Health and Medical News and Resources

General interest items edited by Janice Flahiff

[Reblog] Four insurers reveal what they pay for 70 health care services

Four insurers reveal what they pay for 70 health care services | Association of Health Care Journalists.

From the 26 February 2015 article at Covering Health

Health insurers are taking incremental steps to release information on what they pay to health care providers. Each month, they reveal just a bit more.

This week, Aetna, Assurant Health, Humana and UnitedHealthcare released state and local cost information through the nonprofit Health Care Cost Institute (HCCI) on a consumer site called Guroo.com. The data show the costs for about 70 common health conditions and services and are based on claims from more than 40 million insured individuals, HCCI announced.

No other organization has made these data available, HCCI said. In that way, this release is significant. Or, as the Guroo site says of the data: “The biggest collection of cost information is now at your fingertips, so you know what care really costs.”

Well, not exactly. The data show what insurers paid. Or, as Jason Millman pointed out in The Washington Post, “The site doesn’t break down what a consumer pays for services versus what the insurer pays.”

The release of cost-transparency data seems to be gaining some momentum. Last month, the North Carolina Department of Health and Human Services published what it said was “the most current price information” from hospitals and ambulatory surgery centers. In so doing, North Carolina joined Maine and Massachusetts as the only states that publish price data on the web, according to last year’s Report Card on State Transparency Laws  from the Catalyst for Payment Reform and the Health Care Incentives Improvement Institute.

Within days of the publication of the state data, Blue Cross Blue Shield of North Carolina published data on what it pays hospitals and physicians. In an earlier blog post we covered those events in North Carolina.

March 3, 2015 Posted by | health care | , , , , | Leave a comment

[Medical Journal Editorial] Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace

From the Perspective article by Douglas B. Jacobs, Sc.B., and Benjamin D. Sommers, M.D., Ph.D.at the 5 Feburary edition of the New England Journal of Medicine

Eliminating discrimination on the basis of preexisting conditions is one of the central features of the Affordable Care Act (ACA). Before the legislation was passed, insurers in the nongroup market regularly charged high premiums to people with chronic conditions or denied them coverage entirely. To address these problems, the ACA instituted age-adjusted community rating for premiums and mandated that plans insure all comers. In combination with premium subsidies and the Medicaid expansion, these policies have resulted in insurance coverage for an estimated 10 million previously uninsured people in 2014.1

There is evidence, however, that insurers are resorting to other tactics to dissuade high-cost patients from enrolling. A formal complaint submitted to the Department of Health and Human Services (HHS) in May 2014 contended that Florida insurers offering plans through the new federal marketplace (exchange) had structured their drug formularies to discourage people with human immunodeficiency virus (HIV) infection from selecting their plans. These insurers categorized all HIV drugs, including generics, in the tier with the highest cost sharing.2

Insurers have historically used tiered formularies to encourage enrollees to select generic or preferred brand-name drugs instead of higher-cost alternatives. But if plans place all HIV drugs in the highest cost-sharing tier, enrollees with HIV will incur high costs regardless of which drugs they take. This effect suggests that the goal of this approach — which we call “adverse tiering” — is not to influence enrollees’ drug utilization but rather to deter certain people from enrolling in the first place.

We found evidence of adverse tiering in 12 of the 48 plans — 7 of the 24 plans in the states with insurers listed in the HHS complaint and 5 of the 24 plans in the other six states (see theSupplementary Appendix for sample formularies). The differences in out-of-pocket HIV drug costs between adverse-tiering plans (ATPs) and other plans were stark (seegraphAverage HIV-Related Costs for Adverse-Tiering Plans (ATPs) versus Other Plans.). ATP enrollees had an average annual cost per drug of more than triple that of enrollees in non-ATPs ($4,892 vs. $1,615), with a nearly $2,000 difference even for generic drugs. Fifty percent of ATPs had a drug-specific deductible, as compared with only 19% of other plans. Even after factoring in the lower premiums in ATPs and the ACA’s cap on out-of-pocket spending, we estimate that a person with HIV would pay more than $3,000 for treatment annually in an ATP than in another plan.

Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans. A recent analysis of insurance coverage for several other high-cost chronic conditions such as mental illness, cancer, diabetes, and rheumatoid arthritis showed similar evidence of adverse tiering, with 52% of marketplace plans requiring at least 30% coinsurance for all covered drugs in at least one class.3 Thus, this phenomenon is apparently not limited to just a few plans or conditions.

Adverse tiering is problematic for two reasons. First, it puts substantial and potentially unexpected financial strain on people with chronic conditions. These enrollees may select an ATP for its lower premium, only to end up paying extremely high out-of-pocket drug costs. These costs may be difficult to anticipate, since calculating them would require knowing an insurer’s negotiated drug prices — information that is not publicly available for most plans.

Second, these tiering practices will most likely lead to adverse selection over time, with sicker people clustering in plans that don’t use adverse tiering for their medical conditions.

Read the entire Perspective here

February 6, 2015 Posted by | Consumer Health, Public Health | , , , , , , | Leave a comment

[Reblog] Journalist explains what to expect from new mental health parity rules

From the 27 January 2014 post at Covering Health – Monitoring the pulse of health care journalism

by | January 27, 2014

Joseph Burns

About Joseph Burns

Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.

Michelle AndrewsMichelle Andrews

Later this year, health plans will be under new mental health parity rules affecting how insurers should cover patients with mental health and substance abuse disorders.

Michelle Andrews, a health policy reporter and columnist for Kaiser Health News, explains the issue in a new tip sheet,  “Mental health parity rule clarifies standards for treatment limits, coverage of intermediate care.”

These rules, governing the limits that health insurers can place on coverage for patients needing mental health and substance abuse care, will be important to consumers for several reasons. One reason involves what services health plans must provide when covering mental health benefits –keep in mind that health plans do not need to offer mental health care. But if they do, they need to cover inpatient and outpatient services, emergency room care and prescription drugs, Andrews reports. Also, the rules prohibit health insurers from setting limits on treatment that are more restrictive than the limits set on a plan’s medical-surgical coverage, she adds.

In addition, intermediate-level mental health services, such as residential treatment and intensive outpatient services for patients needing substance abuse treatment or mental health care, should be covered at the same level as the insurer covers residential and intensive outpatient services for medical-surgical patients, Andrews adds. Often patients needing mental health and substance abuse care require residential or intensive outpatient treatment.

The new parity rules also do not allow health insurers to charge higher co-payments, deductibles, or out-of-pocket maximums for mental health and substance abuse treatment without setting similar co-payment, deductibles, and out-of-pocket limits for medical-surgical coverage.

 

 

Read the entire article here

January 28, 2014 Posted by | health care | , , , , | Leave a comment

   

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