Perhaps no one of Murdock's tribe can explain how the new Health Insurance Reform Bill will pay for ITSELF, but, most of the rest of us actually HEARD for ourselves how President Obama explained how it would be paid for. Goes to show the folks watching and listening to Murdock's news don't get ALL the information in the way the rest of us do.
HMO claims-rejection rates triggers state investigation (click title to entry - thank you)
California Atty. Gen. Jerry Brown is joining state regulators in scrutinizing the payment practices of seven major health plans in response to complaints from physicians and hospitals.
By Lisa Girion
September 4, 2009
California Atty. Gen. Jerry Brown is joining state regulators in scrutinizing how HMOs review and pay insurance claims submitted by doctors, hospitals and other medical providers.
His announcement came Thursday as regulators said they had stepped up scrutiny of the payment practices of the state's seven largest health plans in response to complaints from physicians and hospitals.
The increased attention also comes on the heels of a first-of-its-kind report issued this week that said the California health insurers reject 1 in 5 medical claims....
Returning to The House Health Insurance Reform Bill, on page 355, lines 21 through 25 and Page 356, lines 1 through 6 regarding changes in Medicare, Part D, Prescription Drug Program.
‘‘(A) IN GENERAL.—For each year beginning with 2011, the Secretary shall consistent with this paragraph progressively increase the initial coverage limit (described in subsection (b)(3)) and decrease the annual out-of-pocket threshold from the amounts otherwise computed until there is a continuation of coverage from the initial coverage limit for expenditures incurred through the total amount of expenditures at which benefits are available under paragraph (4).
This is about closing the 'Donut Hole.' Every year the coverage limit increase while the out-of-pocket expenditures decrease. By gradually changing the ratios it can be discerned to the effectiveness of the provision. The concern here is that once those covered by Part D run out of coverage they stop taking medications or selectively take medications of which opens up the possibility of re-hospitalization or hospitalization for a worsening disease. The cost to health insurance goes up for every hospital admission. If re-admissions can be avoided with adequate coverage for perscriptions the cost effectiveness will be incredible.
Any content not mentioned previous to Page 355, Line 21 continued to return control from Medicare Advantage (MA) to the consumer of Medicare.
Page 358, line 11 is the beginning of a very interesting provision. This provision requires drug manufacturers that give drug rebates to the Secretary for persons with full eligibility under the new 'Donut Hole' law. Wow. Who would ever consider this as an issue to bring down the cost of perscriptions issued through Medicare Part D. I'll be darn. This bill has been 'in the works' for a long time. This level of scrutiny of the USA health care system and its relationship to Medicare Part D didn't take place in a couple of weeks. These legislators have been compiling this information and initiative for quite some time. Probably since the passage of the bill creating Medicare Part D under the previous administration. Well. Leave no stone unturned.
Page 359, lines 3 through 18.
‘‘(2) REBATE AGREEMENT.—A rebate agreement under this subsection shall require the manufacturer to provide to the Secretary a rebate for each rebate period (as defined in paragraph (6)(B)) ending after December 31, 2010, in the amount specified in paragraph (3) for any covered part D drug of the manufacturer dispensed after December 31, 2010, to any full-benefit dual eligible individual (as defined in paragraph (6)(A)) for which payment was made by a PDP sponsor under part D or a MA organization under part C for such period. Such rebate shall be paid by the manufacturer to the Secretary not later than 30 days after the date of receipt of the information described in section 1860D–12(b)(7), including as such section is applied under section 1857(f)(3).
The Bill goes on from there providing terminology, definitions, oversight, penalites for non-compliance, how the new law will be instituted and the high degree of confidentiality accompanying this law.
Page 370, lines 1 through 8 introduces the same level of government reimbursement for drugs with a discount. I guess so.
‘‘(g) REQUIREMENT FOR MANUFACTURER DISCOUNT AGREEMENT FOR CERTAIN QUALIFYING DRUGS.—
‘‘(1) IN GENERAL.—In this part, the term ‘covered part D drug’ does not include any drug or biologic that is manufactured by a manufacturer that has not entered into and have in effect for all qualifying drugs (as defined in paragraph (5)(A)) a discount agreement described in paragraph (2).
Here again The Bill discusses the definitons, etc. that accompanies such a provision. It also has scrutinized the 'discount' when it appears as a supplement to 'out-of-pocket' expenses. Everyone has an angel I suppose. The House didn't miss a trick.
Go, House Membership, Go !
Page 375, line 1 begins an entire provision in regard to perscription drug coverage under Part D as it applies to dispensed medications by Nursing Homes. Anything else?
Yep.
Page 375, line 1 begins to discuss the provisions for medications provided by special programs for HIV/AIDS (Properly entitled AIDS Drug Assistance Program - which actually falls under Medicare - Part B) and for medications utilized by Native American Indian.
Page 377, starting with line 21 prohibits changes in any medication formulary eligible for Part D from being removed or cost changes that would increase subscribers out of pocket costs. These insurance companies are so tricky. They don't care for nobody. They want their money and that is all they want.
‘‘(F) CHANGE IN FORMULARY RESULTING N INCREASE IN COST-SHARING.—
‘‘(i) IN GENERAL.—Except as provided in clause (ii), in the case of an individual enrolled in a prescription drug plan (or MA–PD plan) who has been prescribed and is using a covered part D drug while so enrolled, if the formulary of the plan is materially changed (other than at the end of a contract year) so to reduce the coverage (or increase the cost-sharing) of the drug under the plan.
Well, all right now. I think we have some very engaged legislators.
Page 379, line 8 starts to add the concept of 'Telehealth Services' to an expanding role to enhance health care.
Page 380, lines 6 through 17.
‘‘(c) TELEHEALTH ADVISORY COMMITTEE.—
‘‘(1) IN GENERAL.—The Secretary shall appoint a Telehealth Advisory Committee (in this subsection referred to as the ‘Advisory Committee’) to make recommendations to the Secretary on policies of the Centers for Medicare & Medicaid Services regarding telehealth services as established under section 1834(m), including the appropriate addition or deletion of services (and HCPCS codes) to those specified in paragraphs (4)(F)(i) and (4)(F)(ii) of such section and for authorized payment under paragraph (1) of such section.
Telehealth delivery (click here) could be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using videoconferencing between providers at facilities in two countries, or even as complex as robotic technology. It is my understanding that Robotic Technology is used in long distance surgery when a physician specialized in any discipline not widely practiced cannot be 'in the surgical suite' to personally perform the surgery. There is a surgeon attending the patient at all times that guides the robotics. This is used in health clinics in Africa.
Telehealth helps Bristol GP practice improve care for chronic heart failure patients (click here)
3 September 2009
GPs at The Orchard Medical Centre in Bristol have reported on the success of telehealth in improving care for patients with chronic heart failure (CHF), keeping them independent and out of emergency care, and promoting greater self-management.
The Bristol-based practice has successfully integrated telehealth into its CHF service, to provide more preventative support within the community setting, help avoid hospital admissions and reduce some of the burden on secondary care providers whilst providing a cost-effective model of care for the management of the condition....
That discussion goes on upto page 390 and with line 12 The Bill begins provisions to Eliminate Barriers to Enrollement
SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT (a) ADMINISTRATIVE VERIFICATION OF INCOME AND RESOURCES UNDER THE LOW-INCOME SUBSIDY PROGRAM.—
It authorizes the sharing of income tax returns to validate ineligibilty of those earning too much to receive the benefit. It also allows for retroactive payment of medications when a citizen is found eligible. There are exceptions for enrollees for RFP plan. They cannot be enrolled in both. Those provisions continue with technical explanations upto page 401, which starts the provisions for Subtitle B - Reducing Health Disparities. I'll end it there and pick up there later.
