NJ governor orders review of "drive-through"
mastectomies for managed care patients
TRENTON, NJ—Gov. Christie Whitman has ordered the state’s health commissioner and insurance commissioner to investigate reports that health maintenance organizations are forcing women to have "drive through" mastectomies.
"We want to determine the extent of the problem," says Carl Golden, spokesman for the governor’s office. The commissioners will be looking into reports that women are undergoing mastectomies on a one-day outpatient basis without a hospital stay.
The HMO industry is trying to head off the issue, reminiscent of the "drive-through" delivery controversy which led to national legislation requiring a 48-hour hospital stay for childbirth.
Paul Langevin, president of the New Jersey HMO Association, says he welcomes the review and predicted that commissioners would find that when mastectomies are done on an outpatient basis, it is because of the wishes of the patient and her physician.
A report about two Connecticut HMOs adopting guidelines suggesting that breast surgery can be done on an outpatient basis helped spark the controversy over outpatient mastectomies. Also of concern to advocates and lawmakers is a trend reported by HCIA Inc. The Baltimore-based health research company reported that 7.6% of 110,000 mastectomies recently performed in the U.S. were done in an outpatient setting, up from 1.6% in 1991.
Bergen Record, Hackensack, NJ, Nov. 23, 1996
Newspaper survey shows rates of outpatient
mastectomies vary widely among Calif. providers
SACRAMENTO, CA—According to an informal survey of plans and hospitals in the Sacramento area, outpatient mastectomies are fairly common, but rates vary widely. The chief of surgery for one Kaiser Permanente medical center estimated that up to 20% of its "total mastectomy" patients--those who have both breasts removed--went home the same day of surgery. Dr. Susan Kutner, chairwoman of a Northern California Kaiser Regional Breast Cancer Task Force, says the percentage of women who go home the same day after a "lumpectomy" is much higher.
About one in five patients who have one or both breasts removed at Sutter Community Hospital go home the same day. At another hospital, Mercy Healthcare Sacramento, less than 10% of mastectomy patients at its four local hospitals go home the same day. In contrast, an official at UC Davis Medical Center says that all mastectomy patients stay in the hospital at least one night.
Sacramento Bee, Sacramento, CA, Nov. 15, 1996
Massachusetts insurers would contribute more to charity care pool under proposed legislation
BOSTON—Health insurers in Massachusetts would have to shoulder more of the costs of uncompensated care under legislation being proposed by Massachusetts hospitals. Similar to a new law that will go into effect in New York Jan. 1, the proposed legislation would require insurers to pay an assessment on their payments to hospitals and other health care providers for uncompensated care.
State government also would be required to contribute about one-third of the total cost of uncompensated care. Hospital officials say the state, which now contributes $15 million a year to the uncompensated care pool, should increase its contribution with some of the extra funds it gets from the federal Medicaid program; these extra funds are estimated at $157 million.
The Massachusetts Association of Health Maintenance Organizations proposed its own plan in November that would levy a 2% assessment on doctors, clinics, ambulance services, hospitals and health centers owned by insurance companies. The tax would be based on gross revenue and would raise about $295 million. Physicians and hospital leaders said the plan is unfair and can’t
cover the projected $511 million cost of caring for 670,000 uninsured Massachusetts residents in1997.
Boston Globe, Nov. 27, 1996
NY commissioner says HCFA is stalling on waiver
ALBANY, NY— State Health Commissioner Barbara DeBuono accused the federal government of stonewalling New York’s plans to go to mandatory Medicaid managed care and of holding New York to different standards than other states. About 20 months have passed since New York submitted its waiver to the the Health Care Financing Administration (HCFA).
The health commissioner noted that Medicaid recipients in Maryland, for example, can be auto-assigned after a voluntary enrollment period of only 21 days while, in New York, HCFA wants to give recipients at least 60 days to choose their own plan.
Dr. DeBuono suggested that the problem may be political, but Sally Richardson, acting deputy administrator, insists the long time frame is due solely to the huge number of Medicaid recipients in New York and the complexity of the issues. Ms. Richardson noted that 75% of Maryland’s Medicaid recipients are already in managed care and that New York’s population is much more diverse and potentially harder to reach.
Another difficulty is the issue of whether managed care plans will be able to have separate panels of providers for Medicaid recipients. Dr. DeBuono says she is concerned about a federal condition that would prohibit participating plan doctors from refusing to see Medicaid patients. "We want to avoid having double panels, where one panel serves mainstream folks and the other just Medicaid folks," Ms. Richardson says.
Newsday, Nov. 20, 1996
Kentucky insurance department to monitor shifts
of unhealthy people from association plans
LEXINGTON, KY —Kentucky’s Department of Insurance has issued an emergency regulation that will allow the state to monitor whether associations are "cherry-picking" people buying insurance. Concerned that associations are using their exemption from state health care reform laws to eschew high-risk people, state officials will be reviewing information from associations about their policies and members.
In a recent speech, Gov. Paul Patton called the exemption for associations a "serious flaw" in the state’s health care reforms.
Associations can continue to rate people on health history while insurers in the market for individuals and groups and in the state-run purchasing alliance cannot. The insurance department’s emergency rule will allow the state to monitor any large shifts of unhealthy people from associations to the state alliance.
Lexington Herald-Leader, Lexington, Ky, Nov. 19, 1996
Anthem Blue Cross reducing fees to agents writing individual policies in Kentucky as of Jan. 1
LEXINGTON, KY —Citing losses it blames on the state’s 1994 insurance reforms, Anthem Blue Cross-Blue Shield says it plans to sharply reduce fees to insurance agents for writing policies for individuals. The reduction in commissions, from 12% for new policies and 6% for renewals to a flat $5 fee per policy, is scheduled to take effect Jan. 1. Anthem is the only carrier outside the state-run purchasing alliance that is writing individual policies.
The company said it was taking this step because of financial losses it blames on 1994 insurance reforms. State officials fear that with no incentive to write individual policies, agents are likely to move healthy individuals into association insurance plans which are exempt from reform and high-risk individuals into the purchasing alliance. Currently, only one vendor, Kentucky Kare, a state employee plan, is writing policies for individuals in the alliance.
Cincinnati Post, Nov. 30, 1996
Enrollment in PA’s HealthChoices delayed again
HARRISBURG, PA—HealthChoices, Pennsylvania’s mandatory Medicaid managed care program, has been delayed once again. Scheduled to start up Jan. 1, enrollment of Medicaid beneficiaries in a five-county area around Philadelphia has now been postponed until Feb. 1. The state had earlier slated start-up for Nov. 1.
The Welfare Department says the latest delay was to allow the four HMOs participating in this first phase of the program more time to get ready. A spokesman for the Department says the Health Care Financing Administration (HCFA) played a part in the delay, because the agency did not want auto-assignment to begin until Feb.10. Given that limitation, the state decided to push back its deadline for the entire program.
Among other recent developments:
• A coalition of AIDS organizations has mounted a protest campaign against HealthChoices, maintaining the HMOs are unprepared to care for the 13,000 people with HIV/AIDS who the coalition says will be affected. At a recent news conference, AIDS activists said that plans were unable to satisfactorily respond to "undercover" callers who requested the names of doctors with expertise in treating patients with the virus. The activists have criticized the state for not developing a higher payment rate for HIV patients and other patients with chronic illnesses.
• Two of the more experienced HMOs, U.S. Healthcare and Qualmed, decided not to participate in the program. Another HMO, Philcare, backed out after the state required the company’s principals to invest more money than they were willing to put up.
The Inquirer, Philadelphia, PA, Nov. 14, 1996, Dec. 6, 1996
Justice Department agreements with hospitals
on Medicare overbillings being kept quiet
HARRISBURG, PA—The Justice Department is entering into "gentlemen’s agreements" with hospitals that are charged with Medicare overbillings, according to a report in the Philadelphia newspaper, The Inquirer. Federal authorities say they have found a pattern of overcharging Medicare at 4,660 hospitals and expect to collect $120 million and have launched a nationwide crackdown.
But, the Justice Department has declined to disclose the findings of its investigations or the civil settlements reached with hospitals, sparing the hospitals some bad publicity and leaving the public in the dark, The Inquirer reports. Justice Department officials said the settlements have been kept quiet in order to avoid costly litigation and to encourage hospitals to abide by compliance agreements.
Filing under the Freedom of Information Act, The Inquirer learned that the University of Pennsylvania has paid one of the biggest settlements yet—$976,034. Two other Philadelphia hospitals, Graduate and Thomas Jefferson University, paid settlements of $311,575 and $297,386, respectively.
Mary Catherine Frye, the Harrisburg-based prosecutor for the Justice Department, said the University of Pennsylvania violated the Medicare rule known as the 72-hour window. Under this rule, tests such as X-rays and blood work taken within three days of admission are considered for billing purposes as part of the hospital stay and are reimbursed at a flat rate for the hospital stay.
Inquirer, Philadelphia, PA, Nov. 24, 1996
New HealthPartners plan allows consumers
to choose doctor based on price and options
ST. PAUL, MN—HealthPartners has created a plan called Ultimate Choice which will let consumers choose their doctor based on price and options. Ultimate Choice will let consumers choose from among 39 clusters of doctors, clinics and hospitals. Each cluster will provide a certain basic package of services but will try to attract enrollees with its business hours, locations, types of specialists or hospital referral patterns. The group will then place itself in one of three price brackets. The price brackets differ one from the other by 10%.
About 7,000 doctors and 350 clinic locations will participate in the plan. The plan is similar to Choice Plus, a plan HealthPartners will administer beginning January for the Buyers’ Health Care Action Group (BHCAG), a group of large employers which has attracted national attention because of its plans to move toward direct-contracting with provider groups. The idea is to create more competition in the marketplace at the provider level and to let consumers, not benefit managers, make the choice of physician. Ultimate Choice will be offered to employers with 50 or more workers (more than 80% of insured Minnesotans receive their coverage from employers with 50 or more workers).
St. Paul Pioneer Press, St. Paul, Minn., Dec. 6, 1996
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