Andy Miller, Georgia Health News, Author at ��ϳԹ�� News

Georgia Legislative Panel Hears Concerns About Surprise Medical Billing

Andy Miller, Georgia Health News — Wed, 08 Feb 2017 18:00:16 +0000

Physician, hospital and insurer groups each expressed concerns Tuesday about Georgia Senate legislation that aims to prevent “surprise billing’’ of patients, but perhaps the most compelling testimony came from a legislator’s wife.

The Senate Health and Human Services Committee heard testimony on a proposal to halt these medical bills, which can come from ER doctors, anesthesiologists, radiologists, pathologists and others who are not in a patient’s insurance network — even though the hospital where they work is.

Vicki Willard, wife of Rep. Wendell Willard, a Sandy Springs Republican, testified that in August, she went to Emory Saint Joseph’s Hospital after experiencing numbness in her cheek and arm.

She knew St. Joseph’s was in her insurance network. “I’m an educated advocate for my health care,’’ she told the panel.

But four weeks after her treatment there, Willard said, she received an unexpected $700 bill from a cardiologist.

She then called her insurer. The first cardiologist who had seen her, she found out, was a network doctor. But a second cardiologist —��the one who sent her the bill —��wasn’t in her network, even though that doctor was in the same medical group as the other doctor.

“I have absolutely no control over that,’’ Willard said. “That’s extremely frustrating.”

Sen. Renee Unterman (R-Buford), a nurse who chairs the panel and sponsor of Senate Bill 8, said health insurers and medical providers can’t agree on a solution to the “complicated issue.’’

“It’s like putting cats and dogs in a room,’’ she said. “The one that suffers the most is the consumer.”

Beth Stephens of Georgia Watch, a consumer watchdog organization, said issues with medical bills were the No. 1 reason why consumers called her organization in 2016.

The two current proposals on surprise billing — Unterman’s in the Senate and one in the House — call for greater transparency about which doctors are in an insurer’s network and an estimated cost of the procedure.

The Unterman proposal would also create a database of reasonable charges for a procedure. If a bill is disputed, the insurer and doctor would have to work out a resolution.

“I have tried my best to be fair,’’ said Unterman. “To listen to both sides.”

Representatives from the insurance industry said that one database of rates that Unterman’s bill would use, Fair Health, should not be used as a benchmark for reimbursements because it’s too high.

Physician organizations have said they support Fair Health, and blamed “narrow’’ insurance networks for many instances of high non-network charges.

Hospital groups, meanwhile, said the transparency required to educate patients about network providers should be shared among hospitals, physicians and insurers.

Other states, including Florida, recently passed legislation to address the problem.

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Interstate Health Insurance Sales Has A Tryout In Georgia But No Takers

Andy Miller, Georgia Health News — Thu, 08 Dec 2016 19:28:06 +0000

Among Republican ideas to transform the health care system is a proposal to allow health insurers to sell their policies across state lines.

President-elect Donald Trump and Rep. Tom Price, the Georgia congressman picked by Trump to lead the Department of Health and Human Services, have backed the proposal. They and other advocates see it as a way to boost competition. The interstate sales idea is part of a general GOP blueprint to replace the 2010 Affordable Care Act, often called Obamacare.

In Georgia, the interstate sale of health insurance has already had a five-year tryout.

The state legislature in 2011 passed a bill letting insurers sell any policies in Georgia that they offer in other states. The legislation was hailed by supporters and business groups as a way to skirt the state’s required benefit coverages —��such as screenings for cervical, prostate and colorectal cancer, along with mammograms — and thus lower the sticker price of insurance.

The law is still in effect. But since it was passed, no health insurer has taken advantage of it.

And since January, an obscure provision of the ACA has been in effect, letting individual states agree among themselves to allow sales by one another’s health insurance companies. Although several states have passed laws to move toward such a compact, none has made any deals to sell across state lines, insurance experts and regulators told .

Each state has its own set of health insurance regulations, though large employers that self-insure (those that use their own funds to cover employees’ health expenses) are exempt from these state rules.

Currently, the idea of eliminating barriers to interstate sales is drawing some opposition from state insurance regulators and insurance industry officials, last week. “That sounds like a silver bullet to solve a major problem, and there are no silver bullets,” said Louisiana Insurance Commissioner Jim Donelon. “There are no simple answers.”

Some Democrats have about the erosion of state consumer protections.

Graham Thompson, executive director of the Georgia Association of Health Plans, an industry group, said Wednesday that the GOP proposals aimed at helping health insurers are “a positive change in tune’’ after industry losses suffered under the Affordable Care Act.

A federal law allowing interstate sales across the country “could be different’’ from the more limited Georgia experience, Thompson said. “We’ll have to see the details.”

He said that one obstacle to insurers selling out-of-state policies in Georgia is that “all health care is local —��and all health care costs are local.” So insurers would still have to strike contracts with local hospitals and other medical providers, Thompson noted.

Bill Custer, a health insurance expert at Georgia State University, said a handful of other states have passed interstate insurance laws similar to Georgia’s, but the effect has been the same.

State insurance regulators told the Journal that in states requiring locally licensed insurers to offer extensive coverage, healthy people might abandon those companies to buy bare-bones policies from out of state. That, in turn, would leave local plans insuring mostly people with health problems, who need broader, more expensive coverage. As the locally registered insurance companies absorb the financial hit, the state might feel pressure to relax standards to give them a break.

But the proposals pushed by Price and House Speaker Paul Ryan (R-Wis.) would still require a minimum set of essential benefits at the federal level in order to qualify for tax credits, said Custer of Georgia State. So the effect of interstate insurance could be minimal, he said.

“It’s unlikely to have a large effect on competition in any market,’’ he said.

An industry trade group, America’s Health Insurance Plans, said in a statement to Georgia Health News on Wednesday that “our first interest is in providing consumers with competition and choice, which empowers them to better health and financial stability. We want to work with lawmakers to bring our experience and lessons learned to the table, and we want to cooperate and collaborate to find solutions that work for consumers.’’

Cindy Zeldin, executive director of consumer group Georgians for a Healthy Future, said interstate sales “would erode rights and protections for health care consumers, complicate their efforts to find in-network providers, and do little to nothing to improve affordability.’’

More than 500,000 Georgians are at risk of losing their coverage if the ACA is repealed without an adequate replacement, she said. “Buying a health insurance plan from Texas or Idaho isn’t going to solve the problem, and would leave consumers in Georgia with little recourse if they were treated unfairly by an insurance company based in another state or in cases of fraud.”

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Ga., Calif. Hospitals Sue Blue Cross Plan For Sending ER Reimbursements To Patients

Andy Miller, Georgia Health News — Thu, 30 Jun 2016 09:00:46 +0000

Blue Cross and Blue Shield of Georgia faces separate lawsuits accusing it of sending reimbursement money for emergency room care directly to patients — and not to the hospital because it isn’t part of the insurer’s network.

That’s costing the hospitals money since patients don’t always turn over the funds, according to the lawsuits, filed by Polk Medical Center in northwest Georgia and Martin Luther King, Jr. Community Hospital in Los Angeles — 2,000 miles apart. Each suit also says some patients have sought to profit from receiving the direct payments for their ER care.

By sending money directly to patients, Polk Medical Center says the insurer forces the hospital to find ways to collect it. Even though patients are obligated to pay the facility the amount sent to them by Blue Cross, in some cases they have spent the money, according to the lawsuit.

The Polk lawsuit said that Blue Cross, in its new payment process, was pursuing “retaliation’’ for the Cedartown, Ga., hospital’s not agreeing to “unreasonable and unfair” terms in order to be part of the insurer’s network. Hospital officials said the payment shift has hurt the hospital financially.

“Blue Cross insures a significant number of individuals in Polk County,’’ said Tommy Manning, the attorney for the Floyd Medical Center system, of which Polk Medical Center is a part.

Manning said that Blue Cross has sent ER payments to patients for several months.

And he said he was unaware of the Los Angeles lawsuit prior to the filing of the Polk complaint.

The lawsuit from Martin Luther King, Jr. Community Hospital alleges that “most of the MLK patients who receive checks from [Blue Cross of Georgia] are unaccustomed to receiving payments in such large amounts. Some of these patients do not know that they are required to endorse those checks over to MLK. Other patients know that they should endorse those checks over to MLK but instead use such funds to pay for their personal expenses. When MLK attempts to collect the amounts from these patients, the money is often spent.”

In the case of patient “B.G.,’’ the suit alleges that the patient went to the MLK emergency room 11 times between Oct. 19 and March 27 for various ailments, including complaints of chest or back pain. Blue Cross of Georgia paid the patient a total of more than $70,000 for these visits to MLK, according to the lawsuit.

The lawsuit said the practice overall has caused MLK to suffer damages in excess of $350,000.

Blue Cross declined comment on the lawsuits, citing pending litigation.

Patients are protected under federal law when seeking care in hospital emergency rooms. Under the Emergency Medical Treatment and Labor Act (EMTALA), they must at least be stabilized and treated, regardless of their insurance status or ability to pay.

Manning said this month that he’s not aware of any other insurer in Georgia paying the patient instead of the hospital.

At least one other major hospital that is not part of the suits has reported difficulty in getting payments from Blue Cross when it was out of the insurer’s network. Officials at Grady Memorial Hospital in Atlanta said that when it was out of Blue Cross’ network for the four months ending in March 2015, the insurer sent reimbursement payments to some patients and not to Grady.

Daron Tooch, a Los Angeles attorney representing MLK Hospital, said other Blue Cross plans in the United States use similar tactics. The Los Angeles patients worked for a company that has Blue Cross of Georgia coverage, he said. MLK is out of network for the Blue Cross plans in California.

“This is not unique to MLK,’’ said Tooch. “This happens to all out-of-network providers for Blue Cross of Georgia.”

Going after the patients for payment instead of the health plan simply hasn’t worked, attorneys for MLK said. The patients “are typically unable or unwilling to pay MLK for the medical services received,” according to the suit.

Manning agreed. “We will continue to pursue collection with patients, but filing numerous lawsuits would not be fruitful, particularly given that Blue Cross Blue Shield is the party ultimately at fault,” he said.

Asked about the Blue Cross of Georgia payment strategy, the national Blue Cross Blue Shield Association, through a spokesman, declined comment. Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group, said that those types of reimbursement arrangements would vary by plan and by contract. She added that she did not have details on other plans that may do the same.

Paying patients directly is an insurer tool used more commonly in the West, “particularly when non-network facilities are unwilling to negotiate reimbursement related to out-of-network service,’’ said Janet Guptill of the Tatum firm, which provides interim chief financial officers and other executives to health care organizations.

“The insurer takes the position that the provider claim is a private pay issue between the provider and the patient, so the facility has the responsibility to collect the payment from the patient,’’ Guptill said.

Guptill said that when a hospital isn’t in network, its charges for ER and other care tend to be higher than the charges from facilities in the insurer’s network.

For insurers, paying patients directly is “a clever and probably effective tactic,’’ said Chris Kane, a consultant with DHG Healthcare. The hospital, he said, may already be dealing with other collection challenges, including those involving high-deductible health plans.

A hospital attempting to collect the money may end up alienating the patient and thereby discouraging future visits, Kane said.

And patients pocketing the money is another problem, he added. “It’s more troubling if a patient views this as a source of cash.’’

This story was done in partnership with Georgia Health News.

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Will Louisiana’s Medicaid Expansion Be A Harbinger For Georgia?

Andy Miller, Georgia Health News — Wed, 29 Jun 2016 09:00:47 +0000

Louisiana and Georgia have many political similarities. Both states face significant health challenges affecting their populations. And until recently, both states had identical approaches to Medicaid expansion.

Georgia��Gov. Nathan Deal, a Republican, has rejected expansion since he took office in 2011, and GOP lawmakers have repeatedly backed him up. They point to concerns about the future cost of expansion, saying it would eventually put too much strain on the state budget.

But on Friday, Louisiana will become the 31st state — and only the third Southern state — to expand the government program, which is jointly financed by state and federal governments. Gov. John Bel Edwards, a Democrat elected last fall, on his second day in office reversed the course set by his predecessor, Republican Bobby Jindal, by signing an executive order that began the process. Already, have been signed up.

“This isn’t just about��expanding health care coverage and saving money,’’ Edwards said earlier this month when addressing reporters at a seminar sponsored by the Kaiser Family Foundation. “We want��healthier people in Louisiana.” (KHN is an editorially independent program of the foundation.)

And there are small signs of a crack in the opposition to expansion in Georgia.

Georgia state Sen. Renee Unterman (R-Buford), who chairs the Senate Health and��Human Services Committee, recently made��headlines calling for Georgia to “re-examine’’ the possibility of Medicaid��expansion, perhaps looking at a “waiver’’ plan similar to the Arkansas expansion program.

“We have to open that box and look just a��little bit and see what’s available,” , the NPR affiliate in Atlanta. “Hopefully, if you��draw down federal dollars, you can free up some of those state dollars. Right��now, we’re just pumping out state dollars to stay in the midst of the crisis.”

A task force created by the Georgia Chamber of Commerce is formulating proposals that would extend coverage to more of the state’s uninsured but not along the lines of a conventional Medicaid expansion.

Yet Georgia state Rep. Sharon Cooper of Marietta, the Republican chairwoman of the��Georgia House’s Health and Human Services Committee, told Modern Healthcare that she��and her colleagues will entertain the proposals, but added that she doesn’t��believe an expansion plan will solve the problem of access to care.

“The problem with expansion is, ‘Who is going to��treat these people?’ ” Cooper said. “We don’t have the physicians, nurse��practitioners or physician assistants to care for them in rural areas of the��state.”

Since the beginning of��2013, five rural hospitals have closed in Georgia.

A Tale Of Two Southern States

puts Louisiana 50th among states — 10 spots behind Georgia. The��state has high rates of obesity, hypertension and diabetes, and a high��mortality rate from cancer. For Georgia, the rankings note its large number of low-birthweight babies.

Louisiana also has a��very high share of people living in poverty, but Georgia has a��larger percentage without health insurance (16 percent).

One key difference between��Georgia and Louisiana is the Peach State’s much stronger fiscal situation. Louisiana, where the energy industry is very important,��has been hit hard by a decline in oil prices.��Edwards inherited what he calls a record state deficit.

But ironically, that��deficit eased the road for expansion, officials say. “The budget crisis was a��catalyst for the Legislature to come aboard,” said Dr. Rebekah Gee, secretary��of the Louisiana Department of Health.

Aretha Frison, of the New Orleans area, works at an animal hospital part time and battles depression. (Andy Miller/Georgia Health News)

A study found that the��expansion would produce net savings of $184 million for Louisiana, including in-state money paid to hospitals and moving some current Medicaid patients into a��better federal matching rate of 95 percent.

Part of Louisiana’s push to enroll new people in Medicaid��has come through a unique mailing to 105,000 food stamp recipients,��like Aretha Frison, of the New Orleans area, who works at an animal hospital part time and battles depression.

She said she “had been hitting a lot of brick walls” when trying to get psychiatric care but now “it seems like Medicaid is the golden ticket.”

About 180,000 other people��were ‘’auto-enrolled’’ from a��previous��“waiver’’ program that did not provide coverage��for hospital services or prescription drugs.

Help For Hospitals��

Advocates for Medicaid expansion in Georgia often tout the expected benefits for the state’s hospitals, many of which are financially stressed. Though hospitals in��other states have reported substantial revenue gains as a result of��expansion, Louisiana’s complicated system of funding for hospitals may not��yield many clear winners.

Louisiana has had an��unusually heavy reliance on ‘’disproportionate share’’ funding, which the state��pays out to those hospitals serving a large number of indigent or uninsured��patients.

While the giant Ochsner��Health System said Medicaid expansion would be slight improvement for the system financially, Baton��Rouge-based Our Lady of the Lake Hospital said expansion may bring a payment cut overall with the loss of disproportionate share funds.

But low-income��residents should benefit greatly.

More than half of the 4,000 medical patients at the New Orleans CrescentCare health center are expected to qualify for Medicaid under expansion, which may lead to better care options.

For example, Alicia Honomichl, a registered nurse there, said expansion��will help more people obtain PrEP, a medication that can prevent a person from getting HIV from an infected individual, whether through sexual contact or sharing of drug-injection equipment.

Dr. Peter DeBlieux, chief medical officer of��the brand-new University Medical Center New Orleans, said the Medicaid change is��“earth-shattering’’ for his patients.

Patient access��to regular medications will be “low-hanging fruit’’ that will come from��expansion, and “I expect [cancer] screenings to skyrocket,” he said.

This story was done in partnership with .

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A Third Of Ga. Pediatricians Join Together To Form Network To Improve Care

Andy Miller, Georgia Health News — Tue, 01 Sep 2015 09:00:10 +0000

ATLANTA, Ga. — More than 1,100 Georgia pediatricians have joined a new physician-led network that aims to improve quality of care and eventually contract for payments from insurers.

The sign-ups represent roughly one-third of the pediatricians practicing in the state.

Children’s Healthcare of Atlanta, the major pediatric hospital system in the metro area, helped create the nonprofit entity, called the Children’s Care Network.

Dr. Robert Wiskind, an Atlanta pediatrician who is the network’s board chairman, said in an interview that members will share and encourage the use of national “best practices’’ of medical care, such as identifying which children with concussions need to get a CT scan.

The doctors, who practice in the Atlanta region, will also share data on how the services and care they each give to kids compares to their peers.

The creation of the Children’s Care Network comes at a time of dramatic change in the way medical providers are paid for their services. Medicare and private insurers are now emphasizing reimbursement based on quality of care, rather than just paying according to how many procedures are done. That’s known as a “value-based’’ model.

At first, the Georgia network will seek a payment bonus from insurers if members meet quality-of-care standards, Wiskind said. The next step may be providing medical services for a fixed fee.

“At some point, once clinically integrated, we may take on [financial] risk,” Wiskind said. “We’re gearing up to be a value-based provider.”

Wiskind pointed to a pediatric organization in Columbus, Ohio, as a model. Nationwide Children’s Hospital in that city runs a large pediatric accountable care organization, managing the care of 300,000 children on Medicaid through its Partners for Kids organization.

In addition, the Georgia network aims to improve the coordination of the care of children needing to see a specialist. It also seeks to achieve group purchasing power and produce overall cost savings.

The pediatric organization is set up as a “clinically integrated network,” which can allow physicians to maintain their independence while taking advantage of their strength as a group.

Chris Kane, a consultant with DHG Healthcare, says that model “is appealing to physicians and hospitals because it can enhance the coordination of care yet maintain the autonomy of the parties.”

Children’s Healthcare, “with its excellent reputation and scope of services, is a natural partner in the network,” Kane said.

Clinically integrated networks have been established in many urban and suburban areas of the U.S., consultant Kane said.

He said that to be successful – and allay any federal regulatory concerns that the networks could fix prices – the networks “have to show strong clinical and financial integration.” That includes use of common information technology, development of clinical protocols, and care review based on those protocols being implemented, Kane added.

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Freestanding ERs Target Suburbs, Rural Panel Told

Andy Miller, Georgia Health News — Thu, 28 Aug 2014 05:08:30 +0000

This copyrighted story comes from . ��ϳԹ��.

Freestanding emergency departments (ED) have been proposed in Georgia as a potential solution for struggling rural hospitals, or newly closed ones, that want to remain operational in downsized form to help patients in need.

But the trend toward such standalone emergency rooms nationally is totally different from that picture, members of the Georgia Rural Hospital Stabilization Committee were told Monday.

Freestanding EDs are actually proliferating in suburban areas, targeting high-income patients who have private insurance, said Charles Horne of accounting firm Draffin & Tucker. The prevailing emphasis is on patient convenience, not need, he told committee members at a meeting in Cordele.

Earlier this year, Gov. Nathan Deal backed a change in state licensing rules that would permit a stand-alone emergency department and some other services in rural areas that have a financially ailing – or closed – hospital.

But so far, no organization has applied to create such a facility in the state.

Meanwhile, four rural hospitals have closed in the past two years in Georgia, and others are having severe financial problems.

One major drawback for freestanding EDs, as they are currently being proposed in Georgia, is that they would not be able to bill Medicare or Medicaid at the current hospital rates. They would have to bill those programs at a lower “provider’’ rate, or as a hospital outpatient clinic.

“As it is currently constituted, a freestanding ED would have great difficulty in solving the problems of rural health care because of reimbursement,’’ said Jimmy Lewis, CEO of HomeTown Health, an organization of rural hospitals in the state. Those freestanding EDs that are successful financially are in suburban areas and are run by large urban hospitals, Lewis added.

(Last year, a Georgia health agency denied Augusta hospitals a license to build a freestanding ER in Columbia County, an affluent area in the city’s suburbs. Now three Augusta hospital organizations are seeking to build a full-scale hospital in the county.)

Horne said that nationally, the freestanding ERs typically are located within 15 to 20 miles of a full-service hospital.

The number of such facilities has doubled to more than 400 in the past five years, thanks in part to hospital chains such as HCA.

They have been built in Southern states such as Florida, Alabama, Mississippi, Florida, North Carolina and South Carolina.

Horne said 86 percent of standalone emergency departments nationally are hospital-affiliated.

Gov. Deal told lawmakers in March that the kind of downsized hospital facility he envisioned could provide childbirth services and some kinds of elective surgery as well as the usual emergency room services.

Many rural hospitals have large numbers of uninsured patients, and have to absorb the costs of treating them.

That’s one of the reasons why such hospitals are struggling financially.

Experts say these hospitals would be helped by an expansion of Medicaid, as outlined under the Affordable Care Act. That would extend the government program’s coverage to many currently uninsured patients, which in turn would allow the hospitals to get reimbursement.

Beth Stephens, director of the Health Access Program at Georgia Watch, told GHN on Monday that rural hospitals “can’t sustain themselves financially because of all the uninsured patients coming into their ERs.”

Some execs have said Medicaid expansion would boost their revenues.

The state’s political leaders, including the governor and top legislators, have rejected expansion, citing the costs to the state.

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Georgia Seeks Delay On Health Insurance Rate Approval

Andy Miller, Georgia Health News — Tue, 30 Jul 2013 21:17:13 +0000

This story comes from our partner .

Georgia’s insurance commissioner has asked for an “emergency delay’’ of a deadline for approving proposed premiums in the state exchange – an online marketplace – set to roll out under the health reform law.

The commissioner, Ralph Hudgens, cited ‘‘massive rate increases’’ in the insurers’ proposals that led him to make his request.

The deadline for state regulators to approve the insurance rates for the exchanges is Wednesday. Hudgens on Tuesday that Georgia is the only state that has asked for a 30-day extension to continue to analyze the rate increases.

“I was always skeptical of Obamacare,” said Hudgens, a Republican who, like many political leaders in his party, opposed the Affordable��Care Act. “But I never imagined that it would lead to rates being doubled or tripled.”

Nearly everyone with an individual policy will see their premiums rise, he said.

The increases are up to 198 percent for individuals, Hudgens said in a statement Tuesday. “Increases of this magnitude will make coverage less affordable and increase the number of uninsured in Georgia.”

Consumer advocates, though, pointed out that under the ACA, many individuals will have a .

In addition, the current system locks out people with pre-existing health conditions,��according to��Cindy Zeldin of the group , which strongly supports the ACA.

The current average rate for an individual policy “is only average for people whom the insurance industry wanted to cover,’’ Zeldin said. With the health law, she said, “many more people will gain coverage.’’

Hudgens told GHN that his agency had four independent actuaries review the rates submitted for the health insurance exchange in Georgia, which will be run by the federal government.

Six of the seven health insurers had “reasonable’’ rates, but one company submitted premiums that were 11 percent too high, Hudgens said. He did not identify the company with the highest rates.

Hudgens said he is asking��Health and Human Services Secretary Kathleen Sebelius to review the Georgia premiums as well. Hudgens asked that HHS respond to his request for an extension by close of business Tuesday.

An HHS spokesperson told GHN by email late Tuesday that “we are working closely with states to help them meet all deadlines and ensure that the marketplaces are ready for consumers to begin shopping on October 1. We have received Georgia’s request and are reviewing it.”

Nationally, premiums in the health exchanges have been reported higher than current rates in some states but lower in others. The insurance��commissioner in Florida said the individual market will see rate increases of 30 percent to 40 percent for next year.

insurance premiums would drop 50 percent next year for individuals buying their own coverage in the new online marketplaces. But that’s because New York already bars insurers from rejecting people with health problems — a rule that the ACA will be instituting nationwide.

In Maryland, meanwhile, the premium rates proposed by every insurance carrier in the individual market, some by more than 50 percent, according to an analysis by Maryland officials who will be operating the marketplace.

Zeldin urged Hudgens and his staff to follow Maryland’s lead and work to lower the proposed premiums.

The preliminary filings of exchange rates in May showed that companies are offering rates comparable to or even below current employer premiums, said Bill Custer, a health insurance expert at Georgia State University, who was asked to evaluate the filings for GHN.

Custer compared the filings to large employers’ average premiums, which include unhealthy as well as healthy workers, and whose coverage is comparable to that in an exchange.

Graham Thompson, executive director of the Georgia Association of Health Plans, an industry group, said Tuesday that a majority of people are going to see their premiums increase because of the changes under the Affordable Care Act.

The more robust coverage requirements under the reform law “come with higher costs,’’ he said.

“There will be extremes at both ends of the spectrum,’’ Thompson said. “Young, healthy people will see more rate shock,’’ while older people who are unhealthy will see decreases.

But the 198 percent increase, Thompson added, “is an extreme case.’’

Hudgens also said the benefits required under the exchange, or marketplace, are more sweeping than under the present system. “They’re saying that the only thing available is a Cadillac, not a stripped-down Chevrolet,’’ he said.

Young people under 35 will see increases of more than 100 percent, Hudgens said. Middle-aged people will see hikes of up to 100 percent, and older residents will face increases of up to 40 percent, he said.

He predicted that many young people will skip the required coverage and instead pay the penalty for not having it, which is $95 or 1 percent of household income, whichever is greater.

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Economic Changes Hurt The Bottom Line For Rural Ga. Hospitals

Andy Miller, Georgia Health News — Wed, 27 Mar 2013 06:01:00 +0000

This story comes from our partner .

ATLANTA—In the small Georgia town of Demorest, Habersham Medical Center, like many rural hospitals, has seen its patient base change in a way that hurts its bottom line.

As unemployment in the northeast Georgia mountains remains stubbornly high, more of the hospital’s patients have no health insurance.

Among those patients with private coverage, an increasing number have high-deductible policies, which means that patients must pay all or a large portion of the bills out of pocket. And a large share of patients have Medicaid, the federal-state program for low-income people that often doesn’t reimburse enough to cover the cost of services, hospital officials say.

The hospital has enough cash to meet its payroll and service its debt, but that’s about it, says Jack Fulbright, the acting CEO.

Still, Fulbright and hospital authority board member Rick Austin assert that Habersham Medical will survive these tough times. “Habersham Countians are resilient,” Austin says. “We’re tough as a boot up here. We’re not going anywhere.”

Its financial squeeze reflects trends facing rural health care providers, both in Georgia and nationally.

Financial problems recently led Calhoun Memorial Hospital in Arlington in southwest Georgia to close its doors. Earl Whiteley, the hospital’s CEO, cited as a major reason the increase in charity care that the 25-bed facility incurred. “You just can’t continue to give away free care,” Whiteley said in a recent interview.

Stewart-Webster Hospital, 50 miles north of Calhoun Memorial, announced that it, too, was halting operations effective last Friday.

The closure of a hospital can have broad repercussions for a rural area, including:

–Deteriorating health care. People in rural areas tend to have poorer health than elsewhere. Patients’ health outcomes in Stewart County, where Stewart-Webster Hospital is located, were ranked next to last among Georgia counties, according to new�� produced by the University of Wisconsin and the Robert Wood Johnson Foundation. The bottom 10 Georgia counties in the rankings are mainly rural.

–Recruiting doctors to the community. “Rural hospitals are struggling to produce an economic quality of life for young physicians,” says Jimmy Lewis, CEO of , an organization of rural hospitals in Georgia.

–Maintaining economic stability. The availability of health care is vital for a rural area’s economy. A hospital itself is often the top or No. 2 employer in a rural county. Habersham Medical, for example, employs more than 500 people, and the closing of Calhoun Memorial will result in a loss of 100 jobs. Stewart-Webster Hospital is the largest employer in the town of Richland. In addition, a rural area’s ability to attract businesses is partly tied to the availability of a hospital and other health care services.

–Losing important services. In a sign of the overall predicament of rural hospitals in Georgia, at least 40 of them have given up delivering babies. The hospitals blame high costs and low reimbursements. Another big factor is the shortage of rural obstetricians.

A Thin Margin

Rural hospitals generally operate on a very thin margin, even in the best of times.

Brock Slabach of the��says that the latest figures available show rural hospitals nationally have a negative profit margin of 5.68 percent.

That negative trend will be aggravated by sequestration,��the automatic federal spending cuts that went into effect this month. It will reduce Medicare payments by 2 percent and could result in the loss of 12,000 rural hospital jobs, from nurses to support staff, according to Slabach.

Rural health care is accustomed to tough times, but this period appears especially tough, he says.

The Georgia legislature moved quickly this year to help��rural hospitals, passing a bill that will speed renewal of a��fee hospitals pay��allowing the state to draw down an extra $400 million in federal Medicaid funding.

But Georgia hospitals will also lose $400 million in federal indigent care funds under the Affordable Care Act, which has many hospital industry officials concerned. The law cut back payments, called Disproportionate Share Hospital funding or DSH, that had helped cover care for uninsured patients.

The law assumes that most of these uninsured patients would get coverage through an expansion of the Medicaid program. The U.S. Supreme Court ruled last year, however,��that states don’t have to expand Medicaid to cover such people, and Republican Gov. Nathan Deal says Georgia won’t do it because it’s too costly.

Medicaid expansion is necessary to add more paying customers for hospitals, Lewis says. “We don’t have a choice’” in order to save rural providers.

Fulbright of Habersham Medical Center says Medicaid expansion “would certainly help us.” Meanwhile, the hospital is seeking a partnership or affiliation with a bigger hospital, perhaps Northeast Georgia Medical Center in Gainesville.

“We’re looking at everything we’re doing [to find] the best way forward,” Fulbright says. Recently the hospital sought to be annexed by the city of Demorest, which would lower its utility bills and security costs.

No More Deliveries

For many rural hospitals, a key way to cut costs is to eliminate childbirth services.

Last year, Burke Medical Center, south of Augusta, gave up obstetrics, saying it was losing more than $1 million on the services.

Unless a birth is considered so imminent that it’s an emergency — in which case the delivery is performed in Burke’s emergency room — pregnant women must travel 25 miles or so to Augusta to have their babies.
Among Georgia’s “critical access” hospitals — rural facilities with no more than 25 inpatient beds — 32 of 34 have given up maternity services, according to Lewis of HomeTown Health.

One reason is that it’s difficult to maintain a high-cost service with low reimbursement rate.

About 60 percent of births in Georgia every year are covered by Medicaid, and Georgia physicians and hospitals say the government insurance program generally does not pay them enough to make up for the costs of the care. Georgia obstetricians have not had a Medicaid pay increase in more than a decade.

“Payments don’t cover deliveries and follow-up care,” says Lewis. And if there’s only one OB in an area, that doctor is always “on call,” he adds.

Pat Cota, executive director of the Georgia OBGyn Society, says roughly 40 counties in Georgia — one in every four — has no OB/GYN. “Between Athens and Augusta, there’s no delivery hospital.” Cota says. “It continues to get worse and worse.”

Pregnant women in Burke County get prenatal care through family medicine physicians and nurse practitioners in the area.

Infant mortality is improving in the state, though Georgia still ranks among the bottom 10 states on that measure, says Dr. Paul Browne, director of maternal-fetal medicine at Georgia Regents University in Augusta, which is helping Burke County with its prenatal care. He adds that the maternal death rate in the state is actually getting worse.

Increased reimbursement for physicians is a critical need, Browne says. But he acknowledges that it’s hard to persuade budget makers to include such funds given the state’s financial crunch.

The big question, he says, is: “Will the state subsidize rural health care in Georgia?”

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Grover Norquist Prods Georgia Legislators To Drop Hospital Tax Used To Raise Funds For Medicaid

Andy Miller, Georgia Health News — Wed, 03 Oct 2012 13:42:04 +0000

This story comes from our partner��.

The battle over Georgia’s hospital tax suddenly heated up last week, ignited by the attention-grabbing entrance of national anti-tax leader Grover Norquist.

The Washington-based activist, in a letter to Georgia legislators, said renewing the hospital fee, which raises money for the state’s Medicaid program, would kill jobs and raise health costs. He urged state lawmakers to oppose renewing what he called “a bed tax.”

Norquist is the author of an anti-tax pledge that has been signed by many of the nation’s Republican lawmakers, including leading ones from Georgia. He said renewing the hospital tax would amount to “a violation” of that promise.

Now, some major Georgia hospital organizations have fired back at Norquist and come out strongly in support of the tax, which expires in July.

Children’s Healthcare of Atlanta, Grady Health System in Atlanta, Memorial University Medical Center in Savannah and HomeTown Health, an association of rural hospitals, delivered a letter of their own to leading Georgia officials Tuesday. It said that not renewing the provider fee could double Medicaid’s already sizable financial shortfall.

If the fee is killed, “the burden of funding Medicaid and caring for the most vulnerable Georgians would fall entirely on the backs of state and local taxpayers,” said the hospital group, called the Coalition for Medicaid Payment Equity.

A rejection of the hospital tax, the coalition letter said, would probably cause Medicaid patients to lose access to health care; endanger the finances of safety-net hospitals; and raise costs to the state.

They noted the hospital fee is not levied on individual patients or on hospital beds, but is based on hospital net patient revenue. More than 40 states use such provider assessments to help cover the costs of their Medicaid programs. With bad economic times battering state budgets, some states in the past five years have increased taxes already in place or approved new ones on hospitals, nursing homes or managed care plans.

The states use the funds to increase the federal spending on their Medicaid programs.

In Georgia, the provider fee generates more than $200 million a year in state revenues, the hospital coalition said. When matched with federal funds, Georgia receives about $400 million in added funds to support the budget.

Two-thirds of that money goes to shore up Medicaid’s budget. The rest goes to raise Medicaid reimbursements to hospitals.

The amount raised from hospitals is returned to the hospital industry through reimbursements. Individual hospitals get different amounts based on how much Medicaid business they do.

There are winners and losers under this formula. Grady Memorial Hospital, which has a large Medicaid patient mix, received more than $9 million from the state’s hospital provider tax in fiscal year 2011. The biggest loser during that period was Piedmont Hospital in Buckhead, which lost $6.4 million.

Piedmont Healthcare, along with a few other hospitals, has been a strong opponent of the current formula.

The Georgia Hospital Association has been working on a revised formula for the hospital tax.

The Medicaid program in Georgia already faces a steep deficit. For the 2013 and 2014 budget years, the state faces a $700 million shortfall in its Medicaid program, Gov. Nathan Deal recently noted.

Medicaid, jointly financed by the state and federal governments, currently covers 1.5 million poor and disabled Georgians.

Georgia spends less than every state but California in Medicaid payments per beneficiary, the hospital coalition noted in its letter.

Norquist, in his letter, argued that the bed tax “is not only a state issue.”

“The reason it is so enticing to state lawmakers is that it allows state government to take advantage of the federal matching program for Medicaid,” Norquist wrote. “Fiscal conservatives should not be looking to Washington for more federal aid, especially when the national debt climbed above $16 trillion for the first time last week.”

An Americans for Tax Reform official said Tuesday that the fight over the hospital assessment will be a top priority in the 2013 Georgia General Assembly.

The “losing” hospitals either pass the cost on to consumers or absorb it as a new cost of doing business, said Josh Culling of Americans for Tax Reform in an e-mail to Georgia Health News.

Neither move is good for Georgia’s economy, Culling said.

“Gaming the Medicaid matching system is bad for the entire country,” Culling said. “We have been on record in opposition to similar tax increases in other states.”

The hospitals responded by saying that the matching funds are made up of tax dollars that Georgians pay to the federal government. “We should accept our own tax dollars back and use them for the benefit of our residents and their health,” the hospital letter said.

The hospital group delivered its letter, dated Monday, to Deal, state legislators, House Speaker David Ralston, Lt. Gov. Casey Cagle, and David Cook, the commissioner of the Department of Community Health.

If the hospital fee revenues disappear, the coalition said, Medicaid would be forced to cut reimbursements to hospitals and doctors. That, in turn, would force many providers to stop seeing Medicaid patients.

A spokesman for Deal, responding to questions about Norquist’s involvement in the controversy, sidestepped the debate, saying only, “We haven’t started the budgeting process in earnest yet; we’re still in the preliminary stages. It’s far too early to say what’s going to be in the governor’s budget proposal.”

Tim Sweeney of the Georgia Budget and Policy Institute said the chronically underfunded Medicaid program needs the provider fee revenue.

“Georgia’s policymakers should stand up to Norquist and, more importantly, focus on what’s in Georgia’s best interest,” Sweeney said. “Ensuring that Medicaid is adequately funded – whether through the hospital fee or some other means – is the right choice for Georgia.”

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Insurance Plan Cuts Waiting List for HIV Drugs

Andy Miller, Georgia Health News — Tue, 19 Jun 2012 13:22:30 +0000

This story comes from ,��an independent, nonprofit news service.

In January, Georgia had the longest waiting list in the nation for people with HIV to receive government drug assistance.

At that time, the state had 1,348 people waiting to join the AIDS Drug Assistance Program (ADAP). Now, less than six months later, it’s only about one-third of that: 490.

who have low or moderate incomes and no health insurance. HIV is the virus that causes AIDS, and drug treatment is a major factor in preventing infected people from developing the full-scale disease.

The decrease in the waiting list reflects the movement of many Georgians into the Pre-Existing Condition Insurance Plan. That’s a provision of the 2010 health reform law that serves as a safety-net plan for the “uninsurables’’ who can’t get coverage due to medical conditions.

The new June 7 figure still leaves Georgia with the second-highest waiting list, behind Virginia’s 599.

The state Department of Public Health said last week that more than 350 ADAP clients were electronically enrolled into the Pre-Existing Condition Plan at the end of April, and these patients are nearing the final stages of enrollment.

Currently, the 29 individuals fully enrolled in that insurance plan will save the state the state about $46,500 ‘‘while also receiving a higher quality of care,’’ said Ryan Deal, a spokesman for Public Health, in a statement.

Soon, eligibility requirements for ADAP will change to allow greater eligibility, he said.

Most people on the waiting list are getting help through pharmaceutical companies’ assistance programs for low-income patients. But advocacy groups have expressed concern that some people have fallen through the cracks.

Larry Lehman, executive director of the AID Gwinnett/Ric Crawford Clinic, which serves HIV patients in Gwinnett, Newton and Rockdale counties, said, “We are grateful for all the hard work of the state’s ADAP/Pre-Existing Condition Insurance Plan office, along with the network of the enrollment sites around the state.’’

The insurance plan “does take a few weeks to get a patient completely enrolled,’’ said Lehman, who called the plan “an excellent opportunity for so many of our patients, many of whom have gone without health care coverage for years.’’

More than 4,000 Georgians are served by ADAP.

Reasons for Georgia’s long waiting list include the state’s high rate of HIV/AIDS; flat funding by the state; an increase in testing for the disease, which leads to more people being diagnosed; and people losing their jobs and health coverage.

The average cost of an ADAP patient is $10,800 per year.

The Pre-Existing Insurance Plan is scheduled to expire in 2014, to be replaced by state insurance exchanges, if the health reform law is upheld by the Supreme Court. The fully implemented law would eliminate insurance discrimination based on health conditions.

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