HHS seems to really be trying to use the internet and social media.  Thier latest is widgets and gadets for the new section of the HHS website about how to find health care programs for you where you live.  They call it “What insurance options are available to you?” 

They also have new tabs for understanding the new law, Prevention, and quality.

• There were 39.4 ER annual visits per 100 persons
• There were 88.5 ER annual visits per 100 U.S. infants
• Persons aged 75 years and over had an annual ER visit rate of 62.0 visits per 100 person
• The visit rate for homeless persons was almost twice that of those living in private residences (71.8 compared with 35.9 visits per 100 persons per year)
• There were about 222 visits to U.S. ERs every minute
• Annual ER visits increased 23% from 1996 to 2007
• 25.2% of ER visits were covered by Medicaid SCHIP (39% Private Insurance; 17% Medicare)
• There were 121 ER annual visits for asthma per 10,000 children under 5 years of age
• 2% of visits resulted in admission to an observation unit

Source: CDC. National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary National Health Statistics Reports. August 6, 2010

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Grandfathered plans basically have more time. Grandfathered plans must comply with all of the health reform laws and are required to implement them this September (or the next anniversary date).  Grandfathered plans are free from certain mandates that all other plans must do, until 2014.

·         Cover preventive services without cost-sharing;

·         Do not discriminate in favor of highly compensated individuals;

·         Report on their quality of care improvement activities;

·         Provide their enrollees internal and external appeal procedures against claims denials (although group plans must already provide internal appeals under ERISA and most states require that plans provide both internal and external appeal procedures);

·         Provide unimpeded access to emergency, pediatric, clinical trials, obstetric, and gynecological care; and

·         Reporting on quality and wellness to HHS.

Grandfathered plans can lower patient deductibles, co-pays and premiums and can add additional benefits and coverage.  Grandfathered plans are limited on cost share increases and cannot impose additional restrictions or remove covered benefits.  All changes have to be in the favor of the patient.

http://www.healthreform.gov/about/grandfathering.html

http://www.mcguirewoods.com/news-resources/item.asp?item=4719

The written rules are here and the video of the press conference is here.

Compared to their polices in effect on March 23, 2010, grandfathered plans:

• Cannot Significantly Cut or Reduce Benefits.  For example, if a plan decides to no longer cover care for people with diabetes, cystic fibrosis or HIV/AIDS.
• Cannot Raise Co-Insurance Charges.  Typically, co-insurance requires a patient to pay a fixed percentage of a charge (for example, 20% of a hospital bill).  Grandfathered plans cannot increase this percentage.
• Cannot Significantly Raise Co-Payment Charges.  Frequently, plans require patients to pay a fixed-dollar amount for doctor’s office visits and other services. Compared with the copayments in effect on March 23, 2010, grandfathered plans will be able to increase those co-pays by no more than the greater of $5 (adjusted annually for medical inflation) or a percentage equal to medical inflation plus 15 percentage points.  For example, if a plan raises its copayment from $30 to $50 over the next 2 years, it will lose its grandfathered status.
• Cannot Significantly Raise Deductibles.  Many plans require patients to pay the first bills they receive each year (for example, the first $500, $1,000, or $1,500 a year). Compared with the deductible required as of March 23, 2010, grandfathered plans can only increase these deductibles by a percentage equal to medical inflation plus 15 percentage points.  In recent years, medical costs have risen an average of 4-to-5% so this formula would allow deductibles to go up, for example, by 19-20% between 2010 and 2011, or by 23-25% between 2010 and 2012.  For a family with a $1,000 annual deductible, this would mean if they had a hike of $190 or $200 from 2010 to 2011, their plan could then increase the deductible again by another $50 the following year. 
• Cannot Significantly Lower Employer Contributions.  Many employers pay a portion of their employees’ premium for insurance and this is usually deducted from their paychecks. Grandfathered plans cannot decrease the percent of premiums the employer pays by more than 5 percentage points (for example, decrease their own share and increase the workers’ share of premium from 15% to 25%).
• Cannot Add or Tighten an Annual Limit on What the Insurer Pays.  Some insurers cap the amount that they will pay for covered services each year.  If they want to retain their status as grandfathered plans, plans cannot tighten any annual dollar limit in place as of March 23, 2010.  Moreover, plans that do not have an annual dollar limit cannot add a new one unless they are replacing a lifetime dollar limit with an annual dollar limit that is at least as high as the lifetime limit (which is more protective of high-cost enrollees). 
• Cannot Change Insurance Companies.  If an employer decides to buy insurance for its workers from a different insurance company, this new insurer will not be considered a grandfathered plan.  This does not apply when employers that provide their own insurance to their workers switch plan administrators or to collective bargaining agreements.

o   Predictive Index™ - uses claims data and outcomes from more than 2 billion historical claims to make informed forecasts of future healthcare costs, high-risk situations and provider treatment comparisons.

o   E.A.R.L® - a revolutionary application that translates health data, claims histories and treatments into a visual representation of the patient’s body for quick assessment of high-risk situations.

o   Global Analysis Reporting – a standard and customized report to classify and trend information based on utilization, cost, chronic disease, or other specific needs.

o   Data Analytics –ad-hoc reporting tool that allows user to design, build, and manipulate complex medical and pharmaceutical data, at the group summary and the patient level.

SBG was introduced to MDI through our work with Wells Fargo Insurance Services.

MDI is located in Ponte Vedra Florida. 

But for health reform, SBG sees this as a three phase program; the first year which will stretch out through September of 2011, the second phase that ends in December 2014, and then every thing else in the law that extends beyond 2014.  There is going to be a lot of confusion among patients and employees as the first part of the law is enacted.  People have been lead to believe that the first phase will all happen in September of 2010 but that is not true. Insurers and employers will have a full year to enact phase one changes. The only phase one change that must occur this September is the lifting of the preexisting condition rules for children.

All this discussion about phase one changes is highly speculative anyway.  There are no rules, policies, or procedures written for employers to follow.  Nothing has been written and when it is written it must go through a comment period.  It is possible that September will arrive and we may have no rules.  The agencies that will sit on the committee and that will be writing the rules have just been announced.  These agencies are HHS, IRS, EEOC, FTC, and the National Association of State Insurance Commissioners. 

There is some concern about two of the phase two initiatives; the high risk pool and the Medicare gap reinsurance program.  Georgia has announced that they will not be participating in either program.  The health reform law allows HHS to establish these programs for Georgia without the State’s cooperation. 

Phase two is the time period that the exchanges will be created.  There are actually three types of exchanges, one for individuals (The Exchange), one for groups of individuals (Co-op), and one for small businesses (SHOP).  SBG is investigating the exchange concept and believes it may be able to be very effective in the small business insurance option program.

CHIP (which in Georgia is Peachcare) requires universal health care for all children.  There are requirements in the reauthorization bill that require the State and employers to cooperate in providing coverage to all children.  Employers have already had to amend there plans to include new eligibility open enrollment periods based on this law.  The reauthorization act was passed and signed in February 2009 and we are still waiting for the rest of the rules to be released.

Employers will be very busy trying to implement all these new programs but in the end none of these new laws do anything to control the costs of health care.  The expected cost increase for 2011 is at least 7% plus the increases caused by the new laws.  Employers will continue to implement programs to control costs for their own individual health plans.  They will continue to expand health risk assessments and clinical screenings.  There will be more disease management and wellness.  Employers will continue to expand value based benefit reform and will be more aggressive by putting in place tiered benefit programs.  Physicians and hospitals will also be targeted as the employers will expand quality programs to include never events, hospital acquired conditions, public reporting, transparency, expansion of health information technology, and episodic care payments mechanisms.

The next 4 years will be very busy and there will be plenty to do.  It will be very important that information be timely, accurate and it must come from trusted sources.  SBG will be there to assist our members and the employers of Savannah, Chatham County, the Coastal Empire and Low Country.

 The conclusion states “Our data quantify the relationship between surgicenter ownership and surgical volume. “  It continues by stating that there is a clear physician induced demand that requires federal intervention and restriction of physician ownership.  All the things we have every heard about case mix, patient mix, caseloads, and costs were proved to be true in this study.  Physicians really do refer lower complexity cases and high paying patients to their surgicenter and the frequency of the surgery increases.  

 ”…. what underlies the association between ownership and surgery use is more than just a “high-volume surgeon” phenomenon alone.  In other words, it isn’t just that the surgeons who own surgicenters tend to be high-volume surgeons it’s that surgeons become high-volume surgeons once they became owners of surgicenters.”

 The core of this editorial is based on an article in the Health Affairs April 2010 29:4 issue; “Physician Ownership of Ambulatory Surgery Centers Linked to Higher Volume of Surgeries“.  The study was conducted in Florida using their Healthcare Cost and Utilization State Ambulatory Surgery Database for the years 2003 through 2005.