RE­FORM:

Hos­pi­tals en­cour­age designs re­duc­ing neg­a­tive ef­fects

Modern Healthcare - - MODERN HEALTHCARE - Rich Daly

Hos­pi­tals seek ex­change designs that lessen un­in­tended con­se­quences

As a grow­ing num­ber of states mold health in­sur­ance ex­changes un­der the fed­eral health­care law, hos­pi­tals and other providers are push­ing designs that would min­i­mize un­in­tended con­se­quences.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act re­quires states to cre­ate ex­changes or have a fed­eral model es­tab­lished for them, and the law out­lines many com­po­nents and min­i­mum stan­dards.

Na­tion­ally, public hos­pi­tals have fo­cused on en­sur­ing that the ex­changes re­quire their plans to in­clude many types of health­care providers within their net­works, in­clud­ing es­sen­tial com­mu­nity providers.

Ex­change plan net­works should in­clude “es­pe­cially high-vol­ume Med­i­caid providers, or the folks that are al­ready treat­ing the vul­ner­a­ble pop­u­la­tion so that there is con­ti­nu­ity of care,” said Xiaoyi Huang, as­sis­tant vice pres­i­dent for pol­icy at the Na­tional As­so­ci­a­tion of Public Hos­pi­tals and Health Sys­tems.

In Washington state, hos­pi­tals strongly sup­port the cre­ation of an ex­change but are con­cerned that the Leg­is­la­ture may add an op­tional pro­gram for low-in­come en­rollees to a bill that would es­tab­lish the state’s mar­ket- place. The ba­sic health op­tion would use fed­eral in­sur­ance pre­mium sub­si­dies to cre­ate a pub­licly funded health in­sur­ance plan for en­rollees whose in­comes range from 133% to 200% of the fed­eral poverty level, or an es­ti­mated 60,000 to 100,000 peo­ple. Providers are con­cerned that states may con­trol costs in this new in­sur­ance plan by drop­ping provider re­im­burse­ments to less than even state Med­i­caid plans must pro­vide.

“It does not of­fer pro­tec­tions for providers at rates that would be above Med­i­caid,” said Che­lene Whiteaker, pol­icy di­rec­tor for the Washington State Hospi­tal As­so­ci­a­tion. “Med­i­caid lev­els are un­sus­tain­able; they don’t cover the cost of pro­vid­ing care.”

Nonethe­less, Washington providers are urg­ing quick cre­ation of an ex­change to avoid even tem­po­rary use of a fed­er­ally cre­ated ver­sion, as are providers in many of the 22 states where leg­is­la­tures are work­ing to en­act ex­change ex­changes, ac­cord­ing to the Na­tional Con­fer­ence of State Leg­is­la­tures.

Providers in New Jer­sey have closely tracked leg­is­la­tion to cre­ate the state’s ex­change and urged spe­cific designs, in­clud­ing a mid­dle-ground ap­proach to de­ter­min­ing in­sur­ance plan el­i­gi­bil­ity be­tween the ap­proaches used in Mas­sachusetts and Utah, states that es­tab­lished in­sur­ance ex­changes be­fore the pas­sage of the Af­ford­able Care Act. The Mas­sachusetts in­sur­ance mar­ket­place has used a nar­row def­i­ni­tion of qual­i­fy­ing plans that has limited the num­ber in its ex­change, while Utah’s al­lows nearly any type of plan.

“We want this thing to be in­de­pen­dent of state gov­ern­ment so that it is out­side of the po­lit­i­cal and fis­cal pres­sures of the state bud­get but still pub­li­cally ac­count­able so that stake­hold­ers will be in­volved in the decision-mak­ing and if there has to be some sort of leg­isla­tive over­sight, that that still ex­ists,” said Neil Eicher, deputy di­rec­tor for leg­is­la­tion and pol­icy at the New Jer­sey Hospi­tal As­so­ci­a­tion. New Jer­sey’s Leg­is­la­ture is ex­pected to vote on final pas­sage of the ex­change as early as mid-march.

Mary­land is one of 10 states that have moved ag­gres­sively to pass leg­is­la­tion to es­tab­lish and re­fine a state-run ex­change. Hos­pi­tals have sup­ported cre­ation of the ex­change, but at least one un­re­solved de­tail is caus­ing worry. The fed­eral grants that fund the ad­min­is­tra­tion of the state-run ex­change end in 2014, and Mary­land has not yet de­cided how to cover those on­go­ing op­er­a­tional costs.

“One of the con­cerns is that in the early dis-

cus­sions there was some con­sid­er­a­tion given to do­ing an as­sess­ment on providers as one of the ways to de­velop on­go­ing fund­ing for the ex­change,” said Michael Rob­bins, se­nior vice pres­i­dent of fi­nan­cial pol­icy at the Mary­land Hospi­tal As­so­ci­a­tion.

For now, new provider fees ap­pear un­likely be­cause providers have al­ready reached the max­i­mum fees the state is al­lowed to as­sess un­der a unique statewide provider as­sess­ment sys­tem es­tab­lished in the 1970s, Rob­bins said.

Providers also have been in­volved in ex­change plan­ning ef­forts in states that have nei­ther en­acted laws cre­at­ing an ex­change nor ap­pear likely to do so be­cause they be­lieve ex­changes are in­evitable, de­spite strong po­lit­i­cal op­po­si­tion.

For ex­am­ple, North Carolina hos­pi­tals have par­tic­i­pated in an ex­change de­sign task force or­ga­nized by the North Carolina In­sti­tute of Medicine, which is hash­ing through ex­change op­tions. Hos­pi­tals there have urged the in­clu­sion of ex­change com­po­nents to en­sure the ad­e­quacy of provider net­works and fair con­tract­ing be­tween providers and plans.

That pri­vate ef­fort is on­go­ing, de­spite strong Re­pub­li­can op­po­si­tion in the state that stymied leg­is­la­tion in 2011 to es­tab­lish an ex­change as a not-for-profit or­ga­ni­za­tion.

“We be­lieve that a state ex­change will be more re­spon­sive as change is needed and as the sys­tem de­vel­ops here than a fed­eral ex­change could be,” said Don Dal­ton, a spokesman for the North Carolina Hospi­tal As­so­ci­a­tion. “We’re at the ta­ble to see that this hap­pens here and to keep in place the good things that we have in place.”

In Texas, where the po­lit­i­cal hos­til­ity is sim­i­lar, providers have fo­cused their ef­forts on urg­ing state lead­ers to over­come their ob­jec­tions to the con­tro­ver­sial fed­eral health­care law enough to es­tab­lish an ex­change, be­cause the al­ter­na­tive is that HHS will es­tab­lish an ex­change in the state.

“We want our state to step up and opt to cre­ate that given that we know our mar­ket bet­ter than Washington,” said John Hawkins, se­nior vice pres­i­dent of fed­eral re­la­tions for the Texas Hospi­tal As­so­ci­a­tion.

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