December 12, 2013 | No Comments
Posted by Frank Ciesla
As everyone should be aware by now, Horizon has made the decision that it will not extend the policies it cancelled, even though both the President and the Commissioner of Insurance in New Jersey have authorized them to do so. It appears clear that the position of Horizon is that it has committed its resources, going forward, to only plans compatible with the Affordable Care Act.
As a provider, this could create problems for you in that the patients who you treat may select a different insurance provider on the exchange as the result of not being able to renew their Horizon policy, which will impact the patient-doctor relationship, depending on whether or not you are in network for the purposes of that policy. As we pointed out in prior blogs, the other issue that you need to be concerned about, even though you may be in the network, are that physicians to whom you have referred this patient for additional care or institutions to which you have referred this patient, may no longer be in that network.
The additional change for your practice will be reorienting your staff towards the deductibles and the copays under the various levels of bronze, silver, gold or platinum policies.
In light of this business decision by Horizon, it would appear that as employer policies come up for renewal, Horizon will be looking at conforming them to the requirements of the Affordable Care Act probably, during 2014 and certainly, unless the waiver is extended, for 2015. This, of course, will impact a much greater number of patients and beneficiaries, which will have an impact on a much greater number of providers.
December 5, 2013 | No Comments
Posted by Frank Ciesla
In today’s New York Times (December 5, 2013), a guest editorial by Scott Gottlieb, an internist and fellow at the American Enterprise Institute; and Ezekiel J. Emmanuel, the former health care policy advisor to the Obama Administration; representatives of both the right and the left, argue that there will not be a doctor shortage due to both the growth of technology as well as the shifting of care to limited licensed personnel, such as nurse practitioners, health aides, pharmacists, dieticians, psychologists, and others. This reference to the expansion of the provision of services by limited licensed individuals, has been referenced previously in our blog (http://www.njhealthcareblog.com/2013/10/expansion-of-the-scope-of-practice-of-non-physicians-a-harbinger-of-things-to-come/) of October 10, 2013, discussing the issue of the standard of care that will be applied for malpractice as well as the reimbursement when the care is provided by such limited licensed provider.
As they state in the article “that means expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care, changing laws inhibiting telemedicine across state lines and reforming medical malpractice laws that force providers to stick with inefficient practice simply to reduce liability or risk.” Further, the article states that “new payment models must reward investments in technology that can save money in the long run”. The bottom line is that “most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.”
The relationship between the patient and their physician obviously will be radically changed in this environment. We are already progressing towards that radical alteration of the relationship in the expansion of the state statutes regarding limited licensed practitioners as well as in the creation of new delivery systems, such as the ACOs, whether they be ACOs under the Affordable Care Act, ACOs under State Medicaid laws, or ACOs created by third party payors or in conjunction with third party payors.
This probably is necessary to reduce the cost of health care, since the cost of educating physicians must be recovered one way or the other, in the cost of providing health care. It is obviously less expensive to educate a nurse practitioner, a physician’s assistant or other limited licensed practitioners. In the future, it may be that you can keep your doctor, but you will rarely see your doctor. You will be treated primarily by limited licensed individuals.
This projection as to the future must be considered by all providers, whether they are physicians or other limited licensed individuals or licensed hospitals, clinics, etc. in structuring and investing in how they will deliver care in the future. One of the key questions going forward will be, will you be able to recover the investment and some return on that investment under the payment system that will evolve?
December 4, 2013 | No Comments
Posted by Beth Christian
CMS has published the Medicare Physician Fee Schedule Final Rule for 2014. One of the modifications adopted by CMS is the implementation of a separate payment for chronic care management services under the Physician Fee Schedule starting in calendar year 2015. The separate payment will be made for chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Chronic Care management services will include the following:
- The provision of 24-hour- a-day, 7-day- a-week access to address a patient’s acute chronic care needs.
- Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
- Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications. The practitioner furnishing chronic care management services must create a patient-centered plan of care document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care will typically include, but will not be limited to, the following elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identification of the individuals responsible for each intervention, requirements for periodic review and, when applicable, revision, of the care plan.
- Management of care transitions within health care, including referrals to other clinicians, visits following a patient visit to an emergency department, and visits following discharges from hospitals and skilled nursing facilities. The practice must be able to facilitate communication of relevant patient information through electronic exchange of a summary care record with other health care providers regarding these transitions. The practice must also have qualified personnel who are available to deliver transitional care services to a patient in a timely way so as to reduce the need for repeat visits to emergency departments and re-admissions to hospitals and skilled nursing facilities.
- Coordination with home and community based clinical service providers required to support a patient’s psychosocial needs and functional deficits, with communication to and from home and community based providers documented in the practice’s medical record system.
- Enhanced opportunities for a patient and caregiver to communicate with the provider regarding the patient’s care through not only the telephone but also through the use of secure messaging, internet or other non face-to-face consultation methods.
The addition of a payment category for chronic care management services evidences a recognition on the part of CMS that physicians and other clinicians are spending a significant amount of time providing care coordination services that are not adequately compensated under existing evaluation and management codes. It is also evidence of the continued focus by CMS on the furtherance of the patient-centered medical home model, the reduction of hospital re-admissions and an increased reliance on technology and non-face to face methods to coordinate the delivery of care.
November 26, 2013 | No Comments
Posted by Ari Burd
As part of the Affordable Care Act, beginning in 2014, health insurance companies will be charged additional fees and costs, including a $63 per person tax on each person covered. Because the vast majority of large businesses (200 employees or more) are self-insured and do not use managed care plans, the Congressional Budget Office is predicting that small businesses and consumers will bear the brunt of these costs in the form of higher premiums. Current predictions are for increases of between 1.9% to 2.3% in 2014. The majority of the money raised will ill go into a fund administered by the Health and Human Services Department. According to the regulation, the fund is “intended to help millions of Americans purchase affordable health insurance, reduce unreimbursed usage of hospital and other medical facilities by the uninsured and thereby lower medical expenses and premiums for all.”
November 26, 2013 | No Comments
Posted by Ari Burd
Generally, a Business Associate Agreement is a written agreement between a Covered Entity (Doctor, Clinic, Hospital, HMO, etc) and a Business Associate that establishes the permitted and required uses and disclosures of personal health information by the Business Associate. Most often, a Business Associate is a vendor who creates, receives, maintains or transmits personal health information. Although a Business Associate can provide a variety of different services, the most common services provided will usually be billing services, claims processing, data analysis and electronic storage. Read more
November 21, 2013 | No Comments
Posted by Frank Ciesla
Attached is a Washington Post article and an Associated Press article which highlight, from the patient beneficiary point of view, one of the next big issues in the Affordable Care Act implementation. That issue is the narrowing of the provider networks which will significantly reduce the patient beneficiary’s choice of providers. This could result in the patient beneficiary not being able to keep their current providers. As I pointed out in our prior blog, that information right now does not appear to be readily available to the patient beneficiaries.
I also pointed out in our prior blog that while you, as a provider, may be in the network, the physicians or other providers to whom you refer may not be in the network so this will force you to rearrange your referral pattern. You may also not be in the network and no longer be able to maintain the professional relationship with the patient.
As time goes by, it is clear that more and more of the disruptions to both patient/beneficiary and the providers that will be caused by the Affordable Care Act are surfacing and being discussed.
November 19, 2013 | No Comments
Posted by Beth Christian
Here are the most recent health care related regulatory developments as published in the New Jersey Register on November 4, 2013:
- On November 4, 2013 at 45 N.J.R. 2378, the Department of Human Services published notice of its proposed readoption of its rules governing partial care services standards.
- On November 4, 2013 at 45 N.J.R. 2385, the Department of Banking and Insurance published notice of its adoption of new rules and the repeal of certain rules regarding standard health benefit plans under the individual health coverage program.
- On November 4, 2013 at 45 N.J.R. 2405, the Alcohol and Drug Counselor Committee of the Board of Marriage and Family Therapy Examiners published notice of its partial grant and partial denial of a petition for rulemaking from Glenn Duncan on behalf of Advanced Counselor Training. The committee agreed with the petitioner that to be a qualified clinical supervisor, alcohol and drug counselors should obtain the certified clinical supervisor credential from a certification authority that is a member of the International Certification Reciprocity Consortium of Alcohol And Other Drug Abuses, Inc., a credentialing organization. The committee denied the petitioner’s request to: (1) amend the regulations to require additional hours of work experience for new licensees who are licensed to provide substance misuse services; (2) distinguish between those that hold another New Jersey license and are also licensed clinical alcohol and drug counselors and those who hold only another New Jersey license; (3) allow licensed clinicians in the process of getting the CCS credential to be considered qualified supervisors; and (4) require qualified supervisors to directly observe the supervisees in one of four specified activities at least once annually.
- On November 4, 2013 at 45 N.J.R. 2406, the State Board of Dentistry published notice of its receipt of a petition for rulemaking from the New Jersey Dental Association. The petition seeks an amendment to the Board’s rules to reaffirm and clarify that non-licensees are not permitted to improperly use management companies or other devices to acquire or exercise dominion and control over licensed dentists and/or their dental practices.
November 18, 2013 | No Comments
Posted by Frank Ciesla
While the media is focused on the impact on the patients/beneficiaries, the failures of the rollout have significant impact on the providers.
One of the most significant impacts is the cancellation of numerous health insurance policies (so far approximately 800,000 in New Jersey) and a necessity for these individuals to have obtained new insurance policies by December 15th. A failure to obtain those policies by December 15th, will result in the individuals not being covered by insurance on January 1. At this point in time, it is not clear whether the President’s “fix’ can or will be implemented and whether it is doable as a practical matter by the states and/or the insurance companies. This, of course, is a major impact on the beneficiary/patient, but it is also a major impact on the providers. These individuals, not able to obtain insurance, will now fall into the category of the uninsured, impacting the payments for services rendered by the providers, to these beneficiaries/patients.
For those lucky enough to obtain insurance by January 1, those policies may have a significant deductible. Again, while this has a substantial impact on the patient/beneficiary, it has a substantial impact on the providers. Under those policies, the providers will not be paid by the third party payors until the patient has exhausted their deductible. Providers will, therefore, need to pursue the procedures, which they now have for collecting deductibles, in a much greater number of situations, than in today’s environment, where the deductible is generally a much lower deductible, than could be in effect under the selected insurance policy going forward.
In addition, there is no guarantee that the new policies obtained by the patient/beneficiary will have the same provider network. This, of course, has two impacts upon providers. The first impact obviously is whether or not the provider is in the new network, so that they can continue rendering care to the patient, as an in network provider, but in addition, whether or not the providers, to whom the provider refers this patient for other care, are also in the network. There is no assurance that the patient’s care patterns will not be disrupted, even if they are able to obtain new insurance that complies with the requirements of the Affordable Care Act.
If the proposed “fix” is not implemented on a wide basis, the patient/beneficiaries, whose policies have been cancelled, have two possible choices for obtaining replacement policies. Under either choice, the policies must meet the requirements of the Affordable Care Act. The first choice is for the patient to be able to obtain a policy from their current insurance carrier, that is consistent with the Affordable Care Act and not have to go onto the problem-plagued health insurance exchange website. However, obtaining insurance through this route denies the patient/beneficiary a subsidy. To the extent the patient/beneficiary qualifies for a subsidy, they can only obtain that subsidy, if they obtain their insurance through the website or in New Jersey the “alternative” federal enrollment process, which ultimately is through the website.
While the next 30 days are critical to the patient/beneficiary, they are also critical to the providers, who will want to know whether or not their current patients will be able to continue to have insurance, as of January 1, that will permit them to continue to access and use their current providers.
One of the additional difficulties in the current federal enrollment environment appears to be the fact that patients/beneficiaries do not have ready access to the network of physicians or other providers, who are in the various insurance product networks, that are now being made available, effective January 1 and, whether or not other physicians, who are presently providing care to these patients/beneficiaries are in that network.
It is very likely that the provider will have to take the pro-active step of informing patients as to what networks they, the provider, are in.
November 14, 2013 | No Comments
Posted by Frank Ciesla
In addition, in light of the ObamaCare rollout fiasco, both the failure to have people enroll as well as the insurance cancellations, it appears that the attention in Congress and the media are now focused on resolving the issues arising from this fiasco. It is not at all clear whether or not there will be appropriate attention paid and action taken in regard to the Sustainable Growth Rate issue, which needs to be resolved by December 31st, otherwise physicians will sustain a substantial reduction in payments for care rendered to Medicare beneficiaries.
As we have in other years, we will keep you informed as to significant proposed solutions in the countdown to December 31st, and whether or not and how this issue is resolved.
November 12, 2013 | No Comments
Posted by Frank Ciesla
Attached is a link to the news release regarding Horizon’s announcement for ACOs and PCMHs. One of the most important parts of the article is the quote from Linda J. Schwimmer where she stated, “(This will only work) if the providers actually do manage patients well and have all the things that drive down cost.” She also stated, “There are specific things the doctors are going to need to do to drive down costs and hit the quality metrics.”
In joining either of these delivery systems, providers must be careful to review the rates they will be paid, the calculation of the quality metrics, what they will be paid if they meet the quality metrics, and their ability or the ability of the delivery system to compel the beneficiary/patients to conform to the required medical regimen so that the metrics can be met.
Currently, the noncompliance by patients with the medical regime prescribed by the physician or other providers, is on the third party payors. This clearly is an attempt by Horizon to shift that risk and the expenses incurred, as a result of the patient’s noncompliance, to the provider.keep looking »