Lack of Transparency Continues to Haunt HHS

A lack of information is driving consumers into poor health care choices, and Health and Human Services is to blame; at least according tothe Government Accountability Office.

In a 43-page report released this September, the office slammed HHS, claiming that a lack of transparency is keeping consumers from easily accessing the pricing information of health care plans until after they are already covered. FierceHealthcare summarizes, “In one example, the agency contacted a variety of physician offices to get the price of a diabetes screening--and was consistently told an office visit was required prior to disclosure of such a price. The GAO also noted that the negotiated prices between an insurer and provider were often kept from consumers for legal and trade purposes.”

Transparency in HHS is not a new topic. In fact, the department was criticized for similar reasons when they removed public access to National Practitioner Data Bank in early September.

This new report, the creation of which was heavily pushed by congress, has found a severe lack of initiative from HHS when it comes totransparency.

Several health care and legal factors may make it difficult for consumers to obtain price information for the health care services they receive, particularly estimates of what their complete costs will be. The health care factors include the difficulty of predicting health care services in advance, billing from multiple providers, and the variety of insurance benefit structures.

The entire industry is keeping a close eye on this developing story, and Merrill Corporation will be among them.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Final Rule Addresses ACO Criticism

At their first announcement, the Centers for Medicare and Medicaid Services’ rules for ACOs caused an uproar. Accountable Care Organizations will reward medical providers that meet certain quality of care requirements, but health professionals found the rules to be needlessly complicated, hard to follow, and unrealistic. CMS responded quickly, committing to rework and improve the rule set.

On October 20^th, the proposed changes, collectively called the final rule, released to public acclaim. CMS Administrator Dr. Donald Berwick told Kaiser Health News, “We have been able to fine tune and improve the rules for a range of stakeholders, providers and patients.” Across the board, health industry officials are praising CMS for the new rule changes, and it seems that these requirements will finally move toward improving the country’s health care.

FierceHealthCare.com put together a table outlining the changes CMS made. We have an excerpt below, or you can view the full table here.

Topic	Proposed rule	Final rule
Transition to risk in Track 1	ACOs offer two tracks. Track 1 would entail two years of one-sided shared savings; then participants would have to transition in third year to a performance-based risk, two-sided model of savings and losses.	ACOs still offer two tracks. Track 1 now removes two-sided risk.
Prospective vs. retrospective	Retrospective assignment based on primary care service use, with prospective identification of benchmark population	Preliminary prospective-assignment with beneficiaries identified quarterly, with final reconciliation after each performance year
Quality measures	65 measures in 5 domains	33 measures in 4 domains
Shared savings	One-sided risk model: Sharing begins at savings of 2 percent Two-sided risk model: Sharing on first dollar	Share on first dollar for all ACOs in both models once min. savings rate is achieved

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Medicare Annual Open Enrollment Begins Early

This year, CMS has announced an early launch for Open Enrollment, which will begin October 15^th, instead of the usual date of November 15^th. The enrollment will end on December 7^th. CMS made this change under hopes that it would improve the enrollment process for Medicare beneficiaries, according to the official press release.

This gives people with Medicare a full seven weeks to compare and make decisions, and ensures that they will have essential plan materials and membership cards in hand on January 1, 2012 when new coverage starts.

In the press release, CMS also made efforts to stress the importance of investigating and exploring plan options.

There'll be a wide range of health and drug plan options available across the country, including Original Medicare. Most people with Medicare can choose a "Part D" plan to help them pay for prescription drugs. And people who have chosen to enroll in a "Part C" Medicare Advantage plan for their basic health care services have the option of staying in that plan, choosing a different plan, or going back to the Original Medicare program. Plans can change from year to year, so these are important choices that should be made with care.

As usual, the organization is making a big push to promote information sources such as 1-800-MEDICARE and http://www.medicare.gov. We saw many efforts being made around this time last year to promote those educational channels, and it is certainly good to see them remaining a large part of CMS’s enrollment initiative.

 

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

A Summary of Uniform Coverage (Part 1)

On Tuesday, March 23rd, 2010, President Obama signed into law the “Patient Protection and Affordable Care Act” (“PPACA”). A Reconciliation Bill making changes to the Act was signed by the President on March 30th, 2010.  On August 17, 2011, the Departments of Health and Human Services, Labor and Treasury issued proposed regulations for implementation of the Summary of Benefits and Coverage and the Uniform Glossary requirements under Section 2715 of the PPACA. Per regulation the Uniform Coverage Summary is now called “The Summary of Benefits and Coverage” or the “SBC”.

The proposed regulations provide rules for providing participants and beneficiaries with an accurate Summary of Benefits and Coverage (SBC). The proposed regulations also provide rules for SBCs that must be provided by insurers to plan sponsors wishing to purchase group health insurance. The rules apply to both group health plans and health insurers providing insurance in the group and individual markets. The rules also apply to Employee Retirement Income Security Act (ERISA) and non-ERISA group health plans and include grandfathered plans.

Here is an overview of the SBC requirements:

Every health insurer in the individual and group markets, and every group health plan (insured or self funded) must provide policy holders or certificate holders (“Subscribers/Members/Beneficiaries”), applicants, and enrollees a SBC using a uniform format that accurately describes the benefits and coverage under the plan. This was called the Uniform Coverage Summary (UCS) and is now known via regulation as the Summary of Benefits and Coverage (SBC). Under the new proposed regulations health plans are provided instructions, templates, samples, a guide for coverage example calculations to be used in completing the SBC template which includes a “Why this Matters” column and a Uniform Glossary of terms and definitions to help with beneficiary understanding.

Health plans are required to send each member an SBC and Coverage Examples. The Uniform Glossary of terms and definitions must be made available upon request in paper or electronic form within 7 days of request. The Uniform Glossary is provided by HHS and issuers cannot make any modifications to this glossary. Translation services for the SBC will follow the 10% by county rule.

Next week, we will go into further detail on what this will mean to both the business community and the American public.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.