According to the Illinois Department of Insurance, health insurance premiums have risen on average 181 percent since 2005. This could be the week action is taken in Illinois to fix our health insurance marketplace for Illinois families and small businesses.
Lawmakers are expected to consider legislation that would create an Illinois health insurance exchange that, if designed right, would help increase choices and lower costs for Illinoisans purchasing health insurance.
There’s no need to start from scratch though. Many states have already taken action to create health exchanges to deliver better value for consumers, and Illinois should follow their lead.
In fact, a report recently released by Illinois PIRG, "Making the Grade: A Scorecard for State Health Insurance Exchanges," closely examines the 12 states that have already created exchanges and rates them according to how accountable they will be to consumers and the public, how much they can do to lower premiums and improve the quality of care, how friendly they will be to consumers, and how stable they will be.
Not all exchanges are created equal. That’s why it’s important to evaluate the policies that will matter most to consumers, including whether the exchange will be protected from insurance industry influence, and if it will negotiate with insurers for better rates.
Among the important policies to consider to make an Illinois exchange consumer-friendly include:
Giving it the power to leverage enrollee’s buying power to negotiate with insurers for higher-value, more affordable coverage.
Barring insurers and other industry representatives from serving on the exchange board, so it will be more accountable to the public and to consumers.
Making sure consumers will have an easier time shopping for coverage through easy-to-use tools and comparisons between plans.
For the sake of our pocketbooks, let’s hope Illinois lawmakers do their homework and ensure that our exchange makes the grade.
I remember the bad old days. By which I mean, I remember the 1990s era of “capitation” and all its ills — the rigid HMO spending limits that made money come between patients and their physicians.
But I’m not scared that they’re coming back.
Some worry that the coming “global payment” phase of Massachusetts health reform — in which health care providers are put on annual “global” budgets for each patient’s total care rather than paid for each procedure — will mean a return to capitation.
That would be terrible. As a pediatrician of 25 years, I remember the problems with capitation. It discriminated against special-needs children. It drove a wedge into the doctor-patient relationship, creating conflicts of interest by making doctors responsible for controlling costs. Access was restricted. Chronic disease management was not a priority.
But I welcome the impending era of global fees. If the concept of the Medical Home is incorporated — with its family-centered care incentives and rewards for innovations that save families money and time as well as improving quality — it could work.
Some see global payments as “capitation in sheep’s clothing.” However, if negotiated properly, there can be enormous opportunity for physicians to unleash their creative skills as never before in collaboration with families. It could be an opportunity to empower and educate families to manage more of their own minor health-care issues if they so choose — and as their deductibles increase, they will so choose.
Also, in our current system, insurance rate increase are coming more and more out of families’ pockets, not employers. Will there be a day when they just simply can’t afford going to the doctor? We need to act!
My practice, Westwood-Mansfield Pediatric Associates, is preparing for global fees. In our office, the most common reason for an illness visit is a sore throat. We responded to this by giving patients (at certain routine check-ups) a free home strep test to be used if certain criteria are met, with the proviso that patients must be seen in the office if the home test is positive or if the individual is not feeling better within 48 hours.
Since 65%-75% of rapid strep tests are negative in our office, we have been able to reduce office visits for sore throats by 20% and replace them with healthy lifestyle visits for overweight children.
We also give a prescription for a course of oral steroids, along with a written “Nighttime Asthma Attack Plan,” to parents whose children have asthma and instruct them on how to manage an asthma attack in order to prevent an ER visit. In addition, we have produced and posted, ourselves, videos of many common problems and how to avoid the emergency room.
The old fee-for-service system has stifled our capacity to be creative. The existing categories of services that can be billed for has also contributed to these barriers. Our own fear of change also plays a role.
The late Steve Jobs and Apple have been successful because they have been able to give people what they want before they realize they need it. This is what we strive to do. By empowering families to manage minor illnesses themselves (through patient handouts, websites, YouTube videos, and even “Apps”) we can shift the focus to the top health care problems of children – obesity, asthma, ADHD/learning style issues, mood disorders and allergies. In this model pediatricians can have a very rewarding job and make a good living.
Ultimately, the fact is that pediatrics has changed, and we have to change with it. Immunizations have eradicated most serious infectious diseases. Pediatrics must redefine itself as a specialty focused on wellness, seriously ill children, and chronic disease management and less on volume.
We can work on the concept of the Medical Home to improve care for our families in a team-based manner. In market terms, we need to give parents more value for either their co-pay dollars or their deductibles. Empowering our families is where our value will be coming from in the future, and global payments can help us get there.
Dr. Lester Hartman Guest blogger Dr. Hartman is a senior associate at Westwood-Mansfield Pediatrics, a Masters in Public Health candidate at Harvard and vice president of the Haitian Organization Program for Education and Health.
Today, Illinois Health Matters launched the third release in their ongoing multimedia series,Neighborhood Stories.This installment reveals through video and investigative journalism the importance of community based organizations, such as neighborhood health centers and grassroots health coalitions. Such organizations provide a variety of comprehensive services to people in underserved communities, such as the South and West Sides of Chicago, who often do not have health insurance or access to quality, affordable care.
In “Community-Based Organizations Play a Critical Role in Reform,” author Jeffrey Steele finds community organizations act as a vital link between the federal level ACA, the state-level policies that result from the act, and the people who will benefit from the health care reform. Steele describes various ways that community organizations in Chicago are helping to implement the ACA. For example, there is an individual in every community-based organization that Celine Woznica, program director for the Asian Health Coalition in Chicago, calls a “mother hen.” They are usually trusted and respected members of community that people come to and ask questions. Inquiries may range from where to go for a flu shot to how to get heating assistance to when to go for citizenship classes. “These staff are the very people who have to be well versed on the Affordable Care Act, and how to help people take advantage of it -- from preventive care to the health exchange,” Woznica says.
Community organizations are integral to distributing accurate information about the health reform process. At Erie Neighborhood House, a west side social service organization and community service agency, they are focusing on more “in person” workshops while other groups may utilize ethnic media and webinars. As Jim Duffett, Executive Director of Campaign for Better Health Care, sums up, “The more people who take ownership at the local level, the stronger we’ll all be in winning comprehensive reform.”
The video, “Wellness on the West Side,” profiles the story of Eliazar Mejia, a woman diagnosed and treated for diabetes at Lawndale Christian Health Center (LCHC). LCHC is a shining example of “coordinated care” – where they provide a multitude of different types of care and programs all in one place. Many people who do not have insurance, such as the 38% of LCHC’s patients, end up letting a health problem develop and worsen until it sends them to the emergency room. LCHC fills the gap between no care and the emergency room for its 60,000 patients. Bruce Miller, the CEO of LCHC, sums up the organization’s overall commitment to its patients: “Our goal as a community-based organization is to provide care for everybody who needs care. Whether they have insurance, whether they don’t have insurance, we’ve never cared. So, as we think about the future, what the impact could be of health care reform, it’s our hope certainly, that many of our uninsured patients will have…better access to care, and will use that care more frequently.”
“Wellness on the West Side” is just one in the Neighborhood Stories series, presented by Illinois Heath Matters. Previous videos profile individuals and families, small businesses, and the importance of a consumer-focused health policy in Illinois. All videos and articles are featured in the “Neighborhood Stories" section of the Illinois Health Matters website, along with articles that share how community organizations, includingHealth & Disability Advocates,local Chambers of Commerce and others are educating and informing underserved groups about their health care coverage options under the new law. The multimedia series is part of theLocal Reporting Initiative,supported in part byThe Chicago Community Trust.
Last week was an important one for Illinois consumers and small businesses as lawmakers inched closer to establishing a state-run Health Insurance Exchange.
Why is this important? As Timothy Jost, exchange expert writes in aCommonwealth Fund blog: “The health insurance exchange is the centerpiece of the private insurance reforms in the Affordable Care Act (ACA). If the exchanges function as planned, they will expand coverage to more Americans, reduce insurance costs, and improve the quality of coverage and perhaps of health care itself.” However, if designed poorly, “experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums."
First, some background:
On July 14, 2011, Senate bill 1555 was passed and signed by Governor Quinn, which created the Illinois Legislative Health Insurance Exchange Study Committee to aid in going forward with the establishment of a health insurance exchange (also known as the competitive insurance marketplace) in Illinois. The legislative study committee held five meetings, and commissioned two reports, one from Deloitte Consulting on the current state of healthcare in Illinois, and the second from HMA/Wakely Consulting Group, on the possible options and directions the exchange could take. On September 27, 2011, the Committee released a draft report of their findings from the five meetings and the two consultant reports. Although no definite decisions were made in the report, it is still the most substantive picture of the Illinois exchange to date.
Response to the Report:
Most of the report focused on the possibilities that Illinois must consider and decisions that must be made regarding the type of governance and the financing of the exchange. Many organizations weighed in with written comments in response to the report. Below are some of the issues and concerns that have been raised over the policy options outlined in the report:
·The HMA/Wakely report listed two options for the operating model of the exchange: either as a “market organizer” or “market developer.” The market organizer approach means that the exchange would simply certify any health insurance plan that met the requirements for the exchange, relying on the competition of the marketplace to keep the cost of insurance down. The market developer style would have the exchange taking a more active approach to use their leveraging power in order to get the best possible value of plans from insurance agencies. Much support has been shown for the market developer option, aligning the exchange model with the interests of consumers for quality, affordable insurance.
·Out of the three options presented for the governmental structure of the exchange, the overwhelming majority of opinions expressed have been in favor of a “quasi-governmental” model, as opposed to the “state-run” and “non-profit” models. The quasi-governmental model would keep the exchange in connection with other state-run agencies that it may need to coordinate with and promote a high level of transparency and accountability, while remaining a higher level of political neutrality.
·The membership of the exchange governing board is one of the hot button topics in the report. The report underscores that members of the board should be well versed in the domain of health care, but should not have conflicts of interest, specifically noting that insurers, agents/brokers, HMOs, Prepaid Service Providers and other individuals with an interest in the Exchange should not be voting members of the board, though they could be members of an advisory committee. Some groups are advocating for a list of constituencies that must be represented on the board (for example, more representative of minority populations who are over-represented among the uninsured), while others think that a list of that nature would cause more problems for the board than it would solve. Another major concern is whether or not legislators should be allowed on the board. Many groups have expressed their disapproval of legislators holding seats on the board – so that the exchange could be truly independent, non-partisan, and non-political — although some see their presence as non-voting members as a possibility.
·To finance the exchange, there are many options on the table, including charging consumers a fee to access the exchange, assessments on health plans offered in the new marketplace, assessments on all Illinois health insurance companies, the use of state general revenue, levying a fee on all health care stakeholders in the state (a list that could include prescription drug and medical supply companies, providers, hospitals, etc.), or assessing a progressive surtax on the revenues of all insurance providers. Many advocacy groups are against the idea of a fee to consumers, as the exchange targets those who are currently uninsured, who typically tend to have lower incomes, and could be put off or prevented from using the exchange if there is a fee. However, there are doubts that a funding option like the insurance revenue surtax would be approved. Some groups have stated that the best option might be for the enacting legislation to leave open the description of funding, so as to allow for multiple sources.
Stay tuned! The final report will be issued this week and we’ll let you know if there are any changes.
