The Exchange: What You Need to Know

As part of the federal health care reform legislation, known as the Patient Protection and Affordable Care Act (ACA), states were instructed to establish American Health Benefit Exchanges and Small Business Health Options Program Exchanges (collectively “the Exchange”). In September 2010, California became the first state to create a Health Benefit Exchange following the ACA’s passage.

California’s Exchange is an independent public entity that is overseen by a five-member board appointed by the Governor and Legislature. The Exchange’s role in health care reform is to create a new insurance marketplace for individuals and small businesses to purchase health coverage.

It’s important to note that not all health plans interested in offering a product in the Exchange will be eligible to do so. Based on criteria yet to be developed, the Exchange Board will select the plans eligible to be offered in the Exchange sometime in 2013.

California’s Exchange is poised to have a huge impact on the state’s healthcare landscape in 2014 and beyond, with an estimated 8.3 million Californians eligible to purchase coverage on the Exchange in 2016. This represents an estimated 12 to 34 percent of California’s private insurance market.

One of the most highly publicized provisions of the Exchange has been the “essential health benefits” package (EHB). The EHB is a set of benefits chosen by the state that will establish the scope of services provided by most Exchange-offered plans. Most plans may not impose benefit caps on services in the EHB. Additionally, the value of Exchange-offered plans will be categorized in levels (Platinum, Silver, Gold and Bronze) by their value as a percentage of the value of the state’s EHB.

States are required to select one of four benchmark plan options by September 30, 2012. Preliminary studies suggest that, while covered services across plan choices may not vary greatly, cost-sharing and other coverage limits are likely to differ significantly.

A number of major issues affecting physicians have yet to be decided, including the Exchange Board’s plan standards (higher thresholds are likely to result in fewer Exchange plans being available); how to handle individuals with frequently changing eligibility status (e.g., losing and gaining Medi-Cal eligibility); how to ensure plans offer the required adequate networks of providers; and finally, how the Exchange Board will pull all of this together before its target pre-enrollment date of July 2013.

Currently, the Exchange board is still awaiting final federal regulations on the standards and the EHB – with both expected by fall 2012.

Please click here for more information about the California Health Benefits Exchange.

Seeking Reviewers for the Health Care Innovation Challenge

The Center for Medicare and Medicaid Innovation is currently recruiting reviewers nationally to serve on evaluation panels for the Health Care Innovation Challenge. SFMS encourages our physician members to apply to participate.

The Health Care Innovation Challenge (Innovation Challenge) is an exciting new initiative designed to test a wide range of innovations in communities across the country in order to accelerate system-wide health care transformation across our nation.

Applications for review will be accessed electronically via a web-based system, and the entire review process will take place remotely from your location; travel is not required. An honorarium of $500 to non-Federal employees will be offered for successful participation in the process.

The review will take place February 16 – February 29, during which time you will need to be available to read and score the applications. The timeline for evaluation is as follows:

• February 16 or 17 – Attend one mandatory training conference call session (2 hours)
• February 21 – February 29 – Remote Scoring/Commenting/Paneling
• February 27 – 28 – Panel Conference Call Days (complete schedule availability is required)

To apply, please visit http://innovations.cms.gov/initiatives/innovation-challenge/index.html.

WSJ Blog: Back on ‘Doc Fix’ Watch as Medicare Cuts Loom

It seems like just yesterday that Congress passed a one-year fix for Medicare reimbursement cuts.

Unfortunately, time has flown, and we find ourselves back on the “doc fix” watch — though this year, there’s a 24.7% cut looming.

(Last year, it was 20%; every time cuts are put off, cuts for the next potential round get bigger.)

The current (and unsustainable) payment formula pegs the increase in Medicare reimbursement to the GDP. That’s problematic, since growth in health-care spending outstrips growth in GDP. Automatic cuts kick in if spending reaches a certain level.

The deficit-reduction supercommittee, which wrapped up last week without an agreement on budget cuts, failed to find a long-term solution to the problem.

As the Associated Press reports, Congress must act before Jan. 1 to keep physicians from facing the cuts, and their options include both one-year and two-year fixes. But they must be paid for — about $22 billion for the one-year and $35 billion for the two-year fix. And these are just patches until a far pricier permanent solution is found.

Source: Wall Street Journal Health Blog, November 28, 2011.

Cancer Screening Reform Needed

Since the National Cancer Institute developed the first guidelines on mammography screening over thirty years ago, advocacy and professional groups have developed guidelines focused on who should be screened, instead of communicating clearly the risks and benefits of screening, according to a commentary by Michael Edward Stefanek, PhD, the associate vice president of collaborative research in the office of the vice president at Indiana University, published online on November 21 in the Journal of the National Cancer Institute. Stefanek writes that too much time has been spent debating guidelines, instead of ongoing debates about who should be screened. He advocates educating people about the potential harms and benefits of screening.

The U.S. Preventative Task Force (USPTS) recommendations against routine mammography for women aged 40-49 sparked controversy followed by more studies on screening, notably a Norwegian study comparing cancer-specific mortality in screened and unscreened women, which found a small and statistically insignificant breast cancer mortality reduction in the screened group. Stefanek writes that “similar ambiguity” exists for prostate cancer screening, noting that the two largest and high quality studies gave conflicting results, with the USPTS recently issuing recommendations against PSA testing in healthy men. The National Lung Cancer Screening Trial reported a 20% relative decrease in lung cancer deaths among subjects undergoing CT scans compared with those receiving chest x-rays, but with the majority of positive results being false positives. Overall this situation leads Stefanek to the conclusion that despite all the analyses to date, we are on unsteady ground when we attempt to dictate who should and shouldn’t undergo screening.

Stefanek poses the question of what we have taught the public about cancer screening, since the public invariably seems to feel that screening is almost always a good idea and that finding cancer early is the key to saving lives. He cautions that the public may persist in holding a biased view of screening if we continue to engage in guideline debates. Furthermore, new technologies, despite the potential for combating cancer, will likely result in false positives, false negatives, overtreatment, and under treatment, and incur important patient harms.

Stefanek writes that we have failed to truly educate the public about cancer screening, and that our approach to screening needs to be reformed. He says engaging patients in shared decision making, tracking the number of patients provided with information related to the harms and benefits of screening instead of just those who are screened, and uniting scientific and advocacy organizations with primary care provider organizations in this effort to inform about costs and benefits is needed. “If we agree on the premise that individuals are supposed to be informed before making medical decisions, including decisions about cancer screening, then the time and talent of such groups could be much better spent educating the public on the harms and benefits of cancer screening,” Stefanek writes. “Screening can be very beneficial (or not), and screening messages should reflect the complexity of this decision.”

Contact: mstefane@iu.edu

SFMS Welcomes the Hiroshima 18th Medical Team

A team of physicians from Hiroshima visits San Francisco every other year to examine local hibakusha — survivors of Hiroshima and Nagasaki.  The 18^th Medical Team, consisting of physicians specializing in radiation effects from Hiroshima, Japan is in San Francisco this weekend to conduct the 18^th biennial medical examinations of Americans of Japanese and Korean ancestry who survived the atomic bombings during World War II.

This year marks the 34^th anniversary since the Hiroshima Medical Prefectural Association has participated in these missions.  Since 1977, the Hiroshima Prefectural Medical Association has sponsored official biennial medical missions for the benefit of American survivors living in the United States.

Participating Japanese medical team members for the San Francisco examinations are: Jitsuro Yanagida, MD, (Team Leader), Member of Board of Directors, Hiroshima Prefectural Medical Association, Vice Director, Aki City Hospital; Hiroaki Tsumura, MD, Chief Director of Surgery, Hiroshima City Funairi Hospital; Hideki Nakahara, MD, Director, Hepato-Biliary Surgery, Hiroshima Prefectural Hospital; Takenori Okada, MD, Physician, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital; Yoshimi Tatsukawa, MD, Associate Senior Scientist, Division of Health Examinations, Department of Clinical Studies, Radiation Effects Research Foundation; Misa Egawa, MD, Physician, Hiroshima University Hospital; Mitsunobu Kubota, MD, Clinical Staff, Dept. of Endocrinology and Diabetes, Hiroshima University Hospital; Kazumochi Nakamoto, Chief, General Affairs Section, Hiroshima Prefectural Medical Association; Hideo Shinoda, Personnel Section Chief, Radiation Effects Research Foundation; Naoki Kono, Supervisor, Hiroshima City Office Health and Welfare Bureau Atomic Bomb Survivors Relief Department Relief Division; Hiroyuki Mori, Staff, Nagasaki City Office Investigation Division, Atomic Bomb Survivors Department.

The SFMS has had a sister relationship with the Hiroshima Prefectural Medical Association since 1981 and provides the local affiliation necessary to conduct the medical examinations in San Francisco.