Anthem Blue Cross and more about health reform...

Monday, March 01, 2010

HEALTH ACCESS UPDATE
Monday, March 1, 2010

ANTHEM BLUE CROSS RATE HIKES SPUR MOVEMENT ON HEALTH REFORM IN CA AND DC
* Rate Hikes Draw Scrutiny; CA's AB 2578 Rate Regulation Bill Gains Momentum
* Deep Details from D.C. Hearing with Anthem Blue Cross/Wellpoint CEO
* DMHC Holds Hearing on So-Called "Discount Health Card Plans"
* Health Access to Help Represent Consumers at Natl Assn of Insurance Commissioners

* Read Our Health Access Blog! Join Us on Facebook! Follow Us on Twitter!

NEW MOMENTUM FOR HEALTH REFORM: A real life and timely example of what needs fixing--in the form of the actions of Anthem Blue Cross of California--can spur momentum for needed reforms of the broken health care insurance market. In Washington, DC, the rate hikes by California's biggest insurer have become Exhibit A in the fight for comprehensive health reform. President Obama even adopted, as part of his proposed unveiled a week ago Monday, a proposal by California Senator Dianne Feinstein for additional federal rate authority to review and reject increases, where appropriate.

These rates were also brought up in the much-commented on White House bipartisan health reform summit this past Thursday. Legislative leaders, including Speaker Nancy Pelosi of California, continue to press to pass a major reform with the goal of completing work before Easter. This would involve the Senate bill--which had already passed the Senate by a 60-vote supermajority--and some changes and improvements done through "reconciliation," which is the purpose of that majority-vote procedure.

RATE REVIEW TO GET A REVIEW: Back in California at the Assembly Health Committee's informational hearing on the rate increases planned by Anthem Blue Cross, Chair Dave Jones (D) cited Anthem's upcoming premium hike of 39% as reason to move aggressively forward with his AB 2578. The bill would allow the Department of Insurance as well as the Department of Managed Health Care to regulate rate increases. Assemblyman Mark Leno (D) is principal co-author. According to Assembly procedural rules, the first date it can be heard in committee is Tuesday, March 23rd.

CONGRESS RELEASES SOME OF THE ANTHEM DOCUMENTS: The Congressional subcommittee of the House Energy and Commerce Committee (chaired by California Rep. Henry Waxman) holding a hearing last week on Anthem's rate increases released a lot of in-depth financial information about WellPoint, Anthem Blue Cross' parent corporation. We've got links and details on the Health Access blog for the wonkish and curious.

SPEAKING UP FOR CONSUMERS AT THE NAIC: This past week, sixteen consumer representatives were named to regularly attend the National Association of Insurance Commissioners--including Health Access and other state-based consumer organizations throughout the country. Health Access' Elizabeth Abbott, was selected by NAIC as one of the official consumer representatives appointed to advise state insurance commissioners and their national organization on health policy and market regulation. The designation of consumer representatives is designed to ensure consumer protections and good public policy are adopted in regulations and policies drafted by the NAIC which often serve as a template for state regulators. Health Access sees this appointment as particularly well-timed to influence state-based and national health care reform efforts with this influential association, which has some specific tasks under the pending health reforms.

In addition to the four years Ms. Abbott has worked for Health Access, she has considerable experience as a long-time federal employee with the Social Security Administration and most recently as the Centers for Medicare and Medicaid Services (CMS) Regional Administrator for the western states and the Pacific Territories.

CRACKDOWN ON "DISCOUNT" PLANS: Health Access and several of our coalition partners (including the California Pan Ethnic Health Network [CPEHN], Health Rights Hotline, and the Health Consumer Alliance) testified before the Department of Managed Health Care (DMHC) in Oakland on February 22 regarding new regulations concerning so-called Discount Health Plans.

Many consumer advocates generally favor the new DMHC regulations because of the strict new requirements laid out governing the actions of these so-called discount health plans operating in California. DMHC has received over 1,000 consumer complaints regarding the deceptive practices engaged in by more than 150 plans selling what they portray as “comprehensive health insurance.” However, many of these companies do not offer a valid discount off the price from a known network of providers. After consumers buy this “discount card” for $25 to even $100 a month, they find that the doctors do not accept the card, do not provide a discount, or would have granted the same or an even greater discount for free based on other affiliations such as churches, unions, automobile clubs, or fraternal organizations.

DMHC has ordered 8 of these companies to “cease and desist” operations in the state, and are establishing requirements and consumer protections for those companies who want to do business in the state. The discount companies were at the public hearing in force claiming these proposed regulations are an unfair restriction on their ability to do business in California and an infringement of their free speech rights. DMHC will take all comments under advisement and release new regulatory language within the next several months. We urge organizations who have members under this predicament to contact us,

Labels: BlueCross, DMHC, Insurers, Updates, YearOfReform

posted by Anthony Wright | Permalink | 10:18 AM


 

New accountability for so-called discount health plans: Key hearing in Oakland on Monday!

Thursday, February 18, 2010

HEALTH ACCESS UPDATE
Friday, February 19, 2010

DMHC PROPOSES REGULATION ON SO-CALLED "DISCOUNT HEALTH PLANS"
* CA Department of Managed Health Care cracks down on wild west of unlicensed products
* Discount health plans are not health insurance, but some pay premiums thinking they are.
* Many provide less benefit than a pizza coupon: illusory discounts with phantom providers
* Health Access argues in favor of real discounts, real networks, and real notices

* DMHC HEARING on new consumer protections: MONDAY, February 22nd, in Oakland

* Other Items: Updates on Federal Health Reform, Anthem Blue Cross rate hikes,
State Budget Issues, and much more on our Health Access Blog.
* Join Us on Facebook! Follow Us on Twitter!


The California Department of Managed Health Care has now embarked on the formal process to regulate so-called "discount health plans." This will begin with a public hearing at the Elihu Harris State Building, 1515 Clay Street in Oakland at 11:30 am on Monday, February 22, 2010 and it is expected that industry representatives, advocates, and consumers will all give testimony on this regulation. The specific language can be seen at DMHC’s website at http://www.dmhc.ca.gov/. Interested persons or organizations may also submit written comments to the Department on their website by 5:00 pm on Monday, February 22.

The Department has reacted to many industry abuses where so-called discount health plans marketed a discount health card as real, comprehensive health insurance—which it is not. Some of the documented abuses are:

* Consumers are charged high fees and co-payments by discount health plans ($25 to over $1000 per month) which are of questionable value for that money

* Discount health plans advertise what turns out to be a phantom network of doctors, hospitals, and clinics that allegedly offer discounts to cardholders. However, these providers often are unaware they are part of discount health network and are reluctant to provide services.

* Consumers pay a monthly premium for a discount health card that is billed as a dollar deduction or “percentage off”—but is often no more than or even as great as other discounts commonly given to consumers for free, such as AAA, religious groups, or fraternal organizations.

* In most cases in health care, the value of the discount is illusory because there's no set price of the service to begin with. Many "billed charges" for doctor and hospital care are multiple times what insurers and government programs pay, so a discount off that "sticker price" is still inflated.

* However, the most insidious impact on these consumers is that they believe they have purchased true health insurance that provides some peace of mind; however, they find they are spending good money for a largely worthless product.

DMHC has undertaken to put discount health plans through a rigorous licensing process to establish requirements and test screening and oversight guidelines to separate what may be legitimate businesses from outright fraud artists. They have, for example,
· Prohibited from marketing as health insurance
· Required the discount health plan to maintain a public website with a complete and accurate directory of all providers by specialty and geographic location
· Required plans to provide a toll-free customer assistance call center number and disclose availability of interpretation services for languages other than English where calls must be answered within 5 minutes
· Required to offer bona fide discounts tied to the established Medicare fee schedule

Health Access has previously supplied significant policy guidance to the Department in drafting the language of this regulation. Consequently, with some changes, consumer advocates generally support the language in this version of the regulation.

Health Access and many of consumer allies will be present at the upcoming public hearing to support the Department’s strong language to rein in the most egregious abuses in this industry. ORGANIZATIONS AND INDIVIDUALS ARE INVITED TO JOIN US IN SUPPORT OF THE REGULATIONS AT THE MONDAY FEB 22nd OAKLAND HEARING.

If you have questions, or need further information, please contact Elizabeth Abbott at Health Access at (916) 497-0923 or via email at eabbott@health-access.org.

Labels: DMHC, MedicalDebt, Updates

posted by Anthony Wright | Permalink | 7:01 PM


 

It's Time for Timely Access Patient Protections!

Wednesday, January 20, 2010

HEALTH ACCESS UPDATE
Wednesday, January 20, 2010

CALIFORNIANS WIN FIRST-IN-NATION CONSUMER PROTECTIONS
SETTING STANDARDS FOR TIMELY ACCESS TO CARE
* CA Department of Managed Health Care Announces New Standards Today in LA
* HMO Patients Can Expect Quick Phone Advice; Urgent Care within 2-3 Days
Routine Appointments within 2-3 Weeks
* Timely Access Rules To Help Prevent Health Problems From Getting Worse;
and Reduce Unneeded Trips to Emergency Rooms

* Read Our Health Access Blog for More on the Massachusetts Senate Election,
and How Health Reform Can Advance, and Why It Must
* Join Us on Facebook! Follow Us on Twitter!

SACRAMENTO--California consumers will have greater assurance of getting appointments and care when they need them. New first-in-the-nation consumer protections are being put in place this week by the California Department of Managed Health Care. As a result, consumers should get a primary care appointment within 10 days, an appointment with a specialist within 15 days and urgent care much more quickly.

Taking effect January 17th, these new regulations to ensure timely access to care implement a 2002 law (AB2179, authored by Assemblywoman Rebecca Cohn, and sponsored by Health Access California), and respond to common consumer complaints about their inability to get health care advice or appointments within a reasonable amount of time.

These groundbreaking consumer protections will help ensure that HMO patients get the care they need, when they need it. Consumer advocates argued that care delayed is often care denied, leading to worse health outcomes or unnecessary visits to the emergency room. These new first-in-the-nation patient rights will provide consumers with clear expectations about how quickly they should get in to see a doctor or specialist.

The new rules ensure that when managed care consumers agree to a limited network of providers, insurers fulfill their promise that their networks of doctors and specialists have the capacity to take care of their paying patients. While the concept of timely access to health care was one of the cornerstones of the original Knox-Keene Act of 1975 that established and regulated managed care in California, it remained largely unrealized and unenforced.

For the first time, the new consumer protections detail specific time-elapsed standards by which patients can expect to get a telephone questioned answered, an urgent care appointment, or a routine appointment for a primary care doctor or specialist.

Here are some examples of the new Consumer Time Elapsed Standards contained in the regulation:

* Triage or screening by telephone 24-7
* Waiting time for telephone triage no longer than 30 minutes
* During normal business hours, waiting time to speak to a plan’s customer service representative no longer than 10 minutes
* 48 hours for urgent care appointments that do not require prior authorization
* 96 hours for urgent care appointments requiring prior authorization (including specialists)
* 10 business days for non-urgent primary care appointments
* 15 business days for non-urgent appointments with specialists
* 10 business days for non-urgent appointments with a mental health care provider
* 15 business days for non-urgent appointments for ancillary services (x-rays, lab tests, etc.) for diagnosis or treatment of injury, illness, or other health condition

For Dental Plans
* 72 hours for urgent care
* 36 business days for non-urgent care
* 40 business days for preventive care

Consumers who believe they have been denied timely access to care, should promptly complain to their health plan. If that doesn’t resolve the issue, they should file a complaint with the Department of Managed Care (DMHC) at the HMO Help Line at (888) HMO-2219 [(888) 466-2219] or (877) 688-9891 [TDD] or at www.hmohelp.ca.gov

These new first-in-the-nation consumer protections have several benefits for individual patients and for the health system:

* Patients will get some clear standards for how long they should—and should not—wait to see a doctors or specialists. They also have a place to com
* Patients will get better guidance about when and where to get treated, through telephone triage and urgent care appointments within 1-3 days. This may reduce inappropriate use of emergency rooms, where patients face long waits and expensive cost-sharing.
* Emergency room overcrowding may be eased, since the recent increases have been with *insured* patients—who likely could not get in to their doctors in a timely manner.Health outcomes can improve if problems are caught early and before they grow, when there are more and usually less expensive options for treatments.
* New attention to wait times can expose broader issues with a health insurer’s lack of an adequate network of provider, lack of appropriate financial resources to patient care, regional shortages, insufficient accountability or oversight of providers, or financial insolvency.
* In an era of health reform, when people have been scared about talk of waiting lists and rationing, these rules provide reassurance that patients get the care they need, and that the reforms work to reduce, rather than expand, waiting times.

Consumer groups, including Health Access California, Western Center on Law and Poverty, and the California Pan-Ethnic Health Network, were pleased that the Department did not adopt industry proposals to allow health plans to determine their own standards, or to exempt providers offering language interpretation services.

The rules will be officially unveiled at a press conference today at Cedars-Sinai Hospital in Los Angeles. More information, including fact sheets, is available at http://www.health-access.org, and at http://www.dmhc.ca.gov.

Labels: DMHC, TimelyAccess, Updates

posted by Anthony Wright | Permalink | 1:12 AM


 

A timely bonus on timely access...

Tuesday, December 22, 2009

An end of the year bonus—and one that we really earned!

On Friday, December 18, 2009, Health Access received word that the timely access regulations will be final effective January 17, 2010.

We have worked on this issue for more than a decade. The original HMO Patient Bill of Rights, a package of more than twenty bills, included timely access inAB497 (Wildman). AB497 was vetoed in the face of bitter opposition from the HMOs and the Wilson Administration. The legislative staff for the Department of Corporations which was responsible for regulating at that time told us that whatever an HMO decided was timely access was the standard. That was not nearly good enough for Health Access.

AB497 set specific standards for timely access, standards that are remarkably similar to those that are now in effect. AB497 required that:
* A telephone call be answered within four minutes
* A non-urgent appointment be provided within ten days
* A medically urgent appointment be provided within 48 hours

And what do we have in the regulations just finalized?
* A physician, registered nurse or other appropriately licensed health care professional must provide telephone triage within 30 minutes
* A non-urgent appointment must be provided within ten days
* An urgent appointment must be provided within 48 hours
Plus a variety of other standards for mental health services and dental care.

Well, maybe four minutes was a bit of a stretch but the notion that every consumer can get triage in time to get to an emergency room within the so-called golden hour, if needed, is now part of the requirements for all physicians who contract with DMHC plans, which is virtually every practicing doctor in California.

Timely access was not part of the package of legislation adopted in 1999 that we usually refer to as the HMO Patient Bill of Rights. Instead, timely access (AB2179 Cohn) and language access (SB853 Escutia) were adopted later along with standards of prescription drug coverage (SB842 Speier), all enacted in 2002 or 2003. And the strategy for both timely access and language access was the same: the law required the DMHC to adopt regulations that specify how HMOs and PPOs would meet the obligation to provide care in a timely manner and in the language spoken.

Language access regulations were completed prior to those for timely access but the timely access regulation ties down one key piece of language access: that the requirements for interpretive services run concurrent with the timely access requirement—that is, when you show up for the doctor’s appointment within ten days, they should be prepared to provide care in the language you speak.

We have worked on this issue for more than a dozen years. The enactment of the regulations are a major milestone. But our work is not done—now we will look to see whether HMOs and providers comply and how vigorously the regulations are enforced.

Labels: DMHC, TimelyAccess

posted by Beth Capell | Permalink | 8:11 AM


 

A win in the courts on autism...

Tuesday, October 27, 2009

We are pleased to see that a Superior Court has agreed with our colleagues at Consumer Watchdog that the refusal of the Department of Managed Health Care to refer denials of care for autism to independent medical review was an underground regulation as well as a violation the Mental Health Parity statute, as reported by the LA Times.

Autism is a difficult condition to treat but there are at least some treatments, including intensive behavioral therapy, that increase the odds that a child will be able to lead a more normal and productive life. Intensive behavioral therapy such as applied behavioral analysis is no picnic for either the child or the parents and demands extensive efforts on the part of parents as well as skilled intervention of certified practitioners.

We have been troubled about how DMHC has handled autism claims: a number of cases were referred to independent medical review and the independent medical reviewers found that peer-reviewed science justified the treatment as medically necessary. HMOs than asserted that the care was being denied because it was not a covered benefit rather than on grounds of medical necessity.

Independent medical review was one of the victories consumers won in the HMO Patient Bill of Rights, sponsored by Health Access California and signed into law in 1999. Consumers who are denied care on the grounds that it is not medically necessary can appeal to an independent panel of medical experts who determine whether the science and the particular circumstances of the patient justify the care. (Some treatments work but not for the particular patient.)

There are some flaws in California law with respect to independent medical review. One of them is made obvious by the autism case: independent medical review deals only with determinations of medical necessity, not with whether something is a covered benefit. In some instances whether something is a covered benefit is clear: the coverage does not include durable medical equipment so wheelchairs are not covered. But other times the line between a covered benefit and a determination of medical necessity is murkier: does someone need more than the normal regimen of physical therapy after breaking a leg either because the injury is worse than usual or the individual has diabetes so recovery is delayed? Are the additional physical therapy visits a covered benefit question or a medical necessity determination? The autism question falls into this category as well: the HMOs allege that it is not a covered benefit; the consumer side said the care is medically necessary and a denial violated the Mental Health Parity Act.

Another flaw in the California law with respect to independent medical review is that appeals are not automatic: consumers must push forward at each step, first filing a grievance, then seeking an independent medical review. In this case, a number of very determined parents pushed even further---by filing a lawsuit with the help of Consumer Watchdog. It is an important case and one we will watch carefully as it progresses.

Labels: DMHC, Insurers

posted by Beth Capell | Permalink | 9:44 PM


 

Looking Ahead: Insurance Regulators Galore

Saturday, October 24, 2009

While the U.S. Senate tries to merge the HELP and Finance measures and the House tries to blend the products of three committees (Ways and Means, Education and Labor, and Energy and Commerce), we have been looking at what we would need to do here in California to implement health reform if it is enacted at the federal level.

While the proposals differ in specifics, all of them have an important role for the states in continuing to regulate key aspects of health insurance as well as having either the option or the obligation to operate an “exchange” at the state level.

In particular, as we read the Senate Finance proposal, we were struck by the repeated reliance on the National Association of Insurance Commissioners (NAIC). California is unique in having two regulators for health insurance: the Insurance Commissioner and the Department of Managed Health Care. It is the Insurance Commissioner, currently Steve Poizner, who participates in NAIC, not the DMHC.

Yet most of health insurance in California is regulated by the Department of Managed Health Care. The numbers vary year by year but roughly out of the approximately 20 million Californians with private health insurance, about 80% have products regulated by DMHC and about 20% by DOI. For the 2-2.5 million who buy insurance as individuals, the split is closer: it is usually 60/40, with DMHC sometimes having the majority and other years DOI having the majority of covered lives.

As readers of this blog know from our fights to improve health insurance for those Californians who buy their own coverage, DOI products are much less comprehensive than DMHC products. Insurers regulated by DOI sell hospital-only coverage or coverage that covers three doctor visits, two days in the hospitals, and a few generic drugs and that counts as health insurance at DOI. Of course, the premiums are lower for such junk than for real insurance that actually covers basic health services.

In the real world of the politics of protecting consumers, what does it mean that California has two regulators? Well, it depends. When Pete Wilson was governor vetoing HMO consumer protections left and right, we were grateful to have Insurance Commissioner John Garamendi for four of those years. When Gray Davis signed the 21 bills that made up the HMO Patient Bill of Rights and created the Department of Managed Health Care, headed by Daniel Zingale, while Insurance Commissioner Chuck Quackenbush was taking questionable contributions from insurers, we thought more fondly of DMHC than DOI.

The two departments try to work together—and as would be expected, sometimes and on some issues that works better than other times and other issues.

If health reform is enacted at the national level, and we are doing everything in our power to make that happen, then implementation will occur under a new Governor and new Insurance Commissioner—so it is hard to say whether we will be happy or sad about the prospects for implementation. But what is certain is that winning health reform at the national level is only the first step in making sure that consumers are protected.

Labels: DMHC, Insurers, YearOfReform

posted by Beth Capell | Permalink | 9:02 AM


 

Timely coincidence...

Tuesday, February 24, 2009

Earlier today, Assemblyman Dave Jones chaired an informational hearing of the Assembly Health Committee had a hearing on emergency room access.

There was a lot of talk about minimizing "avoidable" emergency room use, to lessen the overcrowding in emergency rooms. There's probably a distinction between the use of the emergency room for non-emergency purposes, and emergency care that could have been avoided if the patient got care earlier.

Part of the solution was being heard just a day earlier at the Department of Managed Health Care, which considered regulations on timely access to care. Recent research suggests the increase in emergency room use is not from uninsured but insured patients. Part of the problem is that people, not being able to get appropriate triage or timely access to a primary care doctor or a specialist, end up needlessly in the emergency room.

It's nice that at least part of the solution to the problem is finally close to implementation, and to able to report that to the Assembly Health Committee.

Labels: DMHC, Hospitals, TimelyAccess

posted by Anthony Wright | Permalink | 11:39 PM


 

Last time? A timely access hearing on Monday...

Friday, February 20, 2009

With so much going on regarding the budget, it's important not to forget and highlight the upcoming hearing and DMHC comment deadline THIS MONDAY, FEBRUARY 23rd, on the crucial issue of timely access to care, an important plank in our ongoing work on HMO Patients Bill of Rights.

After six years since the law we passed, we have a chance to win clear standards for timely access to care!

ALERT: DMHC TO HOLD FINAL HEARING
ON NEW TIMELY ACCESS TO CARE STANDARDS
* CA Department of Managed Health Care Finalizes New Regs on Timely Access to Care
* Need Public Comments to Support Time Standards to Get Primary and Specialty Care
* ACTION ALERT: Letters & DMHC Hearing Testimony Needed on Monday, Feb 23rd


After years of advocacy by consumer and health advocate, California patients are close to a major victory in winning clear standards to ensure timely access to health care from their health plan.

One of the most common complaints from consumers is that they cannot get in to see their doctor on a timely basis. These HMO regulations will put in place requirements and establish expectations for concrete, time-elapsed standards based on type of service needed and degree of medical urgency. These rules stipulate that consumers should be able to:
* See a primary care physician for urgent care in less than 48 hours,
* Consult with a specialist within 96 hours of an urgent referral,
* Obtain a non-urgent appointment for primary care within ten business days, or
* Receive advice from a health care professional 24/7 regarding whether a symptom indicates an emergency or the consumer can safely wait until regular business hours on the next workday.
* Have interpreter services coordinated with scheduled appointments.

Research shows that insured Californians often obtain medical care from emergency rooms, the most expensive place to get medical care, because they cannot get in to see their doctor on a timely basis. In many cases, care delayed is care denied, leading to worst health outcomes and more expensive treatments.

The History: Health Access first sponsored legislation in this area in 1997, when we sponsored AB497 by then-Assemblymember Scott Wildman. In 2002, AB2179, authored by Assemblymember Rebecca Cohn (D-Saratoga), passed the legislature, and was signed by Governor Davis.

Not surprisingly, HMOs and providers have fought over these years not only to delay the regulations but to make them meaningless. Health Access opposed earlier versions of the regulations that were no better than the inadequate procedures in place since 1975 when the Knox-Keene Act was created.

After numerous consumer advisory panels, stakeholders’ meetings, public hearings, informal comments, formal written comments to the Department of Managed Health Care, withdrawal and reissuance of previous versions of this regulation, we now may be close to this regulation being enacted. The proposed regulations are at the DMHC website:
http://wpso.dmhc.ca.gov/regulations/docs/regs/20/1231519617847.pdf

Support Needed for Specific Standards: Health Access beleives that the language of the regulation, while not perfect, provides reasonable protections and specific time-elapsed standards for consumers to obtain timely access to health care. It also outlines reporting responsibilities of the plans, appeals actions available to consumers, and oversight duties to be performed by DMHC.

The Department has formally issued this regulation and they are soliciting comments on it from the public through February 23, 2009. For more information about the issue, go to recent posts on Timely Access issues on the Health Access WeBlog, at:
http://www.health-access.org/labels/TimelyAccess.htm

Consumer advocates need to act now to support these regulations. We need to make our voice heard so that consumers can get the care they need when they need it.

LETTERS/COMMENTS REQUESTED: Comments should be addressed to Department of Managed Health Care, Office of Legal Services, Attn: Regulations Coordinator, 980 9th Street , Sacramento , CA 95814 or you may comment on DMHC’s website at www.dmhc.ca.gov. Your comments should reference Timely Access to Non-Emergency Health Care Services, Control No. 2008-1579 and must be received by DMHC no later than 5:00 pm on Monday, February 23, 2009. The fax number is 916-322-3968. Contact Health Access for additional materials.

PUBLIC HEARING/ORGANIZATIONAL TESTIMONY REQUESTED: The Department will hold a public hearing THIS MONDAY, February 23rd, at 9:00am, in Sacramento, at 980 9th Street, 2nd Floor conference rooms.

Labels: DMHC, Insurers, TimelyAccess

posted by Anthony Wright | Permalink | 6:12 PM


 

It's about time...

Tuesday, January 27, 2009

HEALTH ACCESS UPDATE
Tuesday, January 27, 2009


THE RIGHT TO TIMELY ACCESS TO CARE: New Regulations Pending!
* CA Department of Managed Health Care Prepares to Finalize Important New Regulation on Timely Access to Health Care
* Public Comments Solicited on Newest Version of Regulation that Establishes Time Limits for Consumers to Receive Primary and Specialty Care in California
* ACTION ALERT: Letters Needed To Support Key Consumer Protections

New on the Health Access WeBlog: The Senate Stimulus; New Assembly Committees; The Reinvestment and Recovery Act in the House; Jump-Starting the Economy and Health Reform; Healthy Families Cuts Implemented; Health Wonk Review; President Obama’s First Health Care Actions; Bush’s Record; Do Bi-Partisan Efforts Help or Hurt Reform?; Federal Decisions Will Dramatically Impact Help to California.


Consumer and health advocacy groups may be close to witnessing the final regulation by the Department of Managed Health Care (DMHC) to write the “rules of the road” on timely access to health care. One of the most common complaints from consumers is that they cannot get in to see their doctor on a timely basis. These regulations will put in place requirements and establish expectations for concrete, time-elapsed standards based on type of service needed and degree of medical urgency. These rules stipulate that consumers should be able to:
* See a primary care physician for urgent care in less than 48 hours,
* Consult with a specialist within 96 hours of an urgent referral,
* Obtain a non-urgent appointment for primary care within ten business days, or
* Receive advice from a health care professional 24/7 regarding whether a symptom indicates an emergency or the consumer can safely wait until regular business hours on the next workday.
* Have interpreter services coordinated with scheduled appointments.

Research shows that Californians often obtain medical care from emergency rooms, the most expensive place to get medical care, because they cannot get in to see their doctor on a timely basis. It is also true that because consumers do not have clinical training, it is difficult for them to judge whether they are facing a true emergency and they need immediate care or whether they can safely wait.

A Long Road

This seemingly basic health care right to timely access to care has been a long time in coming. Health Access first sponsored legislation in this area in 1997, when we sponsored AB497 by then-Assemblymber member Scott Wildman. In 2002, AB2179 was carried by Assemblymember Rebecca Cohn (D-Saratoga), passed the legislature, and was signed by Governor Davis.

In 2002, many in the advocacy community thought California would soon usher in “a new era” where consumers and patients would have a clearly-defined right to timely access to health care for all those who were enrolled in managed care plans (HMOs). Those in favor of the statute anticipated a drop in health care costs (because of a decrease in people seeking care in emergency rooms) and an increase in quality of health care because it would be dispensed in a much more timely fashion resulting in better health care outcomes for patients.

Regulations Matter

However, some would say the battle over issue of timely access to care was just beginning. The statute laid the groundwork in the law (like an architect’s design for the building). However, many realized that the regulations written by the responsible state agency represented the actual detailed instructions about how the law would operate and resemble the general contractor’s plan for the building. This is where the phrase “the devil is in the details” comes from. The requirement to write detailed rules about how the law is supposed to work, what planning, measurement, reporting and auditing offered all stakeholders another opportunity to discuss (and disagree!) on the principles underlying the law and the key provisions of how it should operate. In many cases, legislation prescribes specific standards. However, Health Access took a different approach in AB2179: the legislation directed DMHC to develop the standards for timely access. It is no coincidence that almost seven years have elapsed since the legislation was signed into law.

Not surprisingly, HMOs and providers have fought over these years not only to delay the regulations but to make them meaningless. Health Access opposed earlier versions of the regulations that were no better than the inadequate procedures in place since 1975 when the Knox-Keene Act was created.

We now are at a major juncture in the road and consumer advocates eagerly await the finalization of this important regulation. After numerous consumer advisory panels, stakeholders’ meetings, public hearings, informal comments, formal written comments to the Department of Managed Health Care, withdrawal and reissuance of previous versions of this regulation, we now may be close to this regulation being enacted.

Support Needed for Specific Standards

Health Access and other members of our health care coalition generally agree that the language of the regulation, while not perfect, provides reasonable protections and specific time-elapsed standards for consumers to obtain timely access to health care. It also outlines reporting responsibilities of the plans, appeals actions available to consumers, and oversight duties to be performed by DMHC.

In our role as advocates, we have offered pages and pages of specific comments over the years: DMHC has not adopted every comment we have ever offered but the regulations provide basic consumer protections along with mechanisms for monitoring HMO compliance with those protections.

The Department has formally issued this regulation and they are soliciting comments on it from the public through February 23, 2009.
Action Needed Now
Consumer advocates need to act now to support these regulations. We need to make our voice heard so that consumers can get the care they need when they need it.
Key Points to Make:
* Consumers need care in a timely manner.
* Specific time-elapsed standards are reasonable minimums, getting urgent care within 48 hours and non-urgent care within 10 days are standards consumers should be able to expect.
* Being able to get triage and advice 24/7 from a qualified professional is an important consumer protection.
* Interpreter services should be coordinated with the appointment.
* Providing timely access will mean consumers get care from their doctor, rather than being forced to go to an emergency room to get care quickly.

Comments should be addressed to Department of Managed Health Care, Office of Legal Services, Attn: Regulations Coordinator, 980 9th Street , Sacramento , CA 95814 or you may comment on DMHC’s website at www.dmhc.ca.gov. Your comments should reference Timely Access to Non-Emergency Health Care Services, Control No. 2008-1579 and must be received by DMHC no later than 5:00 pm on Monday, February 23, 2009. Health Access can make available draft comment letters including model language for you or your organization to use if requested.

Please feel free to contact Elizabeth Abbott at Health Access if you have questions or need further information. She may be reached at (916) 497-0923, ext. 201 or at eabbott@health-access.org.

Labels: DMHC, TimelyAccess, Updates

posted by Anthony Wright | Permalink | 12:27 AM


 

The right to communcate...

Wednesday, January 07, 2009

Bobby Caina Calvan of the Sacramento Bee had the write-up about the new regulations on language access finally getting the force of law.

Millions of Californians with limited English proficiency now have the right to an interpreter from their commercial health and dental plans – made possible by a first-in-the-nation law aimed at dismantling the language barriers that get in the way of good medicine.

The new regulation – implemented New Year's Day after five years of hearings, delays and wrangling among insurance companies, regulators and consumer advocates – is widely hailed as a milestone in reducing mistakes because of miscommunication.

We were happy to be part of the broad coalition in support of the original law, SB852(Escutia), and the ongoing regulatory process at the Department of Managed Health Care.

Health Access has also been pleased to work to pilot and implement video medical interpretation at various public hospitals, providing an example of how providers can meet these requirements in a cost effective and efficient manner.

Now we need to make sure that patients know their rights--that they don't have to mime their way through a doctors appointment, or bring their child to translate inappropriate information.

Labels: DMHC, LanguageAccess

posted by Anthony Wright | Permalink | 11:44 PM


 

Victory on balance billing...

Wednesday, December 03, 2008

It's official. We now have a final ruling by Sacramento Superior Court Judge Michael Kenny in California Medical Association (CMA) et al. v. California Department of Managed Health Care and Cindy Ehnes, upholding the DMHC’s recent regulations to protect consumers from balance billing for emergency services.

We went into the details in a previous post, but it's good news for consumers, so they (and their credit history and financial futures) are not held hostage in billing disputes between insurers and providers.

Labels: BalanceBilling, DMHC

posted by Anthony Wright | Permalink | 11:37 PM


 

Progress on Balance Billing!

Friday, November 21, 2008

It is ironic, on the day Health Access celebrated its founding 20 years ago, a founding that started out of a consumer victory against the California Medical Association (CMA) and other providers, we get word of a new victory in a fight that has Health Access on one side and doctors on the other.

The big news: A court sent out its preliminary decision against CMA and other providers, denying their efforts to stop new regulations on “balanced billing” at the Department of Managed Health

Insured patients can breathe easier that if they get needed care in an emergency situation, they will not be billed unnecessarily and used as a pawn in a contractual dispute between insurers and providers.

The practice of balanced billing, where insured patients are sent the bill when a provider has a billing dispute with the insurer, is a significant problem for consumers. Patients get sent to collections, and have their entire credit history ruined---when legally they owe nothing and have done nothing wrong, except get the care they need.

We are pleased the courts sided with the Department of Managed Health Care (DMHC), and against the CMA’s lawsuit. There’s more work to do on this subject, but this is good news for patients.

Two final notes on the ruling, from my colleague and legislative advocate, Beth Capell:

* First, it is evident from the court’s ruling that the case made by the California Medical Association, the California Hospital Association and other providers ignored the economic impact on consumers and focused only on the economic impact on providers. While it is reasonable for provider trade associations to represent their members, we are weary of these same organizations claiming that they care deeply for consumers when they oppose consumer measures time and again... it is plain that their pocketbooks are their primary concern.

* Second, the court’s ruling rests on the plain language of the law which states that a “unfair billing pattern” means engaging in a demonstrable and unjust pattern of nbundling of claims, upcoding of claims, or other demonstrable and unjustified billing patterns, as defined by the department.

Put simply, DMHC defined balance billing as an “unfair billing pattern”, the court found that the law permits it to do so and the providers are squawking because they thought “unfair billing pattern” only applied to provider-plan disputes with consumers as collateral damage.

Here’s excerpts from the case, below:

The following shall constitute the Court's tentative ruling on the Petition for Writ of Mandate and Complaint for Declaratory and Injunctive Relief filed by Petitioners California Medical Association, California Hospital Association, California Chapter of the American College of Emergency Physicians, California Orthopeadic Association, California Radiological Society, and California Society of Anesthesiologists, set for hearing in Department 31 on Friday, November 21, 2008 at 9:00 a.m.

II. Background

This case challenges DMHC’s promulgation of 28 CCR § 1300.71.39 (the “Balance Billing Regulation”). The Balance Billing Regulation was enacted under the authority purportedly granted to DMHC by provisions in the Knox-Keene Act, Health and Safety Code §§ 1340 et seq., in which the Legislature delegated certain regulatory authority with regard to health care service plans (“HMOs”) to DMHC. Of particular interest here is Health and Safety Code § 1371.39, which was added to the Act as part of Assembly Bill 1455 (Scott, 2000). Among other things, § 1371.39 allows HMOs to report “instances in which the plan believes a provider is engaging in an unfair billing pattern” to DMHC.

The Balance Billing Regulation defines “unfair billing pattern” to include a practice known as “balance billing” when that practice is engaged in with respect to emergency care recipients who are enrollees in a health care service plan (an “HMO”). Balance billing occurs when a provider receives less than the total amount billed from a patient’s HMO and subsequently bills the unpaid balance directly to the patient. The Balance Billing Regulation provides:

(a) Except for services subject to the requirements of Section 1367.11 of the Act, “unfair billing pattern” includes the practice, by a provider of emergency services, including but not limited to hospitals and hospital-based physicians such as radiologists, pathologists, anesthesiologists, and on-call specialists, of billing an enrollee of a health care service plan for amounts owed to the provider by the health care service plan or its capitated provider for the provision of emergency services.
...
Petitioners contend that DMHC acted unlawfully in promulgating the Balance Billing Regulation and seek a writ of mandate (under CCP § 1085) ordering DMHC to repeal the Balance Billing Regulation, a declaration that the Balance Billing Regulation is invalid, and an injunction stopping DMHC from implementing and enforcing the Balance Billing Regulation.
...
III. Analysis

A. Standard of Review.
...
In reviewing the legality of a regulation adopted pursuant to a delegation of legislative authority, the Court’s inquiry is limited to three questions: (1) whether the regulation is within the agency’s delegated authority; (2) whether the regulation is reasonably necessary to effectuate and not in conflict with the purposes of the statute being implemented; and (3) whether the regulation was promulgated pursuant to proper procedure. (Moore v. Cal. State Bd. of Accountancy (1992) 2 Cal.4th 999, 1014-15; Cal. Gov’t Code §§ 11342.1, 11342.2, 11350(b).) The Court accords the regulation a strong presumption of regularity, and Petitioners bear the burden of showing its invalidity. (Moore, 2 Cal.4th at 1014-15; Credit Ins. Gen’l Agents Ass’n v. Payne (1976) 16 Cal.3d 651, 657.)
...
B. Discussion.

Petitioners challenge the Balance Billing Regulation under each of the three areas of Court review listed above, and additionally challenge the regulation as unconstitutionally vague. Petitioners’ many arguments can be organized into the following categories: (1) that the regulation was not within DMHC’s delegated authority to enact; (2) that DMHC did not follow proper procedures under the California Administrative Procedure Act in promulgating the regulation because its economic impact statement conflicts with substantial record evidence; (3) that the record lacks substantial evidence that the Balance Billing Regulation was reasonably necessary to effectuate the statutory purpose; (4) that the regulation conflicts with the Knox-Keene Act’s purpose that contracts between HMOs and providers be “fair and reasonable to ensure adequate networks”; and (5) that the regulation violates due process because it is overly vague. The Court will address each category of argument in turn.
...
* The DMHC Acted Within Its Delegated Authority in Promulgating the Balance Billing Regulation....
a. Health and Safety Code § 1371.39(b)(1) Plainly Authorizes DMHC to Define Unfair Billing Practices....
b. Health and Safety Code § 1371.39(b)(1) Authorizes DMHC to Regulate Providers With Regard to Unfair Billing Practices.
c. DMHC’s Determination that Balance Billing Can Constitute a Billing Pattern is Reasonable..
* The DMHC’s Economic Impact Statement Does Not Conflict with Substantial Record Evidence.
* The DMHC’s Conclusion that the Balance Billing Regulation Was Reasonably Necessary Is Supported by Substantial Evidence.
* The Balance Billing Regulation Does Not Conflict with the Knox-Keene Act’s Requirements for HMO-Provider Contracts.
* The Balance Billing Regulation Is Not Unconstitutionally Vague.

IV. Disposition
..
The petition is denied. The requests for declaratory and injunctive relief are denied. DMHC, as the prevailing party, is directed to prepare a formal order, incorporating the Court's ruling herein verbatim or attaching it as an Exhibit, and a judgment consistent with the ruling; submit them to opposing counsel for approval as to form; and thereafter submit them to the Court for signature and entry of judgment in accordance with Rules of Court 3.1312 and 3.1590.

Labels: BalanceBilling, DMHC

posted by Anthony Wright | Permalink | 7:37 AM


 

Credit where credit is due to protect credit...

Tuesday, October 14, 2008

The California Department of Managed Health Care implements new regulations tomorrow to prevent "balanced billing," good first steps to protect patients.

When insured patients find themselves going to an emergency room or ER doctor that is not contracted with their health plan, there is sometimes a dispute between the provider and the insurer about what the payment should be. The problem is that the patient is then sometimes used as a pawn in these billing disputes. The patient, who pays their premiums and is doing everything right, gets the bills for the disputed--or whole--amount, which also gets sent to collections and court.

So patients have their credit and their financial future ruined. The last few weeks have proved the essential importance of credit in today's economy, and the practices of some providers have created a crisis for many California families.

As Lisa Girion at the Los Angeles Times reports, there is significant opposition from health care providers to these regulations. There's a real need to resolve these provider-insurer disputes, fairly. Health Access California and other consumer groups supported SB921(Perata), a compromise measure to help resolve these differences, but the Governor vetoed it.

The regulations focus on the appropriate role of the agency, which is consumer protection: making balance billing an unfair billing practice, subject to civil penalties and "cease-and-desist" court actions. Nevertheless, these regulations are a good first step... but more work is needed.

Labels: BalanceBilling, DMHC

posted by Anthony Wright | Permalink | 11:08 PM


 

Dealing with ER overcrowding...

Thursday, August 07, 2008

How do we reduce emergency room overcrowding and waiting times?

Certainly, people have pointed to reducing the ranks of the uninsured, who lack primary care and end with worst health conditions as a result; and to prevent budget cuts, that threaten some ERs directly, and the coverage and benefits and clnics that help people avoid the ER in the first place.

But to follow-up on Hanh's post about the new study on Emergency Room use, there's another important solution that needs to be in the mix as well: make sure the insured get timely access to care.

Here's Victoria Colliver's article in the San Francisco Chronicle:

"...What's new is the rise ... in frequency in visits, and that's occurring in the insured," said Dr. Stephen Pitts, author of the report and a CDC fellow who teaches emergency medicine at Emory University's School of Medicine.

Pitts said the difficulty in getting primary care appointments could be contributing to the rise in emergency room use, particularly by those with insurance or on government programs such as Medicare or Medicaid.

"The likely cause is there are just fewer and fewer primary care physicians," he said. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."

Under managed care plans, people agree to a limited network of providers with the assurance that that network has enough doctors, hospitals, and specialists to provide timely and appropriate care. The state Department of Managed Health Care (DMHC) is charged with ensuring that there is "network adequacy" and people are able to get "timely access" to care.

There is currently a stakeholderregulatory process at DMHC to implement standards for timely access, as required by AB2170(Cohn). Health Access California, the sponsor of that bill, along with Western Center on Law and Poverty, California Pan-Ethnic Health Network, and other organizations, are representing consumers against many, many provider groups.

We hope the resultion will not only ensure that people get timely access to care... and in turn, help with the ongoing issue of ER overcrowding.

Labels: DMHC, TimelyAccess, Underinsurance

posted by Anthony Wright | Permalink | 11:27 AM


 

Balancing act...

Saturday, August 02, 2008

Well, it's not a balanced budget deal, but there's some progress on balance billing.

Yesterday, the Department of Managed Health Care (DMHC) issued regulations to the Office of Administrative Law on the contentious issue of "balance billing." The new regulations would restrict the practice of emergency health providers sending the bill to *insured* patients if they are having a dispute with their insurer. The OAL will provide a legal review of the regulations before putting them in full effect.

The patient--and their credit rating and financial future--should not be used as a pawn in these reimbursment disputes between insurers and providers. The regulations restrict this "balance billing" by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers.

It's a good step. There is also pending legislation, by Sen. Pres. Perata, Assemblywoman Salas, and others, that would go broader, and look to help resolve these disputes between providers and insurers in the first place. But the first principle is to do no harm--to the patient, or their pocketbook.

Labels: BalanceBilling, DMHC

posted by Anthony Wright | Permalink | 3:30 PM


 

Blue Shield and Blue Cross settle on rescissions...

Thursday, July 17, 2008

Big day on rescissions. I was in Los Angeles, testifying before the LA County Commission on Insurance in support of SB840, health reform, and specific pending legislation on recissions--after all there are no less than four bills, sponsored by Assemblymembers De La Torra, Deleon, Hayashi, and Lieu, that include a number of reforms.

I thought I was providing the most up-to-date information, but a lot happened.

The Capitol Weekly and The Los Angeles Times reports on two major settlements, with Blue Shield to restore coverage to 450 rescinded patients and pay a $3 million fine, and Blue Cross to restore coverage to 1770 patients and pay a $10 million fine. Earlier settlements were already reached with Kaiser, HealthNet, and Pacificare, albeit with smaller fines and numbers of people impacted, given their market share.

We'll need to watch over the Department and the insurers to ensure their goals are reached for these consumers:"guaranteed issue coverage, a process for full monetary losses and no back premiums owed," as Department of Managed Health Care Director Cindy Ehnes had identified in the LA Times.

It's good that there has been a focus on getting these folks coverage as soon as possible, even as other court and other proceedings continue. The question is what laws can help moving forward so we radically reduce or eliminate these practices once and for all. The ideas pending include:
* providing a independent review of all rescission cases;
* standardizing the underwriting proccedings;
* shortening the time frame where a patient can be rescinded;
* eliminating bonuses paid to employees who rescind more patients;
* protecting family members' coverage when a family member is rescinded; and
* setting standards for brokers due diligence.

Finally, at the federal level, Congressman Henry Waxman and the House Committee on Oversight and Government Reform held a hearing on the subject, featuring testimony from several rescinded patients, a representative of the insurers, and from California, Secretary Dale Bonner, which oversees the DMHC. It put a federal spotlight on the issues, hopefully helped in getting some attention on these issues in a new light, maybe helped serve as an impetus for these settlements, and sets what being "a regular" may mean.

Labels: BlueCross, DMHC, GuaranteedIssue, Insurers

posted by Anthony Wright | Permalink | 10:53 PM


 

Over a thousand patients reinstated...

Thursday, May 15, 2008

Major news today from Los Angeles, where the Department of Managed Health Care (DMHC) announced settlement agreements with Kaiser Permanente and HealthNet to automatically restore coverage to over 1200 patients who had their coverage rescinded.

Lisa Girion of the Los Angeles Times, who's been on this story like a hawk, has an early story.

Here's the Department of Managed Health Care's press release and text of the actual settlements with the two insurers. Kaiser had the bulk of the rescissions--over 1,000, even though they stopped the practice two years ago. The real question now is whether the other leaders in the individual market--Blue Shield, and especially Blue Cross, will also come to terms.

A few weeks ago, consumer advocates stood with the DMHC Director Cindy Ehnes when they announced that all of the 5,000+ people who had their coverage retroactively rescinded since 2004 would be provided an independent review process so that they can get their past treatments paid for, get appropriate restitution, and get reinstated for coverage going forward.

These settlements go beyond that, in getting the plans to reinstate the patients without the uncertainty and administrative hassle of a review, and with the agreement not to challenge the reinstatement in court--something that some plans were threatening.

We appreciate the Department's focus on getting people their care and coverage first and foremost. We are pleased that over a thousand patients will get reinstated without further procedural barriers and heartache. The patients will appropriately be made whole for the expenses they have had to bear, but also ensured coverage so that are not left alone and abandoned, uninsured and uninsurable because of their so-called pre-existing conditions.

And while we think the fines don't match the scale of the insurer's wrongdoing, the priority is to make the patients whole, and to make sure they have coverage. We appreciate the focus on back-end enforcement of this settlement and the possibility of much steeper fines, and hope the Department adopts a 'zero-tolerance' policy for further bad behavior by these insurers.

Thousands of other patients are waiting to see if their health plan will agree to a settlement, or if they will have to go to a more cumbersome process to get coverage, either through the Department or in court. It's sad that after all the attention on this reprehensible practice by insurers, we don't have the entire industry seeking to make this right.

Labels: DMHC, Insurers, Rescissions

posted by Anthony Wright | Permalink | 8:43 PM


 

Rescinding rescissions...

Thursday, April 17, 2008

Earlier today, the Administration announced plans to allow for the reinstatement of all Californians who were rescinded for coverage in the past four years. This includes some immediate reinstatements, and an automatic process for those who can be identified to have their cases get a third party review, and have their care retroactively covered.

I was pleased to be at a press conference with Cindy Ehnes, Director of the Department of Managed Health Care, and Daniel Zingale, Senior Advisor to the Governor. There's more to be vigilant about, to make sure that these patients get the care as quickly as possible, and their financial issues settled expeditiously, but this is positive movement forward.

More details are coming, including in articles by Lisa Girion and Marc Lifsher in the Los Angeles Times, and Dorsey Griffith in the Sacramento Bee. The other part of the story, that seems to be getting less play but is crucially important, is that the Governor has put forward principles for a legislative solution moving forward, so that no innocent person is ever rescinded again. As supporters of bills in the legislature, like AB1945(De La Torre), that help do that by requiring independent third-party review for every rescission case, that's welcome as well.

Labels: DMHC, Insurers, Schwarzenegger

posted by Anthony Wright | Permalink | 5:14 PM


 

Balancing priorities on balanced billing...

Tuesday, April 01, 2008

The practice of balanced billing gets the spotlight in an excellent article by Jordan Rau in the Los Angeles Times today. It deserves attention not just in California but across the country.

The piece focuses on the new regulations by the Department of Managed Health Care to ban the practice of "balanced billing," where *insured* consumers are unfairly billed and even sent to collections for going to the doctor or hospital.

The bill should go to the insurer, but because there's a dispute between the health provider and the insurer, the provider also bills the patien--the whole bill or the "balance" of what the insurer won't pay--as a way to leverage the insurer to pay more.

The patient, as a result, either unwittingly pays an bill (often inflated beyond what anybody pays) that is the insurer's responsibility, and even if they don't, they are dragged into this contractual dispute and could be sent to collections--with their credit history and financial future at risk.

Either way, it's not what the consumer was expecting when they signed up for health insurance in the first place. As our Health Access California colleague Beth Capell is quoted, "Consumers who do the right thing and go to a hospital that's in their network should not be leveraged in a fight between doctors and insurers... It's just wrong."

But in deference to our policy advocate, the quote of note comes from the Administration, which illustrates how contentious this issue, describing how regulatory efforts to broker a deal failed after the Schwarzenegger Administration had issued an executive order on this issue in 2005.

The Department of Managed Health Care spent the last two years trying to negotiate a compromise between insurers and providers to work out their payment differences, but couldn't find common ground. So the department decided to simply outlaw the practice through new draft regulations issued Friday.

"We tried to say, when we were young and naive, that we could find a mutually acceptable resolution to make sure physicians were being paid fairly and on time," said Cindy Ehnes, the department's director. "We finally said, we can't solve this marketplace dispute, but what we can do is our core mission of protecting consumers."

The draft regulations would prohibit hospitals and hospital-based physicians from billing a patient for the cost of emergency services that are the responsibility of the patient's health plan.

There will continue to be pending legislation, including by Senate President Pro Tem Don Perata, to see if there is a legislative agreement to settling the contract wars between providers and insurers.

There are issues to work out: these are often cases where a patient goes to an in-network hospital, but has no idea that the ER doctor on call, or the anasthesiologist or other specialists, are not contracted with their insurer. Unlike contracted doctors, there's no negotiated agreement on the rate. The doctor, who was not in a position to refuse the patient, feels the insurer is underpaying. The insurer isn't going to pay the full billed amount by the doctor--a "sticker price" that is more than any insurer pays. So when there isn't an agreement up front, what should be the payment? There's lots of alternatives--and that's what the various legislative proposals seek to address--but the answer shouldn't be to simply stick the consumer with the bill.

But while we are working through those issues, it is appropriate for the Department to focus on what should be the consensus item; to focus on the core issue of protecting consumers from this unfair billing behavior.

Labels: BalanceBilling, DMHC, Legislation

posted by Anthony Wright | Permalink | 6:51 PM


 

The DMHC Oversight Hearing...

Thursday, March 27, 2008

HEALTH ACCESS UPDATE
Friday, March 28th, 2008


SENATE PANEL QUESTIONS HMO REGULATOR
* Lawmakers question Department of Managed Healthcare’s oversight of health insurers
* Inquiry into regulations for timely access, discount plans, rescissions, language access and mental health parity
* Sen. Kuehl sees "pattern" of siding with industry against consumers
* Laws passed more than five years ago still not implemented


Click Here for What's New on the Health Access WeBlog: Health Care Consumers Views; GAO Individual Market Investigation; More Debriefings on California Health Reform; A Health Reform Backlash Against San Francisco Restaurants?; Health Budget Cuts Nationally; Shooting for 60 Votes; 1,000 Posts!; Web Wonkery; McCain's Misstep: Do We Go to the Doctor Frequently?; The Hot Hearing for the Week; Mayor Newsom Suing Sacramento Over Medi-Cal Rates; So-Called Consumer Directed Health Plans; Overseeing the DMHC


SACRAMENTO--At a special hearing of the Senate Health Committee on Thursday, Department of Managed Health Care Director Cindy Ehnes was questioned for over nearly seven hours about her department’s handling of five separate regulations and whether it had met its charge as a consumer protection agency in implementing and enforcing laws to help patients. “This hearing is meant to provide a level of oversight to ensure that legislation that is passed gets implemented in a way that is consistent with the way it was intended,’’ said Sen. Sheila Kuehl, chair of the Senate Health Committee.

At issue were three laws, passed in the late 1990s and earlier this decade, which still have not been put into practice: Timely access to health care, access to health care that is both culturally and linguistically sensitive and mental health parity. Additionally, Ehnes was interrogated about the Department’s rationale for regulations regarding retroactive cancellations of health policies and so-called "discount health cards".

For more detailed information on all these issues, you can visit the Health Access website and blog. As well, the Senator posted a detailed agenda and background papers on her website, at:
www.sen.ca.gov/kuehl


TIMELY ACCESS TO CARE

Background: First on the list was the issue of timely access to care, which were intended to prescribe specific time-elapsed standards for how long it should take patients to get into to see a physicians. The law was passed in 2002, and after many years of hiccups, regulations were on the path to implementation in 2007. The regulations spelled out exactly how quickly patients should be able to get in to see a doctor in certain situations. (I.E. Urgent primary care needs: 24 hours; Routine primary care needs: 10 days; Urgent specialty care: 72 hours; Routine specialty care: 14 days)

But in December, the Department yanked that version, stripped out all specific requirements, and left it up to health plans to determine their own standards, as had been the practice in the years before the law was passed. Health Access California and Western Center for Law and Poverty testified that the law did not meet the legislature's intent in having the Department set clear, prescriptive standards. Last month, the Office of Administrative Law rejected the regulations, saying the department had not allowed enough time for public comment given the dramatic changes in the regulations. To read Health Access' writings on this, click here.
The difference between the August and December versions of the regulations was so stark that Sen. Sam Aanestad, R-Grass Valley, asked, “It looks like the department just punted. What was the amazing turnabout?’’

Department’s take: Ehnes said she felt that the August regulations – 26 pages – were too complicated and would force plans to micromanage physicians they contract with. She said the department focused on the clinical triage via phone, where patients could call in and get a professional to tell them what they needed to do. Health Access’ Beth Capell later said this telephonic triage was available during limited times -- weekdays during work hours.

Legislative comment: “Regulations are supposed to go further than the statute. Sometimes they are going to be very complicated. I would encourage a little more complication,’’ Kuehl said. She urged that the Department set prescriptive, time-elapsed standards when developing new regulations in the new year. Aanestad indicated he thought the Department was "almost there" with previous version of the regulations that had set standards.

DISCOUNT HEALTH CARDS

Background: Discount health cards aren’t health plans, but cards that consumers pay a monthly premium, for access to a list of physicians that will purportedly provide them discounts. The problem is, often, physicians don’t know they’ve been put on a list, and consumers don’t know what the base price off which they receive a discount, making the discounts meaningless. These plans are often marketed toward lower-income or limited-English consumers who believe they are actually buying health coverage, and these plans rely on this confusion to thrive.

The plans have been deemed illegal by the state Attorney General; but there has been confusion about if they should be allowed or licensed and regulated, and even what agency should do the regulating. The DMHC has started a process of developing regulations to license these discount cards, working with the industry. Health Access testified that while the value of these products was questionable, any regulations must at a minimum ensure real discounts to a real network of providers with real notice of what consumers are and are not getting for their money.

Department’s take: The department has investigated 53 discount health plans and ordered cease and desist orders against 7. Ehnes said developing regulations and licensing such products was not meant to be an endorsement, but to try to better understand the products.

Legislative comment: Kuehl asked the department, as it continued its work, to strongly consider whether these products offer any real economic value to consumers.


RESCISSIONS

Background: In the past couple of years, the startling practice of retroactive cancellation of policies by insurers has arrested the public’s attention. Consumers, who have been paying monthly premiums and believed they are insured, receive high-dollar treatments for cancer, heart disease and the like. These expensive treatments often trigger insurance companies to review the enrollees’ initial application and rescind policies, claiming enrollees did not properly disclose pre-existing health conditions. Policies are cancelled, retroactively, as if consumers were never insured. Consumers are then sometimes left with thousands –if not hundreds of thousands of dollars -- in debt for treatments they believed were covered. The courts have determined this practice is illegal unless consumers willfully misrepresent their health status.

Department’s take: Ehnes said the DMHC has been aggressive in investigating plan behavior since the practice came to light. The department, along with the Department of Insurance are developing regulations so that plans do not have the ability to rescind without reason and that consumers can’t misinterpret applications.

Legislative comment: Kuehl’s primary concern was how consumers could obtain coverage after they’ve been cancelled. These cancellations occur on the individual market where consumers are often denied coverage due to pre-existing conditions. Once consumers’ coverage is cancelled, it would be impossible for them to obtain coverage through any carrier.Aanestad believed the department was not properly protecting consumers and making that the focus. “The first priority is to reinstate coverage for consumers. The second priority is to make headlines and change the industry, but it doesn’t sound like that’s really happening.’’


CULTURAL AND LINGUISTIC ACCESS

Background: In 2003, the legislature passed a law, SB853(Escutia), that required health plans to ensure that the consumers who did not speak English as a first language had proper medical interpretation services. Up until then, consumers brought in their children to translate, did not get care, or got the wrong care because they were unable to communicate with their doctors. This is particularly important in California where 55 percent of the population reports not speaking English well. The California Pan-Ethnic Health Network, Latino Issues Forum, and other groups were concerned that the notice about these new rights were left to the industry to determine, without consumer input. Plans have complained it is costing them millions to translate materials.

Department’s take: Ehnes said she was committed to this issue and was attempting to evaluate all aspects, including whether the regulations go beyond the law and whether it will cost too much.

Legislative comment: Kuehl said when the legislature passes something, that’s the rule. “We don’t care what it costs everybody. Cost is important…but that’s not the top consideration. …We really mean it about providing real access to language minorities,’’ said Kuehl, who was also critical about the department’s process in listening to all stakeholders and allowing enough time to comment on regulations. “Please push the envelope on this one, because I know you want to.’’


MENTAL HEALTH PARITY

In 1999, the Legislature passed mental health parity, providing consumers with access to mental health benefits equal to coverage in other health services. But to this day, consumers are still finding it difficult to obtain mental health services they need on the same level as other health services. Timely access to providers remains a problem as well as plans’ treatment and financial obligation toward mental health. The Senators urged the department to be more aggressive about following up on surveys and studies that found consumers lacking access to mental health.

PARTING NOTES

Ehnes said the department would continue to work on these – along with other issues – under the department’s jurisdiction. Kuehl reiterated that the hearing was intended to ensure that laws were actually implemented and not allowed to wither once passed. She also continued to encourage the department to have more open and collaborative process.

For more information, contact Elizabeth Abbott, director of administrative advocacy at Health Access California, at eabbott@health-access.org. Interested organizations can also contact the author of this report, Hanh Kim Quach, policy coordinator at Health Access, at hquach@health-access.org.

Labels: DMHC, Kuehl, LanguageAccess, Sacramento, TimelyAccess, Updates

posted by Anthony Wright | Permalink | 10:12 PM


 

Oversight about oversight...

Victoria Colliver at the San Francisco Chronicle has a preview of today's Senate Health Committee hearing--which is expected to be at least five hours of grilling on a range of meaty issues.

The Senate Health Committee, chaired by Senator Sheila Kuehl, will hold a hearing today on "Consumer Protection under the California Department of Managed Health Care: Adequacy of Implementation and Enforcement," reviewing the DMHC's oversight in five key areas: timely access, language access, so-called discount health plans, retroactive denials of coverage; and mental health.

In all these issues, they strike to the core of whether the coverage is meaningful, and whether the consumer is getting value for what they paid for. And on all these topics, there are pending decisions regarding regulations or implementation issues at the DMHC.

It won't be a surprise to readers of this blog that health and consumer advocates will press for stronger standards and more aggressive oversight for the health insurance industry--and for good reason.

Consumers are increasingly concerned that their coverage won't be there for them when they need it--that they won't be able to get in to see a doctor or specialist, to get a translator if necessary, or even that their coverage will be retroactively rescinded.

In light of these HMO practices, the Department needs to be more--not less--aggressive in protecting patients and investigating the insurance industry.

Yet, the tendency by the Schwarzenegger Administration is to leave the decisions up to the insurers. Recent regulations would let insurers decide their own standards on timely access; to determine their own method of notifying patients about their rights to an interpreter. On new regulations of discount cards, the Department were shaped by the industry they were purporting to regulate-an industry that offers a product of dubious value to consumers.

The regulations to ensure timely access to care has been a particular subject of controversy--and focus for Health Access. For years, the Department of Managed Health Care has had numerous drafts of regulations to implement a 2002 law to establish and enforce standards to ensure access to care within clear timeframes. Yet the most recent draft let the insurers set their own standards. Senator Kuehl recently wrote a letter indicating this conflicted with the intent of the Legislature is passing the bill.

We hope this hearing provides much-needed legislative push to the Department to resolve these issues quickly, and the political cover to prioritize protecting patients, regardless of industry opposition. Consumers want and need more assurances that their coverage will provide the protection that they paid for.

If nothing else, the hearing brings additional *public* scrutiny to these issues--which is important, given the stakes for the average health consumer, but rare, given that DMHC regulations usually get attention from the industry and a handful of consumer advocates.

We have an ongoing interest--Health Access California, the statewide health care consumer advocacy coalition, was the sponsor of the HMO Patient's Bill of Rights in the late 1990s that created the Department of Managed Health Care, to be a stand-alone department with a specific focus on consumer protection. Our group continues to advocate on behalf of consumers at the DMHC on a range of issues. More recently, Health Access was the sponsor of AB2179(Cohn) in 2002, which required the Department to establish and enforce standards for timely access to care; and a strong supporter of SB853(Escutia) to require language access to care.

So we'll be continuing to do our own oversight, over the insurers--and their regulators.

We'll have a report on the hearing later in the day.

Labels: DMHC, Kuehl, Sacramento

posted by Anthony Wright | Permalink | 1:36 AM


 

Back in session... and the hot hearing for the week...

Tuesday, March 25, 2008

The legislators came back to Sacramento this week after spring break... and it's getting frantic, quick. Bills (see the Health Access bill list) introduced this year only have a few weeks to pass their first policy committee.

While the budget and policy committees continue their regular work, the most interesting and high-profile hearing this week will probably be the Senate Health Committee, chaired by Senator Sheila Kuehl, hold a special Thursday session.

The hearing is entitled "Consumer Protection under the California Department of Managed Health Care: Adequacy of Implementation and Enforcement," is expected to take several hours and maybe more.

The issues to be discussed at this informational hearing are meaty, as it asks for reports on the DMHC's implementation of regulatons in many areas of strong interest to consumer advocates, including timely access, so-called "discount health plans," rescissions, language access, and mental health parity.

We're posted some about the pending regulations to ensure patients have timely access to care. A month ago, Senator Kuehl urged the Department to withdraw their proposed regulations, stating that they were not in line with the legislature's intent when passed AB2179. The author, Assemblywoman Rebecca Cohn, has been termed out, but Health Access California was a sponsor, and Senator Kuehl was a member of the Legislature that voted for it.

But it's clear that this hearing is about more than just timely access--or even about the other key issues. It's about being clear that the DMHC should be focused on consumer protection as its core mission--it's the reason that the DMHC was created in the first place. There's too many important issues for anything else to get in the way.

Labels: DMHC, Kuehl, Sacramento, TimelyAccess

posted by Anthony Wright | Permalink | 3:55 PM


 

Overtime for timely access standards...

Monday, March 10, 2008

Aurelio Rojas of the Sacramento Bee had a good Sunday story on the long saga of the timely access to care regulations at the Department of Managed Health Care.

As has been reported on this blog before, after going back-and-forth with specific standards, the DMHC decided a few months ago to simply let the HMOs determine their own standards. As the article indicates, Health Access California and Western Center for Law and Poverty were prepared to go to court, since it's just unacceptable for the DMHC to abdicate their role to insurers, and the regulations simply did not implement the intent of the legislature.

But that was avoided, since the Office of Administrative Law rejected the regulations on a technical process issue. The Bee has a statement by the DMHC:

"With the disapproval of the timely access regulations, we will take the
opportunity to re-examine the concerns of all stakeholders and determine the
best approach going forward."

It would be inappropriate for the DMHC to respond to just the procedural issues and resubmit the same, flawed regulations. We truly hope the Department, in the short winodw of time before they need to resubmit in the next few months, commits to a process that results in clear standards of timely access, standards that consumers can understand and demand the next time they are told they can't see a specialist for two months.

Until such a process is set, the next step is a special oversight hearing by the Senate Health Committee, chaired by Sen. Sheila Kuehl, set for later this month.

Labels: DMHC, InTheNews, TimelyAccess

posted by Anthony Wright | Permalink | 6:41 PM


 

A coda on confirmation...

Wednesday, February 27, 2008

By the way, Secretary Dale Bonner was confirmed today by the Senate Rules Committee.

But not before several Senators asked a series of tough questions about his oversight over the Department of Managed Health Care. This was part of a wide-ranging hearing that reflected the broad scope of the department, from housing to transportation issues as well.

Senator Padilla asked about the level of fines levied at Blue Cross and other insurers over rescissions, and said he's "not convinced [they] get to the level of deterrence needed" and that he's thinks that "all of the players have not gotten the message." After being asked about how the Department is made aware of consumer complaints, Bonner stated "I don't think [the Department] is sufficiently pro-active."

Senator Padilla also asked about the letter by Senate Health Committee Chair Kuehl expressing concern that the timely access regulations adopted are not reflecting the will of the legislature. He ask about the Department's adoption of new regulation that allow the health plans to set their own standards: "that sounds a little permissive to me." He made the argument for such clear, enforceable standards. "We know that justice delayed is justice denied. Well, health care delayed is health care denied," and he pointed out the additional costs and burdens that such delays place on emergency rooms. Padilla also asked about the implementation of language access regulations. Bonner stated that he thought the implementation of language access is "all over the map," and that "I don't believe we have enough coherency" with regard to the goal of language access.

Senator Ashburn asked about the appropriateness of Blue Cross' letter to get doctors to reveal information to the insurer that would get patients retroactively denied. Bonner stated that he didn't read the infamous letter himself, but that he recognized "the discomfort in anything that interferes in the doctor-patient relationship," and he thought Blue Cross' restraction of the letter "confirms that there was a serious problem." asked more specifically about the actions that Bonner took with regard to the issue, including any conversations with DMHC Director Cindy Ehnes. He said he hadn't spoken with her directly, but did through staff, and was satisfied that there was a investigation underway. Later, Senator Perata followed up Ashburn's scolding, saying "you should have seen the letter, and you should have been all over it."

Senator Perata also agreed about the need for more responsive DMHC. "This isn't an academic exercise, for those who are in trouble with their HMO, someone who is being horsed around." Senator Perata also urged higher fines: "you have to put a sharper point on it," he said, and later, "fines are a real attention getter." Senator Perata even asked if the DMHC should be in his far-flung Business, Transportation, and Housing Agency. Bonner indicated that it should, given the kind of expertise it regarding business oversight and solvency issues.

Consumers groups like Health Access California and Western Center on Law and Poverty were there, not to oppose Bonner's confirmation, but to make clear our concerns about how the Department is abdicating their responsibilities to the industry they are supposed to be overseeing.

Senator Cedillo followed up on the language access issue and making sure people have notice of their rights under the law, saying "this is an absurdity. You don't know you have a right unless someone communiciates it to you. If you don't know it, it doesn't exist.... It's the law. The Escutia law is the law." Senator Perata suggested that Bonner didn't want former Senator Escutia coming back to ask questions.

Secretary Bonner was confirmed, but promised to reach out to stakeholders, including consumer groups, to deal with these issues and the other issues presented.

Labels: DMHC, Perata, TimelyAccess

posted by Anthony Wright | Permalink | 8:44 PM


 

What they don't teach in civics class...

While we glow about how the Department of Managed Health Care's regulations on timely access to care were returned to them yesterday -- without approval -- by the Office of Administrative Law, we also want to take the opportunity to talk about the obscure process in state government called rulemaking.

I'll strongly note here that the OAL's refusal to finalize DMHC's proposed Timely Access regulations had nothing to do with how miserable the regulations actually were. Office of Administration Law merely dinged DMHC because they did not follow the proper waiting periods and rules -- (hey, we'll take our wins where we can get them). This is an importnat point as we embark on another year of rulemaking for Timely Access to Health Care standards.

First, I want to point everyone to the Office of Administrative Law's handy dandy lay person's guide on How to Participate in the rulemaking process.

Secondly, some context. Here's how the Timely Access regulations came to be:

• January 1, 2003: AB2179 (Cohn) takes effect, having passed in 2002, requiring the state to adopt regulations to ensure that enrollees have "timely access to needed health care services.'' (Timely access means reasonable waiting times for appointments with physicians, quick and timely care when a patient is sick or needs services, etc. )
  
• January 1, 2004: The date by which DMHC was supposed to have adopted regulations.


• July 9, 2004: DMHC begins writing regulations, but withdraws them in April 2005 because of feared "unintended consequences" and restarts discussions with various parties, including insurers, providers and consumers on how to craft the rules.


• January 11, 2007: DMHC reopens the rulemaking process with Office of Administrative Law on this date; the department has 365 days from this date to complete the regultions.
  
• March 5, 2007: DMHC holds its first public hearing on its first set of proposed regulations. The 14-page regulations (among many other things) spells out exactly how quickly patients should be able to get in to see a doctor in certain situations. (I.E. Urgent primary care needs: 24 hours; Routine primary care needs: 10 days; Urgent spcialty care: 72 hours; Routine specialty care: 14 days).
  
• July 15, 2007: DMHC releases second version of regulations. As in the March version, this draft also contains time-elapsed standards.
  
• September 18, 2007: DMHC holds second public hearing on a revision of the proposed regulations and accepts comments.
  
• December 10, 2007: DMHC's third version of these rules completely strips out all specificity. Gone are state standards requiring that a patient who needs urgent care be able to see a primary care physician within 24 hours. Instead, the new rules allows health plans to define, for themselves, what constitutes "timely access.'' This stripped-down draft shrinks from 28 pages to 7 pages. The Department gives interested parties 15 days to submit comments -- from Dec. 10 - 26. (Note: It's this final 15 days where DMHC gets into trouble).
  
• January 11, 2008: DMHC submits final regulations for approval with Office of Administrative Law. (The Office of Administrative Law has 30 days to approve the regulations -- which it refused to do yesterday.)

Health Access, the sponsors of of AB2179, and consumer advocates have many substantive reasons to scream and howl about the latest draft of the regulations. We believe the state flouted the law, intended to get consumers proper health care when they need it (not weeks and months later). In doing so, we believe they lacked the "statutory authority'' to do what they did. We also believe that the Department was deliberately vague and unclear, allowing insurers to willy nilly make up their own rules.

But what hung the DMHC was its "belief" that the differences between the second and third versions were not substantial (though, anyone who is not color blind looking at all the red in the "track changes'' function could see otherwise.) The Department gave the public only 15 days to comment on the rules -- clearly not enough time for "major changes,'' which require 45 days. But the full 45 days would have meant that the Department blow its January 11 deadline.

What OAL inadvertently did this week was provide consumer advocates time to make the regulations right. That means we'll have another year to fight at the Department level (again) to ensure patients get care when they need it. In the meantime, Health Access will continue to keep advocates abreast of movements on Timely Access and post relevant documents. (We'll post letters, correspondence from the past year soon).

Labels: DMHC, TimelyAccess

posted by Hanh Kim Quach | Permalink | 6:12 PM


 

A Timely Decision...

Perhaps coincidentally with the confirmation hearing of Dale Bonner, perhaps not, the controversial regulations on timely access to care have been dis-approved by the Office of Administrative Law.

We understand the disapproval is on the specific matter that the Department didn't provide enough time for hearings and comment on a substantive change in the regulations.

We actually thought the regulations didn't actually comply with the law in the first place.

Regardless, this gives consumer advocates an opportunity to re-make the case that the regulations need to have clear standards for timely access for care, as the law requires and the Legislature intended.

What isn't acceptable is to let the insurers each set their own standards, so that those standards are hard to enforce, and hard for consumers to even know what their rights are.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 11:36 AM


 

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