I appreciated the opportunity to attend the NBCH conference and meet some of the thinking and doing people involved in the healthcare purchasing and delivery challenges across the country.

It was an impressive event and the key note speakers were excellent, most notably Francois de Brantes of HCI3 and Dr. Donald Berwick of CMS.

The theme, “A New Era for Employers: Better Health, Better Care, Lower Costs” succinctly reflected the challenges we have here in Savannah. A lot of information was packed into the conference. Business and Health Coalitions are working hard to improve health and transform healthcare in the midst of many challenges facing all of us and our nation today. The provocative and heady questions and information included:

• “Value Based Purchasing”, paying for what we want – health, excellence, responsiveness.
• How do we create or stimulate Healthcare Purchasing comparable to other industries (product purchasing)?
• How do we achieve better efficiency, quality (and competitiveness), affordability and tools to support related to “Healthcare product delivery” as other companies (such as Microsoft, GE, Delta or other major corporations) have done for years with their various products and services?
• How do we streamline how we do things to achieve universality of measures, costs, objectives?
• How do we incentivize hospitals to want to reduce hospital admissions?
• How do we use our self-insured platforms to do more to accomplish desired outcomes; such as support and implementation of Accountable Care Organizations, Electronic medical Records, and Medical Home/Village approaches?

If I were to boil down the “common denominator” opportunities to make lemonade from the lemons, for coalitions and others concerned about healthcare delivery, it would include the six “lemon issues” Dr. Berkin cited for CMS:

• 1) Failure to coordinate care
• 2) Failures in the care delivery system (never events such as embolism, ulcers, infections)
• 3) Overtreatment problems
• 4) Excessive administration
• 5) Healthcare prices
• 6) Fraud and abuse
• And add a seventh concerning electronic record support and data collection/access.

Healthcare in all its various forms and aspects is a dynamic issue at the forefront of our national politics, public policy and economy, affecting every American.

Thanks to our Savannah coalition, SBG continues to make progress in improving the health and productivity of the people in our community, make healthcare more affordable, and ensure quality healthcare is accessible. I am proud that our Coalition seems to be on the leading edge of tackling the challenges and issues confronting employers and society today.

Sharon Herrera
President, SBG
Director, Human Resources, Lummus Corporation

Georgians for a Healthy Future will be conducting a symposium in Savannah on November 30th; “Building a Healthy Georgia”.

As a Georgia based health policy and advocacy organization focusing on health care issues from the consumer perspective, they are engaged in a campaign across the state called “Building a Healthy Georgia” where they will have a community forum in Savannah to bring together key stakeholders, health care professionals, the academic community, health care consumers, etc. to have a constructive dialogue on how to face Georgia’s most pressing health issues.

Georgians for a Healthy Future will have an event in Savannah at the Coastal Georgia Center on November 30 starting at 4pm and ending at 6pm.  Everyone is invited but are asked to register. Here is the link for you to register.

Below is an editorial by the Center for Health Transformation, Nancy Desmond, CEO of the Center and Vincent Frakes the federal policy director for the Center, which appears in today’s Washington Times  regarding the US Supreme Court’s decision to hear the appeal on the constitutionality of President Obama’s healthcare reform bill. It lays out a clear message: Repeal is but step one … healthcare reform is necessary but needs to be private sector based, individually centered, and focused on saving lives and saving money.

Court Needs to Readdress Health Care Reform

For almost two years, Americans have lived in limbo – not knowing if the 2,770-page health care reform law would forever change how we conduct the business of health care. This week, we found out that an answer is not far away. The U.S. Supreme Court has agreed to hear the legal challenge to President Obama’s signature health care law, which was drafted with little public input; created 159 new agencies, offices and programs; and granted a litany of unchecked powers to a few Washington bureaucrats, most notably the secretary of health and human services.

The nine members of the nation’s highest court will decide not only whether it is constitutional for the federal government to mandate that citizens purchase health insurance but whether the federal government can force states to expand their enrollment in Medicaid.

The legal arguments to be heard in the spring will be the Super Bowl of Supreme Court cases, and the court’s ruling will be one of the most heavily anticipated outcomes in years. It should have a profound effect on the 2012 presidential election as well as the health care industry, which represents more than one-fifth of the entire American economy.

Whether the court throws out the entire law, upholds it or rules parts of it unconstitutional, we believe there is a need to put in place legislation that focuses on a 21st-century model of health care reform, one based on a patient-centered model that lowers costs while improving health outcomes.

Successful health care reform must not be a top-down federal approach but instead one that allows states and individuals to devise health care models that work for them.

Among a few of the principles we would encourage Congress to consider as well:

- Move away from the traditional fee-for-service delivery model toward one based on positive patient outcomes. A 21st-century model encourages patients to be engaged in their own health care and creates incentives for doctors and hospitals when patients get well and less when patients keep returning to hospitals in a revolving-door fashion.

- Advance consumer-directed health care. To empower patients with their own health care, we should reform the tax code to encourage more Americans to set up health savings accounts (HSAs). HSAs would allow consumers to pay for routine medical care, like we do for regular oil changes or tires on a car, and then use high-deductible insurance plans for major medical expenses. That’s the opposite of Obamacare, which taxes and restricts health savings accounts, dealing a blow to consumer-driven health care.

- Stop paying crooks through an aggressive crackdown on criminal activity within Medicare and Medicaid and beef up fraud-prevention programs for state children’s health care plans. Some crooks claim it is more profitable to cheat the government in these programs than to deal drugs. The inspector general thinks nearly 10 percent of Medicare cases are fraudulent. Hundreds of billions of dollars could be saved through better enforcement, whether rooting out nursing homes billing the government for deceased patients or criminals running HIV clinics at the back of pizza parlors.

- Encourage states to enact civil justice reform to prevent frivolous lawsuits that drive up health care costs. A Jackson Healthcare/Gallup physicians poll last year found that $1 in $4 spent on health care is dedicated to unnecessary tests, procedures and drugs that doctors order to prevent being sued. As long as doctors play defense, health care costs will continue to escalate and drive up costs for all of us.

- Create additional federal incentives to ensure nationwide implementation of electronic health records by hospitals, physicians and other health care providers. An electronic platform not only reduces the chance for medical errors in treating patients, but also makes it more efficient and safer to transfer a patient’s history from one provider to another.

These are but a few of the ways we can incorporate solutions that will bring health care into the 21st century, put patients at the center of health innovation and achieve the No. 1 goal of saving lives while saving money.

On Monday the United States Supreme Court agreed to review the constitutionality of President Barack Obama’s healthcare overhaul law (PPACA). Arguments should start in March 2012.

You can read more details at the San Francisco Chronicle or the Business Insurance.

The Georgia Association of Health Underwriters announced today that HHS has granted a modified version of Georgia’s request to phase in new medical loss requirements.  Insurers in the individual market will have to reach 70% MLR in 2011, 75% in 2012, and 80% by 2013. 

Health care reform requires commercial insurers spend at least 85 cents out of every premium dollar on medical claims for its large-group policyholders. For small-group and individual policies, the figure is 80 cents. The remaining 15 – 20 percent is used by the insurance companies to cover administrative overhead, commisions, and profits. (See the federal definition here.)

Section 2718 of the Public Health Service Act, as added by the Patient Protection and Affordable Care Act (PPACA) signed into law on March 23, 2010, requires that beginning in 2011, insurance companies must meet new medical loss ratio requirements.  This law is designed to ensure premium dollars go to health care. (For more information read the Proskauer newsletter.)

“Leah Binder, CEO of The Leapfrog Group, an employer coalition for healthcare quality, called the final rules ‘far too cautionary.” Binder called the transparency requirements ‘anemic’ and said focus on outcomes and did nothing to discourage overuse of healthcare services. She also cautioned that too little transparency would leave consumers unable to drive completion among providers.”

Modern Healthcare October 24, 2011

Atlanta 16 November 2011, 10 AM – noon at 61 Forsyth St. SW, Suite 5B95, Atlanta
POC - ORDAtlanta@hhs.gov

The Affordable Care Act ensures Americans have access to quality, affordable health insurance.  To achieve this goal, the law ensures plans offered in the new Affordable Insurance Exchanges offer a package of essential health benefits, which are to be defined by the Department of Health and Human Services (HHS). The statute directs the Secretary to consider the scope of benefits provided under a typical employer plan in defining essential health benefits.  To inform the Department, HHS received a survey of employer-sponsored coverage conducted by the Department of Labor as well as recommendations from the Institute of Medicine on the criteria and methods for defining and updating essential health benefits.HHS is committed to receiving broad public input on essential health benefits from all stakeholders, including States, patients, providers, employers, legislators, insurers, and all other interested Americans.

To that end, HHS has invite people to comment sessions for regional, state, and local stakeholders on essential health benefits.  Senior HHS officials will be in attendance to listen to stakeholder feedback. If you plan to attend the session, HHS asks that you consider these questions in preparing your comments:

·     In keeping with the title of the Institute of Medicine report “Essential Health Benefits—Balancing Coverage and Cost”, how can the Department best meet the dual goals of balancing the comprehensiveness of coverage included in essential health benefits and affordability?

·     How might the Department ensure that essential health benefits reflect an appropriate balance among the categories so that they are not unduly weighted toward any category?

·     What policy principles and criteria should be taken into account to prevent discrimination against individuals because of their age, disability status, or expected length of life as the Affordable Care Act requires?

·     What models should HHS consider in developing essential health benefits?

·     What criteria should be used to update essential health benefits over time and what should the process be for their modification?

To register for the event, please send an email with your name, organization, title, email address and phone number to the designated RSVP by the RSVP Due Date listed above.   (NOTE: In some locations, RSVPs are needed for building security and will be accepted on a first come, first serve basis)

If you have any questions regarding this meeting, please contact Brian Chiglinsky, HHS Office of External Affairs at 202.619.1066 or brian.chiglinsky@hhs.gov<mailto:brian.chiglinsky@hhs.gov>.

The Centers for Medicare and Medicaid Services: Consumer Alert – October 9, 2011

Website Warned on Suggesting Linkage to Government Agency – Could Mislead Consumers

The Centers for Medicare and Medicaid Services (CMS) has recently become aware of a website that has the appearance of being an official government website for the Pre-Existing Condition Insurance Plan.

This new website is not maintained by any government programs and consumers are strongly urged not to submit any personal information requested by this website under the assumption that it is a government website.

CMS is taking the appropriate steps to protect consumers from being misled.

The Pre-Existing Condition Insurance Plan made available through the Affordable Care Act makes health insurance available to people who have had a problem getting insurance due to a pre-existing condition.

The Pre-Existing Condition Insurance Plan:

• Covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.
• Does not charge you a higher premium just because of your medical condition.
• Does not base eligibility on income.

Individuals interested in this new federally backed program should visit: www.pcip.gov or call 866-717-5826.

Are you uninsured? Do you have a pre-existing condition? If so, you may be eligible for the new Pre-Existing Condition Insurance Plan. Call toll free 1-866-717-5826 (TTY 1-866-561-1604) or visit www.pcip.gov and click on “Find Your State” to learn more.

“This proposed merger, if allowed, would have grave consequences for consumers and the nation’s community pharmacies that serve them, as well as for health plans and employers that utilize PBM services, including Medicare Part D, specialty pharmacy services and mail-order pharmacy services.” These were the comments to the U.S. House panel on September 9, 2011by NACDS who argued that the planned merger of Express Scripts and Medco not be approved.

While following this issue I thought this would be an appropriate time to compare the dynamics of the current PBM marketplace with the contract SBG has with its PBM vendor – Envision.

1- Envision will contractually ‘rep and warrant ‘ pass through of all revenue to the plan sponsor. No provider spread on retail, mail, or specialty. No manufacturer retained rebates of any sort.

2- Envision will pass 100% of the available savings to health plans and plan sponsors. Envision does not retain any of the gains for themselves.

3- Envision is the pioneer of not only transparency but pure pass through. Envision aligns incentives with the payors, (both consumers and employers). Envision is the opposite of ‘opaque’ passing on savings, with proven outcomes. Envision can verify and demonstrate, that their PBM business savings model, runs counter to the ‘traditional’ PBM.

4- Envision does not shift scripts to mail because they are not about driving mail utilization. Envision’s only source of revenue is the admin fee and thus they are not positioned to exploit mail for profitability. If retail 90 with lower of U&C pricing allows for lower cost for payors, they will promote the lowest cost provider whether it’s retail, or mail.

5- NACDS questions how to regulate the PBMs. The best way to ‘regulate a PBM’ is through tight contractual audit provisions. Envision is the ‘only’ PBM that allows a full audit of all claims to prove pure pass through. To prove, unequivocally, that all revenue is appropriately passed to the plan sponsor.

New Coverage Option for the Uninsured

If you have had a hard time finding health insurance because of a pre-existing condition or if you’ve been turned down for insurance coverage and feel like you’re out of options, you’re not out of luck. You may now be eligible for a new program created by the Affordable Care Act — the Pre-Existing Condition Insurance Plan.

This transitional program is available for children and adults in all 50 states and the District of Columbia who have been locked out of the health insurance market because of a pre-existing condition. In 2014, Americans—regardless of their health status—will have access to affordable health insurance when the nation transitions to a new marketplace.

Under this new program, you’ll receive health coverage for a wide range of medical benefits including physician’s services, hospital care, and prescription drugs. All covered benefits are available to you—even to treat a pre-existing condition. You won’t be charged a higher premium because of your medical condition and your eligibility is not based on your income. Like standard health insurance plans, you’ll be required to pay a monthly premium, a deductible, and some cost-sharing expenses. Premiums may vary depending on where you live, your age, and which health plan you choose.

The Pre-Existing Condition Insurance Plan is already getting results that are changing the lives of Americans across our nation who don’t have health coverage and need medical care. James H., who lives in Texas, was diagnosed with brain cancer in 2010. . Shortly after his diagnosis, James’ insurance company rescinded his insurance coverage claiming that his cancer was a pre-existing condition. James knew that his lack of coverage was a death sentence. Fortunately, James was able to join the Pre-Existing Condition Insurance Plan in Texas and is now receiving the medical treatment he needs.

Cathy A., who lives in Ohio and is a small business owner, has Systemic Lupus which has required very little treatment over the years, but she has consistently been denied health insurance because of her medical condition. Cathy noted that “without me working and paying the bills, my firm would close.” After enrolling in the Pre-Existing Condition Insurance Plan in Ohio, Cathy now has the peace of mind she deserves and she doesn’t have to worry about the financial instability that goes with being uninsured.

These stories are just a snapshot of what we’re hearing from people across the nation who are participating in the Pre-Existing Condition Insurance Plan.

To qualify, you must: be a citizen of the United States or residing here legally, have been uninsured for at least 6 months before applying, and have a pre-existing condition or have been denied insurance coverage because of your health condition.

Each state may use different methods to determine whether you have a pre-existing condition and whether you have been denied health coverage. To find out more about the Pre-Existing Condition Insurance Plan, including eligibility, plan benefits and rates and how to apply, visit www.pcip.gov or Click on “Find Your State” and select your state from a map of the United States or from a drop-down menu for details.

You can also dial the Call Center toll free at1-866-717-5826 (TTY 1-866-561-1604). The Call Center is open 8 A.M. to 11 P.M. Eastern Time.