Is Healthcare’s Fear of Change Justified?

Information technology, particularly in the fields of social media and mobile communication, is a notoriously slow-moving concept in the health industry. Complex compliance issues, data security, and expense have largely kept health workers on the outskirts of today’s technology boom. Now, some analysts are asking if the industry has fallen too far behind.

“I doubt that anybody within airlines, financial services, or manufacturing goes to meetings to debate whether information technology can improve what they do. It already has,” says BMJ’s Richard Smith. “But in healthcare we’ve grown very [skeptical] about information technology.” Smith believes that bad experiences with innovation in the past have helped foster an environment of stagnation, citing examples such as Britain’s 2005 initiative: Connecting for Health. The program, costing NHS billions of dollars, achieved almost nothing over the following years.

Leaders in healthcare are reluctant to invest in information systems that may not deliver a financial return or may take years to do so. We remembered how five years ago the leaders of Connecting for Health were being invited to tour the world talking about the remarkable things they were doing. Now those who have survived the wreckage are invited to talk on how not to do it.

This isn’t a problem limited to Britain, either.

In our own past blogs, we’ve looked at HIPAA’s reluctance to allow faster, more efficient mobile technology instead of outdated pagers. We also described July’s sharp increase of HITECH violations, caused by HIPAA’s refusal to update archaic requirements for electronic records. It should be obvious that compliance and security are top concerns for the health industry, but many experts believe that some technological advances could be improving those factors, in the long run. They wonder if, by the time HIPAA catches up, it will already be too late.

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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 3)

We’ve spent a lot of time talking about healthcare and the recent Summary of Benefits and Coverage (SBC) regulations, along with a few other topics, so perhaps it is time for a wrap up, and a few last explanations.

A few months ago, on the 17^th of August, 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. These regulations were issued with the intention of providing every health plan provider and beneficiary with an accurate SBC in time for them to make effective decisions regarding their health plan enrollment.

Insurers are required to provide accurate, uniform SBC’s to all beneficiaries through the use of a provided template. The regulations also ensure that every insurer is provided with the tools, templates, and information required to meet the previously outlined requirements. Health plans are also required to be able provide a uniform glossary of terms and conditions, by request, within 7 days.

There are 12 main requirements outlined in the SBC regulations, including uniform definitions of standard insurance terms, description of the coverage, cost-sharing provisions of the coverage, coverage provisions, and a statement explaining that the provided SBC is only a summary of benefits and that the entire plan document should be consulted as well.

If they function as intended, these regulations should ensure that consumers are provided with the best possible information to make an informed decision about their healthcare. Health plans also stand to benefit from the regulations, as any outlined rules can help plans through the complex red tape of health compliance.

Merrill Corp supports the HHS regulations, and we are well-equipped to handle these new compliance requirements.

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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 2)

Back in October, we began a series of blogs describing the proposed regulations issued by the Departments of Health and Human Services, Labor and Treasury on August 17, 2011. A few time-sensitive industry events have occurred in between, but we are now happy to be back on track.

When we last left off, we had described some of the basic requirements of ‘The Summary of Benefits and Coverage,’ or SBC. In this blog, we will go into some more detail on 12 of those requirements with help from a general list provided by HHS.

• Uniform definitions of standard insurance terms and medical terms so that consumers may compare health coverage and understand the terms of (or exceptions to) their coverage.
• A description of the coverage, including cost sharing, for each category of benefits identified by the HHS Secretary in guidance.
• The exceptions, reductions, and limitations of the coverage.
• The cost-sharing provisions of the coverage, including deductible, coinsurance, and copayment obligations.
• The renewability and continuation of coverage provisions.
• Coverage examples in accordance with the regulation as identified by the HHS Secretary.
• A statement that the SBC is only a summary and that the plan document, policy, or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage.
• Contact information for questions and obtaining a copy of the plan document or the insurance policy, certificate, or contract of insurance (such as a telephone number for customer service and an Internet address for obtaining a copy of the plan document or the insurance policy, certificate, or contract of insurance).
• For plans and issuers that maintain one or more networks of providers, an Internet address (or similar contact information) for obtaining a list of network providers.
• For plans and issuers that use a formulary in providing prescription drug coverage, an Internet address (or similar contact information) for obtaining information on prescription drug coverage.
• An Internet address for obtaining the uniform glossary.
• Premiums (or in the case of a self-insured group health plan, cost of coverage).

In our next blog, we will provide some more detail, information, and analysis of the SBC proposals.

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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.

Banner Health Considers Pioneer ACO Contract

Arizona may be the home of the first pioneer ACO, if the state’s Banner Health accepts a contract presented by CMS this week. The largest health system in the state, Banner has a lot to gain from the early adopter ‘pioneer’ program.

In a statement describing massive funding cuts, Banner CEO Peter Fine explained the thought behind the move to ACO.

The traditional model of fee-for-service is gradually giving way to a collaborative model in which reimbursement is shared by hospitals, physicians and other providers based on the health management of defined populations…Doubtless, there will be those who will decry ACOs as a by-product of health-care reform and therefore unworthy of consideration. However, ACOs and similar collaborative models are moving forward whether health-care reform is implemented or not.

For Banner, the only point of concern was timing. “The issue before us now is that of timing. How fast can we bring new models of collaboration into existence?” Fine asked in his statement. As it turns out, it’s a question that many people are asking.

In a white paper available from the Robert Wood Johnson Foundation, authors Berenson RA and Burton RA explain that “…so far, the reception to CMS’ final regulations has been positive, but how many organizations will actually apply to CMS to be ACOs is another question.” The paper attempted to explain CMS’s motives for the ACO Pioneer program, and to establish a prediction on the widespread success of the program. FierceHealthcare summarizes:

How many and how fast will ACOs spread? CMS estimates 50 to 270 ACOs will sign up to participate, generating a net savings of $940 million during the first four years through Shared Savings, according to a recent report by the Urban Institute and the Robert Wood Johnson Foundation…

…According to the report, it's unclear if the Shared Savings Program and the earlier Pioneer ACO model are intended to test the ACO concept for large-scale implementation, to see whether it generates sustainable governmental savings, or to move as many providers as possible to ACOs to curb Medicare spending.

A few years will probably pass before we can come to any definitive conclusions on the program, but the Banner exercise at least demonstrates how much is at stake.

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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.