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The Politics of Healthcare

Fixing Healthcare Costs
May 17, 2013 10:42 AM by Kelly Wolfgang
Editor's note: This blog post is written by Alex Tolbert, founder of Bernard Health.

Our healthcare system is broken partly because consumers don't know what anything costs. As patients become more proactive in making informed healthcare decisions, we all agree this should be fixed. But why is it so hard?

Achieving price transparency in healthcare is difficult because healthcare business models rely heavily on a lack of transparency.

Insurers, hospitals and providers want a better healthcare system as much as anyone, but can't afford to inflict damage on their businesses by making prices transparent overnight.

To better understand how transparency affects healthcare, let's take a look at the business models for insurers and hospitals.

Insurer Business Model

If prices were completely transparent, then insurance companies who had negotiated the lowest prices would begin to lose their primary advantage. This is because that pricing information would give medical providers and other insurance companies more power when negotiating and competing with them.

An insurer's business model can be boiled down to this:

  1. Negotiate discounted prices with providers.
  2. Insure people, collect premiums.
  3. Pay claims to providers at discounted prices.
  4. Keep the difference.

Since that is the business, here is how you win financially:

  1. Negotiate the lowest prices with providers.
  2. Offer the lowest premiums so you can attract the most insured people.
  3. Enjoy the virtuous cycle that ensues.

What virtuous cycle?

The more people you insure, the lower the prices you can get from providers. If you can get the lowest prices, you can offer the lowest premiums. Offering the lowest premiums will win you the most insured people, and so you can continue to negotiate the lowest prices from providers. And so on.

Hospital System Business Model

If prices were completely transparent, then it would be difficult for the hospitals to justify the high prices they charge for things available elsewhere for a fraction of the price. In other words, if everyone knew that "Procedure ABC" costs $3,800 at the hospital and $600 for the same quality at a standalone facility next door, the hospital would lose a lot of business.

The typical hospital system business model can be boiled down to this:

  1. Negotiate prices with insurers to be "in-network."
  2. Get paid at those prices on patient claims submitted to insurers.
  3. Pay your doctors, "midlevel" providers, nurses and facility/equipment costs.
  4.  Keep the difference.

Since this is the business, here is how you win financially:

  1. Negotiate the highest prices with insurers.
  2. See as many patients as possible.
  3. Submit as many claims as possible for each patient.

It's a lot easier to do more tests/procedures per patient than to attract more patients. As such, your contracted prices for tests and procedures are really important.

Fortunately, as a hospital system, your size gives you leverage when negotiating with insurers. The insurers need you in their network more than they need a given imaging center. As a result, you're able to negotiate prices that are a lot higher and still be in-network.

Fueling the Movement Toward Transparency

Creating a better healthcare system starts with price transparency. The growth of health savings accounts and transparency start-ups, like Healthcare Blue Book and Change:Healthcare have fueled the movement toward price transparency.

In addition, insurers and hospitals are working hard to provide transparency. To offset the damage transparency will inflict on their business models, they're working to develop other competitive advantages.

As consumers continue to share the burden of ever-increasing healthcare costs, it's only fair that they be armed with the information needed to make informed decisions about their healthcare. This transparency will lead to a better-functioning and lower-cost system with happier providers and patients.

Patient Confidentiality and Social Media
April 26, 2013 11:20 AM by Kelly Wolfgang

Editor's note: This article was posted with permission from its author, Christine Gondos, Igloo Software. She can be reached at cgondos@igloosoftware.com.

The fastpaced healthcare industry is continuously evolving -- whether it be newly released studies, new best practices or new techniques, the healthcare community thrives off of innovation.

While annual conferences provide the opportunity for healthcare professionals to connect, the majority of professionals rely on email to exchange new findings. Healthcare professionals have recently placed an importance on social media networks (such as Twitter) as an additional outlet to exchange ideas. While social media provides an opportunity for medical professionals to connect and discuss best practices, this ultimately becomes problematic due to the confidential nature of the discussions.

So how can healthcare professionals network, engage in conversations about practice and share knowledge while maintaining confidentiality and ethical standards?

Igloo Software's Senior Vice President of Marketing & Operations, Andrew Dixon recently presented at the CIO Healthcare Summit where he discussed "How Healthcare Organizations are Moving from Social Media Marketing to Social Business Strategy." Instead of connecting on public social networks, more and more healthcare organizations are creating a social business strategy so they can collaborate on their own private network.

Secure enterprise social platform organizations like Igloo unite healthcare professionals, practitioners and patients so they can collaborate on ideas and keep information in one area. After a patient leaves the office, you no longer need to feel that sense of ambiguity questioning if you remembered everything he or she said. No longer does a conversation need to live in the room you had it; nor your email inbox, nor your notebook.

Enterprise social software erases ambiguity and allows information to be accessible yet secure. Here are four use cases of how enterprise social software enables healthcare professionals to stay connected outside the office.

  • Kimberly-Clark Clinical Solutions is a health division of a large consumer goods company that has a very large health product portfolio including medical devices & infection prevention. To facilitate research, they launched a social extranet solution to act as a product evaluation center for open innovation & customer engagement.
  • Ontario Health Quality Council, an independent provincial body for patient care, coordinates a myriad of stakeholders in a member portal to report on the health system's effectiveness and opportunities for process improvement.

Patient Communities

Are your patients curious about learning more information about what you said in a recent appointment? While you may question the validity of checking Wikipedia or the intimidating results Google reports back, patients often feel alone when they leave their provider's appointment. Healthcare organizations realize this and have bridged the gap by offering patients a portal where they can connect.

  • Children's National Medical Center provides patients with a secure, private virtual place where they can ask questions, find answers and share experiences around a specific health condition. Their Emergency Medical Services for Children Program (EMSC) National Resource Center also provides a secure portal for grantees to interact and share information with each other in support of EMSC's national child advocacy programs.

Practitioner Communities

Want to bring together key stakeholders within a healthcare association to work together and  improve healthcare delivery? A conference may be a great way to get everyone together, but how will you collaborate after?  

Enterprise social software platforms provide practitioners a specific work area where they can collaborate on documents and share best practices.

  • Drug Information Association uses a social extranet to connect their 18,000 members in the biopharmaceutical industry for online learning, collaboration and managing their communities of practice. Since adopting this new form of technology, their collaboration tools are now streamlined and this area facilitates knowledge exchange and relationship building in a private member portal for their 32 special interest groups.
  • American Academy of Family Physicians (AAFP), representing more than 100,000 family physicians and medical students nationwide, improved their collaboration since launching an online community for peer networking, information sharing and practice transformation. Members have access to online seminars, practice tools and the "Ask An Expert" area. Known as Delta Exchange, the award-winning online network connects physicians, clinical staff, office staff and primary care-focused residency programs committed to the Patient Centered Medical Home.
  • TransforMED, a wholly-owned subsidiary of the American Academy of Family Physicians (AAFP) also capitalized on the benefits of social collaboration. In an effort to improve patient care and assist primary care physicians with medical practice redesign, over 500 practices and more than 5,000 medical professionals across the country connect and collaborate using Igloo Software.

Internal Communities

External facing communities (extranets) have gained tremendous momentum for healthcare organizations. Effective collaboration, improved knowledge sharing, and accessibility anywhere - it is no wonder that more and more healthcare organizations like The College of Family Physicians of Canada, Aetna, and Femnene are adopting social intranets to collaborate inside their organization.  Bye bye filing cabinets and shared folders.

The organizations mentioned above stay organized with hierarchical storage of documents with unlimited folders, inline preview and full version control. Organizations and associations in the healthcare industry now have the power to stay connected to other healthcare professionals, practitioners and patients in a secure environment where confidential information is safe.

For more information, visit http://www.igloosoftware.com/blogs/inside-igloo/continuingtheconversationoutsidethedoctorsoffice4waystostayconnected

Another Perspective on ACO
March 13, 2013 4:00 PM by Lynn

We’ve been covering healthcare reform and accountable care organization (ACO) in detail and, in fact, will be launching an ACO Resource Center next month. And while much of the discussion surrounding the lab’s role has been positive overall—considering that several millions more will have health insurance coverage and will, theoretically, be utilizing laboratory testing, along with the knowledge and value laboratory testing brings to patient care—I received a letter from Joe Plandowski, who says he has

broad experience in operations, sales/marketing and acquisitions within the healthcare field. With his permission, I am sharing his comments. We welcome your replies.


“I read the January 2013 issue with interest; however, all I got from it was what I usually can expect of software companies --- a lot of nothing. Yeah, we all know that lab data is valuable. The point is that a lot fewer lab tests will be performed in the future if ACOs reach their potential. Maybe half of what is performed today. The opportunity of ACOs may be appealing to healthcare in general but is not going to be appealing to laboratorians in particular. There will be a lot fewer laboratorians in the future than we have today, also maybe half. That in itself is not bad if positive health outcomes remain what they are today or hopefully increase.


One of the authors in the January 2013 issue touches on this problem by stating, ‘While we are doing fewer tests per patient, to be successful, the strategy is to expand your patient base.’ In the ACO model, hospitals will control the money from the federal government. To prepare for the ACO environment, hospital systems are getting larger and buying up private physician practices. As that rollup evolves, specimens from those physician practices will flow into the hospital systems' laboratories. Reference labs on the outside will wither away because eventually no specimens will flow to them as private physicians are brought into the ACO hospital web. This includes the big labs, such as Quest and LabCorp. Hospital labs will not be getting proportionately bigger and absorbing the displaced laboratorians because they will be doing fewer tests per patient.


I am continually amazed that no one is picking up on this transition or at least writing about it. It will happen if ACOs are successful. Perhaps the aging of laboratorians will play into this scenario nicely because they may retire at the rate their jobs disappear anyway. I wonder if laboratorians understand this end game?

Implications of the Affordable Care Act
March 13, 2013 12:35 PM by Kelly Wolfgang
Editor's note: This blog is written by Anthony J. Hall, RN, BSN, behavioral health charge nurse at Atlanta Medical Center.

The Affordable Care Act (ACA) means major changes in the way Americans view health issues and treatment options. While there is increased optimism building around the plan's effect on patient care, healthcare providers will bear the burden of the plan's negative impacts, such as a shortage of primary care providers. Though the full impact on the medical profession has been hard to gauge, providers can be primed for some positive adjustments as a result of ACA.

It's easy to see the immediate benefits of the ACA for healthcare recipients - many more families will be able to schedule regular visits to a general practitioner or family clinic, meaning more check-ups and preventative treatments.

For healthcare professionals, this increased patient load means more providers will be needed; some will gain traction in positions of greater authority as those with less experience are hired. The shortage of primary care physicians will mean increased access to nurse practitioners (NPs) and physician assistants (PAs), allowing localized healthcare to more patients, making it unnecessary to travel to distant hospitals.

The increased presence of non-physician providers such as laboratory professionals, respiratory technicians, NPs and PAs in decision-making positions will bring a heightened awareness and a sense of respect that has been long overdue. In my work with patients and the general public, I've encountered many people who are uncertain of the role these professionals play; by virtue of increased demand, more patients will become aware of our importance in healthcare.

While many hospital systems are consolidating, combining forces and units to avoid producing duplicate services, job cuts in the hospital sector will provide an upswing in business for small practices, family clinics and general practitioners. This change is likely to mean an increase in employment for providers in all areas of specialization.

If you are interested in submitting to the Politics of Healthcare blog, please contact Kelly Wolfgang at kwolfgang@advanceweb.com.

Medicaid Expansion
February 15, 2013 1:25 PM by Kelly Wolfgang

Editor's note: This blog is written by Miguel A. Bustillos, department chair and professor at California University of Management & Sciences in Virginia.

Most of us have heard about the Medicaid expansion and how states like Florida, Texas and Virginia are against it. Some do not understand why the Medicaid expansion has become such a big issue or what exactly the Medicaid expansion is.

The Medicaid expansion, expected to be fully implemented by 2014, is a plan under the Patient Protection and Affordable Care Act (PPACA) to expand medical coverage for a number of people who do not qualify under the current plan. The Medicaid expansion mandates that a state must meet PPACA standards to receive full federal funding, which is needed to increase the current plan. The largest problem involving the mandate is how states will cover the "new eligibles," those patients who are receiving Medicaid assistance for the first time. It is estimated that 15.9 million new enrollees will participate in the plan by 2019.

The federal government currently pays, on average, about 57% of the total cost of Medicaid enrollees in each state. Of those that qualify for Medicaid, only 62% have signed up for Medicaid benefits, leaving the remaining 38% without benefits. Generally, those that are not taking the benefit either don't know that they qualify or refused the benefit.

If states were to accept the Medicaid expansion, they would continue to pay for the benefits of the 62% that are currently covered; in addition, they will have to cover the 38% that qualified under the previous requirement, but did not take the benefit. According to the new mandate, states must also provide for the new eligibles.

Under the Medicaid expansion mandate, the federal government will continue to pay the cost for about 57% of the 62% that are currently taking the benefit. With the new law, the 38% that did not receive benefits will now either take the benefit or pay a tax penalty. Some states believe that those who are qualified will take the benefit rather than pay the penalty. Despite the "new enrollee" status of those patients, the government will not support funding for any persons who previously qualified but did not receive benefits.

With regards to the true new eligible, the states believe that the cost of providing Medicaid is just too large for any state to handle.  To lessen the burden, the federal government has penned an agreement to cover 93% of the cost of the true "new enrollees" till the year 2020.

Many states will decline to take on the Medicaid expansion because it's a voluntary program. The new law can be very taxing to any state's budget and in most cases, there are not enough incentives for states to adapt the program.

The federal government is, however, not worried. When Medicaid was first signed into law in 1965, only six states agreed to participate. But by 1982, every state had joined. As 2014 comes along, and the law comes into full effect, it will be interesting to see what develops and what does not. With the cost of providing healthcare to so many people being so high, and the fact that Medicare benefits will be cut to fund the Medicaid expansion, I foresee much resistance on its implementation.

Is Gun Violence a Public Health Issue?
January 18, 2013 10:58 AM by Kelly Wolfgang
As reported on Newswise, the following is a statement by Jo Ivey Boufford, MD, president of The New York Academy of Medicine, one of the nation's oldest and most prestigious medical academies, on the seriousness of gun violence as a major public health issue. The statement is in response to deadly incidents of gun violence in Newtown, CT, Webster, NY, and the shooting of 15 individuals, three of whom died, during separate acts of gun violence in Chicago, IL on New Year's Day.

"As a nation, we can only improve the health of the public when we get our priorities straight. Recent acts of gun violence in Chicago, Webster, NY, and Newtown, CT cannot be ignored. Neither can the 31,000 Americans who die each year at the hands of a gun. This number exceeds the number of babies who die each year during their first year of life (25,000) or people who die from AIDS (9,500) or illicit drugs (17,000).

We institute protective measures enforcing speed limits and requiring the use of safety belts; we implement public health measures such as child vaccinations and regulations around the safety of food, drugs, and products. Yet guns escape this type of regulation despite their significant contribution to the mortality rate each year. We must view gun violence as a serious threat to the public's health if we want to reduce the number of deaths associated with guns.

We can start by banning the sale of assault rifles, high-capacity magazines, and other facilitators of mass murder. And we must allow government agencies like the Centers for Disease Control and Prevention to fully exercise their duties in both surveillance of the incidence and impact of gun violence, and in educating the public on steps for preventing death and injury through the use of firearms.

The evidence is clear, and we must now take action to protect our neighbors and ourselves from this devastating public health crisis."

In December, both the American Nurses Association and the American College of Emergency Physicians, two prominent and national healthcare organizations, issued calls for a ban on the sale of assault weapons.

Sister publication ADVANCE for Nurse Practitioners & Physician Assistants asked its readers, "Do you think it is the responsibility of healthcare provider organizations to urge this type of action?"

Here's what some readers had to say:

  • "We can all do our part. As nurses, as humans." - Teanne
  • "Just stand in a trauma unit for one night and come back and give me your answer." - Melissa
  • "Yes! Absolutely! It's everyone's responsibility to speak up for what they believe!" - Kelli
  • "Absolutely not. I have stood in the trauma unit for 15 years and taking away my legal guns, which I carry concealed because I am licensed to do so, and taking away my rifles, which I enjoy shooting responsibly, will do nothing to stop the common street thug with an illegal weapon, other than allow me no protection for myself and my property when I'm leaving the trauma unit at midnight, sitting at a red light, and getting jacked by said thug." - Dana
  • "Most of our ER staff is armed; we see what's out there. As the Boy Scouts say, be prepared. The bad guys will always find guns; we need to be able to defend ourselves." - Diana
  • "Absolutely. Some individuals have no business having weapons. Period." - Teresa
  • "This is definitely not the responsibility of healthcare provider organizations. This is a civil liberty. I'm sure many members of the groups do not support a ban. These groups should focus on healthcare issues." - Rita
  • "Supporting mental illness awareness and research would be a wiser choice! Let's be honest, what health professional has not taken some form of weapon to work with them?" - Susan

Do you agree with Boufford's statement and the calls for action by the American Nurses Association and the American College of Emergency Physicians? Weigh in on the comments below.

Editor's note: We welcome your comments and topic suggestions; contact blog author Kelly Wolfgang at kwolfgang@advanceweb.com.
Medicare Premiums to Rise in 2013
November 26, 2012 11:05 AM by Michael LaMagna
The premium for Medicare Part B, which is the voluntary Medical insurance covering medically necessary doctors' services, preventive care, durable medical equipment, laboratory tests, x-rays, limited home health and ambulance services will rise by $5 in 2013. This increase will offset the Social Security cost of living increase for 2013 of 1.7%, or an average of $19 per month.

The new Part B cost for the majority of beneficiaries will be $104.90, up from the current $99.90 per month. However, those "high income" beneficiaries, whose income is more than $85,000 for an individual or $170,000 for couples will see an increase of $42 to $230.80 per month. Most beneficiaries will not realize the change because they pay directly from their Social Security check.

In addition, Medicare's hospitalization deductible will increase by $28, to $1,184. The deductible is the amount a person must pay before health insurance kicks in. It is recommended that seniors have supplemental coverage to offset their Medicare hospital deductible.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at The Law Office of Michael LaMagna, LLC, practicing health care regulatory, elder /probate/disability/trusts and estates, social security and general legal practice in both New York and Connecticut. Email him at Mlamagna@nyandctlaw.com, call him at 914-534-1048 or visit www.nyandctlaw.com for more information.

The Medicaid "Wrinkle"
July 2, 2012 10:09 AM by Kelly Bocich

Editor's Note: This is a guest blog from Jill Glomstad, an editor at ADVANCE.

In last week's Supreme Court ruling, seven of the nine Justices agreed that it would be unconstitutional for the federal government to force states to participate in the Affordable Care Act's expansion of the Medicaid program. The expansion had been expected to cover roughly 17 million uninsured Americans, mostly low-income adults. The federal government will foot the full bill for the expansion for the first three years; after that the federal share will slowly decline, but it would still be 90 percent in 2020. 

The Court's decision basically renders the expansion a separate animal from the current Medicaid program. If states don't participate in the expansion, they can keep their existing programs (and existing federal money) without consequence. The question now is, what will the states choose to do?

So far seven states and the District of Columbia are already offering expanded coverage, paying for it with state funds until the federal payments via the ACA kick in in 2014, according to CBS News.

However, 26 were plaintiffs in the case the Court heard; the governors of some of them, including Texas, Mississippi and Wisconsin, have already hinted that they will not implement the expansion, while others have refused to say what they're willing to do. Virginia Governor Bob McDonnell isn't saying, but told Politico.com that the expansion would cost his state $2.2 billion over 10 years, even with the federal funds.

It's unsurprising that few want to commit to a decision, given the political hot potato that the Affordable Care Act has become and the huge financial burdens states are already facing due to Medicaid. But if states opt out of the expansion, what's going to happen to their residents?

If all 26 states who were parties to the suit opt out, that's more than half - roughly 9 million people - of those expected to be covered by the expansion who will still be without insurance. What's more, they will be some of the poorest Americans.

"We will have a really strange doughnut hole in this country," said Kevin Outterson, associate professor of law and associate professor of health law, bioethics and human rights at Boston University, during an Association of Health Care Journalists webcast on the Supreme Court decision today. Individuals making up to the federal poverty level (FPL, currently $15,415 for an individual; $26,344 for a family of three in 2012) will have some level of coverage under existing programs. Those making 133 percent of the FPL or more will be able to participate in the state health insurance exchanges that the ACA established, with subsidies to help them purchase affordable coverage. But the people who fall in between are not eligible to participate in the exchanges - the ACA did not include them because it was assumed they would be covered by the Medicaid expansion.

Public and safety-net hospitals in states that opt out could also suffer. Currently hospitals that treat a large number of low-income, uninsured or vulnerable patients receive "disproportionate share" funding to help pay for that uncompensated care. Under the ACA, those hospitals are scheduled to lose about half that funding, on the premise that the expansion of coverage through both the individual mandate and the Medicaid expansion would offset what hospitals will lose. If a state chooses not to participate in the Medicaid expansion, its hospitals will still have to provide care to those populations but with much less funding than they have now to do so.

Providers could lose out too, though that is uncertain. The ACA raises rates for primary care providers in Medicaid up to Medicare levels. It's unclear, based on the Supreme Court ruling, whether providers in states who don't participate in the expansion will get that increase in payments.

Another issue is that "there is nothing out there to give states any sense of when they have to make a decision, because no one thought they would have to," said Alan Weil, executive director of the National Academy for State Health Policy, during the webcast. In states that don't decide, Medicaid programs could be caught in a holding pattern.

Martin Salo, executive director of the National Association of Medicaid Directors, told the New York Times in an article today that his initial sense is that many states will participate in the expansion. Many Republican governors may be waiting until after the November election to decide, hoping that Mitt Romney will win and make good on his promise to dismantle the entire law - Wisconsin Governor Scott Walker said on Thursday that was his position, CNBC reported. However, governors don't necessarily hold all the cards here. Much of Medicaid is regulated by the legislature, and when state legislatures come back into session in January they may take some or all of this decision out of the governors' hands, said Weil. It's also possible that Congress or HHS could act in the way of new legislation or new regulations to encourage states to participate.

By way of analogy, several Republican governors initially said they would not take federal stimulus money from the American Recovery and Reinvestment Act of 2009, said webcast moderator AHCJ President Charles Ornstein. Eventually, they all did. Americans - especially the poorest - will just have to wait and see if they do the same with the Medicaid expansion.

24-hour News Cycles & the ACA
June 29, 2012 2:45 PM by Kelly Bocich

A decision as major as yesterday's Supreme Court ruling to uphold most of the Patient Protection and Affordable Care Act (PPACA) is bound to spur a lot of conversation. We've been asking for opinions on our social media pages -- as well as sharing statements from healthcare associations as we get them.

We're interested in hearing your thoughts about the PPACA, especially now that certain parts have already been implemented and a lot more will come into play in the coming years. Join the conversations happening in our different networking areas-here's a peek at some of the conversations happening:

From the ADVANCE for Administrators of the Laboratory LinkedIn Group:

"How will the Supreme Court’s decision to uphold the Affordable Care Act impact: 
1) Your Business. If you haven't already moved your practice or service into the 21st century, you better hurry. Interoperable SaaS solutions offer the best flexibility and conversationality with little IT impact and hardware/software costs. You need to be nimble and get out of the compliance business and focus on your core competencies. Find a partner if you haven't already. 

2) The Healthcare Sector Overall.The health ecosystem is growing, not just because of increased regulation and shifting business models but also advances in the delivery of care and the diagnosis of conditions and illnesses. As healthcare becomes smarter, things will at first get more tedious and costly but long term we will gain economies of scale from shared knowledge and big data. For now everyone is focusing on "go live" when the crucial question is how to stay alive."

From the ADVANCE for Medical Laboratory Professionals Facebook Group:

  • "More people who can afford healthcare means more healthcare delivered. Since lab tests are how care often begins, this means more jobs for clinical lab professionals. It's a win/win for patients and all healthcare workers in my opinion. I do seem to be one of the few lab folks I know who think this way however....."
  • "If the fee schedule is anything like the current Medicare fee schedule, it won't be a good thing."

On another note, as a journalist, I can't help but to reflect on the major gaffes by both CNN and Fox News, who initially reported that the PPACA had been struck down by the Supreme Court, before retracting those statements and explaining that most of the bill had been upheld. In this era of 24/7 news access, it seems some news organizations are so concerned with being the first to break the story that they forget to check facts. I'm sure the report released by the Supreme Court was lengthy, maybe a little wordy and dense. But the mistakes reminded me to slow down and absorb the facts before jumping into the fray. Disinformation contributes to fear and misunderstanding, and news organizations have a responsibility not to be the first to report, but to report the facts.

Pitch in with your thoughts about the PPACA below or on one of our networking sites. We'll continue to cover the various ways the Act could affect your laboratory.

Impact of Healthcare Reform on Insurance Plans
June 8, 2012 2:29 PM by Michael LaMagna
If the Affordable Care Act (ACA) is upheld by the Supreme Court later this month, many existing health plans will be required to enhance health insurance benefits by early 2014 to comply with the new regulations. The law will require basic or essential health benefits be offered to all insured. According to the journal Health Affairs, more than half of the current health plans do not offer the basic requirements and will have to be enhanced in order to comply.

Under the new standards of the ACA, consumers will not only be entitled to additional health plan benefits, but will also pay lower out of pocket costs; however, the new expansive benefits will not come without an increase in premiums. Under ACA, there will be four types of insurance plans offered through the insurance exchanges: bronze, silver, gold and platinum. Using the bronze plan as the benchmark, Health Affairs found that most of the health insurers will have to increase the basic coverage, more specifically in the following areas:

  • Annual out of pocket costs will be capped at $6,050 for an individual or $12,100 family;
  • Maternity coverage will be required to be covered; and
  • Eliminate an insurer's ability to refuse to offer coverage for individuals with pre-existing conditions.

It is hard to tell how much premiums will increase due to the new regulations; estimates are in the 6-7% range. The increase will most likely occur because patients with pre-existing illnesses will now be able to purchase insurance, which should drive the total costs upward.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /disability/veteran's law, trusts and estates, Social Security and general legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Email him atMlamagna@nyandctlaw.com, call him at 914-819-0663 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.

Money Saved Vs. Quality Care
May 21, 2012 9:33 AM by Michael LaMagna
With all of talk about JP Morgan Chase's $2 billion blunder and whether more regulations will prevent the squander of taxpayer's money, HHS just released final rules that will ease regulatory burdens on hospitals and healthcare providers, purported to save nearly $6 billion. However, the question remains to be seen whether the new rules, which ease bureaucratic red tape, will actually save as much as HHS suggests and improve patient care.

The regulatory changes include:

Allowing physician extenders (NPs and PAs) to be appointed to hospital medical staffs, with all of the rights and privileges of physicians, including the ability to administer anesthesia and powerful pain killers, vulnerable to abuse;

  • Permitting podiatrists to lead a hospital medical staff, despite lacking a specific degree in medicine or doctor of osteopathic medicine degree;
  • Allowing one governing board to oversee multiple hospitals within a single system;
  • Eliminate outdated infection control standards for ambulatory surgical centers; and
  • Allowing smaller hospitals to outsource some laboratory and radiology tests.

The administrative changes should save money in the long run and certainly are logical. The effects of expanding the role of physician extenders, while many would argue is needed since there will be a shortage of primary care physicians, remains to be seen. In this instance, the educational programs should be updated in light of the recent changes, to ensure proper training.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /disability/veteran's law, trusts and estates, Social Security and general legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Email him at Mlamagna@nyandctlaw.com, call him at 914-819-0663 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.

Funding for Construction, Renovation of School-Based Health Centers
May 14, 2012 1:21 PM by Kelly Bocich

HHS Secretary Kathleen Sebelius announced the availability of funding for the construction and renovation of school-based health centers. These new investments, totaling up to $75 million, are part of the School-Based Health Center Capital (SBHCC) Program, which was created by the Affordable Care Act of 2010.

School-based health centers enable children with acute or chronic illnesses to attend school as well as help to improve the overall health and wellness of children and adolescents through health screenings, health promotion and disease prevention activities.

"Whether establishing a new site or upgrading an existing facility, the availability of funding for school-based health centers will help kids more easily get the health services they need to thrive," said Sebelius. "The goal is to keep our children healthy so they can learn, grow and prosper."

The Affordable Care Act appropriated $200 million for the SBHCC Program to address capital needs in school-based health centers. The funding opportunity is the third in a series of awards that will be made available to school-based health centers through the Affordable Care Act. The Health Resources and Services Administration (HRSA) oversees the SBHCC Program.

First ACOs Selected
April 23, 2012 11:15 AM by Michael LaMagna
Very soon many readers will be part of a new healthcare program that will integrate cutting edge technology, coordinate care amongst many different providers and even take an active interest in your well-being. Curious?

Twenty-seven large medical groups have been selected by CMS to be the first participants as Accountable Care Organizations (ACOs). ACOs are new multi-provider organizations that incorporate hospitals, physician groups, laboratories, and even nursing facilities, coordinating care among the various levels through technology and follow-up. This should reduce unnecessary and harmful duplication of services, improve the overall quality of patient care and lower costs to the healthcare system.

ACOs are required to adhere to 33 quality standards, including patient safety, usage of preventive healthcare and coordination of care. In return, the ACOs will share in the savings and receive up to 25% of the savings produced.

In addition, ACOs will be required to carefully monitor chronically ill patients, who are known to be the most expensive participants (i.e., diabetics and those with pulmonary and heart ailments). The monitoring of these patients will be particularly challenging,

If the program works, we will all be part of an ACO in the near future.

Click here to see a list of the 27 organizations selected.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /disability/veteran's law, trusts and estates, Social Security and general legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Email him atMlamagna@nyandctlaw.com, call him at 914-819-0663 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.

New Oregon Healthcare Law May Be a New Promising Model
March 9, 2012 9:35 AM by Michael LaMagna
In what may prove to be a model for the Medicaid system and healthcare in general, Oregon Governor John Kitzhaber signed a new Health Care Initiative aimed at significantly decreasing Medicaid expenditures.

The new law, known as Bill 1580, provides legislative approval to start creating local coordinated care organizations. The network of providers will deliver more comprehensive mental, physical and dental care for the state's 600,000 Medicaid clients.

The new health plan utilizes an Accountable Care Organization approach, by using the coordination of care amongst many providers, including physicians, nurses, mental, dental and health providers, to ensure better communication and outcomes. In addition, those providers who save Medicaid money will be financially compensated for keeping their patients healthy, especially those with chronic illnesses, which costs millions of dollars to the Medicaid system each year.

Unlike the federal healthcare law, the Oregon law does not have mandates for the uninsured or for private insurers, but it does create oversights for the program. The new law is expected to save Oregon Medicaid $155 million in the next year, and by 2017, as much as $4.6 billion. If successful, this bill may very well be the future healthcare model.

This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a partner at Timins & LaMagna, LLP, practicing Health Care Regulatory, Elder /disability/veteran's law, trusts and estates, Social Security and general legal practice in both New York and Connecticut. Michael was just appointed to the ACO Task Force of the American Health Lawyers Association. Email him at Mlamagna@nyandctlaw.com, call him at 914-819-0663 or visit Attorney LaMagna's website at www.nyandctlaw.com for more information.

Effects of ‘Super Tuesday’
March 7, 2012 8:49 AM by Lynn

Now that the so-called "Super Tuesday" is behind us, what impact do you anticipate it having on the election and, ultimately, healthcare reform? Too soon to tell? Care to speculate?

Many people shy away from making bold political statements (with the exception of Rush Limbaugh, of course), particularly this year as so much rides politically, economically and globally on who will be in office. The healthcare industry has been feeling the brunt of what's going on in Washington, so it's only fitting to have an opinion on what could and should occur. I welcome your comments.