Kaiser Daily Health Policy Report
Life Expectancy Disparity Between Whites, Blacks in California Persists, Report Says
AFL-CIO Announces Campaign To Expand Health Insurance to All U.S. Residents by End of 2009
Patients Increasingly Arrange Interest-Free Loans for Services Typically Not Covered by Health Insurance
CMS Issues Final Rule on Medicare Reimbursement Rates for Home Health Agencies
Court Ruling Requiring Release of Medicare Physician Claims Data Could Improve Quality Transparency
HSAs Do Not Benefit Lower-Income Individuals, Have Not Led To Reduced Health Care Costs, Report Finds
Adoption of CMS Rule by State Medicaid Programs Could Place Additional Pressure on Hospitals To Reduce Preventable Errors
Georgia Lawmakers Discuss Concerns About Medicaid, SCHIP Beneficiaries' Access to Dental Care
California Measure To End Retroactive Cancellations of Health Plans Taking Longer Than Expected
Conference To Address Physician Shortage in Adirondacks
The Latest Reports in Health Policy
CBO Releases Cost Estimate of Senate SCHIP Bill; Report Examines Effects of Massachusetts Health Insurance Law
Conflict of Interest Inherent in Government-Run Comparative Effectiveness Studies Requires Outside Scrutiny, Opinion Piece Says
Medicare Advantage Plans Provide Valuable Services to Seniors, CMS' Kuhn Writes in Letter to the Editor
Coverage & Access
Newspapers Examine Health Care Reform Efforts in California
[Aug 30, 2007]
With "its potential to set a nationwide model," health policy experts, states and federal lawmakers are closely watching California's health reform efforts, USA Today reports. According to USA Today, proposals in California "could launch an even bolder experiment" than in Massachusetts because California's "problems are so much larger." For example, there are 4.9 million uninsured California residents, compared with 500,000 uninsured Massachusetts residents before the state implemented its health insurance law, according to USA Today.
Larry Levitt, a vice president of the Kaiser Family Foundation, said, "Any progress in California would make a substantial dent in the problem of the uninsured nationally," adding, "Action in California would create real momentum, both in the presidential debate and in other states" (Appleby [1], USA Today, 8/30).
However, the "prognosis for universal health care in California is grim this year," as unions, physicians and "other powerful interests are arrayed against Gov. Arnold Schwarzenegger's (R) $12 billion-a-year plan to make" health insurance mandatory, AP/Long Island Newsday reports. Meanwhile, Schwarzenegger has said he would veto state Democrats' health reform legislation and instead place his measure on the statewide ballot.
The state Assembly on Thursday is expected to vote on Schwarzenegger's plan, and Democrats, who control the state Legislature and have pushed their own proposal through both chambers, are using the vote to "show how little support" the governor's plan has, AP/Newsday reports (Kurtzman, AP/Long Island Newsday, 8/29). Comments
According to USA Today, "Few expect California to find the same consensus" on health reform as lawmakers did in Massachusetts. Lawmakers have only until Sept. 14 to reach an agreement on legislation before this year's legislative session ends. However, Schwarzenegger at a recent health care debate said, "At the end, we will sit down and negotiate. If everyone has the will ... within two weeks ... we can hammer it out." He added, "We want to make it so the rest of the country can look and say it's a great model."
Levitt said, "Compared with almost every other state in the country, they (the governor and the Democratic majority) are remarkably close in their proposals" (Appleby [1], USA Today, 8/30). Robert Ross, president of the California Endowment, said the failure of universal health care legislation in California would "have the effect of a wet blanket on health care reform nationally," adding that "the presidential candidates will all look with a very watchful eye at what happens in California" (AP/Long Island Newsday, 8/29). Schwarzenegger Q&A
USA Today on Thursday published a Q&A with Schwarzenegger on his efforts to overhaul the state health care system. Schwarzenegger said, "I believe we can go all the way and do real reform where everyone is insured and everyone has access ... no matter their medical history." He said that among the "serious players" and "experts" involved in the issue, "[e]veryone agreed ... the only way to get it done is if we all recognize we can't get everything we want." However, Schwarzenegger noted that he is "shooting for" the "whole package" and would be opposed to altering his proposal. He also cited a recent poll showing that 82% of state residents said "they don't mind paying extra money as long as they have insurance" (Appleby [2], USA Today, 8/30). Opinion Pieces
The San Francisco Chronicle on Thursday published two opinion pieces on Schwarzenegger's universal health care proposal. Summaries of the pieces appear below.
- Spyros Andreopoulos: Initially, "Schwarzenegger's mandatory insurance proposal seems to offer a starting point for fashioning a feasible plan for the short term to fix California's health care crisis," but it "now appears doubtful that states can effect health care reform," Andreopoulos, director emeritus of the Office of Communication and Public Affairs at Stanford University Medical Center, writes in a Chronicle opinion piece. "Economists believe that states are incapable of sustaining health insurance programs when economic recessions rob them of the revenue to cover their costs," according to Andreopoulos. He continues, "States cannot respond because, unlike the federal government, they are constitutionally barred from running deficits. Experience from developed countries has shown that nationally financed health care works," he writes, concluding, "Our system will make sure that the uninsured remain a permanent feature deep into the 21st century, unless we stop thinking in terms of what is politically feasible and tailor a solution to what is really needed" (Andreopoulos, San Francisco Chronicle, 8/30).
- Len Nichols/Leif Haase: Universal health care can be achieved in California if "our leaders are willing to work as teammates and share the credit as well as the responsibility," Nichols, director of the health policy program at the New America Foundation, and Haase, director of the foundation's California program, write in a Chronicle opinion piece. The governor's plan, which "was good, but not perfect," has been "effectively blocked" by those "for whom the perfect is the enemy of the good," they write. The plan proposed by Assembly Speaker Fabian Núñez (D) and Senate President Pro Tempore Don Perata (D) "invites a grand compromise, which could bring this saga to a happy ending," according to Nichols and Haase. They conclude, "Now the governor has to find the legislative leaders with a high hard pass that only he can throw and only they can catch and turn into glory" (Nichols/Haase, San Francisco Chronicle, 8/30).
Life Expectancy Disparity Between Whites, Blacks in California Persists, Report Says
[Aug 30, 2007]
White men in California live an average of seven years longer than black men, and white women in the state live an average of five years longer than black women, according to a study released on Wednesday by the Public Policy Institute of California, the Los Angeles Times reports (Engel, Los Angeles Times, 8/30). For the study, titled "Death in the Golden State," co-authors Helen Lee and Shannon McConville, both of the institute, examined 694,317 death certificates issued in California between 2000 and 2002 and compared the causes of death among the largest racial and ethnic groups in the state.
The study found that Hispanic men in California lived an average of two years longer than white men and that Hispanic women in the state lived an average of three years longer than white women. In addition, the study found that Asian men and women in California lived an average of five years longer than white men and women.
The study also found that: - Asian men in California lived to an average age of 80, and Asian women lived to an average age of 85, with common causes of death that included heart disease, cancer, strokes and aneurysms;
- Hispanic men in California lived to an average age of 77, and Hispanic women lived to an average age of 83, with common causes of death that included heart disease, cancer and diabetes;
- White men in California lived to an average age of 75, and white women lived to an average age of 80, with common causes of death that included heart disease and cancer; and
- Black men in California lived to an average age of 68, and black women lived to an average age of 75, with common causes of death that included heart disease and cancer.
According to the study, although heart disease and cancer were common causes of death among all racial and ethnic groups in California, they affected whites and blacks at much higher rates than Asians and Hispanics (Olvera, San Jose Mercury News, 8/30). Men and women in all racial and ethnic groups in California with more than a high school education lived longer than those with less education, although disparities among whites and blacks remained for those with similar levels of education, the study found ( Los Angeles Times, 8/30). Comments
Lee said, "The leading killers are similar across groups. If you target the risk factors for those conditions -- and there are a lot of factors including family history, diet and exercise -- that might lead to improvements for all groups" (Barbassa, AP/Contra Costa Times, 8/30). "Clear racial and ethnic patterns emerge for many conditions," Lee said, adding, "A more detailed understanding of the patterns could help health officials develop strategies that both target the leading causes of death and reduce disparities between groups."
Ellen Wu, executive director of the California Pan-Ethnic Health Network, said, "I think information like this can help us get to the next step" in efforts to reduce disparities among racial and ethnic groups in the state (San Jose Mercury News, 8/30).
California Endowment President Robert Ross said, "The lion's share of what explains health status and life expectancy has to do with nonhealth care factors," adding, "That's when you get into the quality of the environment, poverty, racism and some messier factors" (Los Angeles Times, 8/30).
 The study is available online (.pdf).
AFL-CIO Announces Campaign To Expand Health Insurance to All U.S. Residents by End of 2009
[Aug 30, 2007]
The AFL-CIO on Wednesday at events in several cities nationwide announced a campaign that seeks to expand health insurance to all U.S. residents by the end of 2009, the Louisville Courier-Journal reports. The campaign seeks to help elect presidential and congressional candidates that support such proposals.
According to the AFL-CIO, which did not endorse specific candidates or proposals, the U.S. health care system should reduce "rising and irrational" costs; provide comprehensive, high-quality care to all residents; and continue to allow residents to select their physicians (Howington, Louisville Courier-Journal, 8/30). AFL-CIO President John Sweeney said that the union likely will not endorse a specific presidential candidate during the primary season, although all the unions will hold all candidates accountable for their health care positions. Under current rules, a candidate would have to obtain support from two-thirds of AFL-CIO members to receive an endorsement from the union (Swanson, The Hill, 8/29).
 American Public Media's "Marketplace Morning Report" on Wednesday reported on the campaign. The segment includes comments from Heather Booth, director of the campaign, and David Burda, editor of Modern Healthcare (Hobson, "Marketplace Morning Report," American Public Media, 8/29). Audio and a transcript of the segment are available online.
Patients Increasingly Arrange Interest-Free Loans for Services Typically Not Covered by Health Insurance
[Aug 30, 2007]
Zero-interest financing has increased in popularity in a "big-ticket consumer market: doctors' and dentists' offices," the New York Times reports. According to the Times, "millions" of consumers have arranged financing for procedures not typically covered by insurance -- such as laser eye surgery or ceramic tooth implants -- through more than 100,000 physicians and dentists that offer a year or more of zero-interest financing.
Interest-free financing has become "one of the fastest-growing parts of consumer credit" and likely will increase "as rising deductibles, copayments and other costs ... force more of the nation's 250 million people with health insurance to finance out-of-pocket expenses for even basic medical care," according to the Times. The loans only are available to the "creditworthy" and "only if users are able to make payments on time and close the loan on schedule, typically within 12 months" because "[o]therwise, the loans after defaults can carry interest rates of 20% or more," the Times reports.
Some consumer debt experts warn that "as more people try to bridge widening gaps in their health insurance, paying for medical care on credit could plunge the unwary into a financial crisis," noting that in recent years, the "use of high-interest credit cards to pay big medical bills has become a leading cause of consumer bankruptcy," according to the Times (Freudenheim [1], New York Times, 8/30). The "big problem" with using credit cards to pay medical bills is that the "interest rates on credit cards can be hard to predict" because the rates "may rise sharply if a cardholder falls behind on payments -- even payments on another card or, for that matter, on any other debt," according to the Times (Freudenheim [2], New York Times, 8/30).
However, zero-interest financing "can make it possible to receive treatments that otherwise might be out of reach," the Times reports. For CareCredit, the leader in consumer medical financing, about 80% of medical loans provided are paid off on time and incur no finance charges, according to company President Michael Testa. Red Gillen, a senior analyst at Celent, said, "As more and more of the costs of care are shifted to consumers, people are going to need more credit," adding, "They are still going to need health care" (Freudenheim [1], New York Times, 8/30).
Medicare
CMS Issues Final Rule on Medicare Reimbursement Rates for Home Health Agencies
[Aug 30, 2007]
CMS last week issued a final rule that will revise the Home Health Prospective Payment System, which determines Medicare reimbursement rates for home health agencies, CQ HealthBeat reports. According to CMS, the rule will increase Medicare reimbursements to home health agencies by $20 million in fiscal year 2008. In addition, the rule will reduce the national standardized 60-day episode Medicare reimbursement rate for home health agencies for four years to compensate for changes in the observed case mix not related to the actual conditions of beneficiaries.
Acting CMS Deputy Administrator Herb Kuhn said that the rule will "improve the efficiency and quality of care for Medicare beneficiaries." He added, "And when combined with payment system rules we recently released for inpatient hospitals, inpatient rehabilitation facilities and skilled nursing facilities, we are demonstrating our commitment to ensure that the Medicare program is sustained for future generations by paying accurately and efficiently."
However, the National Association for Home Care and Hospice criticized the rule. NAHC said that the rule will reduce Medicare reimbursement rates for home health agencies by almost 12% over the next four years. NAHC President Val Halamandaris said, "The very availability of access to cost-efficient care for the elderly and disabled is at stake with Medicare's action," adding, "At a time when the Medicare program is threatened with bankruptcy, the Medicare administration institutes a nearly $7 billion cut in the home health care program that has proven that it is part of the solution to meeting the needs of the nation's elderly and disabled" (CQ HealthBeat, 8/29).
Court Ruling Requiring Release of Medicare Physician Claims Data Could Improve Quality Transparency
[Aug 30, 2007]
A recent federal court ruling that requires HHS to publicly release physician-specific Medicare data "appears to open the way for consumer access to such information for the first time" and could transform the "relationship between doctors and patients, as well as the business of health care," the Los Angeles Times reports (Alonso-Zaldivar, Los Angeles Times, 8/30).
The ruling requires the release of Medicare data in Washington, D.C., Maryland, Illinois, Virginia and Washington state, but Consumers' CHECKBOOK/Center for the Study of Services, which filed the lawsuit, has requested similar data for the other 46 states. HHS must release the data by Sept. 21. The group plans to post the data online for public use (Kaiser Daily Health Policy Report, 8/27).
According to the Times, "With information on more than 40 million patients and 700,000 doctors, the Medicare database is far richer than any private insurer's," and "it is considered the mother lode for data on those who treat adults because Medicare recipients are a mainstay of most practices." The data could be used to compare cost and quality, as well as whether physicians order preventive tests or duplicate tests, the Times reports.
Helen Darling, president of the National Business Group on Health, said, "We're very excited that the court has ruled in this direction," adding, "Large employers have been trying to make information available on performance to consumers and to those who make purchasing decisions on which providers might be in a preferred network."
HHS has not yet decided whether to appeal the decision. Agency spokesperson Christina Pearson said, "We're in the process of reviewing the court's decision and evaluating our response." However, Paul Ginsburg, president of the Center for Studying Health System Change, said, "Not supporting this ruling would certainly be inconsistent with [Bush] administration initiatives that favor price and quality transparency in health care," adding, "This represents transparency on the quality side."
Ginsburg added, "There are issues about using this type of information responsibly, and not using it unless you can do some significant adjustment" to account for the severity of cases an individual physician handles (Los Angeles Times, 8/30).
Health Care Marketplace
HSAs Do Not Benefit Lower-Income Individuals, Have Not Led To Reduced Health Care Costs, Report Finds
[Aug 30, 2007]
Health savings accounts linked with high-deductible health plans do not benefit lower-income individuals and have not led to reduced health care costs, according to a report released on Wednesday by the Bell Policy Center, the Denver Post reports. According to the report, although HSAs "have grown rapidly in the last few years, they have missed their mark, attracting enrollees with high incomes who are more likely than low-income people to already have coverage." The report also said that HSAs "do not appear to be making system-wide changes toward lowering costs, as some proponents expected." Blair Woodbury, a public policy fellow at Bell and the author of the report, said that HSAs "may be useful for some consumers" but "are by no means a solution to the major problems in today's health care system" (Raabe, Denver Post, 8/30).
The report is available online.
Medicaid
Adoption of CMS Rule by State Medicaid Programs Could Place Additional Pressure on Hospitals To Reduce Preventable Errors
[Aug 30, 2007]
The Philadelphia Inquirer on Thursday examined a new rule from CMS that will deny reimbursements to hospitals for preventable conditions that develop while patients are in their care, effective Oct. 1, 2008. According to the Inquirer, the goal "is not to punish hospitals but to spur action to improve patient safety."
State Medicaid programs also might adopt the CMS changes. For example, Pennsylvania's Medicaid program has plans to adopt the rule and to expand the number of preventable errors for which it will not reimburse, as part of Gov. Ed Rendell's (D) "Prescription for Pennsylvania" health care reform proposal announced in January. The "financial power of Medicare plus the added influence of state Medicaid spending are likely to propel progress in the fight against medical errors," and the hospital industry "has little choice but to join the effort," according to the Inquirer.
"Hospitals believe that these are reasonable approaches and that for things that were truly preventable there should not be an additional payment," Paula Bussard, senior vice president for policy at the Hospital and HealthSystem Association of Pennsylvania, said (Goldstein, Philadelphia Inquirer, 8/30).
State Watch
Georgia Lawmakers Discuss Concerns About Medicaid, SCHIP Beneficiaries' Access to Dental Care
[Aug 30, 2007]
Georgia lawmakers on Tuesday discussed concerns about low- and middle-income families' access to dental coverage after the state last fall shifted nearly one million Medicaid and PeachCare beneficiaries to "care management organizations," Morris/Augusta Chronicle reports. PeachCare is Georgia's version of SCHIP.
Beneficiaries were shifted to care management organizations, which are similar to HMOs, in an effort to reduce costs. However, one of the three companies operating the plans has decided to terminate its contract with a dental provider with several offices in the western region of the state, and two of the plans are considering terminating contracts with a mobile dental lab that operates in counties throughout Georgia.
Lawmakers also are concerned that the plans have stopped accepting new dentists in their networks and by complaints that plans too frequently change the terms of agreements with existing dentists, according to Morris/Chronicle. State Sen. Greg Goggans (R), chair of the panel that controls state health care funding, said, "If we're talking about a problem with access, why would we limit the number of dentists?"
Kent Jenkins -- senior vice president for communications for AmeriGroup, one of the companies operating the organizations -- said, "The demand for dental care has been much higher than the state or anybody anticipated," adding that prices for dental care in Georgia are much higher than what companies expected when they started the plans nearly a year ago. Jenkins also said the company is not rejecting dentists outright but is being careful in establishing the terms for dentists who would join the network (Larrabee, Morris/Augusta Chronicle, 8/29).
California Measure To End Retroactive Cancellations of Health Plans Taking Longer Than Expected
[Aug 30, 2007]
The California Department of Managed Health Care on Tuesday said new rules to prevent HMOs from retroactively canceling individual policyholders' coverage are taking longer than expected to draw up because of the variety of plans involved, the Los Angeles Times reports. In January, the agency, which regulates California HMOs, said it would introduce in the spring regulations to stop the practice of HMOs retroactively canceling coverage because of a failure to disclose pre-existing medical conditions.
DMHC spokesperson Lynne Randolph said the delay in issuing the new rules is a result of the time required to survey the plans to make sure the rules fit them all. "These regulations need to get out in a timely way, but we also feel that consumers deserve to have regulations that will be able to be quickly adopted so that thousands of people who are now being denied health insurance or are afraid of obtaining health insurance because of possible rescission can get relief," Randolph said.
A survey of Blue Cross of California was the first to be completed in March, but the company is disputing the findings, as well as the department's decision that the HMO routinely violated state law by rescinding policies. Surveys of other plans are ongoing.
Proposed rules could take up to a year to be made public and then approved, revised or discarded. Randolph said rescission regulations would be sought even if Gov. Arnold Schwarzenegger's (R) health reform proposal is approved because major changes to the state's health care system would take a long time to implement and could face legal hurdles. Schwarzenegger's (R) plan would require that insurance be sold to all residents, regardless of medical history.
Jerry Flanagan of the Foundation for Taxpayer and Consumer Rights on Tuesday in a letter to DMHC criticized the delay, writing, "Patients cannot afford for you to allow another company's rescission policy to leave more Californians uninsured, uninsurable and facing unpayable medical bills."
Chris Ohman, executive director of the California Association of Health Plans, said the state's efforts to pursue the regulations are "kind of silly," adding, "Let's focus on issues that are going to be relevant to health care reform" (Girion, Los Angeles Times, 8/29).
Conference To Address Physician Shortage in Adirondacks
[Aug 30, 2007]
Health care providers, government officials and business leaders on Thursday will meet in Warren Country, N.Y., to discuss ways to curb a physician shortage in the state's Adirondack region, which is losing more primary care physicians than in the past to higher-paying jobs with better benefits in other regions throughout the U.S., the Albany Times Union reports. The North Country lost 20 PCPs between 2001 and 2005, a decline of 8%, while the number of PCPs statewide increased by 5%. Currently, there are 258 PCPs, or 60 PCPs per 100,000 people, in the region.
Jean Moore, director of the Center for Health Workforce Studies at the University of Albany School of Public Health, said, "The areas of the state losing physicians the fastest are rural regions where the economy is not strong, especially the North Country."
Stephen Acquario, executive director of the New York State Association of Counties and meeting organizer, said, "The national health care crisis is hitting first in the Adirondack Park because of its unique nature," adding, "We need to address it there while it's still manageable enough to solve."
Rashi Fein, an emeritus professor of medical economics at Harvard University, said that stakeholders will have to work with state officials to fix the problem. Fein said, "In many ways, the Adirondacks are a reflection of a national problem" (Grondahl, Albany Times Union, 8/29).
The Latest Reports in Health Policy
CBO Releases Cost Estimate of Senate SCHIP Bill; Report Examines Effects of Massachusetts Health Insurance Law
[Aug 30, 2007]
Opinion
Conflict of Interest Inherent in Government-Run Comparative Effectiveness Studies Requires Outside Scrutiny, Opinion Piece Says
[Aug 30, 2007]
"The proposal for a 'comparative effectiveness' center" included in the House version of SCHIP reauthorization legislation (HR 3162) "has become a seductively simple idea that few are willing to challenge in Washington, making it almost inevitable, save a veto of SCHIP altogether," Scott Gottlieb, resident fellow at the American Enterprise Institute and former senior official at FDA and CMS, writes in a Wall Street Journal opinion piece. However, the "difficult nature of these 'comparative' drug studies, the sort contemplated in SCHIP, requires more care, not less" because these studies "are hard to execute by their nature, a fact given short shrift by policymakers who believe the conclusions gleaned from the research will provide immediate cost savings," according to Gottlieb.
He writes, "Problems arise when the government pursues studies to achieve its own economic goals, where political motivations seem to intrude on the design and conduct of the trials and bias not only how results are interpreted, but more especially, how they are reported." Gottlieb continues that because the results of government studies will affect payment decisions under Medicare -- which in turn will affect reimbursement in the private market -- the government "should at least make bottom-line results public so others can test the government's conclusions," which it has not done effectively in the past.
He continues, "The political cover offered by government-directed research will surely help when it comes time to impose unpopular limits on prescribing," which is "about the only certainty in this legislative gambit and maybe the only one that mattered when it was drafted." Gottlieb concludes, "For many, these proposals weren't about medical discovery but bean counting. What Medicare hasn't achieved in policy circles, it's hoping to impose through the fiat of 'science'" (Gottlieb, Wall Street Journal, 8/30).
Medicare Advantage Plans Provide Valuable Services to Seniors, CMS' Kuhn Writes in Letter to the Editor
[Aug 30, 2007]
A recent Washington Post editorial "erroneously criticized Medicare for paying private Medicare Advantage plans more per beneficiary than is paid under traditional fee-for-service Medicare," CMS Acting Deputy Administrator Herb Kuhn writes in a Post letter to the editor (Kuhn, Washington Post, 8/30).
In the editorial, the Post wrote that the "extra spending" on reimbursements to private MA plans compared with payments to traditional Medicare for equivalent benefits -- "more than $50 billion over the next five years -- makes an already financially unstable Medicare program more expensive" (Kaiser Daily Health Policy Report, 8/21).
In his letter, Kuhn says the editorial's "statement 'Some of the money is plowed back into extra benefits'" was "misleading," adding, "In fact, Congress requires that plans invest all of the difference between what we pay them and their expected costs for basic Medicare benefits in enhanced benefits for enrollees." He notes that these benefits "often exceed those available in regular Medicare."
MA plans are "especially important for people whose incomes are too high for Medicaid enrollment but not high enough to pay for Medigap policies to cover costs not paid by traditional Medicare," Kuhn says. He continues, "Medicare Advantage enrollees are more likely to get all-important preventive care -- immunizations, cancer screening and diabetes management -- that will result in better quality of life and lower long-term health care costs." Kuhn concludes, "To cut payments to Medicare Advantage plans, and risk reducing beneficiary access and benefits, would be penny-wise and pound-foolish" (Washington Post, 8/30).
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