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And the ‘Winners’ Are…(Part III)

Winners in Health CareMy blog, Seeking Truth in Health Care (Part I) briefly discussed my observations in the employer community regarding health insurance, while last week’s blog, ‘Disruption’ Will Be Painful (Part II) touched on potential implications for the health care providers here in Iowa. This blog attempts to tie together both blogs – in other words, help identify what providers will need to do in order to ‘win’ in the future.

I must mention again that there are no easy solutions – disruption is painful. However, there does appear to be a consensus on the ‘winning’ strategy for those organizations who are willing to face the inevitable disruption in health care.

So here goes.  The ‘Winners’ are those organizations that:

  1. Completely embrace a ‘Culture of Full Transparency’ – both in cost of services and successful health outcomes delivered
  2. Develop and consistently demonstrate a ‘Culture of Safety’
  3. Master a ‘Coordination of Care Culture’
  4. Tie Value to Costs

Perhaps you may have noticed a common word in three of the four elements – CULTURE. It will be difficult, actually impossible, for any organization to ‘win’ without first instilling full Transparency, Safety and Coordination of Care within the fabric of the organization. Simply put, the culture is the DNA of the organization. Being patient centric should be the destination for all providers in the future – no exceptions allowed.

Merely broadcasting to the public through various media channels that these four elements are present within the organization will no longer cut it. The public is not that gullible. People talk…and people listen. If these essential changes are not incorporated into the organization’s DNA, the health care provider is nothing more than a marketing organization – and having a winning strategy will be unattainable.

Tying value to costs will help employers and their employees better assess which provider to use under varying circumstances of care. The health providers that can apply all four elements will earn the TRUST from their communities.

In health care, TRU$T is the ‘currency of commerce.”*

This new transformation will not take place overnight. After all, it has taken many decades to get us in the situation we are today, and it will take time to transform into a new and improved “system” of care. The new transformation has begun for some organizations, while for others, not so much. Every journey begins by taking a first step.

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*Dr. David A. Shore, Harvard School of Public Health

Proposed Rules on ACA

David P. Lind BenchmarkJust two days before Thanksgiving, the Department of Health and Human Services released three newly proposed health care rules that are created by the Affordable Care Act (ACA). The regulations provided are not yet final – there is a 60-day comment period for the Wellness Program rules and a 30-day comment period for the other two rules. The comment period begins after date of publication in the Federal Register (November 26, 2012). The rules, combined with the turkey and the trimmings may have caused many to reach for the Tums!

The rules relate to the following:

  1. Health Insurance Market
  2. Essential Health Benefits, Actuarial Value, and Accreditation Standards
  3. Wellness Programs

Totaling over 330 pages, the three-part rules provide guidelines for online exchanges specifically prohibiting insurance companies from discriminating against individuals because of a pre-existing or chronic condition. Insurance companies are allowed to vary premiums within a limited basis on age, tobacco use, family size and geography. In addition, companies are prohibited from charging higher insurance premiums to certain enrolled persons because of their current or past health problems, gender, occupation, and small employer size or industry. The proposed rules also address fair health insurance premiums, risk pools and non-group market catastrophic plans.

The proposed rules also outline “essential health benefits” (EHB), a core set of benefits that will hopefully allow consumers to consistently compare health plans within the exchange for both individual and small group markets. EHBs must be included in all plans offered, which consists of 10 statutory benefit categories of coverage, such as hospitalization, maternity and newborn care, prescription drugs, and so on. Each plan offered through the exchange will be required to meet specific actuarial values (Bronze, Silver, Gold and Platinum).

Finally, rules have been established for wellness programs offered by employers, making sure that such plans do not discriminate against people with physical and mental conditions. Wellness programs must be reasonably designed to promote health or prevent disease – meaning programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals. In addition, programs must be reasonably designed and be available to all similarly-situated individuals, which would allow for “reasonable alternative means of qualifying for the reward” to those individuals who have medical conditions that make it unreasonably difficult (or medically inadvisable) to meet the specified health-related standard. This proposed rule provides employers with sample notice language to give employees the opportunity to qualify for the same reward through other arrangements.

With wellness programs, the key word appears to be “reasonable”…which means employers must be very careful when devising and implementing wellness strategies.

Whew! With that, please pass the Tums!

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Iowa Exchange – Heavy Lifting (Required)

The votes have been cast, counted and duly noted for the next few years. From this election, we now have more certainty that the Patient Protection and Affordable Care Act (PPACA) – “Obamacare” to many – will survive into the future. Now the heavy lifting must begin…and quickly.

Under health reform, every state must have an approved health insurance exchange by January 1, 2014. Exchanges are competitive marketplaces for individuals and small employers (initially under 51 employees, but moving up to 100 employees by 2016) to directly compare and purchase private health insurance options based on price, quality, and other factors.  For those individuals who qualify, federal subsidies will be provided to keep health insurance affordable.

Until recently, states had until November 16 of this week to notify Health and Human Services (HHS) of its’ intent to either establish a local exchange or defer to a federal exchange. Iowans will be able to enroll in health exchanges next October for coverage starting in January 2014. Last Friday, the Obama administration extended the deadline for states to submit plans to HHS by December 14 (for states who wish to run their own exchanges) – or February 15, 2013, for states that want to run exchanges in partnership with the federal government (also known as a State Partnership Exchange).

Much work is needed for Iowa to establish an exchange. Unfortunately, waiting for the Supreme Court ruling in late June and the November elections have stunted any real progress on performing key functions to make a state-based exchange possible in Iowa for a 2014 implementation date. In addition, the administration has yet to release crucial regulations and guidance to establish exchanges. Such guidance is expected soon, however.

So what will Iowa do?

Iowa has three options:

  1. Develop a “State-based Exchange”
  2. Defer to a “Federally-facilitated Exchange”
  3. Elect a “State Partnership Exchange” (a hybrid of #1 & #2)

Developing a State-based Exchange customized to specific Iowa insurance issues, is both complex and laden with minefields. Making hasty, ill-conceived decisions may cause havoc in the Iowa insurance market. (This discussion must be left for a future blog.)

Electing the Federally-facilitated Exchange is perhaps the least onerous of the three options currently available. However, deferring to a federal exchange abrogates local control. Many argue that Iowa has unique insurance market issues that require local and flexible solutions, not inflexible federal control. Because of this, Iowa will most likely refrain from embracing the full federal exchange.

By default, the State Partnership Exchange may be the most logical choice for Iowa – at least for 2014. Once Iowa has had time to perform necessary due diligence on establishing its’ own exchange, the Partnership Exchange can then be replaced with a home-grown model that makes sense for the Iowa insurance market.

Unique challenges are usually solved with unique solutions – solutions that require input from stakeholders who are most familiar with the local market. It is now time for some heavy lifting.

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