House Passage of H.R. 4015, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014

The following note regarding the passage of HR 4015 was released today, March 14th, by the National Organization of State Offices of Rural Health (NOSORH).  It provides some helpful insight into the next steps and political viability of the bill.    

Today, in a largely partisan vote, the House of Representatives passed a bill permanently repealing the Medicare Sustainable Growth Rate (SGR). H.R. 4015, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, is the previously agreed upon bipartisan/bicameral framework put forth by the three Congressional Committees with jurisdiction over the SGR.

In addition to formally repealing the SGR, the bill:

• Authorizes annual automatic 0.5% payment update for five years (2014 – 2018).
• Consolidates the three existing Medicare quality programs into a single value-based incentive program.
• Provides incentives for providers to switch to alternative payment models (APMs) such as a 5% bonus to providers who receive a significant portion of their revenue from an APM.

Although the framework for the permanent fix has broad support, finding $138B over ten years to pay for the permanent fix has been a serious obstacle that has become increasingly partisan as today’s vote approached.

The bill passed today by the House, pays for the permanent fix with a Republican supported measure delaying the Affordable Care Act’s individual mandate for five years (starting next year). In addition to covering the cost of a permanent fix, the Congressional Budget Office has estimated that this “pay for” will save an additional $30B but will also result in 13 million more people being uninsured and an average increase of health insurance premiums between 10 and 20 percent. Democrats have attempted to use unspent war funds as the offset; however Republicans are adamantly against such a measure.

The bill still must pass through the Democrat-controlled Senate and be signed by the President in order to become law. The prospect of this bill, with a five year delay of the individual mandate as the offset, becoming law is extremely unlikely. The Democrats in the Senate are publicly opposed to this offset and the President has already stated he will veto the bill if it comes to his desk in this form.

Congress has until March 31st, when the current patch expires, to prevent automatic 24% cuts in Medicare payments to physicians under the SGR. Congress could still come together to figure out agreeable offsets for a permanent fix or they could pass another short-term patch to give them more time to come to an agreement on offsets. A nine-month patch to prevent the 24% cuts through the end of the year has been discussed.

With Deadline For Open Enrollment Looming, Nearly 4.2 Million Have Enrolled in Private Health Plans Sold Through Exchanges

More than 4.2 million people have enrolled in private health plans sold through the Affordable Care Act's insurance exchanges as of March 1, the Obama administration reported Tuesday.

However, the administration didn't say how many of those people have paid their first month's premiums or how many were previously uninsured.

The 4.2 million mark is well below the goal of 5.6 million that federal health officials had when open enrollment started last October. Open enrollment ends March 31 and the White House had hoped to enroll 7 million by that time. Read the rest of the article in Medpage Today here.

Are Rural Interests Being Met By the Colorado Legislature This Year?

As the legislature reaches mid-session, lawmakers are receiving an “incomplete” grade for addressing rural Colorado; being told by rural interests that they still have much more work to do.

Even though both sides of the aisle included rural Colorado in their talking points at the beginning of the session, provincial interests have watched as proposals they supported this year were killed. And they have not seen other bills move to address several important issues to them, including lowering healthcare premiums and addressing transportation needs. Read the full article in the Colorado Statesman here.

It's Looking Likely That We'll See Yet Another SGR Patch (That Makes 18!)

Lawmakers can't agree on a way to plug the $122 billion hole in the budget that would be created by the elimination of the reimbursement cuts and "chances are not great" for a permanent fix by the March 31 deadline, says the co-chair of the GOP Doctors' Caucus.

Congress likely will not find a permanent solution for the Sustainable Growth Rate (SGR) funding formula before the deadline expires at the end of March, and will impose yet another temporary fix and re-address the issue later this year, a leading House Republican says. Read the rest of the article in Health Leaders Media here.

For more information, check out last week's article by Emily Ethridge of CQ Roll Call, or read the article by Kristin Paulson, CIVHC's Senior Manager of Policy and Initiatives, on how the Doc Fix has the potential to improve readmissions here.

Bill Aims to Encourage Doctors to Try Rural Colorado

A bill making its way through the legislature this year aims to encourage doctors to give rural Colorado a try. Senator Aguilar's bill, Senate Bill 14-144, would require the state to study how rural residency programs aid rural communities in recruiting and retaining doctors, what effect massive medical school loans have on physician retention, and investigate possible future funding options from federal, state or private sources. Read the full bill here, and check out the rest of the article here at Colorado Public Radio.

President Obama's Budget Includes Largest Increase of National Health Service Corps Ever

President Obama will propose boosting the National Health Services Corps (NHSC) from 8,900 a year to 15,000 a year over the next five years, as well as spending $5.23 billion to train 13,000 primary care residents over the next 10 years, in his budget next week, administration officials told USA TODAY. The budget, which Obama will reveal Tuesday, marks the first time Medicare funds will be used to increase the number of medical residents, and it's the largest-ever proposed increase of the corps, officials said.

The administration hopes to boost both team-based care, as well as send residents out to rural areas and areas with lower access to care, officials said. The president's budget proposal:

• Adds $5.23 billion over 10 years to train 13,000 primary care residents in high-need communities, and in team-based care, such as an accountable care organization.
• Extends higher payments to Medicaid providers, including physician assistants and nurse practitioners, by one year at a cost of about $5.44 billion.
• Adds $3.95 billion over the next six years in the National Health Services Corps to support growing the program from 8,900 primary care providers in 2013 to at least 15,000 annually starting in the 2015 fiscal year.

"This is a booster shot unlike any other before now," said Mary Wakefield, administrator of the Health Resources and Services Administration.

The proposal also addresses a shortage of mental health providers by offering residencies for psychiatrists, psychiatric nurse practitioners and other mental health providers as part of the team-based approach.

Read the article in USA Today.

Community Tools Are Available to Combat the Higher Rates of Childhood Obesity In Rural Areas

The Altarum Institute, a nonprofit health-systems research and consulting organization, reported today that children living in rural areas are about 25 percent more likely to be overweight or obese than children in urban areas. Rural communities have come up with several strategies to battle childhood obesity. 

According to Sarah Lifsey and Karah Mantinan of the Altarum Institute, studies have found that there is little open public space in rural areas, often because of a lack of a strong government to provide and maintain such public spaces. They also cite research showing that rural children are also at increased risk of poverty compared to children in cities or suburbs, and face lower access to healthcare, lower levels of physical activity and lower-quality food.  Many rural families who lack access to fresh and healthy foods live in “food deserts,” Studies have found poverty and childhood obesity are more likely in rural food deserts.

Tools are available to help with this planning such as the Rural Active Living Assessment Tools, developed by the Robert Wood Johnson Foundation. Other resources include the Rural Assistance Center, funded by the U.S. Department of Health and Human Services Rural Initiative, which features a Rural Obesity Prevention Toolkit developed by the Nutrition Obesity Research Center’s Walsh Center for Rural Analysis, as well as a resource guide for rural areas developed by the University of North Carolina’s Active Living by Design.

Read the article in the Lane Report.

Grace Period Option Can Be Burden on Small Practices

A provision in the Affordable Care Act offers patients who qualify for an advanced tax subsidy when purchasing a product through the exchange a grace period in which they may neglect to pay their premiums for up to 90 days. During the first 30 days of the grace period, insurers have to pay any claims incurred by the patient. But for the next 60 days, nothing is guaranteed. If the patient visits the doctor, the insurer can “pend” the claim – wait to pay the provider until the patient pays his premium. At the end of the 90-day grace period, if the patient has not paid the premium, the insurer can cancel the coverage and refuse to pay the pended claims, or recoup the payments it’s already made. That puts the provider's office at risk.

Practices are encourages to check first with the insurer to make sure everything is in order before proceeding with the visit. If the premium has not been paid, the provider can give the patient the option of rescheduling the appointment or paying in cash and then applying to his insurer for the payment. But this extra step for verification takes time. Insurance companies are scrambling to staff up in order to answer phone calls, as well as offer portals to verify eligibility for these patients. Read more here.   

Commissioner Salazar Convenes Health Care Cost Study Group

According to an analysis from the Kaiser Family Foundation, the Colorado resort region that includes Aspen, Vail and Garfield and Summit counties has the highest health insurance premiums in the nation (click here to read the report about the rates in new geographically delineated health insurance markets). Earlier this year, Colorado Insurance Commissioner Salazar decided not to change Colorado's geographic rating system for either this year or next. Now Garfield County is threatening to sue the Commissioner for approving the rates for 2015 (read the article here).

Commissioner Salazar has convened a group to study the issue and to produce proposals for reducing health costs and premiums by May. The Health Care Cost Study Group, which which began meeting last week, includes industry representatives, health policy cost experts and consumers.

“It will be a challenge to dig into the costs of healthcare and the factors behind those costs, but this group is up to the challenge,” Salazar said in a written statement. “This is the first step in a journey to a better understanding.” Read more about the first meeting and the representatives of the study group here.

SGR "Pay-fors" Still Up in the Air

If Congress doesn't take action, the current SGR patch is set to expire at the end of March enacting a 24% pay cut.  While ideas for "pay-fors" for the repeal seem to be scarce, provider groups agree on one thing - the time to repeal the SGR is now.  Discussion of a nine month delay until after the elections surfaced, but Congressional leaders and provider groups rejected that proposal.  The delay would have been the 17th temporary legislative patch delaying the cuts.  Read more in Modern Healthcare. 

As part of a discussion draft of pay-fors, the Senate Finance Committee looked at Critical Access Hospital (CAH) mileage and reimbursement.  While these are ideas and not endorsed options, CAHs are vulnerable.  It's important to continue to advocate.  Engage your mayor, Chamber of Commerce, and county commissioners - make your letters to your electeds patient-focused.  Critical Access Hospitals protect patient access, protect the rural economy and save taxpayer dollars.

Rural Physicians More Likely to Participate in QI Efforts and Discuss Cost of Care with Patients

A new study in the National Rural Health Association’s Journal of Rural Health finds rural primary care physicians are more likely to participate in quality improvement activities than their urban counterparts. According to Alan Morgan, CEO of the National Rural Health Association, “Quality healthcare can be found in rural towns all across America. Rural primary care often faces significant challenges with equal or better patient outcomes. It’s time to start looking at what’s done right in rural.” 

A survey of 2,000 rural and urban family practitioners indicated that while rural communities may have fewer training options, rural primary care physicians are significantly more likely to participate in quality improvement activities. The study also found that rural physicians were more likely to agree that physicians should discuss the costs of care with their patients and to report having added Medicaid or uninsured patients during the preceding year.

The peer-reviewed article on the study can be found here (a subscription may be required).

 

Rural Providers Come Together to Test Out ACO

Nine rural communities have joined forces to qualify the National Rural ACO (NRACO) for the Medicare Shared Savings Program. The NRACO includes a diverse cross-section of healthcare providers across the country, including Rural and Critical Access Hospitals, Rural Health Clinics, Federally Qualified Health Centers, and independent physician practices.

Accountable Care Organizations (ACOs) are required to have at least 5,000 Medicare beneficiaries and meet rigorous program requirements. This patient base can make it extremely difficult for rural areas to form ACOs. The number of beneficiaries attributed to each NRACO member community ranged from 252 to 3,507, well shy of the 5,000 beneficiaries required to participate. CMS estimates an average start-up cost and first-year operating expense of $1.7 million for an ACO, which is unaffordable for small rural community health systems. By themselves, none of the NRACO's member communities could have qualified or afforded to become Accountable Care Organizations.

According to the NRACO's founder, Lynn Barr, the organization was formed to overcome these barriers and make the program accessible to small community health systems: "Rural communities can join the NRACO at a fraction of the cost of setting up their own program, and reap the benefits for their communities and patients."

"Rural health systems provide about 70% of all care to their community. This program will help them coordinate the care provided outside their community and act as advocates for their patients," according to NRACO Board Chair, Timothy Putnam, CEO of Margaret Mary Community Hospital. "Forming the NRACO allowed us to do what is right for our patients and fulfill the mission of serving the health needs of our community, while at the same time blazing a trail for other rural communities to follow."

The vision of the NRACO is to be the national leader of the transformation of rural healthcare systems from fee-based to value-based care by creating an affordable, replicable framework that results in the best possible health for rural communities, at the lowest possible cost, and strengthens and preserves the rural health safety net.

You can read more about NRACO here or by signing up for a free subscription to Modern Healthcare here.

New ACA Communications Webinar Online Now

The Department of Health Care Policy and Financing, Division of Insurance and Connect for Health Colorado have released a new joint communications webinar. The webinar discusses how community partners can assist in reaching the uninsured and begin to educate consumers on how to use their coverage. The webinar also provides an overview of the resources available for consumers, partners and providers about the Affordable Care Act, Medicaid expansion, Connect for Health Colorado and the changes to private health insurance.

The webinar can be found on Colorado.gov/HCPF/ACAResources or by clicking here. Following the webinar, if you have questions you may submit them to ACAImplementation@hcpf.state.co.us.

Study Shows One in Four Families Struggle to Pay Medical Bills

According to a government survey published in the Bloomberg Personal Finance this week, one in four US families struggled to pay medical bills in 2012, and one in 10 said they had costs they couldn't pay at all.

The survey, released from the National Center for Health Statistics at the US Centers for Disease Control and Prevention, also found the lack of health insurance increased the burden of medical debt.

Major provisions of the Affordable Care Act take effect this year as the Obama administration seeks to extend healthcare coverage to most of the nation’s 48 million uninsured. The law may help lessen some of the financial burdens of medical care, said Karen Pollitz, a fellow at the Kaiser Family Foundation. "Unpaid medical bills is the number one reason why families declare personal bankruptcy,” Pollitz said in a telephone interview. “It causes people to lose equity in their homes, to endanger their retirement and their kid’s college education. It will destroy a family financially.” Read the rest of the article here.

Connect for Health Colorado and Colorado Medicaid Update

Read the latest enrollment number from Colorado Medicaid and Connect for Health Colorado below. You can read the press release in your browser by clicking here.

For immediate release:

January 17, 2014

CONNECT FOR HEALTH COLORADO AND COLORADO MEDICAID UPDATE

DENVER, CO – Between October 1, 2013, and January 15, 2014, more than 165,000 Coloradans have signed up or been approved for 2014 health coverage, according to data released today from Connect for Health Colorado and the Colorado Department of Health Care Policy and Financing.

After an extremely busy December, the first two weeks of January continues to see steady interest from Colorado shoppers and enrollment activity. January 15 was the deadline for Coloradans to sign up for private health insurance that takes effect February 1. The next deadline is February 15 to have private health insurance start on March 1. Open enrollment continues until March 31. Enrollment for Medicaid is year-round.

“We are encouraged to see steady interest from Coloradans during the second half of our open enrollment period and we are focused on reaching as many Coloradans as possible to help them shop for health insurance and apply for new tax credits to reduce costs,” said Patty Fontneau, CEO of Connect for Health Colorado.

“Together with our partners at Connect for Health Colorado, we are reaching and enrolling the uninsured,” said Susan Birch, Executive Director of the Colorado Department of Health Care Policy and Financing. “The numbers released today further demonstrate Colorado as a leader in the nation. We are among a handful of States with technology in place to allow for real time eligibility determinations for Medicaid. The technology, along with our strong network of county and community partners, has allowed us to enroll individuals into new coverage faster than many other states many of which have much larger populations to reach.”

Coloradans signed up for health insurance:
165,137 (Total) 101,730 (Medicaid) 63,407 (private health insurance)

Individual and family customer accounts:
86,235 (from PEAK) 155,854 (private health insurance)

Daily website visitors (average daily from January 1st - 15th):
4,546 (Medicaid) 7,982 (private health insurance)

** More metrics information about Medicaid is available here and more metrics information about Connect for Health Colorado is available here.

Through state laws, Connect for Health Colorado was established as a non-profit entity with a Colorado mission. In addition, Colorado is expanding eligibility for Medicaid. Private health insurance purchased through Connect for Health Colorado’s competitive marketplace and the expanded eligibility for Medicaid both take effect in 2014. Enhanced federal funding that is available starting January 1, 2014 will support the Medicaid expansion.

Connect for Health Colorado has been open since October 1, 2013 and operates with separate technology and customer service operations from the federal marketplace, healthcare.gov. Connect for Health Colorado is open to individuals, families and small businesses. Individuals and families can choose from up to 150 private health insurance plans from ten carriers and small employers can create small group plans from up to 92 health insurance plans provided by six carriers. The Customer Service Center is open from 7 am to 8 pm Mondays through Saturdays at 1-855-PLANS-4-YOU (855-752-6749). More information is available at www.ConnectforHealthCO.com.

Colorado Medicaid and the Child Health Plan Plus (CHP+) are public insurance programs for low income Coloradans. The Department of Health Care Policy and Financing administers these programs. Coloradans have multiple ways to apply for coverage, Colorado.gov/PEAK is the online application for public assistance programs including medical assistance. For more information visit Colorado.gov/hcpf or visitColorado.gov/health. The Medicaid Call Center (800-221-3943 for general questions and 800-359-1991 to check application status) are available 8 a.m. to 6 p.m. Monday through Friday. The call center is closed on state holidays.

###

Contact information:
Ben Davis, ben@onsightpa.com, 303-552-6790 (Connect for Health Colorado)
Rachel Reiter, Rachel.Reiter@state.co.us, 303-866-3921 (Colorado Medicaid)

Copyright © 2014 OnSight Public Affairs, All rights reserved.

Office of Rural Health Policy Webinar on the ACA Today

Join the Office of Rural Health Policy's call today on the Affordable Care from 1:00 - 2:00 pm. You can also find a list of previous and upcoming calls on the ORHP website. As always, you can share your experiences or questions at ORHP-ACAQuestions@hrsa.gov. The call information can be found below.

Wednesday, January 29, 2014
1 - 2 pm MST
Call-in Number: (800) 857-3749
Passcode: ORHPACA

$45 Million Set Aside to Strengthen Nursing

The federal government announced late last year it would deliver $55.5 million in fiscal 2013 to programs designed to strengthen, diversify, and grow the healthcare workforce.

The bulk of the funds, 82 percent ($45.4 million), are targeted at the largest segment of the healthcare workforce - nurses. Many of the grants support the Future of Nursing: Campaign for Action’s call for a more highly educated and more diverse nursing workforce and for more interprofessional collaboration among nurses and other healthcare professionals, according to Winifred Quinn, PhD, co-director of the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation, and the Robert Wood Johnson Foundation. Read the full article here.

Medicare Expands Definition of Rural for Telehealth

Effective January 1st, the Centers for Medicare and Medicaid Services (CMS) expanded the definition of “originating sites” to include Health Professional Shortage Areas (HPSAs) that are located in rural census tracts of Metropolitan Statistical Areas. Also, as part of the update to the Physician Fee Schedule for 2014, Medicare added “Transitional Care Management Services” to the list of codes eligible for payment when provided via telehealth.

Medicare defines “originating site” as the location of an eligible Medicare beneficiary at the time the service is provided via telemedicine. To find out if an authorized originating site is eligible for Medicare telehealth payment, check out the new payment eligibility analyzer from the Health Resources and Services Administration. Check out the tool here.

Will the "Doc Fix" Really Happen? The SGR Explained

After years of legislative wrangling and last-minute patches, expectations are high among physician groups, lawmakers and Medicare beneficiaries that Congress could act by March 31st of this year to permanently replace the current Medicare physician payment formula. While committees in both chambers have approved their own "doc fix" proposals, the approaches have yet to be reconciled, and none have identified how they would pay for a repeal.

Kaiser Health News printed these frequently asked questions and answers about the Sustainable Growth Rate (SGR) formula and how Congress may change it. It's one of the best explanations on the SGR I've read. If you have questions, I encourage you to check it out!

Colorado Network of Health Alliances, A Statewide Learning Network Convened by CCMU

In dozens of communities across Colorado, formal health alliances are using collective impact approaches to tackle the major social issues of healthcare. Some of the alliances have been around for decades and others are just now exploring formalization, but all of them are working on a common agenda, using collaborative leadership strategies, to improve the local healthcare system and ensure access to care for all community members.

Since 2012, the Colorado Coalition for the Medically Underserved (CCMU) has convened these alliances in a statewide learning network called the Colorado Network of Health Alliances. Last week, CCMU published a year-in-review document, Progress & Possibilities, detailing the first year of the network, including current membership (21 alliances) and highlights of the work being done by these groups. They also identified three strategies for local healthcare change that are common across the members of the Colorado Network of Health Alliances:

1. Developing Healthcare Leadership for Change – Health alliances are on the front lines of identifying and developing champions for healthcare change in communities across Colorado. These organizations have the unique ability to bring diverse and high-powered leaders and stakeholders together to work toward common goals.
2. Increasing Access to the Healthcare System – Health alliances are working hard to catalyze new healthcare access points, to maximize enrollment in new health insurance coverage options, and planning to care for the needs of Coloradans who will remain uninsured after the Affordable Care Act is implemented.
3. Improving and Strengthening the Healthcare System – Through formal alliances, health and community leaders across the state are constantly searching for ways to coordinate services, limit duplication, and pool resources.

Read the full report here.

Interest in Accelerated Medical School Programs Growing

In an article published in the Journal of the American Medical Association in 2012, University of Pennsylvania Vice Provost Ezekiel Emanuel and Stanford economist Victor Fuchs proposed that a year of medical school could be eliminated "without adversely affecting academic performance." The overall time it takes to train physicians, they wrote, is an example of waste in medical education and could be shortened without affecting patient care or eroding clinical skills; students could be assessed on "core competencies rather than on time served." 

Some experts are raising questions about the length of medical school in part because much of the fourth year is devoted to electives and applying for a residency. If the fourth year were to be eliminated, it could cut the amount of student loan debt for students and get them into the workforce faster. Read the rest of the article here.

Financial Challenges Top Concern for Community Hospital Leaders

For the tenth straight year, "financial challenges" have been listed as the number one concern of healthcare executives, according to an annual survey from the American College of Healthcare Executives. The second concern was healthcare reform implementation, followed by government mandates and patient safety and quality (both which ranked third). Read the article in HealthLeaders Media.

The Challenges of Adopting Health IT for Rural Hospitals

Michael Archlueta, Director of IT for Mt. San Rafael Hospital in Trinidad was recently quoted in Becker's Hospital Review. When discussing the challenges of rural health IT adoption, Mr. Archlueta said, "At times, I've faced difficulty in regards to having limited resources made available to me. "The challenge has been the tremendous work-load that I’m juggling and expectations that I’m continuously striving but successfully overcoming all obstacles." 

Mt. San Rafael Hospital is not alone. Across the country, other small rural hospitals face hurdles when it comes to funding, personnel and other resources needed to implement EHRs and other forms of health IT. Read the article here.

Opening Day Speeches and State of the State

On the first day of the session, Senate President Morgan Carroll and Senate Minority Leader Bill Cadman gave speeches marking opening day, as did Speaker of the House Mark Ferrandino and House Minority Leader Brian DelGrosso. Partisanship, economic development, particularly in rural areas, and unemployment were common topics. 

On Thursday Governor Hickenlooper delivered his State of the State. The Governor stated his number one priority is to focus on job growth in the state. He too emphasized the need for job creation in rural parts of the state. The links to all the speeches are embedded above.

NOSORH Webinar: Preparing to Engage with Legislators and Policymakers

The National Organization of State Offices of Rural Health (NOSORH) invites you to participate in a webinar: Preparing to Engage with Legislators & Policymakers. The webinar takes places on Wednesday, January 22, 2014 at 12:00 p.m. MST. 

As the budget discussion in Washington continues and the Colorado legislative session is underway, it's a good time to connect with your legislators on the issues that matter to you. This webinar provides an opportunity to learn how to educate elected officials and how to tell your story with talking points and messages for legislators. Register for the webinar here.

The 2014 Colorado Legislative Session Begins Today!

The 69th session of Colorado General Assembly begins today! We’re predicting this may not be a healthcare-heavy session. Implementation is in full swing, so this year we’ll see some clean up bills along with some other small changes. However, given the changes in the composition of the Senate due to the recalls (the Senate is now split 18-17 Democrats, a change from 20-15 Democrats last year), and the fact that this is an election year, there may be some surprises yet. Stay tuned for updates on the budget and other bills impacting rural Colorado from CRHC! Use this link throughout the session to see which bills have an official CRHC position.

Obamacare May Cut Bad Debt Says Southwest Memorial Hospital

As more people in Montezuma County sign up for insurance under the federal healthcare law, Southwest Memorial Hospital in Cortez may take on far less bad debt. Southwest Health System said patients were unable to pay about $4.6 million in medical bills during the 12 months leading up to October 2012.

In preparation for Obamacare, the hospital became certified in the fall to sign people up for Medicaid and other forms of insurance. According to Kent Helwig, CEO of Southwest Memorial Hospital, the hope is that people will seek out preventive care and make fewer trips to the emergency room when they have insurance. Read the rest of the article in the Cortez Journal here.

Newly Insured Begin Seeking Care: An Update on Colorado's Enrollment

According to Modern Healthcare, health systems are reporting a flood of phone calls as newly insured patients start seeking care. Approximately 2.1 Americans have signed up for insurance through an exchange, and another 3.9 million qualified for Medicaid, according to Health and Human Services. The roll-out has been uneven across the country, depending largely on the investment each state has made in setting up and promoting its own insurance exchange or whether it defaulted to the federal marketplace. Read the rest of the article here. 

Colorado's exchange, Connect for Health Colorado (C4HCO) achieved a total of 52,783 Coloradans signing up for health insurance on Colorado's marketplace between October 1, 2013 to December 31, 2013. Most of these enrollees began receiving health insurance benefits on January 1st of this year. October and November had a slow but steady pace of enrollees, then December saw a boom in enrollments. For example, on December 23, 2013, the final day of enrollment for coverage starting on January 1st, 5,354 people enrolled in just one day. Open enrollment continues through March 31st of this year. 

On the public insurance side, 86,432 Coloradans have successfully enrolled in Medicaid since October 1, 2013. “The enrollments in Medicaid and Connect for Health Colorado show that Coloradans are becoming more aware of the importance of having health insurance coverage,” said Susan Birch, Executive Director of the Colorado Department of Health Care Policy and Financing. “Whether Coloradans have health insurance coverage through private insurance or through Medicaid, health coverage is the first step to better health.

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.