years: When hospitals buy physician practices, the result is usually higher hospital prices and increased spending by privately insured patients.

The study, published Monday in the journal Health Affairs, was based on an analysis of 2.1 million hospital claims from workers of self-insured employers between 2001 and 2007. The analysis by Stanford University researchers found prices were most likely to increase when hospitals bought physician practices, as opposed to hospitals forming looser contractual relationships with physicians.

Read the article in Kaiser Health News.

Tax Credit Extension Sought to Aid Rural Providers

Advocates are trying to persuade Congress to permanently extend a tax incentive program that helps small and rural healthcare providers obtain financing for building and expansion projects.

The New Markets Tax Credit Program was authorized in 2000 and last extended for two years on Jan. 1, 2013. The current push is to make the program permanent, which President Barack Obama supported in his fiscal 2015 budget proposal. In the House, Reps. Jim Gerlach (R-PA) and Richard Neal (D-MA) reintroduced legislation earlier this month that would make the program permanent rather than requiring reauthorization every two years. Similar bipartisan legislation was introduced in the Senate last summer.

Cuyuna Range Hospital District in Crosby, MN, is among the rural providers that have taken advantage of the program. The district, which operates 25-bed Cuyuna Regional Medical Center, wanted to finance a $15.7 million project last year to expand its operating rooms and surgical clinics. The program allowed Cuyuna to save 18 percent on its borrowing costs, or about $2.3 million. 

“It's a real opportunity for rural healthcare for expansion,” said John Solheim, Cuyuna Regional's CEO. “It helps you create equity and economic development.”

For healthcare providers, the program allows them to reap savings through a lower interest rate from lenders and makes them more attractive borrowers at a time when many rural hospitals are struggling to obtain financing.  

Read the full article in Modern Healthcare (requires a free subscription).  

AHA Files Suit Against HHS Over "Two-Midnight" Rule

The American Hospital Association filed two lawsuits Monday against the two-midnight rule and was joined in its suit by several state hospital associations and individual hospitals.

“The two-midnight rule undermines medical judgment and disregards the level of care needed to safely treat patients,” said Richard Umbdenstock, president and CEO of the AHA, in a release announcing the lawsuits. “Hospitals stand by a physician's decision on what care is appropriate for each patient. The two-midnight rule is misguided and we feel confident the court will agree.”

“The hospitals take issue with the wholly arbitrary requirement that a physician must certify at the time of admission that a Medicare patient is expected to need care in the hospital for a period spanning two midnights to be considered an inpatient,” the release also said.

The doc-fix bill recently approved by Congress included a six-month extension before compliance would be enforced for the two-midnight rule. AHA apparently plans to use that time contesting it in court.

The existing two-midnight rule says admitting physicians must have good reason to believe that a patient will need two nights in the hospital before Medicare will pay full inpatient rates under Part A for the stay. Lacking such documentation, Medicare auditors will generally classify the stay as outpatient observation, which pays hospitals much less under Part B and sticks the patient with a 20% co-payment. That rule went into effect Oct. 1. But it was modified so that Medicare's aggressive recovery audit contractors could not overturn claims under the new policy until Sept. 30, 2014.

The enacted legislation requires Medicare to extend that recovery-auditing moratorium until March 31, 2015. It also gives Medicare officials the discretion to extend what's known as the “probe and educate” process until the same date next year. Under that process, a different set of companies, known as Medicare administrative contractors, can audit a small number of short-stay inpatient claims and train hospitals on how to submit more accurate bills. 

Read the article in Modern Healthcare (requires a free subscription).  

HHS Secretary Kathleen Sebelius Resigns, OMB Director Sylvia Mathews Burwell to Step In

Health and Human Services Secretary Kathleen Sebelius announced her resignation Friday, ending a tumultuous tenure as the public face of the Affordable Care Act. In a Rose Garden ceremony, President Obama nominated his budget director as her successor.

According to federal health officials, Sebelius approached Obama in early March and told him that, with the insurance enrollment period ending that month, the time had come for new leadership at HHS. A White House official, who spoke on the condition of anonymity to discuss internal deliberations, said Sebelius told the president that “she felt confident in the trajectory for enrollment and implementation of the Affordable Care Act.”

Obama on Friday nominated Office of Management and Budget Director Sylvia Mathews Burwell to take Sebelius’s place. Although Burwell does not have an extensive background in healthcare policy, she is known for her strong management skills and has experience in issues of poverty and global health issues from her time at the Bill and Melinda Gates Foundation. Moreover, she is popular on Capitol Hill. The Senate confirmed her as OMB director 96 to 0 almost exactly a year ago. Her nomination to lead HHS will require Senate confirmation as well. Read the full article in The Washington Post.

When A Rural Hospital Closes, The Town Struggles To Survive

The story of Hancock Memorial Hospital in the tiny town of Sparta, Georgia is not unique. Hancock Memorial Hospital was among the first of nine rural hospitals that have closed across Georgia since 2000. Today, it’s overgrown with weeds and vines, while the roof caves on the gurneys and computers still inside. When County Commissioner Sistie Hudson tries to recruit a new industrial employer, one of the first things they ask is: “Do you have a hospital?” That's a non-starter for most businesses. 

University of North Carolina professor Mark Holmes studied the economic impact of 140 rural hospital closures nationwide. He found that three years out, losing a hospital costs a community, on average, “about 1.6 percentage points in unemployment, about $700 in per capita income, and that was in [year] 2000 dollars so that’d be probably about $1,000 currently." 

Read, or listen, to the story on American Public Media, Marketplace.