Highmark Recruits Nurse Practitioners as Primary-Care Providers

Jan. 19, 2011 | Camp Hill, Pa. In order to give Highmark members more health care options, Highmark is working with certified registered nurse practitioners (CRNPs) to expand their role to serve Highmark members in much the same capacity as a primary care physician (PCP).

“The health care reform legislation that was passed earlier this year will likely mean more people will be getting health care coverage and seeking health care services,” said Carey Vinson, M.D., Highmark’s vice president of quality and medical performance management. “By recognizing CRNPs’ ability to work up to the full scope of their medical license, it will allow greater access for members.”

Highmark is reaching out to several hundred CRNPs across Pennsylvania to determine if they would like the designation to serve Highmark members as a network primary care CRNP.

Currently, Highmark works with CRNPs primarily in two ways. The CRNP may work with a physician now and are not credentialed. They typically work closely with a physician in a primary care or family practice setting or they may work for a specialist. The second area where Highmark engages CRNPs is when they function independently. They do, however, collaborate with physicians in the Highmark network, even when working independently.

A CRNP’s duties may often include diagnosing, treating, evaluating and managing chronic disease. Their duties also could include ordering routine tests and prescribing medication.

“During the next few months, we will see just how many of the CRNPs choose to apply for this designation,” said Vinson. “Over time, we believe this is another way to make the state more attractive to CRNPs.” Highmark is also making various CRNP training programs aware of this change.

Dr. Vinson also noted that in many cases CRNPs work in a retail clinic setting, something Highmark supports. These clinics have proven to be cost efficient and very convenient for members.

About Highmark Inc.
As one of the leading health insurers in Pennsylvania, Highmark Inc.’s mission is to provide access to affordable, quality health care enabling individuals to live longer, healthier lives. Based in Pittsburgh, Highmark serves 4.7 million people through the company’s health care benefits business. Highmark contributes millions of dollars to help keep quality health care programs affordable and to support community-based programs that work to improve people’s health. Highmark exerts an enormous economic impact throughout Pennsylvania. A recent study states that Highmark’s positive impact exceeded $2.5 billion. The company provides the resources to give its members a greater hand in their health.

Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. For more information, visit www.highmark.com.

Op-outs, Co ops, and Triggers. Oh, my!

The conservative think tank, The Heritage Foundation, in today’s Morning Bell reacted to Senate Majority Leader Harry Reid’s (D-NV) announcement that the health care legislation he is drafting will include a government-run health insurance plan by saying that it doesn’t matter what vehicle he chose. Op-outs, co ops, and triggers all lead to the same place – everyone in a government-run health plan.

Take the op-out. The piece notes that Reid has not provided a lot of details about how the plan would work. But, what we do know is that the plan would take effect in 2013 and states would have until 2014 to pass legislation declining participation in the program.

Here is what has the Heritage Foundation so worried.

“In 17 states Democrats control both houses of the legislature and the state house. In another 24, Democrats control at least one legislative chamber or the governor’s mansion. That, they say, leaves a total of only 9 states where Republicans run the entire show — Texas, Utah, South Carolina, South Dakota, North Dakota, Missouri, Idaho, Florida, and Georgia. That, according to the Heritage Foundation, means Americans in 41 states are all but guaranteed to have no choice but to endure the government run health plan.”

Turning to the idea of the co-ops that Sens. Chuck Schumer (D-NY) and Kent Conrad (D-ND) have both been pushing, the Heritage Foundation reminds us of the collapse of the mortgage market in warning us that this is a model guaranteed to fail.

“Simply calling some form of a government-sponsored enterprise (GSE) a “cooperative,” for instance, would be only another type of public plan in disguise. … One need look no further than Fannie Mae and Freddie Mac to see how GSEs can distort the market and leave taxpayers with huge liabilities. Decades of market distortions generated by their implicit government backing, compounded by the effects of repeated political meddling by Congress, put those GSEs at the very epicenter of the mortgage market collapse that triggered the current financial crisis and recession.”

Lastly, there is what the Heritage Foundation calls the “Trigger Trap”, an approach favored by Senator Olympia Snowe, (R-ME). A trigger is a legislative tool that would put in place automatic benchmarks that if not met, would immediately unleash the government-run system into the market. For example, if 95% of Americans as defined by the bill don’t have adequate health coverage by a certain date, the public option would be “triggered.”

The Heritage Foundation:

“What a trigger does is hold off the tough decision until future, uncertain circumstances. The public option would essentially become law today, but not go into effect until an undetermined time when economic conditions could be even worse. Had Congress enacted a trigger to save Clintoncare, the trigger would have forced states to implement HMOs at exactly the time everyone was moving away from that overly rigid version of managed care.”

Is it any wonder that the public option has become the most contentious aspect of the healthcare reform debate? It is shaping up to be the overarching factor that will determine how healthcare is financed and delivered going forward. Regardless of your point of view, this is where the action will be going forward.

Scary Numbers.

With Halloween right around the corner, this is the season for scary things. One of the  scariest things I’ve see recently appeared on the pages of the Wall Street Journal. It had to do with the ability of Congress to predict the cost of health care entitlement programs.

In an opinion piece entitled Health Costs and History, the WSJ examined the record of Congressional forecasters in predicting costs starting with Medicaid, the joint state-federal program for the poor. According to the WSJ, the House Ways and Means Committee had estimated that first-year costs for this program would be $238 million. Instead it hit more than $1 billion, and costs have kept climbing.

In fact, the article says, Medicaid now costs 37 times more than it did when it was launched—after adjusting for inflation. Its current cost is $251 billion, up 24.7% or $50 billion in fiscal 2009 alone, and that’s before the health-care bill covers millions of new beneficiaries.

The article goes on to examine Medicare and found that it has a similar record. In 1965, Congressional budgeters said that it would cost $12 billion in 1990. Its actual cost that year was $90 billion. Whoops. The hospitalization program alone was supposed to cost $9 billion but wound up costing $67 billion. The article points out that these aren’t small forecasting errors. The rate of increase in Medicare spending has outpaced overall inflation in nearly every year (up 9.8% in 2009), so a program that began at $4 billion now costs $428 billion.

Now we are being told a new health-care entitlement will actually reduce red ink by $81 billion over 10 years. Does anyone actually believe that? If they do, that is really scary.

Chart by The Wall Street Journal.

Galen Institute Releases Poll Showing Overwhelming Opposition to the Individual Mandate and Other Key Components of Congressional Health Reform Proposals.

The Galen Institute today released new survey results showing overwhelming opposition to the individual mandate and other key components of health reform legislation Congress is considering.

“These findings illustrate strong opposition to fundamental aspects of the bills moving through Congress,” said Galen Institute President Grace-Marie Turner. “People don’t want to be forced to buy insurance they can’t afford or that might not fit their needs, yet the proposals would slap a tax on them if they don’t. And people overwhelmingly oppose reducing seniors’ health benefits or raising taxes on the working and middle class in order to expand coverage to some of the uninsured, yet many in Congress continue to push exactly that.”

“What the public does favor is a targeted approach to solving problems in our health sector, but not a complete Washington-style overhaul of one-sixth of our economy. Washington’s failure to listen is causing great apprehension and concern among the public,” added Turner.

The nationwide random survey of 510 adults was conducted October 8-11, 2009 and has a +/- 4.34 margin of error. International Communications Research (ICR), a non-partisan research firm based in Pennsylvania, conducted the survey.

More Than Seven in Ten Oppose the Individual Mandate

Seventy-one percent of those surveyed said they would oppose “a new law saying that everyone either would have to obtain private or public health insurance approved by the government or pay a tax of $750 or more every year.” Only 21 percent said they would support the law. More than half (54 percent) of all respondents indicate a “strong” opposition to the individual mandate, including 58 percent of those 45-54 years of age and 58 percent of those 55 years and older.

More Than Two-Thirds Oppose Reducing Seniors’ Health Benefits to Pay for Covering the Uninsured

More than two-thirds (68 percent) oppose reducing “some health insurance benefits for senior citizens in order to expand health insurance for some people who are uninsured,” while 28 percent support the idea. Opposition is spread across political party lines as 86 percent of Republicans, 66 percent of Independents, and 59 percent of Democrats oppose this idea.

Opposition to Raising Taxes on the Working and Middle Class to Cover the Uninsured

Fifty-eight percent disagree, most of them “strongly” (44 percent), with the following statement: “I would support an increase in taxes on the working and middle class if it would help provide health insurance to more Americans.” Only 39 percent support the position.

Seventy-one Percent Are Concerned Current Health Insurance Will Change if Congress Passes Health Reform

Seventy-one percent said they were concerned that their current health insurance would change if Congress passes health reform legislation. One-quarter (25 percent) said they were not concerned. Groups with the highest level of concern include: people 55 years and older (84 percent), those aged 45-54 (80 percent), Republicans (82 percent), and Independents (78 percent). Almost half (47 percent) of all respondents indicate they are “very concerned.” Sixty-two percent of people aged 55 years and older are “very concerned,” along with 61 percent of Republicans, 63 percent of those in the South, and 54 percent of Independents.

Support for a Targeted Approach to Addressing Health Care

Forty-nine percent support, “A targeted approach that addresses a few problems at a time.” Forty-one percent support, “A comprehensive approach that makes significant changes to our current health care system.”

Online Tool Shows Government Assistance Available Under Healthcare Reform Proposals.

The Kaiser Family Foundation has come out with a nifty tool to illustrate premiums and government assistance under the types of reform proposals being considered in Congress. The online calculator works for people under age 65 who purchase coverage on their own in an Exchange or Gateway and are not covered through their employer, Medicare or Medicaid.

The tool allows the user to start with the provisions from one of several proposals and examine the impact at different income levels. Advanced settings even allow users to change assumptions to show the effect of different policy choices.

This information is intended to show how people in different circumstances would be affected by the types of reforms under consideration. However, it does not provide estimates of the impact of reform for those with employer or public coverage.

You can check it out at: http://healthreform.kff.org/Subsidycalculator.aspx

Baucus Bill by the Numbers.

$774 billion – the estimated credits and subsidies to be provided through the insurance exchanges, increased net outlays for Medicaid and the Children’s Health Insurance Program (CHIP), and tax credits for small employers.

$215 billion – the revenues expected from the excise tax on high-premium insurance plans.

$20 billion – the estimated penalty payments made by uninsured individuals.

$27 billion – the estimated penalty payments to be made by employers whose workers will receive subsidies via the exchanges.

$12 billion – the estimated indirect effects on federal revenues associated with the expansion of federally subsidized insurance.

$500 billion – the projected net cost over 10 years for the proposed expansions in insurance coverage.

$49 billion – the estimated net reduction in federal budget deficits of over the 2010–2019 period.

29 million – The number of uninsured nonelderly people who would have coverage by 2019.

25 million – the number of nonelderly residents who would still not be insured by 2019 (about one-third of whom would be unauthorized immigrants).

11 million – the projected increase in the number of enrollees in Medicaid.

Source: Congressional Budget Office.

Will the Dems Go It Alone on Health Reform?

CapitolThe New York Times is carrying an article this morning saying that two of the three Republicans in a small group called the “Gang of Six” who are trying to forge a bipartisan compromise on health care have requested numerous major changes in a proposal drafted by the chairman of the Senate Finance Committee, reducing the chances that he can win their support.

Some of the issues they are raising drive right at the core differences between the parties. For example, the Times says that the Republicans, Senators Michael B. Enzi of Wyoming and Charles E. Grassley of Iowa, have told Senate Finance Committee Chairman Max Baucus of Montana that health legislation must include language affirmatively prohibiting the use of federal money to pay for abortion.

The report says that the two senators are asking for the restriction to apply to any subsidies that help low-income people buy insurance. In addition, they said, health plans should not be obliged to provide abortion. Thus, they said, the bill should “include a conscience clause to protect entities from being required to contract with abortion providers.”

In addition to this objection, Enzi and Grassley have raised a number of others. For example, they have apparently objected to the fees that Mr. Baucus wants to impose on health insurance companies, clinical laboratories and manufacturers of medical devices.

Five year wait for legal immigrants.

They also want a five-year waiting period for legal immigrants to receive tax credits, or subsidies, to help them buy insurance.

Perhaps one of the biggest philosophical objections the republicans are making has to do with the individual mandate that would fine a family that went without coverage up to $3,800 a year. Grassley, according to the Times, has reservations about this approach. He believes that “the individual responsibility to have health coverage should be reconsidered and replaced with a reinsurance policy to ensure that affordable health coverage is available to everyone in a voluntary system, with a lower overall cost for the package,” one document says.

This final objection, to me, is sounds like Grassley is saying, “Let’s start over.” While this may not be a bad idea, it will not produce a bill out of the Senate that has bi-partisan support, and could force the Democrats to try to pass a bill without republican support.

Attention shifts to “Group of 17.”

It seems that President Barack Obama recognizes this and  is already gearing up for such a fight. According to the Washington Post, he has already turned his attention from the “Gang of Six” to the “Group of 17” who are moderate Democrats in the Senate and who are leery of the high price tag of health care reform and its impact on the federal deficit.

Nevertheless, the Post points out, if Democrats turn to reconciliation, a procedural move that would cut off a Republican filibuster and enable the bill to pass with 51 votes, the 17 votes could become even more important.

In the next day or, two, we will probably know whether a bill will surface that has bi-partisan support, or if the Democrats will try to go it alone.

Meanwhile, I am sure that many Democrats are reading a USA TODAY/Gallup Poll conducted after President Obama’s speech to Congress last week that “shows Americans almost evenly divided over passing a health care bill. According to the poll, six in 10 “say Obama’s proposal, if enacted, would not achieve his goals of expanding coverage to nearly all Americans without raising taxes on the middle class or lowering the quality of health care. For the first time, a majority disapprove of the way he’s handling health care policy.”

Photo credit:

Kitzhaber Delivers Wake Up Call to AHIP

It is far too easy sometimes to get ourselves bogged down in the intricacies of a debate. Take healthcare for instance. We can talk about the merits of having a public health plan versus the benefits of having the private sector use its innovation to show us the way out of the growing financial woes being caused by our current healthcare system.

Once in a while we need a slap in the face, a cold shower, that Americano with no room for cream.  That is exactly what John A. Kitzhaber, MD, Governor of Oregon 1995-2003, delivered to those gathered to hear the keynote address this morning at AHIP Institute in San Diego, CA.

The third wheel on a panel that featured Jeb Bush, the former Governor of the State of Florida and Howard Dean, MD, Chairman, Democratic National Committee, 2005-2009; Founder, Democracy for America, and the former Governor of Vermont, Kitzhaber stole the show.

Dressed in a jacket, white shirt, tie, pressed blue jeans and cowboy boots, Kitzharber made no bones about the fact that we are borrowing from our kids to pay for health care today. But, rather than dwelling of the finer details of how to fix the current system to provide coverage to more people, Kitzharber told the representatives of America’s health insurance plans that they were missing the point and needed to change their business model.

“Healthcare is a means to an end,” he said. “The end is health.”

Kitzharber noted that most of the factors that contribute to poor health in this country have nothing to do with access to health insurance coverage. They are lifestyle choices, environmental issues and so fourth.

If we really want to address health, we need to work on developing a system that promotes health and not one that is not geared towards spending massive amounts of money on people after they have reached a health crisis that could have been prevented with the proper emphasis in prevention and wellness.

I think that slap in the face was exactly what this audience needed, and I think they knew it too judging by the amount of applause Kizthaber received for his comments.

Kennedy Health Bill Expected Monday.

The Washington Post is reporting this morning that Sen. Edward M. Kennedy (D-Mass.) is circulating the outlines of sweeping health-care legislation that would require every American to have insurance and would mandate that employers contribute to workers’ coverage.

The newspaper noted that in many respects the plan being circulated adopts the most liberal approaches to health reform being discussed in Washington citing as an example the fact that the plan embraces a proposal to create a government-sponsored insurance program to compete directly with existing private insurance plans.

The draft summary, according to the Post, also calls for opening Medicaid to those whose incomes are 500 percent of the federal poverty level, or $110,250 a year for a family of four.

The post also reported that a top administration official said the White House expects Kennedy to unveil his bill Monday. A timetable released by Kennedy’s office calls for Democrats on the Senate health committee to meet Tuesday, with a bipartisan session scheduled for Friday. Committee markups could begin June 16.

If Kennedy keeps to that ambitious schedule, it would put him ahead of several other Democratic leaders crafting health bills.

Could this bill, with its proposed expansion of an already unsustainable entitlement program, just be a way of softening up the opposition for what appears to be a bit tamer bill that is expected to emerge from the Senate Finance Committee? In contrast to Kennedy’s bill, the legislation being crafted by Sen. Max Baucus (D – MT) will probably come across to lawmakers as a much easier to pass alternative.

With this activity going on in Washington next week, it should make for interesting discussion at the meeting of America’s Health Insurance Plans (AHIP) scheduled to kick-off Tuesday in San Diego. I will be there and will be blogging about what I am hearing.

Health Insurers Agree to End Charging Higher Premiums for Women.

Yesterday, on this blog, I referred to the national healthcare reform debate as being like a chess game with each side making moves in turn that will eventually lead to the final outcome.

In yesterday’s blog post, I wrote about how, on Monday of this week, a conciliatory position was struck by Senator Charles E. Schumer (D-NY) who said that any new government-run insurance program should be made to comply with all the rules and standards that apply to private insurance.

Schumer went on to list out a series of principles that should apply to any public plan. This included:

  • The public plan must be self-sustaining. It should pay claims with money raised from premiums and co-payments. It should not receive tax revenue or appropriations from the government.
  • The public plan should pay doctors and hospitals more than what Medicare pays. Medicare rates, set by law and regulation, are often lower than what private insurers pay.
  • The government should not compel doctors and hospitals to participate in a public plan just because they participate in Medicare.
  • To prevent the government from serving as both “player and umpire,” the officials who manage a public plan should be different from those who regulate the insurance market.

Still, the insurance industry through Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, responded to the Schumer plan by saying, “We are very, very grateful that members of Congress have been thoughtfully looking at our concerns.” But she said she still saw no need for a public plan “if you have much more aggressive regulation of insurance,” which the industry has agreed to support.

That was Monday. On Tuesday, Ignagni made her move on the chess board by offering to end the practice of charging higher premiums to women than to men for the same coverage. She made the offer in testifying before the Senate Finance Committee and with a nudge from Senator John Kerry, (D-MA), who, according to the New York Times, told Ignagni, “The disparity between women and men in the individual insurance market is just plain wrong, and it has to change.”

The Times pointed out that women are often charged 25 percent to 50 percent more than men for insurance providing identical coverage. In interviews last fall, insurance executives said they had a sound reason for the different premiums: Women ages 19 to 55 tend to cost more than men of the same age because they typically use more health care, especially in the childbearing years. Moreover, insurers said women were more likely to visit doctors, to get regular checkups, to take prescription medications and to have certain chronic illnesses.

The importance of the leveling the cost of insurance between men and women really has to do with plans for Congress to provide tax credits or subsidies to millions of people with low or moderate incomes to help them buy insurance. If the insurance being purchased is priced higher for a woman than it is for a man then the woman will end up receiving less assistance from the government than would a man.

The move on the part of Ignagni to agree to parity in pricing will help tidy up this issue and will better position the industry to continue argue against the need for a government-run health plan designed to compete with private plans to provide coverage for low income persons.

With these day-to-day serves and volleys, I may soon need to change my analogy from that of a chess match to that of a fast-paced tennis match.