Groups seek to capitalize on federal funding

Cara Matthews writes on pressconnects.com -”Health care advocates said Thursday that Gov. Andrew Cuomo and lawmakers must move quickly this session — before the new fiscal year starts April 1 — to set up a health care exchange and capitalize on millions of dollars in federal funding.

The Health Care For All New York coalition released two reports Thursday detailing the benefits that have already taken effect under the 2010 Affordable Care Act and personal stories of people who have benefited from the law.

The law requires that all states have health exchanges — marketplaces where individuals and small businesses can buy insurance — operating by Jan. 1, 2014. The federal government will intervene and create exchanges in states that have not set up viable models by Jan. 1, 2013.”

To read more click here.

Cathleen Crowley of the Times Union writes:

“With medical costs skyrocketing, the health care industry has turned to a new form of managed care to corral expenses and improve quality: medical homes.

The concept is the same as managed care in the 1990s — a primary care physician guides a patient’s care — but today’s version has a different financial model.

Instead of a fee-per-member arrangement, most medical home models still pay doctors a fee for each service, but add a “care management” fee. The idea is that when a primary care doctor is responsible — and paid — for managing a patient’s care, the patient will receive better preventive care and avoid high-cost hospitalizations and ER visits.”

To read more click here.

The long awaited IOM report on essential health benefits (EHB) recommendations was released today. The report details how the Health and Human Services Department should decide which benefits get covered on insurance exchanges and recommends HHS pick benefits to fit within a certain price range.

In addition, the IRS issued recent guidance and request for comments intended to allow employers to better design their plans to avoid a penalty, or calculate and predict their potential tax liability starting in 2014, when the employer mandates begins.

To read more click here.

According to an article in The New York Times:

“With 2.6 million uninsured residents, a popular Democratic governor and tens of millions of federal dollars at stake, New York would seem to be one of the least likely states to join a growing revolt in the nation’s capitals against facilitating a federal overhaul of health care.

But several Republican lawmakers in New York, saying they do not want to have anything to do with what they call “Obamacare,” have thus far succeeded in blocking the state from seeking large amounts of federal assistance to put into place a mandatory health insurance exchange — a state-run marketplace where individuals and small businesses can buy insurance.”

To read more click here.

The following op-ed by Paul Macielak, President & CEO of the New York Health Plan Association, was featured in the Times Union:

“While focusing on the possibilities he sees the Affordable Care Act bringing to New York, Douglas Turner of the Buffalo News overlooks the many hurdles that impede efforts to achieve the goals of federal reform, including affordability. (”New York tries to salvage Obamacare,” Viewpoint, Aug. 23.)

First there are New York’s taxes on health care, which total more than $4 billion annually and can equal 6 percent of the premium. These include various “assessments” and “surcharges” applied to health insurance premiums as part of New York’s Health Care Reform Act, and other assessments and taxes that are part of the cost of doing business in New York and must be built into the premium base.”

To read more click here.

Cara Matthews writes on pressconnects.com - “Independent pharmacists and mail-order drug companies continue to spar this week about pending legislation that would prohibit insurers from requiring patients to get prescriptions through the mail.

The Pharmacists Society of the State of New York said approval of the bill would help counter the loss of jobs and community drugstores. But pharmacy-benefits managers countered that the number of licensed pharmacists has been growing steadily and that mail-order drug businesses provide hundreds of jobs in New York.

The bill, which has not been sent to Gov. Andrew Cuomo yet, would allow people to fill any prescription covered by mail order at an independent retail pharmacy as long as the pharmacy price was comparable. The Pharmacists Society led a news conference in Albany as it tries to convince Cuomo he should sign it.”

To read more click here.

An article on lohud.com states:

“Independent pharmacists and mail-order drug companies continue to spar this week about pending legislation that would prohibit insurers from requiring patients to get prescriptions through the mail.

The Pharmacists Society of the State of New York said approval of the bill would help counter the loss of jobs and community drugstores. But pharmacy-benefits managers countered that the number of licensed pharmacists has been growing and that mail-order drug businesses provide hundreds of jobs in New York.

The two sides also disagree on how the legislation would affect the market. Pharmacists said Tuesday that it would improve competition, and mail-order drug companies responded that it could lead to higher prices.”

To read the entire story click here.

In a letter sent to State Senator James L. Seward by the Federal Trade Commission on an assembly bill (A5520-B) which regulates the use of mail order pharmacies by health plans offering prescription drug coverage they recommend that the bill not be enacted.

In part of that letter they state, “The Bill will limit a health plan’s ability to steer beneficiaries to a lower cost mail order vendor of maintenance drugs,3 via financial incentives or other terms of coverage, whenever a competing retail pharmacy is willing to fill prescriptions at “comparable” prices. By restricting a health plan’s ability to offer favorable treatment to a low cost mail order pharmacy, the Bill undercuts pharmacies’ incentives to bid aggressively for a share of that health plan’s business. Reducing those incentives is·1ikely to raise the prices that consumers pay for the prescription drugs that their health plans cover. Some cost increases may be passed on to plan beneficiaries in the form of higher out-of-pocket prices. In some cases, plans may respond to higher costs by reducing the scope of prescription drug coverage, or by eliminating prescription drug coverage entirely. For those reasons, FTC staff recommend that the Bill not be enacted.”

To read the letter click here.

Health care spending continues to be the “elephant in the room.” That doesn’t stop any number of entities continuing to provide the data.

The latest National Institute for Health Care Management (NICHM) Foundation Data Brief on U.S. health care found that between 2005 and 2009, total national health spending rose 23 percent from $2.021 trillion to $2.486 trillion. Over the same time period, national spending on premiums for private health insurance rose nearly 15 percent.

And a recent article in Health Affairs on health spending projections to 2020, notes “In 2010, US health spending is estimated to have grown at a historic low of 3.9 percent, due in part to the effects of the recently ended recession. In 2014, national health spending growth is expected to reach 8.3 percent when major coverage expansions from the Affordable Care Act of 2010 begin. The expanded Medicaid and private insurance coverage are expected to increase demand for health care significantly, particularly for prescription drugs and physician and clinical services. Robust growth in Medicare enrollment, expanded Medicaid coverage, and premium and cost-sharing subsidies for exchange plans are projected to increase the federal government share of health spending from 27 percent in 2009 to 31 percent by 2020. This article provides perspective on how the nation’s health care dollar will be spent over the coming decade as the health sector moves quickly toward its new paradigm of expanded insurance coverage.”

The State Senate concluded its session in late June without taking action on legislation to set the implementation of a NY Health Exchange in motion. They are not set to return to Albany until late September at the earliest. The absence of a governance structure and statutory authority has not stopped planners from proceeding with design elements which will have significant influence on the ultimate look and functionality of a health exchange. The Department of Health released a Health Benefit Funding Availability Solicitation on July 15, seeking to award a 4 year contract for the delivery of an operational system. The FAS also notes that it is the Department’s intent to award the successful bidder of this FAS the operational phase for the exchange.

The initial 30 day timeframe for interested parties to submit a bid to this 162 page document has been extended through September 6, 2011. The bid observes that “As an Early Innovator state, the target date for “Operational Readiness” of the NY-HX Solution is October 10, 2012, to facilitate re-use by other states.” NYS is not the only Early Innovator grantee to not pass authorizing exchange legislation; Kansas and Wisconsin legislative sessions ended without agreement on a bill and Oklahoma returned its EI grant to the federal government. Maryland has become a leader among states on exchange implementation – passing its legislation in April, appointing its 9 member board in May which held its first meeting in early June.

With an aggressive timeframe, and with state budget-provided authority to award without competitive bid, the Department of Health will proceed with designing and “building” a health exchange system that will likely anticipate policy decisions, rather than being informed by policy decisions related to the functionality needed for this customer interface.