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Archive: June 2011

Commonwealth Fund issue brief details Innovation Center’s mission and challenges faced

Posted on June 30, 2011

The Commonwealth issue brief, “Identifying, Monitoring, and Assessing Promising Innovations: Using Evaluation to Support Rapid-Cycle Change,” reviews the mission of The Center for Medicare and Medicaid Innovation (Innovation Center) and provides perspectives from the research community on critical issues and challenges. This issue brief focuses on three requirements the Innovation Center must address to meet its objectives: 1) focusing on research-based changes that have the potential to achieve significant impact on improving quality and lowering costs; 2) documenting innovation testing and goals and tracking implementation and performances; and 3) generating evidence requisite to support broad-based policy change. To support these goals, the Affordable Care Act (ACA), has provided the Innovation Center with $10 billion in funding from 2011 to 2019. The intent is to allow quicker and more effective identification and spread of desirable innovations, with the goal of ultimately modifying Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

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Appeals court rules individual mandate constitutional

Posted on June 29, 2011

The U.S. Court of Appeals for the 6th Circuit has ruled that the individual requirement to purchase health insurance under the Affordable Care Act (ACA) falls within Congress’ authority to regulate interstate commerce activities under the Commerce Clause, and is therefore, constitutional. At issue specifically in this case is the whether Congress can also regulate inactivity, that is, a person’s decision NOT to purchase health insurance. To this point, Judge Boyce F. Martin, Jr. wrote for the majority that, “although there is no firm, constitutional bar that prohibits Congress from placing regulations on what could be described as inactivity, even if there were it would not impact this case due to the unique aspects of health care that make all individuals active in this market.”

The 2-1 ruling, which upholds an earlier Michigan District Court Decision, is expected to be appealed by the plantiffs, who include the Thomas Moore Law Center, also of Michigan. They could ask for the case to be heard en banc, before the entire group of 16 judges in the 6th Circuit, or the plaintiffs could proceed by appealing directly to the U.S. Supreme Court.

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The Basic Health Program

Posted on June 29, 2011

An important issue in implementing the Affordable Care Act (ACA) is how to address the needs of uninsured low-income individuals and families whose incomes exceed Medicaid eligibility levels but are less than twice the federal poverty level (about $37,000 for a family of 3 in 2011). Under the ACA, the basic approach to assisting such individuals and families is the state health insurance Exchange, which enables qualified individuals to secure coverage and provides access to premium assistance and cost-sharing subsidies aimed at making coverage and care affordable.

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DOL/IRS issue amendments to IFR on claims appeals

Posted on June 22, 2011

The US Department of Labor (DOL) and the Internal Revenue Service (IRS) have issued separate amendments to the July 23, 2010 Interim Final Rule (IFR) on internal claims and appeals and external review processes for group health plans and health insurance issuers offering coverage in the group and individual markets. The Employee Benefits Security Administration (EBSA) of the Department of Labor has also issued new guidance on the subject.

The IFR, recent amendments, and recent guidance do not apply to grandfathered plans.

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The Consumer Operated and Oriented Plan (CO-OP) Program

Posted on June 22, 2011

During the debate that led to passage of the ACA, concerns were raised that millions of individuals and small groups lack sufficient choice among insurers in the existing private insurance market. Proponents (including those who sought a public insurance option) advocated for congressional investment in alternative sources of coverage in order to assure choice and competition, as well as to address the highly concentrated nature of the health insurance market (in most states 3 or fewer for-profit insurance companies account for over 65% of the market).

A “public option” was proposed as a means of promoting an alternative to private coverage. In lieu of a public option, which proved highly controversial, the ACA included the Consumer Operated and Oriented Plan (CO-OP) program, whose purpose is to develop private non-profit alternatives to for-profit insurers. The central aim of the CO-OP program is to create consumer-run health insurers accountable to members, rather than to investors.

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Nursing Workforce

Posted on June 15, 2011

Strengthening and modernizing the health care workforce was a major goal of the Affordable Care Act (ACA). The ACA contains dozens of provisions related to health care workforce issues, including strengthening primary care, national workforce policy development, increasing the supply of health care workers, education and training of the workforce, and other supports and improvements to the existing workforce. This Implementation Brief focuses on those provisions of the ACA that specifically target the strengthening of the nursing workforce.

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Medicaid Payment Adjustment for Health Care-Acquired Conditions

Posted on June 8, 2011

A high number of deaths occur every year due to potentially preventable adverse events, including medical errors, in the hospital setting. The most commonly cited research on this topic was published by the Institute of Medicine (IOM) in 1999. The IOM report, “To Err is Human: Building a Safer Health System” stated that hospital acquired conditions (HACs) caused by medical errors are a leading cause of morbidity and mortality in the United States.[1] More recently, a 2007 study found that of 1.7 million infections acquired while a patient was receiving treatment in a hospital, 99,000 resulted in death in 2002.[2] In addition, there is also a significant cost burden associated with potentially preventable HACs. In 2000, the Centers for Disease Control and Prevention (CDC) published a report estimating the cost burden of HACs to be almost $5 billion.[3]

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CMS issues health IT guidance on state exchanges

Posted on June 6, 2011

The Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services has issued an updated guidance to assist states as they design, develop, and implement health IT systems for health insurance exchanges mandated under the Affordable Care Act (ACA). The guidance addresses significant structural and business architecural components of the exchange framework, and is designed to promote a “high quality customer experience.”

One highlight of the guidance is a description of the “data services hub” that CMS plans to establish and is designed to help states verify citizenship, immigration status, and income of applicants for health plans offered on the exchanges. Under the ACA, the American Health Benefits Exchanges must be up and running by January 1, 2014.

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CMS issues final rule on barring Medicaid match for certain medical conditions

Posted on June 6, 2011

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has issued a final rule restricting federal Medicaid match funding for payments to providers whose patients have certain preventable medical conditions. The rule is intended to “better align Medicare and Medicaid payment policies,” CMS said in a press release accompanying the rule. The rule implements Section 2702 of the Affordable Care Act (ACA), which requires the Secretary to adjust federal Medicaid payments for health care-acquired conditions (HCACs), similar to what is done in the Medicare program. The final rule extends the effective date by one year, from July 1, 2011 to July 2, 2012.

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Update: Disclosure and Review of Unreasonable Premium Increases

Posted on June 3, 2011

An earlier Implementation Brief provided an overview of the Disclosure and Review of Unreasonable Health Insurance Premium Rate Increases, which was established by §1003 of the Affordable Care Act (ACA) by adding §2794 to the Public Health Service Act (PHSA). On May 23, 2011, the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) published a final rule (with comment period) establishing a rate review program of “unreasonable” health insurance premium rate increases and implementing requirements for health insurance issuers regarding the disclosure and review of such unreasonable premium increases.

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