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“Profit-Motive” Is Negatively Impacting Your Healthcare: Medicare Provider Charge Data

May 8, 2013 9:19 am / Leave a Comment

As part of the Obama administration’s work to make our health care system more affordable and accountable, data are being released by HHS (Health & Human Services) that show significant variation across the country, even within communities as to what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said. “This data and new data centers will help fill that gap.”  For example,

  • In Dallas, Las Colinas Medical Center billed Medicare an average of $160,832 for a lower joint replacement. The price was $42,632 five miles away, at Baylor Medical Center.
  • Average inpatient charges for services for a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.
  • Average inpatient hospital charges to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.
  • Ventilator: $115,00 George Washington University vs. $53,000 at Providence (just 5.4 miles apart)
  • Lower limb replacement: $117,000 at Richmond CJW Medical Center vs. 25,600 at Winchester Medical Center
  • Pneumonia: $124,051 in Philadelphia vs. $5,093 in Water Valley, Mississippi.

According to Ron Pollack, executive director of Families USA, hospital pricing is “the craziest of crazy quilts.” He went on to say, ”It is absurd — and, indeed, unconscionable — that the people least capable of paying for their hospital care bear the largest, and often unaffordable, cost burdens.”

Medicare has begun paying providers based on quality rather than just the quantity of services they furnish by implementing new programs, such as value-based purchasing and re-admissions reductions.  HHS awarded $170 million to states to enhance their rate review programs, and since the passage of the Affordable Care Act (ACA), the proportion of insurance company requests for double-digit rate increases fell from 75 percent in 2010 to 14 percent so far in 2013.

The ACA also makes available many tools to help ensure consumers, Medicare, and other payers get the best value for their health care dollar.  To make data from these tools useful to consumers, HHS is also providing funding  to data centers to collect, analyze, and publish health pricing and medical claims reimbursement data.  The data centers’ work helps consumers better understand the comparative price of procedures in a given region or for a specific health insurer or service setting. Businesses and consumers alike can use these data to drive decision-making and reward cost-effective provision of care.

Data are available in Microsoft Excel (.xlsx) format and comma-separated values (.csv) format.

Inpatient Charge Data, FY2011, Microsoft Excel version
Inpatient Charge Data, FY2011, Comma Separated Values (CSV) version

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes a Medicare Severity Diagnosis Related Group (MS-DRG) amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount.

Data provided by CMS (Centers for Medicare/Medicaid Services) include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the MS-DRG for FY2011.

DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges. Average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

There is some debate about how much patients, insurance providers and the government actually end up paying. “It’s true that Medicare and a lot of private insurers never pay the full charge,” said assistant professor at the University of California at San Francisco Medical School, Renee Hsia, “You have a lot of private insurance companies where the consumer pays a portion of the charge. But, for uninsured patients, they face the full bill. In that sense, the price matters.”

To view the new hospital dataset, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html.

To access the funding opportunity announcement, visit: http://www.grants.gov, and search for CFDA # 93.511.

For more information on HHS efforts to build a health care system that will ensure quality care, please see the fact sheet “Lower Costs, Better Care: Reforming Our Health Care Delivery System,” athttp://www.cms.gov/apps/media/press/factsheet.asp?Counter=4550.

To read a fact sheet about the Medicare data showing variation in hospital charges, please see:http://www.cms.gov/apps/media/fact_sheets.asp.

Related Posts:

Holding Insurance Companies Accountable for High Premium Increases

March 27, 2013 11:18 am

— by Kathleen Sebelius, Secretary of Health and Human Services

The Affordable Care Act (ACA) prohibits some of the worst insurance industry practices that have kept affordable health coverage out of reach for millions of Americans.  It provides families and individuals with new protections against discriminatory rates due to pre-existing conditions, holds insurance companies accountable for how they spend your premium dollars, and prevents insurance companies from raising your insurance premium rates without accountability or transparency.

For more than a decade before the ACA health insurance premiums had risen rapidly, straining the pocketbooks of American families and businesses.  Oftentimes, insurance companies were able to raise rates without explanation to consumers or public justification of their actions.

One of the provisions of the ACA is that insurance companies must now reveal the percentage of premium dollars they actually spend on health care and how much they spend on administration (e.g., salaries and marketing. Prior to ACA, this type of information was a closely held secret and insurance companies pocketed a good percentage of your premium dollars. With ACA in place, that’s no longer the case. If an insurance company spends less than 80% of premiums on medical care and quality (or less than 85% in the large employer, large group market), it must rebate the portion of premium dollars that exceeded this limit. This 80/20 rule is commonly known as the Medical Loss Ratio (MLR) rule

Chart showing the percent of rate filings that requested increases of 10 percent or more. 2009: 72%, 2010: 75%, 2011: 51%, 2012: 34%, 2013: 14% Rate Review in Action
The ACA brought an unprecedented level of scrutiny and transparency to health insurance rate increases by requiring insurance companies in every state to publicly justify their actions if they want to raise rates by 10% or more.  Insurance companies are required to provide easy to understand information to their customers about their reasons for significant rate increases, and any unreasonable rate increases are posted online.

And it’s working.  A new report released today shows that the health care law is helping to moderate premium hikes.  Since this rule was implemented, the number of requests for insurance premium increases of 10% or more has dropped dramatically, from 75% to 14%.  The average premium increase for all rates in 2012 was 30% below what it was in 2010. And available data suggest that this slowdown in rate increases has continued into 2013.

Moreover, when an insurer does decide to increase rates, consumers are seeing lower rate increases than what the insurers initially requested.  In the review of rate requests for 10% or more, over 50% resulted in customers receiving either a lower rate increase than requested or no increase at all.

States have received $250 million in Health Insurance Rate Review Grants to help strengthen and improve their rate review processes thanks to the Affordable Care Act.  Of the 44 states that received rate review grants, 40 have reported enhancements to their rate review websites.  These website enhancements include searchable rate filings, new public comment options, live streaming of rate hearings, and plain language explanations of rate review and rate filings.

The Effective Rate Review program is one of many in the health care law aimed at protecting consumers.  The rate review program works in conjunction with the 80/20 rule, which requires insurance companies to generally spend 80% of premiums on health care or provide rebates to their customers. Insurance companies that did not meet the 80/20 rule have provided nearly 13 million Americans with more than $1.1 billion in rebates. Americans receiving the rebate will benefit from an average rebate of $151 per household.

Additionally, today we issued a final rule that implements five key consumer protections from the Affordable Care Act, including protection against denial of health coverage because of a pre-existing condition.  This rule makes the health insurance market work better for individuals, families and small businesses, and it also increases the transparency brought to rate increases by directing insurance companies in every state to file all of their rate increase requests.

For more information about the Affordable Care Act, visit http://www.healthcare.gov/index.html.

Related Posts

Elements of Essential Benefits: Impact on Those with Mental Health and Substance Use Conditions

March 2, 2013 10:29 am / 1 Comment

The Department of Health and Human Services (HHS) has finalized its regulations on a key element of health reform, the essential health benefits package. These regulations are an important step forward for expanding access to mental-health and addictions treatment in the U.S., because they require a broad range of plans to cover behavioral health services and to do so at parity with medical/surgical services.  According to a new report, this means that over 62 million Americans will gain access to insurance coverage that meets parity standards. This includes 27 million uninsured Americans plus 35.5 million who have coverage that either does not cover MH/SUD or is not required to cover them at parity. Beginning in 2014, the essential benefits package will become the minimum standard of coverage that most insurance plans must meet, including plans sold on the exchanges, individual and small group plans, and Medicaid expansion plans.

Other highlights of the regulation are:

  • The proposed rule includes language to assure non-discrimination in plan design, a major issue for people with chronic conditions. The rule prohibits cost-sharing structures, utilization management techniques and benefit designs that discriminate against beneficiaries based on race, age, disability status, health status, quality of life, having high health-care needs, or other characteristics. States must monitor and identify discriminatory benefit designs.
  • The definition of essential benefits includes both the required preventive services outlined in the ACA as well as any state-mandated benefits (for example, autism coverage mandates) that were in effect prior to December 31, 2011.

However, HHS also left up to states’ discretion several other important decisions, including the definition of habilitative (= rehabilitation) benefits, establishment of non-discrimination standards in plan design, and the enforcement of benefit substitutions within categories. It also adopted a prescription drug policy that requires plans to cover at least one drug in every category and class of the U.S. Pharmacopoeia, an approach that could allow states to offer coverage that does not include the full range of psychiatric medications.

Given the recent report of  blatant patient dumping by Southern Nevada Adult Mental Health Services, I for one am not sure leaving it up to “State” discretion to expand on and flesh out the remaining standards is all that good of an idea.

Other Available Substance Abuse & Mental Health Services Admin Reports at HHS

  • OAS Methodology Reports - “[These reports address] various methodological issues concerning OAS data collection systems including:  statistical techniques and theories, survey methods, sample design, survey instrument design, and objective evaluations of the reliability of collected data.”
  • NSDUH Reports on Substance Abuse and Mental Health - “SAMHSA’s National Survey on Drug Use and Health (NSDUH) is the primary source of information on the prevalence, patterns, and consequences of drug and alcohol use and abuse in the general U.S. civilian non institutionalized population, age 12 and older.”
  • Youth and Substance Use  - These NSDUH reports discuss youth substance abuse.
  • Parental, Peer and School Influences - These reports analyze information regarding parental, peer and school influences on drug abuse from the National Surveys on Drug Use & Health by SAMHSA.
  • Analytic Series and Other Special Reports - “The Analytic Series addresses special topics relating to alcohol, tobacco, drug abuse, and mental health.”
  • Mental Health Reports - These reports analyze information regarding mental health issues as related to drug abuse from the National Surveys on Drug Use & Health by SAMHSA.
  • Violence, Suicide, & Risky Behaviors Reports - These reports provide data on suicide attempts, suicides, violence and risky behaviors as related to and influenced by drug use; data was provided by SAMHSA’s National Survey on Drug Use and Health and SAMHSA’s Drug Abuse Warning Network (DAWN).
  • Reports on Depression - These reports provide information regarding depression, or related activity, and its connection to substance abuse as reported by NSDUH.
  • Mental Health by Racial & Ethnic Group - These reports discuss mental health as it relates to racial and ethnic groupings.
  • Homeless Reports - These reports, provided by DASIS, have information regarding homelessness admissions and substance abuse treatment.
  • Katrina/Rita Areas:  Substance Use and Mental Health - “[These reports present data] on substance use and mental health problems before and after Hurricanes Katrina and Rita”
  • Youth & Mental Health Issues Reports - These reports provide information on mental health and substance use among youths.
  • Serious Psychological Distress - These reports provide information about people suffering from serious psychological distress, its affects on mental illness and the connections that it has to substance abuse.
  • Cities/Counties/Metropolitan Areas - These reports provide information regarding substance use in specific geographic areas.

HHS launches national campaign to educate older adults on registering as organ donors

May 22, 2012 10:09 am

FOR IMMEDIATE RELEASE
May 22, 2012		 Contact: HHS Press Office
(202) 690-6343

People in their 50s, 60s, 70s, and beyond can
save lives by becoming donors

An effort to educate adults 50 and older about the importance of registering to be organ, eye, and tissue donors was launched today in observance of Older Americans Month.  The campaign was developed by the Health Resources and Services Administration (HRSA), in partnership with the Administration for Community Living’s Administration on Aging and the National Institutes of Health’s National Institute on Aging.

More than 114,000 people are on the national transplant waiting list for an organ, and more than 100 of them die each week waiting for an organ that never comes. In 2011, people 50 and older accounted for 32 percent of donors but 60 percent of the total number of transplants.

“It’s important for everyone to know any age can be the right age to be an organ, eye, and tissue donor,” said Howard K. Koh, M.D., M.P.H., assistant secretary for health at the U.S. Department of Health and Human Services. “Imagine how many more lives we could save if the majority of the more than 99 million Americans 50 years old, or older signed up to give the gift of life.”

The 50 plus campaign was developed to dispel the myth that there are age limitations for giving the gift of life through organ, eye and tissue donation or for being a transplant recipient. Adults well into their 90s have successfully donated organs, extending the lives of recipients.  Campaign materials include a brochure in English and Spanish; an article; radio and print public service announcements; and web banners.

“A poll conducted of adults in the United States shows that the majority of them believe organ donation is the right thing to do, but many of those have not yet taken the next step of signing up on a donor registry,” said HRSA Administrator Mary Wakefield, Ph.D., R.N. “Together we can add to the more than 100 million people who have signed up.”

To learn more about the campaign, visit www.organdonor.gov and click on the 50+ campaign button, and continue the conversation on Facebook at www.facebook.com/organdonor.gov

Obama Administration Presents National Plan to Fight Alzheimer’s Disease

May 15, 2012 10:24 am

OR IMMEDIATE RELEASE
May 15, 2012		 Contact: HHS Press Office
(202) 690-6343

HHS Secretary Sebelius outlines research funding, tools for health care
providers, awareness campaign and new website

Health and Human Services Secretary Kathleen Sebelius today released an ambitious national plan to fight Alzheimer’s disease. The plan was called for in the National Alzheimer’s Project Act (NAPA), which President Obama signed into law in January 2011. The National Plan to Address Alzheimer’s Disease sets forth five goals, including the development of effective prevention and treatment approaches for Alzheimer’s disease and related dementias by 2025.

In February 2012, the administration announced that it would take immediate action to implement parts of the plan, including making additional funding available in fiscal year 2012 to support research, provider education and public awareness. Today, the Secretary announced additional specific actions, including the funding of two major clinical trials, jumpstarted by the National Institutes of Health’s (NIH) infusion of additional FY 2012 funds directed at Alzheimer’s disease; the development of new high-quality, up-to-date training and information for our nation’s clinicians; and a new public education campaign and website to help families and caregivers find the services and support they need.

To help accelerate this urgent work, the President’s proposed FY 2013 budget provides a $100 million increase for efforts to combat Alzheimer’s disease. These funds will support additional research ($80 million), improve public awareness of the disease ($4.2 million), support provider education programs ($4.0 million), invest in caregiver support ($10.5 million), and improve data collection ($1.3 million).

“These actions are the cornerstones of an historic effort to fight Alzheimer’s disease,” Secretary Sebelius said. “This is a national plan—not a federal one, because reducing the burden of Alzheimer’s will require the active engagement of both the public and private sectors.”

The plan, presented today at the Alzheimer’s Research Summit 2012: Path to Treatment and Prevention, was developed with input from experts in aging and Alzheimer’s disease issues and calls for a comprehensive, collaborative approach across federal, state, private and non-profit organizations. More than 3,600 people or organizations submitted comments on the draft plan.

As many as 5.1 million Americans have Alzheimer’s disease and that number is likely to double in the coming years. At the same time, millions of American families struggle with the physical, emotional and financial costs of caring for a loved one with Alzheimer’s disease.

The initiatives announced today include:

  • Research – The funding of new research projects by the NIH will focus on key areas in which emerging technologies and new approaches in clinical testing now allow for a more comprehensive assessment of the disease. This research holds considerable promise for developing new and targeted approaches to prevention and treatment. Specifically, two major clinical trials are being funded. One is a $7.9 million effort to test an insulin nasal spray for treating Alzheimer’s disease. A second study, toward which NIH is contributing $16 million, is the first prevention trial in people at the highest risk for the disease.
  • Tools for Clinicians – The Health Resources and Services Administration has awarded $2 million in funding through its geriatric education centers to provide high-quality training for doctors, nurses, and other health care providers on recognizing the signs and symptoms of Alzheimer’s disease and how to manage the disease.
  • Easier access to information to support caregivers–HHS’ new website, www.alzheimers.gov, offers resources and support to those facing Alzheimer’s disease and their friends and family. The site is a gateway to reliable, comprehensive information from federal, state, and private organizations on a range of topics. Visitors to the site will find plain language information and tools to identify local resources that can help with the challenges of daily living, emotional needs, and financial issues related to dementia. Video interviews with real family caregivers explain why information is key to successful caregiving, in their own words.
  • Awareness campaign – The first new television advertisement encouraging caregivers to seek information at the new website was debuted. This media campaign will be launched this summer, reaching family members and patients in need of information on Alzheimer’s disease.

Today’s announcement demonstrates the Obama administration’s continued commitment to taking action in the fight against Alzheimer’s disease.

In 2013, the National Family Caregiver Support Program will continue to provide essential services to family caregivers, including those helping loved ones with Alzheimer’s disease. This program will enable family caregivers to receive essential respite services, providing them a short break from caregiving duties, along with other essential services, such as counseling, education and support groups.

For more information on the national plan to address Alzheimer’s disease, visit: www.alzheimers.gov.

105 Million Americans No Longer Face Lifetime Limits

April 26, 2012 1:46 pm

— By: Thomas D. Musco and Benjamin D. Sommers, ASPE

The Affordable Care Act prohibits health plans from imposing a lifetime dollar limit on most benefits received by Americans in any health plan renewing on or after September 23, 2010.  While some plans already provided coverage with no limits on lifetime benefits, millions of Americans were previously in health plans that did not.  According to the Kaiser Family Foundation’s Employer Health Benefits Survey, 59 percent of all workers covered by their employer’s health plan in 2009 had some lifetime limit placed on their benefits. [1]  In addition, 89 percent of people with individually purchased coverage had a lifetime limit on their benefits. [2]

The Department of Health and Human Services (HHS) estimated the number of Americans receiving these new protections, combining results from the 2009 Kaiser employer survey and 2009 America’s Health Insurance Plans (AHIP) report with data from the 2009 to 2011 versions of the Current Population Survey (covering calendar years 2008-2010). [3]

Overall, we estimated that 70 million persons in large employer plans, 25 million persons in small employer plans, and 10 million persons with individually purchased health insurance had lifetime limits on their health benefits prior to the passage of the Affordable Care Act (Figure 1). [4]  These 105 million Americans now enjoy improved coverage without lifetime limits.

Among the 105 million Americans for whom lifetime limits have been eliminated as a result of the Affordable Care Act, 75.3 million are non-Latino White, 11.8 million are Latino, 10.4 million are African-American, 5.5 million are Asian, and approximately 500,000 are American Indian or Alaska Native (Figure 2). [5]  Approximately 28 million of those benefiting are children, with the remainder of the 105 million split almost equally between adult men and adult women (Figure 3).  Approximately 15.9 million individuals lived in rural areas, with the remainder in urban areas. [6] Table 1 presents totals by state.

Figure 1:  Distribution (in millions) by Market of 105M Americans (Ages 0-64) Benefiting from the ACA’s Prohibition on Lifetime Limits

Figure 1: Distribution by Market of 105 Million Americans (Ages 0-64) Benefiting from the ACA's Prohibition on Lifetime Limits on Health Benefits, in millions, large group = 70, individual = 10, and small group = 25.

Source:  ASPE analysis using data from the Employer Health Benefits: 2009 Annual Survey, Washington, DC: Henry J Kaiser Family Foundation & Health Research & Educational Trust, 9/2009; Individual Health Insurance, 2009:  A Comprehensive Survey of Premiums, Availability, and Benefits, AHIP Center for Policy Research; and 2009-2011 Current Population Survey Annual and Social Economic Supplements

Figure 2: Distribution (in millions) by Race/Ethnicity [5] of 105M Americans (Ages 0-64) Benefiting from the ACA’s Prohibition on Lifetime Limits

Figure 2: Distribution by Race/Ethnicity[5] of 105 Million Americans (Ages 0-64) Benefiting from the ACA's Prohibition on Lifetime Limits on Health Benefits, in millions, White non-Latino = 75.3, Latino = 11.8, Black = 10.4, Asian = 5.5, Native = 0.5, American Indian/Alaska Native = 0.5, and Other = 1.9.

Source:  ASPE analysis using data from the Employer Health Benefits:  2009 Annual Survey, Washington, DC: Henry J Kaiser Family Foundation & Health Research & Educational Trust, 9/2009; Individual Health Insurance, 2009:  A Comprehensive Survey of Premiums, Availability, & Benefits, AHIP Center for Policy Research; & 2009-2011 Current Population Survey Annual and Social Economic Supplements

Figure 3: Distribution (in millions) by Age/Gender of 105M Americans (Ages 0-64) Benefiting from the ACA’s Prohibition on Lifetime Limits

Figure 3: Distribution by Age/Gender of 105 Million Americans (Ages 0-64) Benefiting from the ACA's Prohibition on Lifetime Limits on Health Benefits, in millions, Adult Females=39.5, Adult Males=37.8, and Children=27.8.

Source:  ASPE analysis using data from the Employer Health Benefits:  2009 Annual Survey, Washington, DC: Henry J Kaiser Family Foundation & Health Research & Educational Trust, 9/2009; Individual Health Insurance, 2009:  A Comprehensive Survey of Premiums, Availability, and Benefits, AHIP Center for Policy Research; and 2009-2011 Current Population Survey Annual and Social Economic Supplements

Table 1: Estimated Number of Americans (Ages 0-64) Benefiting from the Affordable Care Act’s Prohibition on Lifetime Limits on Health Benefits, By State & Age/Gender
State Children Adult Males Adult Females Total
AL 396,000 561,000 609,000 1,566,000
AK 64,000 87,000 86,000 237,000
AZ 570,000 752,000 769,000 2,091,000
AR 219,000 313,000 333,000 865,000
CA 3,255,000 4,389,000 4,448,000 12,092,000
CO 521,000 685,000 696,000 1,902,000
CT 367,000 494,000 525,000 1,386,000
DE 86,000 113,000 121,000 320,000
DC 34,000 83,000 91,000 208,000
FL 1,411,000 2,006,000 2,170,000 5,587,000
GA 916,000 1,145,000 1,256,000 3,317,000
HA 115,000 174,000 173,000 462,000
ID 173,000 195,000 198,000 566,000
IL 1,192,000 1,735,000 1,743,000 4,670,000
IN 615,000 822,000 822,000 2,259,000
IA 311,000 443,000 433,000 1,187,000
KS 279,000 368,000 374,000 1,021,000
KY 362,000 524,000 528,000 1,414,000
LA 385,000 488,000 538,000 1,411,000
ME 103,000 156,000 172,000 431,000
MD 585,000 794,000 872,000 2,251,000
MA* 633,000 912,000 975,000 2,520,000
MI 977,000 1,255,000 1,315,000 3,547,000
MN 553,000 736,000 754,000 2,043,000
MS 223,000 294,000 327,000 844,000
MO 581,000 775,000 792,000 2,148,000
MT 81,000 122,000 116,000 319,000
NB 192,000 252,000 257,000 701,000
NV 269,000 339,000 329,000 937,000
NH 140,000 197,000 208,000 545,000
NJ 877,000 1,183,000 1,214,000 3,274,000
NM 148,000 194,000 213,000 555,000
NY 1,609,000 2,294,000 2,529,000 6,432,000
NC 804,000 1,101,000 1,186,000 3,091,000
ND 66,000 94,000 93,000 253,000
OH 1,100,000 1,512,000 1,542,000 4,154,000
OK 317,000 430,000 450,000 1,197,000
OR 342,000 485,000 529,000 1,356,000
PA 1,136,000 1,677,000 1,769,000 4,582,000
RI 89,000 138,000 147,000 374,000
SC 397,000 495,000 566,000 1,458,000
SD 82,000 104,000 109,000 295,000
TN 523,000 744,000 775,000 2,042,000
TX 2,094,000 2,671,000 2,771,000 7,536,000
UT 411,000 385,000 387,000 1,183,000
VT 46,000 82,000 87,000 215,000
VA 817,000 1,036,000 1,121,000 2,974,000
WA 580,000 910,000 937,000 2,427,000
WV 147,000 215,000 219,000 581,000
WI 580,000 771,000 791,000 2,142,000
WY 54,000 73,000 69,000 196,000
Total 27,827,000 37,803,000 39,534,000 105,164,000
* Massachusetts previously permitted lifetime limits only on non-core benefits. Source:  ASPE analysis using data from the Employer Health Benefits:  2009 Annual Survey, Washington, DC: Henry J Kaiser Family Foundation and Health Research & Educational Trust, September 2009; Individual Health Insurance, 2009:  A Comprehensive Survey of Premiums, Availability, and Benefits, AHIP Center for Policy Research; and 2009-2011 Current Population Survey Annual and Social Economic Supplements

Endnotes

[1]  Employer Health Benefits:  2009 Annual Survey, Washington, DC:  Henry J Kaiser Family Foundation and Health Research & Educational Trust, 9/2009.

[2]  Individual Health Insurance, 2009:  A Comprehensive Survey of Premiums, Availability, and Benefits, AHIP Center for Policy Research.

[3]  We used estimates of the percentages of individuals covered by small group and large group plans subject to lifetime limits (from the Kaiser employer survey cited in note 1), and an estimate for the non-group market from the AHIP survey cited in note 2, and multiplied these percentages by the number of individuals in each type of plan, as estimated from the Current Population Survey (CPS) Annual Social and Economic Supplement, 2009-2011 datasets. We then made the same calculations based on the number of individuals covered in each type of plan at the state level.  Similarly, we used CPS data to estimate the distribution of small, large, and non-group coverage by race/ethnicity, and then used the Kaiser and AHIP results to estimate the number of people by race and ethnicity that benefited from the prohibition on lifetime limits.

[4]  Patient Protection and Affordable Care Act:  Preexisting Condition Exclusions, Lifetime and Annual Limit, Rescissions, and Patient Protections, Interim Final Rule, Federal Register Vol. 75, No. 123, June 28, 2010

[5]  Race/ethnicity based on self-report from the Current Population Survey.  White non-Latino, Black, Asian, and American Indian/Alaska Native groups exclude Latinos, who comprise their own category.  ‘Other’ contains any individuals not included in the first five categories (including biracial and multiracial individuals).

[6]  The method for this calculation was analogous to that described for race/ethnicity in Note 4.  We used the Census definition in the CPS of living in a ‘metropolitan area’ as urban, and all others as rural.

HHS’ New Open Government Plan

April 16, 2012 3:45 pm

HHS has released Version 2.0 of the Open Government Plan. The new plan incorporates feedback from the public and guides HHS efforts to be more transparent, participatory, and collaborative.

A number of new projects in the plan will improve the way the department works with the public to solve critical health issues.

Read HHS’ Open Government Plan.

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Repealing Health Care Reform Would Also Repeal Medicare Fraud Tools

April 7, 2012 9:46 am

FOR IMMEDIATE RELEASE
April 4, 2012		 Contact: HHS
HHS Press Office

HHS, Department of Justice highlight Obama administration efforts —
Health Reform tools to combat Medicare fraud

 HHS Secretary and Attorney General host seventh Regional Health Care Fraud Prevention Summit in Chicago

At a Chicago summit highlighting a new high-tech war against health care fraud, Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder today discussed how the Affordable Care Act and the Obama administration’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) are helping fight Medicare fraud.  The Chicago summit is the seventh regional health care fraud prevention summit hosted by the Department of Justice and HHS.

The regional summits bring together a wide array of public and private partners, and are part of the HEAT partnership between HHS and the Department of Justice to prevent and combat health care fraud.  The Obama administration’s HEAT efforts have resulted in record-breaking health care fraud recoveries.  In fiscal year 2011, for the second year in a row, the departments’ anti-fraud activities resulted in more than $4 billion in recoveries, an all-time high.

“We have a simple message to criminals thinking about committing Medicare fraud: don’t even try,” said Secretary Sebelius. “Thanks to health reform and our administration’s work, we have new tools and resources to catch criminals and stop Medicare fraud before it happens.”

“This Administration continues to move aggressively in protecting patients and consumers and bringing health care fraud criminals to justice,” said Attorney General Holder.  “Through HEAT, we have achieved unprecedented, record-breaking successes in combating health care fraud and as a result of the Affordable Care Act, we have additional critical resources, tools and authorities to continue this great success.”

New tools provided by the Affordable Care Act are strengthening the Obama administration’s efforts to fight health care fraud.  As a result of Affordable Care Act provisions:

  • Criminals face tougher sentences for health care fraud, 20-50 percent longer for crimes that involve more than $1 million in losses;
  • Contractors that police Medicare for waste, fraud, and abuse will expand their work to Medicaid, Medicare Advantage, and Medicare Part D programs;
  • Government entities, including states, the Centers for Medicare & Medicaid Services (CMS), and law enforcement partners at the Office of the Inspector General (OIG) and DOJ, have greater abilities to work together and share information so that CMS can prevent money from going to bad actors by using its authority to suspend payments to providers and suppliers engaged in suspected fraudulent activity.

Increased collaboration has yielded significant results through the HEAT partnership.  Since the creation of HEAT in 2009, the Medicare Fraud Strike Force operations have expanded from two to nine locations throughout the United States, including Chicago.  Strike Force operations expanded to Chicago in February 2011 and since that time, charges have been filed against more than 35 defendants in the Northern District of Illinois for offenses related to health care fraud.  Overall, in fiscal year 2011, strike force operations in nine locations charged a total of more than 320 defendants for allegedly billing more than $1 billion in false claims.

In February, as a result of HEAT and strike force actions, a Dallas-area physician and the office manager of his medical practice, along with five owners of home health agencies, were arrested on charges related to their alleged participation in a nearly $375 million health care scheme involving fraudulent claims for home health services.  In conjunction with this action, CMS imposed payment suspensions against 78 home health agencies in the Dallas area.

Today, the Obama administration also announced more progress from its anti-fraud efforts, beyond the nearly $4.1 billion recovered last year:

  • In the early phase of revalidating the enrollment of providers in Medicare, 234 providers were removed from the program because they were deceased, debarred or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations;
  • In 2011, HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers as it took steps to close vulnerabilities in Medicare;
  • In 2011, HHS saved $208 million through pre-payment edits that stop implausible claims before they are paid;
  • Prosecutions are up: the number of individuals charged with fraud increased from 797 in fiscal year 2008 to 1,430 in fiscal 2011 – nearly a 75 percent increase;
  • In the first few weeks of enhanced site visits required under the ACA screening requirements, HHS found 15 providers and suppliers whose business locations were non-operational and terminated their billing privileges;
  • Through outreach and engagement efforts more than 49,000 complaints of fraud from seniors and people with disabilities reported to 1-800-MEDICARE were referred for further evaluation;
  • A recent re-design of the quarterly Medicare Summary Notices received by Medicare beneficiaries makes it easier to spot and report fraud.

See this fact sheet for additional details about the Obama administration’s efforts to combat health care fraud.

Health insurance rate hikes in nine states deemed excessive by HHS

March 28, 2012 10:57 am / 1 Comment

FOR IMMEDIATE RELEASE
March 22, 2012		 Contact: HHS Press Office
(202) 690-6343

Secretary Sebelius calls on insurance companies to drop unreasonable rate hikes

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that health insurance premium increases in nine states have been deemed “unreasonable” under the rate review authority granted by the Affordable Care Act.

“Thanks to the Affordable Care Act consumers are no longer in the dark about their health insurance premiums,” said Secretary Sebelius.  “Now, insurance companies are required to justify rate increases of 10 percent or higher.  It’s time for these companies to immediately rescind these unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so.”

Secretary Sebelius also released a new report today showing that, six months after HHS began reviewing proposed health insurance rate increases, consumers are already seeing results.  Since the rate review program took effect in 2011, health insurers have proposed fewer double-digit rate increases. Furthermore, more states have taken an active role in reducing rate increases, and consumers in all states are getting straight answers from their insurance companies when their rates are raised by 10 percent or more.  As of March 10, 2012, the justifications and analysis of 186 double-digit rate increases for plans covering 1.3 million people have been posted at HealthCare.gov, resulting in a decline in rate increases.  According to the report, in the last quarter of 2011 alone, states reported that premium increases dropped by 4.5 percent, and in states like Nevada, premiums actually declined.

In the decisions announced today, HHS determined, after independent expert review, that two insurance companies have proposed unreasonable health insurance premium increases in nine states—Arizona, Idaho, Louisiana, Missouri, Montana, Nebraska, Virginia, Wisconsin, and Wyoming.  The excessive rate hikes would affect over 42,000 residents across these nine states.

In these nine states, the insurers have requested rate increases as high as 24 percent. These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable, because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

Most rates are reviewed by states and many states have the authority to reject unreasonable premium increases.  Since the passage of the health care law, the number of states with this authority increased from 30 to 37, with several states extending existing “prior authority” to new markets.

The report released today shows that:

  • States like Texas, Kentucky, Nevada and Indiana are reporting fewer requests for rate increases over 10 percent.
  • States like California, New York, Oregon, and many others, have proactively lowered rate increases for their residents.
  • The rate review program has made insurance companies explain their increases, and more than 180 have been posted publicly and are open for consumer comment on companyprofiles.healthcare.gov.

This initiative is one of many in the health care law to ensure that insurance companies play by the rules, prohibiting them from dropping coverage when a person gets sick, billing consumers into bankruptcy through annual or lifetime limits, and, soon, discriminating against anyone with a pre-existing condition.

Information on the specific determinations made today is available at: http://companyprofiles.healthcare.gov/

The rate review report released today is available at: http://www.healthcare.gov/law/resources/reports/rate-review03222012a.html

General information about rate review is available at: http://www.healthcare.gov/law/features/costs/rate-review/

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