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Telehealth Parity Laws -  Ongoing Reforms Are Expanding the Landscape of Telehealth in the Us Health Care System, but Challenges Remain.

August 15, 2016

Despite the fact that no other developed country even comes close to the United States in annual spending on health care, 20 percent of Americans still live in areas where shortages of physicians and health care specialists exist, and the United States still ranks the lowest overall among eleven industrialized countries on measures of health system efficiency, access to care, equity, and healthy lives. Many believe that the answer to issues of cost and access in the US health system lies in telehealth, which increases access to care, alleviates travel costs and burdens, and allows more convenient treatment and chronic condition monitoring.With the implementation of the Affordable Care Act (ACA), the federal government announced the move toward encouraging and including telehealth services in health care coverage. The ACA, however, only implementedtelehealth at the federal level through Medicare, in selected circumstances; the power to determine which, if any, telehealth services is covered by Medicaid still remains largely within the powers of individual states.Also, states can govern private payer telehealth reimbursement policies. This means that telehealth implementation varies from state to state in terms of what services providers will be reimbursed for delivering, as well as what sort of "parity," defined as "equivalent treatment of analogous services," is expected between in-person health services reimbursements and telehealth reimbursements. This variation affects providers' ability to implement telehealth options, thereby reducing the patients' ability to use these services and become comfortable with the telehealth processes. Consequently, telehealth faces significant obstacles in becoming an accepted and used health care option for individuals, and states and the nation as a whole cannot fully realize the cost savings of telehealth.

Regulation of Health Plan Provider Networks: Narrow Networks Have Changed Considerably under the Affordable Care Act, but the Trajectory of Regulation Remains Unclear

July 28, 2016

Health insurance plans with limited networks of providers are common on the Affordable Care Act's (ACA's) health insurance Marketplaces. Recent studies have found that these "narrow network" plans constituted nearly half of all Marketplace offerings in the first two years of coverage, with one analysis concluding that about 90 percent of all consumers had the option of buying such a plan if they chose.Plans with limited networks are not new and are not confined to the Marketplaces. Yet there is reason to believe that they have grown in prevalence partly because of the ACA. Many of the health law's consumer protections--prohibitions on health status underwriting, increased standardization of benefits, a maximum limit on out-of-pocket spending, and the elimination of annual and lifetime limits on benefits, for example--have foreclosed traditional strategies used by insurers to keep costs in check. Meanwhile, other elements of reform, including online Marketplaces that make it easier for consumers to compare plans based on premiums and a financial assistance framework that links the amount of a person's premium tax credit to the cost of the second cheapest plan available to them at the silver metal tier, explicitly encourage insurers to compete on price. These developments appear to have led many insurers to design Marketplace health plans that combined a comparatively low premium with a more restricted choice of providers.Limited network plans might offer value to consumers. Coverage that pairs a low premium with a network that provides meaningful access to health care might meet the needs of many enrollees, no matter the network's overall size. Negotiations between insurers and providers over network participation might encourage more efficient delivery of care. And the power to contract selectively might allow insurers to create networks comprising a subset of providers who meet raised standards of quality, potentially resulting in higher-value care.But these plans also pose risks. A network can be too narrow, jeopardizing the ability of consumers to obtain needed services in a timely manner. This can happen if the network contains an inadequate mix of provider types. For example, a recent examination by Harvard researchers of the network composition of health plans offered on the federal Marketplace during 2015 found that nearly 15 percent of the sampled plans lacked in-network physicians for at least one specialty. Or a network might have an insufficient number of providers: There might be too few physicians who are taking new patients, who are available for an appointment within a reasonable time, or who speak the same language as the enrollee. Certain network limitations also might have the effect of discouraging enrollment by sicker consumers, potentially skewing the risk pool. Plans that provide limited or inadequate access to in-network providers make it more likely that enrollees will obtain care from out-of-network sources, exposing them to significant expenses and the possibility of surprise medical bills.Surveys show that many consumers are open to trading network breadth for a lower premium. They also suggest that, in practice, large numbers of consumers do not find network designs to be transparent. If the features of a plan's network are inadequately explained or its list of participating providers is inaccurate, it might be impossible for consumers to make an informed decision about whether the plan's combination of network and price is right for them.Consumers' experiences with narrow network plans since the ACA's implementation have defied easy characterization. Surveys of the insured, including those with Marketplace coverage, suggest that the vast majority are satisfied with their plan's choice of doctors. Yet anecdotal complaints about networks have proliferated, and the exclusion by some health plans of high-profile hospitals and care facilities has generated media headlines.In light of these developments, and as part of a larger effort to keep pace with changes to the health insurance markets since passage of the ACA, lawmakers and regulators have devoted significant attention to determining how networks should be regulated to ensure they are adequate and transparent. This work has involved efforts to establish or update standards for evaluating the sufficiency of a plan's network, improve the accuracy of provider directories, and protect enrollees from surprise bills from out-of-network providers. This brief offers an overview of state and federal actions that address the first two categories--network standards and provider directories--with a focus on rules that govern plans sold on the ACA's health insurance Marketplaces.

When Patient Activation Levels Change, Health Outcomes and Costs Change, Too

March 23, 2015

Patient engagement has become a major focus of health reform. However, there is limited evidence showing that increases in patient engagement are associated with improved health outcomes or lower costs. This report examined the extent to which a single assessment of engagement, the Patient Activation Measure, was associated with health outcomes and costs over time, and whether changes in assessed activation were related to expected changes in outcomes and costs. The report uses data on adult primary care patients from a single large health care system where the Patient Activation Measure is routinely used. Results indicating higher activation in 2010 were associated with nine out of thirteen better health outcomes -- including better clinical indicators, more healthy behaviors, and greater use of women's preventive screening tests -- as well as with lower costs two years later. Changes in activation level were associated with changes in over half of the health outcomes examined, as well as costs, in the expected directions. These findings suggest that efforts to increase patient activation may help achieve key goals of health reform and that further research is warranted to examine whether the observed associations are causal.

Small Employer Perspectives On The Affordable Care Act's Premiums, SHOP Exchanges, And Self-Insurance

October 28, 2013

Beginning January 1, 2014, small businesses having no more than fifty full-time-equivalent workers will be able to obtain healthinsurance for their employees through Small Business Health OptionsProgram (SHOP) exchanges in every state. Although the Affordable Care Act intended the exchanges to make the purchasing of insurance moreattractive and affordable to small businesses, it is not yet known how they will respond to the exchanges. Based on a telephone survey of 604 randomly selected private firms having 3 -- 50 employees, we found that both firms that offered health coverage and those that did not rated most features of SHOP exchanges highly but were also very price sensitive.More than 92 percent of nonoffering small firms said that if they were to offer coverage, it would be "very" or "somewhat" important to them that premium costs be less than they are today. Eighty percent of offering firms use brokers who commonly perform functions of benefit managers -- functions that the SHOP exchanges may assume. Twenty-six percent of firms using brokers reported discussing self-insuring with their brokers. An increase in the number of self-insured small employers could pose a threat to SHOP exchanges and other small-group insurance reforms.

Health Affairs/RWJF Health Policy Brief: Workplace Wellness Programs

May 10, 2012

Outlines trends in wellness programs, the debate over how best to structure them, the federal healthcare reform provision to allow employers to lower premium contributions for participating employees who meet health status goals, and upcoming issues.

Health Affairs/RWJF Health Policy Brief: Essential Health Benefits

April 25, 2012

Summarizes states' options in choosing benchmarks for essential health benefits covered in the ten categories required of individual and small group insurance plans under federal healthcare reform, such as hospitalization and maternity and neonatal care.

Health Affairs/RWJF Health Policy Brief: Premium Support in Medicare

March 22, 2012

Outlines proposals for providing premium support for private plans in Medicare as a way to curb cost growth by shifting from a reliance on fee-for-service payment to a greater role for private plans. Considers implications for spending and beneficiaries.

Health Affairs/RWJF Health Policy Brief: Public Reporting on Quality and Costs

March 8, 2012

Summarizes the theory behind, evolution of, and initiatives for public reporting of information about healthcare providers' performance. Examines concerns about measures and evidence of its impact on efforts to improve the quality of care and lower costs.

Health Affairs/RWJF Health Policy Brief: The Prevention and Public Health Fund

February 23, 2012

Outlines the rationale for creating a fund under the Affordable Care Act to invest in public health and disease prevention, the fund's spending to date, and the debate over its potential to promote wellness and slow cost growth and over continued funding.

Health Affairs/RWJF Health Policy Brief: Next Steps for ACOs

January 31, 2012

Outlines the origins of accountable care organizations, status of adoption by Medicare and private plans, issues in the debate over whether ACOs will help reduce costs while improving quality of care, and the CMS Innovation Center's future demonstrations.

Health Affairs/RWJF Health Policy Brief: The Independent Payment Advisory Board

January 15, 2012

Outlines arguments for and against the independent payment advisory board created by the 2010 health reform law to control Medicare spending if growth exceeds targets and Congress does not act promptly, including concerns that it may limit access to care.

Health Affairs/RWJF Health Policy Brief: Medicaid Reform

January 12, 2012

Outlines arguments for and against proposals for restructuring Medicaid to slow spending growth, such as converting the entitlement program to a system of block grants, replacing federal rules with state-specific goals, and removing the waiver process.