Group Health has signed an agreement with Swedish Health Services to provide Group Health’s Seattle-based hospital services, a decision that will end a 15-year-long acute-care relationship with Virginia Mason.
Jane Dimer, MD – an OB/GYN and chief of Women’s Services for Group Health – on Tuesday, Dec. 10 from 12-1 pm for an hour-long Twitter chat on pregnancy and childbirth. Dr. Dimer will be covering a variety of topics from getting pregnant to delivery, and answering your questions.
Topics will include:
- Preparing your body for pregnancy
- Is this normal?
- Pregnancy myths
- Making a birth plan
- Back to work/breastfeeding
When: Tuesday, Dec. 10 from 12-1 pm
Group Health Cooperative and Bartell Drugs will open three retail clinics early next year in Ballard and University Village in Seattle and at Crossroads, Bellevue.
The “CareClinics” will be staffed by nurse practitioners from Group Health and provide walk-in service to the general public for common minor illnesses and procedures, such as cold and flu, sinus infections, allergies, minor injuries (burns, rashes, and cuts), pinkeye, sore throat, headaches, sprains and strains, bronchitis, ear infections, urinary tract infections, and diarrhea.
Care will be provided for adults and children over two years of age. Patients will not have to be Group Health members to receive care
The clinics are slated to open between mid-January and early March.
The initial locations will be:
- Ballard – 1500 NW Market St, Suite 101, Seattle, WA 98107-5211
- Crossroads – 653 156th Ave NE, Bellevue, WA 98007
- University Village – 2700 NE University Village St., Seattle, WA 98105
By Jordan Rau
KHN Staff Writer
More hospitals are receiving penalties than bonuses in the second year of Medicare’s quality incentive program, and the average penalty is steeper than it was last year, government records show.
Medicare has raised payment rates to 1,231 hospitals based on two-dozen quality measurements, including surveys of patient satisfaction and—for the first time—death rates.
Another 1,451 hospitals are being paid less for each Medicare patient they treat.
For half the hospitals, the financial changes that started last month are negligible: they are gaining or losing less than a fifth of one percent what Medicare otherwise would have paid. Others are experiencing greater swings.
Gallup Indian Medical Center in New Mexico, a federal government hospital on the border of the Navajo Reservation, will be paid 1.14 percent less for each patient. Arkansas Heart Hospital in Little Rock, a physician-owned hospital that only handles cardiovascular cases, will get the largest bonus, 0.88 percent.
The bonuses and penalties are one piece of the health care law’s efforts to create financial incentives for doctors and hospitals to provide better care. They come at a tumultuous time as the technical problems of the healthcare.gov insurance portal and premium prices are stoking questions about the law’s viability. The incentives are among the law’s few cost-control provisions that have kicked in, but it is too early to tell how effective they will be in making hospitals operate more efficiently.
“This program is driving what we want in health care,” said Dr. Patrick Conway, Medicare’s chief medical officer. He said most hospitals have improved since the program began a year ago. However, even some hospitals that have gotten better are still losing money because they are not scoring as well as others or have not improved as much.
Across the country, hospital executives say they have put renewed focus on excellence in the areas that are judged. Some have clamped down on nighttime noise, one of the questions patients are asked about, by replacing squeaky wheels on food carts and discouraging nurses and workers from chatting on cell phones outside of rooms.
Others have scrambled to ensure heart attack patients always get an angioplasty within 90 minutes of arrival because that is part of the scoring. Some private insurers have adopted similar incentives.
“The thing about the government, if they start paying attention to it, we have to scramble around to pay attention to it,” said Dr. Leigh Hamby, chief medical officer at Piedmont Healthcare, a hospital system in Georgia. “It gets us moving.”
Hospitals in Maine, Massachusetts, Nebraska, New Hampshire, North Carolina, Utah and Wisconsin are faring the best, with 60 percent or more of hospitals getting higher payments, according to a Kaiser Health News analysis.
Medicare is reducing reimbursement rates for at least two-thirds of hospitals in 17 states, including California, Connecticut, Nevada, New Mexico, New York, North Dakota, Washington and Wyoming, as well as the District of Columbia.
How A Hospital Is Rated
Under the program, known as Hospital Value-Based Purchasing, Medicare reduced payment rates to all hospitals by 1.25 percent. It set the money aside in a $1.1 billion pot for incentives. While every hospital is getting something back, more than half are not recouping the 1.25 payment they initially forfeited, making them net losers.
The payment adjustments are applied to each Medicare patient stay over the federal fiscal year that started Oct. 1 and runs through September 2014. The potential bonuses and penalties were higher than they were last year, when the maximum at stake was 1 percent.
To assess quality, Medicare looked not only at how hospitals scored in comparison with each other, but also how much each improved from two years ago compared to other hospitals.
A hospital is judged on whichever score is higher, so some hospitals with subpar quality rankings are still getting more money because they showed vast improvement.
It won’t be clear how much any hospital’s bonuses and penalties amount to in dollar figures until next October because it depends on how much a hospital ultimately bills Medicare.
This year, 45 percent of a hospital’s score is based on how frequently it followed basic clinical standards of care, such as removing urinary catheters from surgery patients within two days to decrease the chance of infections. Thirty percent of the score is based on how patients rate the way they felt they were treated in the hospital, such as whether the doctors and nurses communicated well.
Medicare added its first measure of a medical outcome, looking at death rates of patients admitted for heart attacks, heart failure or pneumonia.Those mortality rates, calculated from the number of Medicare patients who died in the hospital or within a month of discharge, count for 25 percent of a hospital’s score.
The incentive program has received a mixed reception among hospital executives. Some complain that patients’ views sometimes are swayed by the swankiness of the hospital, and that hospitals that treat the very sickest patients often get the worst evaluations.
Physician-owned hospitals that focus on just a few specialties have tended to do particularly well in the program, as evidenced by the Arkansas Heart Hospital’s record bonus this year. Some leaders also object that even if they show improvements, their hospital can lose money if the improvements are not as great as others.
Will Penalties Bring Change?
Researchers are unsure whether the penalties are significant enough to trigger major improvements, especially in areas such as mortality, where there’s no definitive explanation for why some hospitals do such a better job than others in keeping patients alive.
“Shame and penalties, I don’t know if that’s the best way to get organizations to change,” said Leslie Curry, a researcher at the Yale School of Public Health. Her work has found that hospitals with low mortality rates are the ones where it is a priority of executives and where there is a culture where front-line workers such as nurses and lab technicians feel comfortable raising concerns to doctors and devising better methods.
“The fiscal penalties are nominal, frankly, in the scheme of things,” she said.
Others say even small differences in payments provide strong encouragement for hospitals to improve. “Sometimes institutions may think they’re performing excellently until they see outside data that compares to your peers,” said Dr. Richard Bankowitz, the chief medical officer of Premier, a group that works with hospitals to improve quality. “People are motivated to excel. Nobody wants to be in the bottom quartile anymore.”
The addition of mortality rates into the scores provides hospitals with their biggest challenge yet. Amanda Berra, a consultant at The Advisory Board, a Washington health care consulting firm, interviewed 40 chief medical officers at hospitals about mortality rates.
“They were very split. About half of them said you could not have a more powerful measure. On the other side we heard people who were really unenthusiastic,” she said. “We heard that the data is not super meaningful. They felt they had drastically improved in recent years and have kind of gotten where they could go.”
The average penalty grew to 0.26 percent, up from 0.21 percent in the first year of the program. North Georgia Medical Center in Ellijay is the only hospital besides Gallup to lose more than 1 percent of its reimbursements: it will lose 1.04 percent. Denver Health Medical Center, a highly respected safety-net hospital, is losing 0.71 percent of its reimbursements.
The hospital that was penalized the most last year, Auburn Community Hospital in upstate New York, reduced its 0.90 penalty, but will still lose 0.55 percent.
The average bonus was 0.24 percent, almost the same as last year’s 0.23 percent. Large bonuses are going to some major teaching hospitals, such as Thomas Jefferson University Hospital in Philadelphia and Duke University Hospital in Durham, N.C. Most are being distributed among smaller institutions, such as Pikeville Medical Center in Kentucky.
“The dollars are less important in terms of impact than the fact that the nation is sending a signal through the payment mechanism that there’s something to be worked on in the care we deliver,” said Nancy Foster, an executive at the American Hospital Association. “It’s a national symbol to health care providers that here is an area where you can do better.”
Many Past Winners Continue To Get Bonuses
Most winners from last year stayed winners and losers stayed losers. But there were some switches. Oaklawn Hospital in Marshall, Mich., improved its score the most from last year. In place of a 0.26 penalty, Oaklawn will receive a 0.65 percent bonus. A number of prominent academic medical centers also turned around their scores.
Vanderbilt University Medical Center in Nashville, Massachusetts General Hospital in Boston, New York-Presbyterian Hospital in Manhattan, Cedars-Sinai Medical Center and Ronald Reagan UCLA Medical Center, both in Los Angeles, and Yale-New Haven Hospital were among the 300 places that went from a penalty to a bonus.
A total of 416 hospitals that won bonuses last year will be penalized this year. Centura Health-St. Thomas More Hospital in Canon City, Colo., dropped from a 0.08 percent bonus to a 0.72 percent penalty, the largest decrease.
This program is one of several Medicare has launched to make hospitals and doctors pay more attention to how their treatments compare with other hospitals, and to be more careful with public money.
Medicare gives bonuses to the private Medicare Advantage insurance plans that score well on quality metrics. In 2015, the health law calls for the government to begin a quality payment program for physician groups of 100 professionals or more, and that is to be expanded to all doctors by 2017.
The goal of all these programs is to replace the current financial incentive in Medicare, in which the only way for a hospital to get paid more is to perform more procedures and take on more patients.
For hospitals, the quality payments come on top of Medicare’s penalties on 2,205 hospitals with higher than expected readmission rates. The agency is doling out a maximum punishment this year of 2 percent.
As a result two out of three hospitals are losing money starting last month from the combined effects of the quality and readmissions programs. Pineville Community Hospital in Kentucky is losing 2.57 percent of its reimbursements, the largest penalty in the country.
Twenty-one other hospitals are losing 2 percent or more. These cuts come on top of reductions in special payments that go to hospitals that treat large numbers of low-income people.
Only 729 hospitals will end up with an increase in payments from the combined readmissions and value-based programs. Maine Coast Memorial Hospital in Ellsworth fared the best, gaining 0.80 percent.
Hospitals that are designated as critical access facilities, certain cancer hospitals and places with too few cases to be accurately measured were excluded from both programs.
Maryland hospitals are exempt because that state has a unique payment arrangement with Medicare.
Medicare relies on information found on hospital bills to determine the quality of care. In judging death rates, Medicare looked at patients admitted from July 2011 through June 2012, and compared those rates with how the hospitals performed between July 2009 and June 2010.
For the clinical and patient satisfaction measures, Medicare assessed hospital performances from April 2012 through December 2012, and compared them with scores during the same months in 2010.
The amount of money at stake increases to 1.5 percent of payments in October 2014, and continues to grow by a quarter percent until it reaches 2 percent.
Medicare is planning to add new measures next year, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps and infections from catheters.
In addition, the maximum readmission penalties grow to 3 percent next year, and Medicare is launching a third incentive program that takes an additional 1 percent of payments away from hospitals with the most patients who suffered injury or infection during their stay.
Combined, these three quality programs have the potential to strip away as much as 5.5 percent of Medicare payments from the worst performing hospitals starting next October.
“We’re moving more toward outcomes measures,” Conway said. “We’re moving away from volume and toward quality.”
- Data For Individual Hospitals (interactive chart)
- Downloadable CSV spreadsheet
- State Averages
This article was produced by Kaiser Health News with support from The SCAN Foundation.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
By Carol M. Ostrom, The Seattle Times
Group Health Cooperative will not cover abortion in its individual health-insurance plans being offered through the Washington state marketplace put in place by the Affordable Care Act, but says women who buy them will be able to access the service without paying more.
Group Health said it made the decision not to include the coverage because of murky regulations about how it would have to account for federal money in plans that offered abortion.
But the HMO (health-maintenance organization) has long supported women’s reproductive options, officials said, and so it will provide access.
Group Health’s workaround did not satisfy abortion-rights and women’s-rights groups, who reacted angrily to the decision not to cover abortion.
“Group Health asserts that abortion care will be made available to patients in Group Health clinics, but the lack of coverage in the plan creates confusion and presents a barrier to access, while showing an alarming disregard for women,” NARAL Pro-Choice Washington, Legal Voice and Planned Parenthood Votes Northwest said in a statement.
Group Health said it made the decision earlier this year in the face of confusing regulations about how insurers should handle abortion premiums and costs.
The Affordable Care Act requires insurers that cover elective abortion to segregate premiums and expenditures because federal law bars abortion services from being funded by the federal premium subsidies for plans offered through state marketplaces known as exchanges.
“At the time Group Health filed our products, we lacked further regulatory guidance,” Group Health said in a statement. “Group Health determined that in order to ensure full compliance with all requirements, it was advisable to not include pregnancy termination services in our individual products offered through the exchange for 2014.”
Of those plans that have passed muster with state insurance officials, only Group Health’s did not include abortion coverage.
At least 31 plans will be sold inside the exchange, including Group Health’s four, and other companies are now appealing rejections.
BridgeSpan Health Company, Premera Blue Cross and its subsidiary, Lifewise Health Plan of Washington, all said their plans offered abortion coverage, with the exception of eight Premera plans that are among BlueCross/Blue Shield Association multistate plans forbidden by federal law to include abortion coverage.
Stephanie Marquis, spokeswoman for the state Office of the Insurance Commissioner, said revisions flew back and forth earlier this year over Group Health’s plans for the exchange.
“Unfortunately, they made the change to take that benefit away from women, and we can’t require them to include it,” she said. “It’s an unfortunate decision for consumers.”
Group Health spokesman Ed Boyle said women who buy plans in the exchange may still access abortions services because Group Health is not only an insurer but a medical provider.
Although women who buy those plans and seek abortions won’t be covered by their insurance, Boyle said, they will not be at risk financially: “In 2014 our members who enroll through the exchange can be assured they will have access to pregnancy termination services through Group Health medical centers, with no greater financial burden than as if this was a covered benefit,” Boyle said.
Boyle said now that federal and state regulators have clarified rules regarding federal subsidies, Group Health intends to add the benefits to plans sold through the exchange in 2015, and is committed to “providing women access to the full spectrum of reproductive health services that are safe, affordable and accessible.”
Women’s-rights groups said the HMO’s decision was “inconsistent with Group Health’s own record on reproductive rights,” which has been twice affirmed by leadership and consumer members of the consumer-governed cooperative, the groups said.
Rachel Berkson, executive director of NARAL, said it was “particularly galling to see one of the most progressive, pro-women health-care providers in our state placing limits on abortion coverage.”
It’s not clear there will be limits. But Lisa Stone, executive director of Legal Voice, said she was worried that without coverage specified in the policies, women might face administrative burdens or, if they need inpatient care in a non-Group Health hospital, additional charges.
This is the kind of issue anticipated by backers of the Reproductive Parity Act (RPA), a bill that failed to gain approval in the Legislature this year. The bill would have ensured abortion coverage after the federal law took effect.
Late in the session, despite backing from both sides of the aisle, Senate Health Care Committee Chairwoman Randi Becker, R-Eatonville, refused to schedule a vote.
Said Elaine Rose, CEO of Planned Parenthood Votes Northwest: “The need for the RPA has never been more apparent. Women can’t trust insurance carriers to protect all of their pregnancy options.”
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
Dollars for Docs: How to Evaluate Drug Payment Data
by Nicholas Kusnetz
Update: This story has been revised to reflect updated Dollars for Docs data on March 11, 2013.
Drug companies have long kept secret details of the payments they make to doctors for promoting their drugs. But 15 companies have now made some of that information public.
ProPublica’s Dollars for Docs pulls their disclosures into a single database so patients can easily search for their doctor. We created Dollars for Docs database partly as an educational tool. How can patients use it? Here are some suggestions.
Q. My doctor is on this list. Should I care?
A. If your doctor is listed, it’s because he or she received money from one of the drug companies for promotional activities or consulting.
Payments are legal, so it doesn’t mean your doctor has done anything wrong. But research has shown that drug company marketing can influence what a doctor prescribes, and some experts say it is cause for concern.
Others say the information should carry less weight. They say the amount of money a doctor receives is less important than personal recommendations and the doctor’s training and experience.
One word of caution: Some doctors in our database have the same or similar names, so be sure to confirm with your doctor that he or she is actually the one on the list. Names and addresses on the data are as disclosed by the companies, and they sometimes use variations.
Q. My doctor is not on the list. What does that mean?
A. ProPublica included payments only from the drug companies that have made these relationships public so far. Many doctors do not do promotional work or consulting for drug companies.
Others may receive such payments from companies that haven’t yet disclosed them. So even if your doctor isn’t on the list, experts say it’s worth asking about the issue.
Q. What’s the best way to bring up the issue with my doctor?
A. Although it can feel awkward, some experts say it’s important to ask about potential conflicts of interest. Others say patients should trust their doctors to do what’s right for them.
If you do raise the issue, tell your doctor you want to feel confident the drugs he is prescribing for you are best for the job.
According to a 2010 national survey by Consumer Reports, conducted for this project, 70 percent of adults say doctors should tell their patients about payments they’ve taken from a drug company whose drugs they are about to prescribe.
Ask first if your doctor has any financial relationships with drug companies. If so, ask about what companies are involved, the nature of each relationship and the duration.
Most often, doctors are paid for promotional activities, such as speaking to other doctors about a drug, or for consulting or research.
It’s important to ask whether medications you are taking are made by the companies. If the answer is yes, it’s not necessarily a problem but is worth discussing further.
Q. How can I be sure my doctor is offering unbiased advice about a drug?
A. If your doctor has prescribed you medication made by a company he or she receives payments from, you should ask whether there are any cheaper generic alternatives. How does the drug compare to others in its class? What are the side effects? Are there alternatives with fewer side effects? And importantly, are there non-drug alternatives, such as diet, watchful waiting or physical therapy?
It may be that the drug you are on is the best option. But sometimes a drug company will market a new, more expensive version of an established drug even when the older one is cheaper and effective.
Asking these questions will show your doctor you’re aware of these issues.
Q. Where can I learn more about drugs my doctor prescribes?
A. Searching the Web will bring up a wealth of links and literature. One site that has comprehensive drug and supplement information is MedlinePlus.
By Colin Goldfinch, Group Health Public Policy Analyst
From the blog GroupHealth INNOVATES
Health Benefit Exchanges are a signature part of the Affordable Care Act but what is an exchange? Is it just “Expedia” for health insurance? The exchange’s primary role is to make health insurance in the individual and small group market easily accessible through a central online market place.
The exchange will function a bit like the Human Resources department of a large employer. It will support people who purchase insurance on their own by offering a platform for making an apples-to-apples comparison between plans that offer a similar level of coverage and disbursing Federal subsidies like a large employer contributes to premiums for their employees.
Through the exchange, people will be able to:
- compare health plans;
- check qualifications for premium tax credits or cost sharing reductions, as well as eligibility for public programs (Medicaid); and
- choose and enroll in a health plan that fits that person or small company’s needs related to price, provider network, quality, and other plan features.
Here are some additional responsibilities of exchanges. They will:
- certify whether health plans are qualified and will review annual premium increases;
- offer a uniform enrollment form and will direct those applicants that are eligible to a Medicaid plan;
- provide access to a calculator to applicants who are above the income threshold for Medicaid eligibility that will help them compare the cost of different plans, taking into account premium tax credits and cost-sharing subsidies;
- establish a quality rating system to help consumers compare price and value;
- operate a “Navigator” program, contracting with representatives from various communities to provide unbiased support to applicants as they decide between health plans;
- operate a phone-line and website that consumers can use to enroll in the plan of their choice and get access to navigators for help; and
- continue to engage brokers and producers, who will play the important role of steering new enrollees to the exchange and will continue to earn commissions for this work, although the details are still being refined in draft regulations.
Applicants to the exchange living between 100-400 percent of the federal poverty level (FPL) will have access to premium credits. Applicants with incomes between 100-250 percent FPL will also have access to reductions in their deductible, co-insurance, and co-payments.
They will choose between bronze, silver, gold, and platinum-level plans that cover a specified percentage of the total value of the plan for an average population, also known as the actuarial value of the plan.
Exchanges either can be run by the state, by the federal government, or as a state-federal partnership. To date, 18 states and the District of Columbia have stated they will run their own exchange, although not all of those states have received approval from the federal Department of Health and Human Services.
Two years ago, Washington State became one of the first states to announce that it would operate its own exchange. The Washington Health Benefits Exchange is a quasi-governmental organization operated by a Board of Directors proposed by the state legislature and appointed by the Governor.
The Washington State exchange, named Washington healthplanfinder, plans to be ready to assist people with health insurance choice and purchase starting October 1, 2013 for coverage that will be effective on January 1, 2014. Group Health, along with other insurance carriers in the state, is busy working with the exchange staff and Federal and State regulators to offer its products in this new market place.
This article first appeared on GroupHealth INNOVATES blog and is reposted with Group Health’s permission.
A feature article on efforts in Washington state to address the epidemic of prescription painkiller overdose deaths by LocalHealthGuide editor Michael McCarthy appears this week in the BMJ, the journal of the British Medical Society.
Containing the opioid overdose epidemic
In the late 1990s, Washington State began to relax its rules regulating the prescription of opioids. Shortly thereafter, overdose deaths began to climb.
“We saw the deaths increase within a year,” says Gary Franklin, medical director for the Washington Department of Labor and Industries, which administers compensation for job related injuries and illnesses for more than 3.2 million workers in the state.
“These were productive people who were working the day they came into the system with a back sprain or whatever, and three years later they were dead from an accidental overdose of opioids,” Franklin says. “I had never seen anything so sad.” . . .
Read the full article on the BMJ website.
Beginning October 8th, Group Health members in the Tacoma area will now have access to new expanded 24/7 urgent-care facility at the Group Health Tacoma Medical Center’s on 209 Martin Luther King Jr. Way in Tacoma.
The expanded facility will have 19 care rooms—12 exam rooms, four observation rooms, three cardiac beds, and a triage room—all open 24-hours.
The current urgent service, housed in the first floor, has seen approximately 24,000 Group Health member visits a year. With the new expansion, Group Health can now accommodate more than double that amount.
The facility is for patients with non-life threatening emergencies, such as:
- lacerations or severe cuts
- conjunctivitis (pink eye)
- ear infection
- possible broken bones or sprains
- sudden abdominal pain.
Members wanting to know more about urgent care can go to the Group Health website.Group Health also offers its members access to a 24/7 Consulting Nurse Hotline to help members evaluate the situation and find the right care: 1-800-297-6877 for all areas in Washington state and Idaho, 206-901-2244 in the Seattle area.
If it’s a life-threatening emergency, Group Health recommends that members call 911.
This December, Group Health is opening a new Puyallup Medical Center complete with a green roof, the latest in new technology, and access to walking paths to encourage our members and staff to live a healthy and active life. For more on the project go to
By Megan Howell
Director of Public Policy and Regulatory Affairs
Group Health Cooperative
From Group Health Cooperative Innovates blog
As a 30 something mom working at Group Health doing health policy, I’ve had a few friends ask me why we can’t just go get our FREE birth control.
There’s a lot of confusion and part of it may have to do with the fact that on August 1 every newscast in this nation pretty much told women to go get their FREE birth control and that women’s preventive services were now “free.”
If only life were that simple. While it is true that the Affordable Care Act (ACA) did make access to women’s preventive services easier and without significant costs, there’s some fine print of the law you should know before you head to the pharmacy.
- You must have health coverage to take advantage of this benefit.
- If your employer health plan did not start or renew August 1, 2012, you will have to wait until your health plan renews. A popular time is usually Jan. 1, 2013. Group Health non-grandfathered individual health plans currently have this benefit in place.
- If you are on a “grandfathered” health plan, this new benefit may not apply to you. Group Health members can call customer service at 1-888-901-4636 to see if your plan has the option of covering contraceptives.
- For birth control pills to be covered at no cost share to the member, they need to be generic if one is available. Additionally, a specific brand name birth control pill may not be covered by your health plan, which will require you to switch brands to be covered at no cost sharing.
- If you have health care through your employer, and it is a religious organization, you may not receive contraceptive benefits at this time, as there are exemptions for specific religious organizations.
- You must still comply with all other terms of your health plan’s coverage and contract. For example, you may be required to fill your prescription for birth control pills at a Group Health Pharmacy, or see a Group Health provider to receive other contraceptive services.
- One final clarification: the ACA did not make women’s preventive services “free” to everyone; they do cost someone- the health plan still has to pay providers and drug manufacturers. Perhaps the more fitting phrase is actually “at no cost sharing to the consumer.”
If this isn’t clear, then I thought you might like this easy-to-read infographic courtesy of Buzzfeed:
By Barbara Trehearne, PhD, RN
Vice President Clinical Excellence, Quality, and Nursing Practice
Group Health Cooperative
With health care reform moving forward following the U.S Supreme Court decision to uphold the Affordable Health Care Act earlier this month, several issues immediately jump out as key areas ripe for improvement.
One important issue is overtreatment.
Overtreatment is a huge driver of soaring health care costs, and I and a panel of experts will participate in a panel discussion on that challenge and others before the health care system on July 30 at Seattle CityClub.
It’s estimated anywhere from one-fifth to nearly one-third of all tests and treatments are unnecessary. Turning around what is at times thought of as defensive medicine must be tackled and soon, not only to rein in health care costs but to deliver appropriate and high quality care that is evidenced based: More is not always better in healthcare.
Take high-end imaging, such as MRIs and CT scans. Sometimes they are critical diagnostic tools, but in other instances they are unnecessary, and give no better guidance for treatment than less expensive diagnostic methods.
Group Health’s own experience may hold some answers about guiding the use of high-end imaging.
We’ve done work at Group Health to help clinicians with better support tools when it is appropriate. We’ll do monitoring of a practice to give feedback to see if they’re using imaging in its more effective way.
Most of the physicians getting this feedback say it helps them to really look at their own practices and find opportunities for improvement.
Of course, the Group Health integrated model of care, which pays medical professionals a salary, is very different from the vast majority of the health care industry’s current “fee-for-service” model that pays providers for every office visit and tests such as MRIs.
Another area we’ll delve into at the CityClub panel is the notion of who in the healthcare system is able to satisfy and provide healthcare needs.
For example, we know nurse practitioners (NP) can and do satisfy many of our health care needs in areas such as primary care including pediatrics.
It’s an idea that must be discussed throughout the health care system in this country. Over 25 years ago and consistent with today’s estimates, the Office of Technology concluded NPs could safely and effectively provide 75 percent of general primary care. NPs consult when needed in the same way family practice physicians do.
We must help people understand the care that is safely provided by advanced nurse practitioners (APNs) which include NPs, Certified Nurse Anesthetists and Certified Nurse Midwives.
These APNs consistently receive high satisfaction scores from patients. Twenty-five plus years of research demonstrates cost effective, high quality, safe care delivered by APNs. Multiple studies on NP practice confirm the clinical outcomes they achieve are comparable to their physician colleagues.
In fact, the health system must start talking about the role of all nurses on many levels, include other opportunities to use nurses in more effective ways. That includes case managers, nurse navigators, and nurse led clinics.
Nurse navigators have been a focus of research at Group Health to examine how they might improve care across multiple settings and providers. Navigating the health care system is complex, confusing, and intimidating. Nurses are often central to care for complex patients and are best positions to assure care is coordinated and consistent.
Another issue to be discussed by the CityClub panel will be whether there is an overuse of care for end-of-life patients. There must be more widespread understanding of end-of-life issues, because too many gravely ill, very elderly patients still are ending up in ICUs for expensive, painful and futile care when their wishes are otherwise.
In 2009 GHC, began making shared decision aids available to patients with various conditions. Providers can discuss patient options for various procedures with the help of videos, booklets and other online material.
There is very strong evidence that use of these tools increases patient knowledge and allows them to be more engaged in decisions about care. One promising front in this area is using videos for patients and their families to help understand all the issues involved in end of life care.
We need to continue to support clinicians in their very careful assessment of benefits, harms, and costs of treatments and tests and to also determine how value is necessary to reducing cost while maintaining quality.
By Scott Armstrong, president and CEO Group Health Cooperative
In a landmark decision, the Supreme Court upheld most of the provisions of the Affordable Care Act when it handed down its much-anticipated ruling.
As important as the decision is, it’s just one step in a process that started before the Affordable Care Act passed and will continue for a long time to come.
Now that the Court has answered questions about the constitutionality of the law, we can turn our full attention to two critical issues: how to reform a health care system that is unsustainable because it costs too much and provides too little value to the people it is supposed to serve; and how to expand access to high-quality coverage and care.
Many details will emerge in the months ahead as state and federal policymakers begin to implement the provisions of the law that were upheld today. Changes are still possible.
Group Health will move forward with our current strategy to build the systems needed to offer high-quality coverage through the Washington Health Benefits Exchange, the consumer marketplace that opens in 2014.
We are more confident than ever that Group Health is on the right path as we focus on improving affordability and containing costs through care delivery system innovations that enhance quality and increase coordination.
We’ll do this by continuing to develop innovations within our care delivery system and health plan benefits that emphasize primary care and prevention; encourage patients to be active participants in their own health and wellness; and improve coordination, efficiency, and quality.
We’ll continue to work to extend these innovations to our partners by building integrated care delivery systems in local markets. This work is underway through partnerships with Providence in Spokane, the Franciscan Health System in Tacoma, and The Everett Clinic in which we share information about clinical results, coordinate treatment for patients, and work together to adopt patient-centered practices that are proven to deliver better outcomes.
We’ll continue to work with state and federal policymakers to create a framework that increases care coordination through payment that rewards quality and value; that makes information available so that individuals can find high-quality coverage options in the Exchange; and that provides continuity of coverage and care as people move between Medicaid and the Exchange.
The starting point for a successful Exchange is to make sure that as many people enroll as possible. As we move forward, we will focus on working with policymakers to ensure that it is easy for people to participate. We believe that people need to have access to transparent information about quality so they can make smart decisions about their care based on a clear understanding of value.
There are many questions about the Exchange that must be answered to ensure that it is a stable and vibrant marketplace that provides affordable access to quality care and coverage. As policy decisions are made, it’s important to assess what they mean for patients and the goal of providing affordable, high-quality coverage and care.
The important thing to keep in mind now is that the imperative to transform health care in this country will only grow stronger, the pressure to innovate and improve will only increase, and the rapid pace of change will continue.
Now that the Supreme Court decision is behind us, we look forward to continuing to do what we have always done—keep our patients healthy and improve care in our communities.
Last week’s U.S. Supreme Court arguments about the Affordable Care Act created uncertainty over health reform’s immediate future. But the debate about the “individual mandate”—the law’s requirement that everyone get health coverage—strengthened my conviction: To solve our health care system’s cost, quality, and access problems, we must ultimately bring all Americans into that system.
Group Health has embraced the idea that “we’re all in this together” since the Cooperative was established in 1947. Our founders understood the basic principle of insurance: No one can predict when illness or injury may strike, so everyone (young, old, sick, or well) needs to participate to ensure that coverage and care are available and affordable for anyone who needs it. They knew that some would need more care than others. But over time, the population would spread the risk, and everyone would get their fair share from the system.
Group Health didn’t even raise rates with age until the 1980s, when the market forced the issue. Without this change, Group Health would have attracted so many old and sick people that everyone’s rates would have become unaffordable.
Group Health has always stood for universal health coverage—not only because it’s the “right thing”, but also because it’s the most cost-efficient way to provide quality care.
The sick may include those few unlucky, uninsured youths who suddenly need treatment for a broken arm, appendicitis, or that rare, unfathomable case of cancer. Or it may be people with existing illnesses who have been denied coverage. The uninsured often get care through emergency rooms, which are required by law to take all comers.
And ultimately, we all pay for their care through higher taxes and increasing insurance premiums. The new law attempts to deal with this problem by expanding coverage through Medicaid and state health-benefit exchanges for individuals and small businesses.
Group Health has always stood for universal health coverage—not only because it’s the “right thing”, but also because it’s the most cost-efficient way to provide quality care. That’s the challenge our country faces today. Ensuring coverage only for subgroups—say, folks over 65, or the employed—just doesn’t work.
As journalist John Cassidy wrote in The New Yorker last week, “Opting out of the health care market is about as realistic as opting out of dying.”
Weeks may pass before the Supreme Court rules. Meanwhile, leading experts continue to call for reforms to the current fee-for-service payment system—a key driver of rising costs.
One is Stanford’s Victor Fuchs, PhD—our country’s most prominent health economist and author of Who Shall Live, a book that has long defined how economics and social choice effect health.
Last week he told the New York Times: “If we solve our health care spending, practically all of our fiscal problems will go away.” And if we don’t, “almost anything else we do will not solve our fiscal problems.”
Dr. Fuchs is not optimistic that health care can change itself. Rather, it will require “revolutionary” changes that unsettle established interest groups, he believes. But “American history is studded with examples of things that were not politically feasible until they were,” like the emancipation of slaves and a trillion-dollar bailout of the financial industry, he said.
“Major changes in health care policy usually occur because of something outside of health policy—large scale civil unrest, a depression,” he added. One catalyst could be a decision by China to stop buying the American bonds that finance Medicare and Medicaid debt, he explained.
But whether change is triggered by forces inside or outside the broken fee-for-service system that dominates our nation’s health care system, we at Group Health must aspire to demonstrate a successful alternative. Ours is a model born 65 years ago from our founders’ desire “to serve the greatest number”—a mantra that fits health reform today.
As citizens and patients, as health care professionals and researchers, we each have a stake in health care’s future; our place at Group Health gives us a front-row seat to history in the making. More importantly, we have an opportunity to work for positive transformation. Let’s not be spectators, but doers.
Attend 2012 Birnbaum Endowed Lecture on April 30. Dr. Don Berwick, senior fellow at Center for American Progress, and former administrator of Centers for Medicare & Medicaid Services, will describe the important role health professionals play in health care reform. Then Group Health, Geisinger Health System, and HealthPartners leaders will discuss the development of integrated health organizations as learning health care systems.
To learn more:
- Read March 6 New York Times interview with Stanford health economist Victor Fuchs.
- Hear key moments of and commentary on Supreme Court debate over Affordable Care Act on Kaiser Health News.
- Follow ongoing coverage of important health reform developments on Kaiser Family Foundation’s health reform blog.
- Read Center for American Progress on why establishing insurance coverage for people with pre-existing conditions requires enacting an individual mandate.
This article first appeared in the Group Health Research Insitute’s online Research News webpage.
The index measures how equitably large, private-sector businesses in the United States treat their lesbian, gay, bisexual, and transgender (LGBT) employees, consumers, and investors.
The perfect score in 2012 is attributed to the addition of Group Health’s LGBT & Allies Staff Resource Group, along with the improved transgender benefits that went into effect in 2011.
The organization was able to achieve a perfect score despite the fact that the HRC has implemented more stringent criteria standards for the designation, Group Health said.
A total of 636 participating employers were rated this year, and only 190 of them received the top rating of 100 percent.
Group Health’s Score:
POLICIES AND BENEFITS
|Non-discrimination policy includes sexual orientation||+ 15|
|Non-discrimination policy includes gender identity and/or expression||+ 15|
|Company-provided domestic partner health insurance (including parity in spousal and partner COBRA, dental, vision and domestic partners legal dependent coverage)||+ 15|
|Parity in spousal/partner soft benefits (bereavement leave; supplemental life insurance; relocation assistance; adoption assistance; joint/survivor annuity; pre-retirement survivor annuity; retiree healthcare benefits; employee discounts)||+ 10|
|Offers equal health coverage for transgender individuals without exclusion for medically necessary care||+ 10|
|Organizational LGBT cultural competency (diversity trainings, resources or accountability measures)||+ 10|
|Company-supported LGBT employee resource group or firm-wide diversity council that includes LGBT issues, OR would support a LGBT employee resource group with company resources if employees expressed an interest||+ 10|
|Engages in appropriate and respectful advertising and marketing or sponsors LGBT community events, organizations, or legislative efforts||+ 15|
|Engages in action that would undermine the goal of LGBT equality||0|
Group Health Cooperative, which is a consumer-governed health-care system, is seeking candidates from its membership for four Board of Trustees positions.
Candidates must receive their medical coverage through Group Health in order to be eligible.
The Board of Trustees is an 11-member consumer governing body that sets the strategy, direction, and policy for GHC, a nonprofit enterprise with $3.3 billion in annual revenues.
Individuals with the experience and range of skills necessary to help lead GHC’s consumer-governed health care system are encouraged to apply.
Trustees serve a three-year term.
Applications deadline is Monday, April 9th, 2012, and the election will be held in October.
- Go to member ghc.org (www.member.ghc.org) and search for “Board application.”
- For additional information call 206-448-2073 in Seattle, or toll-free 1-800-252-3305, extension 21.