Thursday, December 29, 2011

Physician's Briefing - Palivizumab Often Prescribed Improperly in Primary Practice

Physician's Briefing

Kids with a medical home have fewer sick visits | Reuters

Kids with a medical home have fewer sick visits | Reuters

Weighing in on SHAPE Act

The Marietta Daily Journal - Weighing in on SHAPE Act

State gets $5 million bonus for kids’ program | Georgia Health News

State gets $5 million bonus for kids’ program | Georgia Health News

A real medical emergency | The Augusta Chronicle

A real medical emergency | The Augusta Chronicle

WABE: Georgia's Foster Care System Improves (2011-12-27)

WABE: Georgia's Foster Care System Improves (2011-12-27)

Teens Who Express Own Views With Mom Resist Peer Pressures Best

Teens Who Express Own Views With Mom Resist Peer Pressures Best

Ex-NFL players blame league for brain injuries - The Times-Herald

Ex-NFL players blame league for brain injuries - The Times-Herald

Wal-Mart pulls infant formula batch out of caution after Mo. baby's death; no recall issued - Winnipeg Free Press

Wal-Mart pulls infant formula batch out of caution after Mo. baby's death; no recall issued - Winnipeg Free Press

Tuesday, December 20, 2011

Seven land mines of hospital employment contracts :: Dec. 19, 2011 ... American Medical News

amednews: Seven land mines of hospital employment contracts :: Dec. 19, 2011 ... American Medical News

How states are keeping doctors from moving out :: Dec. 19, 2011 ... American Medical News

amednews: How states are keeping doctors from moving out :: Dec. 19, 2011 ... American Medical News

Increase In Nonalcoholic Steatohepatitis Spurred By Obesity And Diabetes Epidemics

Increase In Nonalcoholic Steatohepatitis Spurred By Obesity And Diabetes Epidemics

Increase In Nonalcoholic Steatohepatitis Spurred By Obesity And Diabetes Epidemics

Increase In Nonalcoholic Steatohepatitis Spurred By Obesity And Diabetes Epidemics

Sun's UV Rays May Stop Spread Of Chickenpox

Sun's UV Rays May Stop Spread Of Chickenpox

Panel backs insurance exchange for small firms | Georgia Health News

Panel backs insurance exchange for small firms | Georgia Health News

Shaping up » Local News » The Daily Citizen, Dalton, GA

Shaping up » Local News » The Daily Citizen, Dalton, GA

Sunday, December 18, 2011

Youth With Behavior Problems Are More Likely To Have Thought Of Suicide

Youth With Behavior Problems Are More Likely To Have Thought Of Suicide

In-Store Calorie Signs Reduce Teenage Sugary Drink Consumption

In-Store Calorie Signs Reduce Teenage Sugary Drink Consumption

Asthma During Pregnancy - Are There Subsequent Risks For Baby?

Asthma During Pregnancy - Are There Subsequent Risks For Baby?

Although Cigarette And Alcohol Use At Historic Low Among Teens, Abuse Of Alternate Tobacco Products, Marijuana And Prescription Drugs Rife

Although Cigarette And Alcohol Use At Historic Low Among Teens, Abuse Of Alternate Tobacco Products, Marijuana And Prescription Drugs Rife

Hospital employment a losing proposition in the short-term - FierceHealthcare

Hospital employment a losing proposition in the short-term - FierceHealthcare

Macon Pediatric Resident Dies in Car Crash


Macon Pediatric Resident Dies in Car Crash

It is with extreme sadness that we inform you of the death
of Empress Hughes, DO, a first year pediatric resident at the Medical Center and Mercer in Macon. She was fatally injured in a car crash en route to the hospital on Monday, Dec. 12. Empress served as the Resident Representative to the Board of Directors of the Georgia Chapter-American Academy of Pediatrics. Dr. Divay Chaudhry was also injured in the same accident and is recovering from his injuries. Both Divay and Empress attended the Fall meeting of the Chapter and participated in the Resident’s jeopardy session at the meeting and many of our members met her there. The entire Georgia Chapter family extends deepest sympathies to Dr. Hughes’ family; and our wishes for a full recovery to Dr. Chaudhry. 

Wednesday, December 14, 2011

Teen Smoking And Drinking Drops, Marijuana Consumption Rises, USA

Teen Smoking And Drinking Drops, Marijuana Consumption Rises, USA

Pediatric Weight Management: Researchers Develop 'Conversation Cards' To Broach The Subject

Pediatric Weight Management: Researchers Develop 'Conversation Cards' To Broach The Subject

Guest Commentary: 4 hard truths about bundled payments - FierceHealthFinance - Health Finance, Healthcare Finance

Guest Commentary: 4 hard truths about bundled payments - FierceHealthFinance - Health Finance, Healthcare Finance

Healthcare spending varies dramatically by state, age - FierceHealthFinance - Health Finance, Healthcare Finance

Healthcare spending varies dramatically by state, age - FierceHealthFinance - Health Finance, Healthcare Finance

Congress likely gridlocked on SGR fix - FierceHealthFinance - Health Finance, Healthcare Finance

Congress likely gridlocked on SGR fix - FierceHealthFinance - Health Finance, Healthcare Finance

Tuesday, December 13, 2011

Preterm Birth Impairs Baroreflex Sensitivity in Infants

Physician's Briefing

Georgia fares worse in doctor supply | The Augusta Chronicle

Georgia fares worse in doctor supply | The Augusta Chronicle

Hospitals Clash With House Republicans On Medicare Cuts – Capsules - The KHN Blog

Hospitals Clash With House Republicans On Medicare Cuts – Capsules - The KHN Blog

Bill would require Medicaid to pay promptly - Modern Healthcare


Bill would require Medicaid to pay promptly


By Jessica Zigmond
Posted: December 12, 2011 - 2:30 pm ET

Reps. Brian Bilbray (R-Calif.) and Anna Eshoo (D-Calif.) have introduced legislation that would require the Medicaid program to reimburse all providers—including nursing facilities, hospitals and community health centers—in a more timely manner.

The bill, known as the Fair Pay to Medicaid Providers Act (PDF), would extend to these healthcare providers a provision that requires Medicaid to reimburse 90% of claims to physicians in 30 days and the remainder within 90 days, according to Eshoo's office.

“This is a common-sense bill directed to patients,” Eshoo said in a news release. “Our healthcare professionals and facilities deserve to be reimbursed in a predictable and consistent timeframe in order to provide optimal care to those in need. We must ensure that our communities' most vulnerable citizens do not face a disruption in healthcare services, and our bipartisan bill helps to make sure their care is not held up by red tape and bureaucracy.”

The bill has been referred to the House Energy and Commerce Committee.

Coverage Of Bariatric Surgery Is Spotty For Obese Kids - Kaiser Health News

Coverage Of Bariatric Surgery Is Spotty For Obese Kids - Kaiser Health News

Berwick: Don’t Blame Medicare, Medicaid. It’s The Delivery System - Kaiser Health News

Berwick: Don’t Blame Medicare, Medicaid. It’s The Delivery System - Kaiser Health News

WABE: Georgia House Health Committee Chair Promises to Look for Ways to Send More Tobacco Settlement Money to Stop Smoking Efforts. But She's Not Optimistic (2011-12-12)

WABE: Georgia House Health Committee Chair Promises to Look for Ways to Send More Tobacco Settlement Money to Stop Smoking Efforts. But She's Not Optimistic (2011-12-12)

More students apply to Medical College of Georgia  | ajc.com

More students apply to Medical College of Georgia | ajc.com

Georgia fares worse in doctor supply | The Augusta Chronicle

Georgia fares worse in doctor supply | The Augusta Chronicle

Football Could Contribute To Strokes In Adolescents

Football Could Contribute To Strokes In Adolescents

Surprisingly Early Gift Of Gab Revealed By Baby Lab

Surprisingly Early Gift Of Gab Revealed By Baby Lab

Medicaid contractor indicted for computer theft  | ajc.com

Medicaid contractor indicted for computer theft | ajc.com

Monday, December 12, 2011

Chronic Pain In Children And Adolescents Becoming More Common

Chronic Pain In Children And Adolescents Becoming More Common

HHS' CHIP Program Launches Medicaid.gov


HHS' CHIP Program Launches Medicaid.gov


The Center for Medicaid and Children Health Insurance Program (CHIP) Services launched a new website last week.

The website features guidance on federal policies, statistical breakdowns of Medicaid and CHIP programs, a State Resource Center and information about the implementation of the Affordable Care Act.

In a letter introducing the website, Cindy Mann, director of the Center for Medicaid and CHIP Services, asked for feedback on how to improve its functionality and content. "We are a work in progress," Mann said. "We wanted to make the key elements available as quickly as possible and we have plans for ongoing improvements."

The new website is located at http://www.medicaid.gov/.

Behavioral Problems ID'd in Moderately Preterm Children

Physician's Briefing

In overweight kids, heart risks can start as young as 3, UM study says - Florida - MiamiHerald.com

In overweight kids, heart risks can start as young as 3, UM study says - Florida - MiamiHerald.com

Thursday, December 8, 2011

Pay cut averted for Medicaid, PeachCare | Georgia Health News

Pay cut averted for Medicaid, PeachCare | Georgia Health News

Sloppy recordkeeping can lead practices to trouble with OSHA :: Nov. 7, 2011 ... American Medical News

amednews: Sloppy recordkeeping can lead practices to trouble with OSHA :: Nov. 7, 2011 ... American Medical News

Parting Shot at ‘Waste’ By Key Obama Health Official - NYTimes.com

Parting Shot at ‘Waste’ By Key Obama Health Official - NYTimes.com

The feds’ big Medicaid spend, in one chart - The Washington Post

The feds’ big Medicaid spend, in one chart - The Washington Post

Progress From Portland on Improving Kids’ Healthy Behaviors - Health Blog - WSJ

Progress From Portland on Improving Kids’ Healthy Behaviors - Health Blog - WSJ

Do you practice in an antibiotic-prescribing hot spot? :: Dec. 5, 2011 ... American Medical News

amednews: Do you practice in an antibiotic-prescribing hot spot? :: Dec. 5, 2011 ... American Medical News

Some Children's Cereals Have More Sugar Than Twinkies And Cookies

Some Children's Cereals Have More Sugar Than Twinkies And Cookies

A Mother's Touch May Protect Against Drug Cravings Later

A Mother's Touch May Protect Against Drug Cravings Later

Children With Special Health Care Needs

Children With Special Health Care Needs

Wednesday, December 7, 2011

Monday, December 5, 2011

NAMD Testifies on Pharmaceutical Treatment Issues for Children in Foster Care


December 1, 2011- NAMD Director Testifies Before Senate Committee on Pharmaceutical Treatment Issues for Children in Foster Care 
Washington, D.C. – National Association of Medicaid Directors (NAMD) Executive Director Matthew Salo today testified before the Senate Homeland Security and Government Affairs Committee’s Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security during a hearing focused on the financial and societal costs of medicating America’s foster care children. Mr. Salo told the committee that pharmaceutical coverage and expenditures have been a large and growing concern of the Medicaid Directors for a number of years, particularly psychotropics which pose a unique concern primarily because the trends in costs and utilization are far outstripping every other baseline.

NAMD’s Director discussed the particular concerns for foster care children in the Medicaid program, including some of the findings in the report released by the Government Accountability Office, entitled “Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions.” He noted while psychotropic medications show enormous promise in treating a wide variety of serious conditions, there are concerns about how current prescribing patterns can negatively impact the foster care population. He went on to urge policymakers to ensure valid comparisons are made before drawing conclusions.
In discussing the challenges and complexities of this issue, Mr. Salo told the Subcommittee. “There are unfortunately a number of reasons why state oversight policy, or medical practice may have failed to keep up with the ever changing literature or other developments. These are not meant to be excuses for failure to act, but indicative of the breadth of the challenges that face systemic reform. Furthermore, it cannot be stressed enough how unique are the challenges faced by the children in the foster care system.”

Several states were part of the GAO study and all have been undertaking efforts to address the identified shortcomings. Mr. Salo noted that there is a need for broader systemic reform.

“There are a number of solutions that can and should be implemented to help improve this situation. 1) The GAO report recommends promulgating additional federal guidance from HHS to the states; 2) More clinical research is needed on the effects and implications of treating children of any age and in any situation with psychotropics that have only been tested on adults; 3) More work needs to be done to break down the barriers to coordinating and integrating care for vulnerable populations in Medicaid, with an added focus on the varied, complex and challenging behavioral health conditions experienced by children in foster care; 4) While Medicaid coverage and payment policy can and should change, many of the challenges in this issue are medical policy issues, and as such, require the broader medical community to also adapt; and 5) NAMD, working collaboratively with key partners such as the Medicaid Medical Directors and the State Mental Health Program Directors can develop and disseminate best practices in this area and work with states to implement them.”

Final Medical Loss Ratio Rule Rebuffs Insurance Agents – Capsules - The KHN Blog

Final Medical Loss Ratio Rule Rebuffs Insurance Agents – Capsules - The KHN Blog

Concerns Over Antipsychotic Drug Prescriptions for Foster Kids Spur Potential Legislation



By Rebecca Adams, CQ HealthBeat Associate Editor  December 1, 2011

Sens. Scott P. Brown and Thomas R. Carper plan to write bipartisan legislation to reduce the risks that children in foster care would be inappropriately prescribed psychotropic drugs.


At a hearing before the Committee on Homeland Security and Governmental Affairs, Bryan Samuels, commissioner of the Department of Health and Human Services’ Administration on Children, Youth and Families, said that HHS would give the panel recommendations on what to include in a bill and would try to steer states to do more to prevent overmedicating foster children.


The moves come after a new Government Accountability Office (GAO) report raised concerns about the use of psychiatric drugs in foster care children. Babies were given medication for mental illness, according to the report, even though the drugs could be harmful to young children. A medical expert testified at the hearing that he could not think of any situation in which a baby would need a psychiatric drug.


Thousands of children who live in the five states that the GAO studied were given high doses that could be unsafe. And hundreds of children were taking five or more drugs at one time, even though the GAO said that there is no medical evidence that a regimen of so many medications was safe or effective.


The drugs are often paid for by Medicaid, the federal-state program for low-income earners.
Samuels said that Health and Human Services officials would comply with the GAO recommendation to issue a guidance to state Medicaid and child welfare agencies explaining the best practices for monitoring the use of psychiatric drugs in foster children. But Samuels said that Congress would have to intervene with legislation before HHS could issue a national standard that all state Medicaid agencies would have to follow. Carper, D-Del., and Brown, R-Mass., encouraged him to send them ideas for a bill soon.


Foster Child Testifies

The hearing featured a 12-year-old boy who had been in foster care until he was adopted a few years ago. The boy, Ke’onte Cook, said he had been given about 20 drugs during his life and had taken as many as five at the same time. He had been given little explanation of what the drugs were for. His former foster parents had told him that he had been diagnosed with attention deficit hyperactivity disorder after he threw tantrums. But the boy also received drugs for bipolar disorder and seizures, which he had never experienced. Cook called the multiple prescriptions the “most idiotic” thing that had happened to him in foster care.


“Meds aren’t gonna help a child with their problems,” he said. “It’s just going to sedate them.”
Ke’onte’s adopted mother, Carol Cook, said she had been concerned about the number of drugs he was taking. “He was just lights out,” she said, acting like a zombie within 15 minutes of taking some of the medication.


After Cook and her husband adopted Ke’onte, they decided with a pediatrician to wean him off all of the drugs. The process was not easy.


“He was very interesting the first few months,” she said with a wan smile. He would scream and cry for no apparent reason, she said.


But after a few months, his behavior improved significantly.
“He went from break dancing on the principal’s desk in her office to not going to the principal’s office for a whole month,” she said. From the time the boy entered school at his new home in January until the summer break in May, “he was almost a different child.”


Sen. Tom Coburn, R-Okla., a doctor, said he had studied the boy’s prescription protocol and found that two of the five drugs that the boy had been taking had the opposite effect as the other three. Coburn also said that three of the drugs were not approved for children.


After Ke’onte testified, the audience clapped. He gave Carper a hug and fist bump as he left the room.
Brown said he was “heartbroken” by Ke’onte’s testimony and said he “really was shocked” by the findings in the GAO study.


Report Findings

The GAO found that in all of the five states evaluated — Massachusetts, Florida, Michigan, Oregon and Texas — foster children were at greater risk of inappropriate medication use than children who were not in foster care. Brown said he is sending a letter to Massachusetts officials asking for an explanation.


The rate of foster children who were prescribed five or more psychiatric drugs simultaneously was 0.11 percent to 1.33 percent in the five states, compared to rates of .01 percent to .07 percent among non-foster children in the states studied. GAO investigator Gregory Kutz said the use of five or more drugs is a “high-risk practice.” The report said that “only limited evidence supports the use of even two drugs concomitantly in children.”


Foster children also were given higher doses of the drugs than is considered safe. About 1.12 percent to 3.27 percent of children in foster care were given levels that were higher than the maximum recommended dosage, compared to 0.16 percent to 0.56 percent of children in other types of homes.
And 0.3 percent to 2.1 percent of babies in foster care were prescribed a psychotropic drug, compared to 0.1 percent to 1.2 percent of other children. Some of the anti-anxiety drugs could have been prescribed for physical rather than mental problems, the GAO said. But the report said that “these cases raise significant concerns because infants are at a stage in their development where they are potentially more vulnerable to the effect of psychotropic drugs.”


Samuels said in his testimony that a 2010 study of children in 13 states showed that foster care children in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of children in Medicaid who were not in foster care.


One change that Medicaid directors in some states could make would be to require prior authorization of the drugs before Medicaid will reimburse for them, if state law allows that. In some states, said Matt Salo, executive director of the National Association of State Medicaid Directors, legislatures have banned prior authorization under pressure from drug companies that make the drugs, patient advocates or a general public that is wary of government interference in the physician-patient relationship. Even in those states, however, electronic systems could be established that would issue a warning when certain types of prescriptions are filled.


Samuels said that in his previous experience as child welfare director in Illinois, the state built an electronic database that tracked the prescriptions that foster children received, which made it easier to identify problems.


All of the witnesses said that some type of additional oversight should be undertaken.
“Clearly, we need to do better,” Salo said.

Foster Kids Get More Psychiatric Drugs

Foster Kids Get More Psychiatric Drugs

Childhood Mistreatment Causes Reduced Brain Volume

Childhood Mistreatment Causes Reduced Brain Volume

Georgia DFCS director is out  | ajc.com

Georgia DFCS director is out | ajc.com

Sunday, December 4, 2011

Tavenner faces skepticism on policies, HCA leadership - FierceHealthcare

Tavenner faces skepticism on policies, HCA leadership - FierceHealthcare

Protests against Delta's in-flight vaccine video message - MedPage Today Blogs - 29744

Protests against Delta's in-flight vaccine video message - MedPage Today Blogs - 29744

AMA meeting: Delegates back state flexibility on uninsured :: Nov. 28, 2011 ... American Medical News

amednews: AMA meeting: Delegates back state flexibility on uninsured :: Nov. 28, 2011 ... American Medical News

Most Pediatric Hospital Food Unhealthy

Most Pediatric Hospital Food Unhealthy

When Babies Awake: New Study Shows Surprise Regarding Important Hormone Level

When Babies Awake: New Study Shows Surprise Regarding Important Hormone Level

When Babies Awake: New Study Shows Surprise Regarding Important Hormone Level

When Babies Awake: New Study Shows Surprise Regarding Important Hormone Level

Thursday, December 1, 2011

Medicaid anti-fraud effort shows success | Georgia Health News

Medicaid anti-fraud effort shows success | Georgia Health News

Crash Experts Find Car Seats Protect Overweight Kids, Too

Crash Experts Find Car Seats Protect Overweight Kids, Too

Mobile Clinics, Home Visits Of Little Benefit To Children With Asthma Who Need Care The Most

Mobile Clinics, Home Visits Of Little Benefit To Children With Asthma Who Need Care The Most

Providers cheer Tavenner as new CMS administrator - FierceHealthcare

Providers cheer Tavenner as new CMS administrator - FierceHealthcare

Make sure the way you use an EMR doesn't unwittingly look like fraud :: Nov. 21, 2011 ... American Medical News

amednews: Make sure the way you use an EMR doesn't unwittingly look like fraud :: Nov. 21, 2011 ... American Medical News

Lawmakers Review Child Abuse Laws

Lawmakers Review Child Abuse Laws

An idea to tackle tort reform, defensive medicine in Georgia | Kyle Wingfield

An idea to tackle tort reform, defensive medicine in Georgia | Kyle Wingfield

Thinking Through Health Exchanges- Governing Magazine


TennCare Director Darin Gordon has distinguished himself by asking hard questions about the impact of the Affordable Care Act.
BY: John Buntin | November 29, 2011   Governing Magizine

Open enrollment in the new health exchanges mandated by the Affordable Care Act (ACA) is two years away (Supreme Court permitting, of course). But according to Darin Gordon, director of Tennessee's Medicaid program TennCare and vice president of the National Association of Medicaid Directors (NAMD), many states are just beginning to understand the full range of the impact the ACA could have.

Over the course of the past year, Gordon has made a reputation for himself by asking tough questions about the impact of the ACA on the state insurance market and on economic competitiveness, questions born of his experience as the longest-serving TennCare director in the agency's history. I caught up with Gordon after the recent NAMD annual conference to talk about how the Volunteer State was thinking through the challenges of how -- and whether -- to implement an exchange in this edited and condensed transcript.

You've said that people need to think more carefully about the ways the new health exchanges will interact with existing Medicaid programs. What do you see as the trickiest points of intersection?

There are basically three areas around exchange planning. There's governance, there's the insurance market and there's exchange operations. It seems to me as though there's been a great deal of focus on how to get the governance structure right, which isn't a bad thing. It's a necessary step. But unfortunately, I think in some instances folks are spending more time trying to ascertain who is going to have a seat at the table than working on some of the areas that have more far-reaching implications: the impact of exchanges on the insurance market and then exchange operations themselves.

Let's talk about the potential impact of exchanges on the state insurance market. What are some of your concerns?

Well, it's obviously different from state to state, but let's look at the individual insurance market here in Tennessee. Some states have already taken steps to further regulate that market in the areas of guaranteed issue [guaranteed acceptance of enrollees regardless of health condition] and modified community rating [calculating premiums based on community risk factors rather than individual risk factors]. But there are other states, such as ours, that have not necessarily chosen to take those additional regulatory steps.

We're moving from medical underwriting to guaranteed issue in 2014. We're moving from exclusions and riders which say that certain pre-existing conditions are not covered, to [new rules that require that] all conditions covered on the first day. Where today we have premiums adjusted for age, tobacco, geography, health, gender, etc., we're going to be moving to premiums being adjusted for age, tobacco and geography only. We may be moving from having a group of state-level benefit mandates, which will differ with varying requirements, to a new essential health benefit (now a national standard), which has yet to be fully defined.

So having all that occur at the same time you are trying to manage a mass expansion in Medicaid enrollment, and having the new player [the exchange] come on the scene, where you have folks in the exchange and folks outside of the exchange -- what's that interplay? Our goal, as we're looking at what's the best solution for Tennessee, is trying to make sure that we approach this thoughtfully and ensure as much market stability as is absolutely possible. The last thing we want to see as we go through these changes is significant market disruption to the point that we don't have the competitive marketplace we believe we have today.

Presumably the worst case scenario would be to have insurers pull out of the state because...

Because we didn't approach it intelligently. Yes, absolutely.

The ACA allows states to either set up their own health exchange or have the federal government come in and set up an exchange for them. More recently, the Centers for Medicare & Medicaid Services (CMS) has also floated the possibility of a hybrid partnership model.  Tennessee hasn't made a decision on whether it's going to create a state exchange or not, but you've created the Tennessee Insurance Exchange Planning Initiative to sort of prepare and keep your options open. Could you explain what you're doing?

We spent the last year meeting with a wide variety of stakeholders, traveling thousands of miles, having literally hundreds of meetings just to solicit feedback from various stakeholders, whether they be businesses, agents, brokers, insurers, providers, advocates, you name it. We've had a discussion with them about what an alternative to a federal exchange might look like. We spent over a year doing that and we've released a draft white paper that lays out some alternatives based on those discussions. Then we will be meeting with [Gov. Bill Haslam] in December to give him a report based on what all we've heard, and then hope to have a recommendation on whether the state should operate the exchange or whether we should defer that authority to the federal government.

Let's talk a little bit about exchange operations and the problem of churn. When Medicaid directors and others talk about churning and the need to address it, what are they talking about?

Churn is what happens when people have to move back and forth between or among programs because some factor in their eligibility changes. For example: An adult could be Medicaid eligible when reform starts in 2014. But because he gets a small raise, he has to move out of Medicaid and into the exchange. His children may still be in Medicaid, or maybe one of them is in Medicaid and one in [the state Children's Health Insurance Program].

This is an area that concerns me a lot because government typically designs new programs and then we all talk about how we make people's transition between the new and old programs more smooth, as opposed to just redesigning multiple legacy programs into a single, more functional program. If you look at all the different programs we have, they all offer subsidized health-care coverage based on different criteria. We set up multiple programs that basically do, in essence, the same thing in the end and then struggle with how to help folks transition between them. We are trying to identify ways to minimize the disruption that will occur as people move from program to program when their circumstances change.

Tennessee's "bridge plan" has gotten a lot of attention as a possible solution. Could you explain it?

The bridge plan would basically allow states to offer an alternative to those individuals who have had Medicaid in the recent past. This plan would only be available to those individuals and, in essence, the health plans that would be in that bridge option would be those Medicaid plans that currently provide services to our members. That means that when an individual's circumstances change, then they would have the ability to stay with the same health plan, and the family could stay together. We think that this approach would assist in minimizing some of the issues around churn while also addressing some of the confusion that some family members would have when different members of the family are eligible for different public programs.

What's has reaction from CMS been to this idea?

I think there's been a lot of interest at the CMS level to try to address the issue but it's been somewhat of a challenge to get everyone to get to an actual approval.

What are some of the more pressing questions that CMS hasn't answered yet about exchanges and about exchange design?

The area that is of most concern to us from a timing perspective, again, is the bridge product. That's an important thing for us because it really helps determine where we may go from here. There are several steps the various health plans will have to make with the state insurance commissioner if the bridge option becomes a real option for us.
We also need some guidance on what the federal essential health benefits will be. The law requires that the full actuarial value of any state-mandated health benefits offered by qualified health plans that are not included in the [federal] essential health benefits must be fully funded with state funds. Our Legislature returns this January and if action will be needed regarding the state-mandated benefits, it will have to occur during this session.

There are still questions related to CMS's [September] proposed hybrid partnership model of running exchanges with the states. They came out with a proposal which didn't really feel like a partnership; it was actually still a federal plan. States were expecting some things that they didn't necessarily see with the proposal that was shared. If the feds want to be able to assist states that choose to operate their own exchange, the federal government should consider developing the process for determining the exemptions from the individual mandate. They could develop the rating system for plan quality and cost metrics. They could develop enrollee satisfaction tools and measurements. Consistency here might be helpful and it should reduce some level of the implementation complexity for the states. Also, the determination of the affordability and the minimum value of employer-sponsored insurance, that's going to be challenging. Some have even talked about having the federal government determine the eligibility for the premium tax credits altogether.
The states have had additional discussions with the federal government on this front. I know they are taking another look at this given the feedback; however, we really do not have enough clarity to be able to determine whether these are functions that the federal government is truly willing to take on.

We're also looking at the process CMS is proposing for what states will be required to do if changes are needed to their programs once fully operational. What has been discussed thus far is a process similar to the State Plan process used in Medicaid. That process is very cumbersome. It's also perplexing given that the state-based exchanges are supposed to be self-sustaining and not dependent on federal funding for ongoing operations, yet states would be required to get federal approval for changes they feel are appropriate. If no federal funding is involved at that point, why should states have to keep going back and asking for federal permission? That makes no sense.

It would also be enormously helpful to the states to have the final exchange rules. While the draft rules were released in the last several months, the comments that were submitted during that time may potentially reshape those rules. At times, CMS has said, "Look, we've answered that in our regulations." But then other times we talk to them about concerns with some of the regulations and their comments are: "Well, submit your comments and we'll change it."
Well, which is it? Are they set in stone, or are they still being shaped? If they are set in stone, we have concerns that have not been addressed, and if they are still being shaped, we have problems, because we need answers now. Not knowing what the final rules will be makes conceptualizing these complex systems much more challenging.

This brings me to a big question. Former CMS Administrator Don Berwick spoke at the NAMD conference and I was struck by how he began his speech. He said, "This is a speech that might fail." I think that why he said that was because his speech was very much about changing the delivery system, improving the quality, and not about helping the states pare costs.

Yeah, absolutely. The states are in the position where we need solutions that could be implemented quickly and see savings in the next several months. The things that he discussed were items that require some significant lead time for implementation and would take a great deal of time before you start seeing the financial benefits.

Right. So was it a speech that succeeded, or was it a speech that failed?

The way that I interpreted it was that the solutions that he was talking about were not necessarily the solutions that can solve the immediate problems we have, from a financial perspective. I believe that his speech sought to explain the types of things we should be looking at just beyond the immediate -- which is fair. The way that I've described it is it's like saying to someone, "We have this fire on our doorstep," and them responding by talking about constructing a fire suppression system in the front room. While it is important to be thinking of the things to minimize these fires in the future (and to the extent bandwidth exists to do so, it is advisable) we have to be focused on the incredible challenge of fighting the fire that is right in front of us first. When the immediate crisis is contained, looking at and implementing various mid to long term strategies to limit future problems must occur, or else the crisis will become far too common.

Let's talk about the vendors with whom states and the feds will have to work. When I talk to vendors, there's a lot of frustration about the high cost of responding to vague RFPs.

If you really look at it, in all fairness to everybody, the timelines are incredibly short and there are many IT projects currently ongoing. In the area of e-health, for example, states are deploying electronic health record systems and setting up infrastructure that allows those systems to interface and exchange information in a seamless and coordinated fashion. Other states have been retooling their Medicaid management information systems while others are working on new eligibility systems. And then, with the insurance exchanges, most every state and the federal government will be coming to market at the same time trying to get quality contractors in to stand these up as well. We've already started to see a strain in that market with respect to having enough people with the right skills to help implement these types of systems successfully. My concern is that when the federal government and the larger states go out to bid on these projects, they will garner the best of the remaining resources. The other states may then be further challenged in finding experienced people with the right skills to stand these things up. The resource challenge coupled with the aggressive timelines make this a very real concern.

A grim diagnosis for our ailing U.S. health care system - The Washington Post

A grim diagnosis for our ailing U.S. health care system - The Washington Post