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Our third panel this morning is on qualified plans and plan design.
And will be moderated by Chiquita Brooks lasure, director of coverage policy in the HHS of
office of health reform. The panelists before lunch include Christina
nigh quest, vice president of head of -- Nyquist, head of public policy in Washington
D.C ., previously she worked for 18 years working on public policy issues.
Prior to the blues, Kristina worked with the national economic Research Associates providing
economic analysis, support for the Department of Justice antitrust filings.
Ruth Liu, director of health policy at Kaiser Permanente.
Ms. Liu is responsible for coordinating the organization policy strategy on national health
reform efforts while also providing input on a range of other policy issuesch Ms. Liu
is associate secretary for health policy at the California health and human services aagency,
one of four advisers to the governor and of health and human services in California.
She co-wrote the governor's reform proposal. Bill Kox, director of the insurance bureau
Wisconsin department of employee trust funds. Bill has managed health insurance programs
for the State of Wisconsin department of employee trust funds for more than 20 years.
In 1987 he was the manager for the Wisconsin public employees program which extended for
the first time the State's managed competition model.
DeAnn Friedholm director health reform consumers union also joins us this morning, she leads
the health reform campaign team at consumers union comprised of policy, grassroots advocacy,
communication, lobby staff here in Washington D.C., New York, California and Texas.
And finally, Meg Murray, Chief Executive Officer, association of community affiliated plans.
She was the founding CEO of the association and has led the organization since its inception
in 2001. Steering it through its origins as association
of 14 community health center owned plans to covering over 7 million people on medicaid
and Medicare. Join me welcoming this panel and I'll turn
it to Chiquita.
-- Thank you so much, good morning, everyone.
[Applause] Some of the other patients have started talking
about what we're going to talk about here. The statute gives the secretary the ability
to set plan standard for participation in the exchanges.
That's the purpose of our panel today. A key question is whether exchanges should
be an active purchaser or entity that certifies all qualified plansch these decisions are
going to affect federal cost of the tax credit as well as cost to consumers, businesses,
and taxpayers. And will have implication for attractiveness
of exchanges to consumers and small business. One fundamental goal of the exchange is to
drive plans to compete based on price and quality rather than the ability to segment
risk. So I would like to start by asking our entire
panel to comment what other factors likely to encourage or discourage participation and
competition among plans in exchanges based on price quality and value.
What factors undermine this goal.
-- There's probably a couple of things you want to build to the exchange in order to
have it be successful for consumers and employers. And also to attract health plan participation.
I think one of the issues is the ability and the incentive for health plans to continue
to innovate. At Aetna we have the care considerations program.
So we use an algorithm to analyze claims data that provides real time feedback to doctors
and consumers saying oh, this patient was diabetic and she didn't get an X, Y, Z when
she came to see you. And we're trying to help transform the healthcare
system through harnessing technology in those types of ways.
The exchange maintains incentive for health plans to continue to do that to make sure
consumers understand that that is a value add of the exchange.
A second thing is to think about efficiency. I know insurance companies are striving and
certainly we understand that we have to be as efficient as possible in our ability to
do is is dependent on what the exchange, how it's set up.
For instance when you think about protocols and interfaces established, it's important
to recognize you don't want 50 different types of computer interfaces because as a health
plan you want to participate in as many as possible and not have to reinvent the wheel
in every state so that's important. Just in general to make sure that the startup
costs to participate in the exchange aren't so prohibitive that it impedes competition.
The last thing is manage for success. The exchange is going to be a new exciting
opportunity but it's also very complex so when it comes to things like for instance
employee choice in the small group market let's look at lessons learned in the Massachusetts
experience about how complex that initiative is.
And let's think about how we might want to start small in some of these areas.
-- I would say certainly to get plan participation in the exchange you want to make sure that
you have appropriate and fair market rules. Both inside and outside the exchange.
A number of panels before have talked about risk adjustment and importance of getting
that right. I think that's absolutely key.
Apart from having fair market rules, making sure that is in place, I think one of the
really key advantages or for the exchanges is the ability to improve quality and drive
delivery reform. This is the way we can keep costs sustainable
long term is transforming the healthcare system through the exchange.
The health reform law gives the federal and state government authority on issues around
quality but I think what we need to do is focus on a few practical goals.
To start that process forward. And two things I would recommend.
From the perspective of Kaiser Permanente that is an integrated care delivery model,
make sure at least some plans in the exchange are the ability to do team care models so
that we can push forward more efficient ways of delivering cost and care and cost effective
ways of -- which is where the costs are. Second thing I would say that's important
is transparency. Specifically at the provider group level on
things that matter to consumers, survival rates for cancer treatments or survival rates
for surgeries. This is something that's literally a life
and death situation for folks. And things consumers should have fair and
transparent access to.
-- One thing that we found in running our managed competition plan over the years is
you have to be -- allow plans to manage and price their risk properly.
And in order to do that, we have uniform benefit certificate, we don't allow deviation from
uniform benefit certificate. We have to adjust premium contribution to
provide employees with an incentive to choose a low cost plan.
Through premium contribution, hopefully something can be done with subsidies in that respect.
And that provides incentive for insurers to be a low cost plan.
That system that we have provide ad stable base of employees, stable base of consumers,
if you will, that has allowed our health plans over the years to manage that risk properly.
It's not a one time or one year question, it's again, being partner with health plans
so they know they're able to provide quality care but also stay in business doing it.
-- This is a question about what would incent health plans.
You have health plans here. But I would think that one of the key factors
with regard to any of the exchanges in the states is how well that exchange manage it
is subsidy this population will get because if that doesn't work smoothly, especially
population that moves between for example medicaid and private coverage or shift in
private coverage, that becomes a disincentive for consumers to want to be in the exchange,
they'll go out and buy in the outside market. And I think it will keyiate disincentives
for health plans as well so it's very important that how consumers are treated how consumers
are treated and hay stay in the exchange are an important factor in addition to things
already raised.
-- Following Ann's point the safety net health plans I represent would like to see more active
exchange in large part to ensure and allow that the safety net health plans which represent
about a quarter of all people medicaid managed care have the opportunity to be in the exchange.
We believe that the continue annuity of care is very important.
We want to make sure the exchange allows as well as perhaps encourages safety net health
plans to play in the exchange. So we want to see the exchange do obviously
ebb rolement in eligibility but also premium collection, we would like to see them make
it easy for them to get in terms of the rules of accreditation so if the plan is accredited
by JACO or maybe not even accredited but instead quality is overseen by state to allow that
to be deemed to be -- to get into the exchange, we'd also like to see some phasing in of the
potential requirements that maybe hard for local smaller and non-profit health plans
the to achieve in the beginning such as solvency so we would like to see some support to allow
these plans to compete in the exchange.
-- That leads us to our next question which there are different ways of thinking about
how much the exchange would accept all plans would be exchange accept all plans that meet
sort of a minimum set of standards or would it be more selective to negotiate with plans
to try to limit numbers that participate in the exchanges.
I'll ask the panel to answer that question and also what bidding requirements are likely
to encourage participation of plans, maybe Ruth if we can start with you.
-- Question around how do you select the plans that come in.
A lot has to do with the question of choice for consumers, how wide should that choice
be. From our perspective we really think it's
crucial to have a broad choice of health plans and delivery systems, and let the consumers
choose for themselves what is plan works best for them.
Particularly in the small group exchange we want the choice available at the inscriber
level. Certainly within the law that's what it says
but I have heard folks saying that's really difficult to have employees select a plan
of their choice. So maybe we want to phase that in over time
but from our perspective we think it's crucial to have employee and subscriber choice at
the very outset that's one of the key advantages of the exchange and consumer choice.
In terms of other criteria, we want to have all the plans be able to participate that
shouldn't negate administrators from thinking how to raise the bar on value and quality.
That focuses on how cow manage chronic care conditions where the costs are.
So as we think about exchange we really need to think about the benefit design, the risk
adjustment, the rules we have in place, to make sure that we have that target population
is dealt with fairly and efficiently. And ideally we want to have the plans compete
for people with chronic conditions, not try to avoid them.
-- You come down on the side of allowing as many health plans to compete as possible.
Our standards, our minimum set of standards for provider access and things like that,
we do feel that it's very important to have annual reenrollment where people can role
over this choice if they decided that it didn't work for them.
But for the most part, we'll take all comers. And try not to make it too complicated, try
not to oversimplify it. The one -- overcomplicate it rather.
The one thing I will say is when we get a new health plan coming in each year, and we
have -- again, I mention a premium contribution formula for determining how much employees
are going to pay, we don't let a first year plan set that contribution rate.
We want to let them have a track record under the program, obviously in the exchange first
opens up, that's going to be difficult to accomplish but going forward we think it's
really important to really let consumers and the exchange understand and work with a plan
before they'll be allowed to set any of the contributions.
-- Have you found new plans have been able to come in and join as implementation has
gone on?
-- Yes. And we have over the years had a number of
new plans come in. Frankly they almost always start small because
of the embedded loyalty of of our existing members but also because the pressure is not
on them to try to come in with a rate so low that they're going to have to adversely impact
our members or whatever. They don't get a lot of subscribers up front
and we think that's an advantage.
-- DeAnn.
-- This is a question I think was mentioned earlier of timing and how we implement this
from scratch. Ideally from a consumer point of view we want
to know any choices we have in an exchange will offer us high quality care and that we
have a lot of choices. The current marketplace I'm not sure that's
going to be true in a lot of places where there are one or two dominant players so you
have to build the exchange in order to be sure that you can attract as many plans as
you can. Over time as the exchange is set up and information
is available for consumers, that consumer consist make their own choices but we do know
and our experience has been that they will not often use information.
I think Steve said in the first panel we don't have consumers trained or experienced in learning
how to choose on important factors in healthcare. Frequently choices are based on one or two
things in their own life as opposed to what insurance might need to do for them if something
changes. So I think it could be a situation as time
goes by, as we get more data that's useful that we could perhaps start using that to
encourage more competition and actually -- the beauty of having more competition from
our point of view would be that you can have a greater impact on cost.
-- As I mentioned before, we would like to see the medicate health plan eligible for
the exchange. This could happen in a couple of ways, one
they could be deemed fully eligible or pieces of the contract deemed to work.
In the extreme accreditation, it's an expensive process not always required by the states
but licensure is another issue that is not always -- many safety net health plans are
not licensed by DOI, instead they are regulated by just medicaid office.
And so to the sense that's deemed appropriate to get into the exchange, that will ebb courage
more medicaid plans, especially the medicaid focused plans, under a subset of that, the
medicaid focus plans are 50% of the medicaid enrollees are in plans that only do medicaid.
Half to quarter are in safety net health plan, non-profit typically only one state or region
so it's still a good chunk of people in these plans that don't have experience in the commercial
market. Yet are doing a good job in some way and are
highly regulated than the commercial plan, more oversite by the states so we would like
to see that deemed eligible to the exchange.
-- Christina.
-- One big issue states have to make a decision on is whether or not the exchange actually
actively negotiates or doesn't. When states consider this, it's important
to look at what would the impact be of an exchange negotiating be on the four Cs, cost
shifting, choice of doctor, competition, and consistency.
The law says insurance companies will have one risk pool with the exchange and outside
of the exchange. So it's an exchange negotiates that means
essentially the exchange is negotiating for the entire individual and small group market.
That puts a tremendous amount of power in the hands of the exchange and there is a concern
that it could make the negotiations completely budget-driven the way medicaid negotiations
are today. We see that the result of that are people
outside the medicaid program have cost shifting put upon themselves.
So for those large employers that are outside the exchange, that are already experiencing
maybe 1700, $1,800 in additional costs due to cost shifting, I think we have to ask ourselves
what happens to those employer costs if you set up a situation where there is more budget
driven premium negotiations. That's one thing to think about.
The second is choice of doctor. Most today, a lot of people, 83% of the individual
market like PPOs, have a lot of choice of doctor, but when you start getting into more
premium setting type of situation whether it's -- you end up driving towards HMO and
closed network plans and in the Massachusetts connector for instance, great programs but
there aren't PPOs offered so that's something because in a lot of different parts of the
country people aren't happy if they don't have PPO as a choice.
The third thing is just competition in general, we talked about wanting to have a competition
drive transformation and innovation and drive the real thing that's impacting affordability
which is the deliver delivery system. There is a concern that heavy negotiating
in the exchange drives down the ability of people to participate in the exchangech final
thing I would say is consistency particularly for small employers, they don't want to have
to change health plans every year if they don't have to.
If you have an exchange determining whether or not there's 7 or 15 plans as opposed to
objective criteria, you may get in a situation where small employer might be happy with their
health plan, people are happy with the doctors in the network and next year the exchange
is making the decision about whether or not that health plan is available to the small
employer or the individual. So consistency has to be taken in consideration.
The consumer or small employer deciding whether to jet son this plan or keep it, is it worthwhile
to keep it as opposed to an outside entity.
-- So I want to switch gears and talk about another issue.
Karen mentioned it in her panel how during a three month period she was switching jobs
and switching coverage. While the bill goes far trying to streamline
who is eligible for what programs, there are going to be many families where one person
personnel for tip, another person available for medicaid, someone else is eligible for
exchange. So there will be people eligible for the medicaid
program year one and year two find they're eligible for tax credits in the exchange.
So I would like to start with Meg and ask what you think are key factors states need
to consider as they're trying to facilitate coordination between medicate coverage and
coverage in the exchange.
-- One issue we have been thinking about is to have some passive enrollment as was done
with the special needs plans in Medicare. For families that have a link to medicaid,
already on medicaid or a child on chip, to have them into one of the medicaid plans back
to my point ant making sure the plans are also in the exchange but to have passive enrollment
where people are defaulted to the medicaid plan or aligned in some way with an easy opt
out. Again, similar to how it was done with the
Medicare special needs plan. So that's one way to help address some of
these continuity of care issues. We realize that people should have choice
but because medicaid plans are a long history of working with low income people they have
the withdrew networks of community health senters and hospitals and provide unique services
or social support services for low income populations such as having links to food networks
and utility helping getting your utility bill turned back on so we want to make sure the
-- especially the low income populations continue to have actess to these providers
and social supports and think that's one way to ensure that.
-- Bill, can I ask you to comment?
-- We think that the -- first of all the passive enrollment, we don't deal with the medicaid
population directly but we think even with small employers, we do have a lot of small
employers in our program that active enrollment is a -- something that frankly shouldn't be
incorporated, make it as simple as possible. We think the exchange should facilitate the
payment portion of the premium regardless where the individual happens to come from
or where they go to. The primary focus that we have is to have
an active negotiating exchange that is the primary source for individuals to come to
for information but also for the employers and health plans to come to.
We think that that will encourage and facilitate the transfer of individual as they hop into
one plan or as they are essentially forced out of another medicaid plan.
So I think from our perspective an exchange that can take on all of these roles and have
the data system to back it up, that that will encourage all the participants to be satisfied
with what they're getting.
-- DeAnn, if I could ask you to talk about from the consumer perspective.
You touched on it a little bit with transparency, you were talking about transparency Ruth.
But what are the factors that are going to be most important to consumers in driving
choice of plan based on price and value trying to evaluate the different options.
-- I don't think that you can say there's a single thing true for all consumers.
The consumer population really is quite diverse in its understanding of complex insurance
terms in thinking about unexpected things that could happen and how to judge their insurance
plans. Frankly, until now, until this law, it's been
difficult for you even if you are a sophisticated purchasertor able to compare things so most
people, I think everybody here knows this, the first choice, if they have a doctor,a
lot of people don't but a lot do, if they have a doctor they want to know if the plan
will include their doctor but for many people, especially the lower income people in the
exchange, the real question is how much is taken out of my check each week.
Our concern is that the exchange can and should be a place where people are given the opportunity
to learn to take other important aspects into consideration.
For example, not what the premium is coming out of your check but what the total cost
would be for you for that plan for a year under a couple of scenariosch maybe you have
a chronic illness or maybe you do want to look at a catastrophic event for yourself
or family. Could we develop and exchange provide the
information to help people compare plans. Obviously provider network and cost and not
just premium cost but we think people need to learn to consider these other very important
very expensive often bankrupting kinds of expenses where they thought they had coverage
and then when the event happened it turned out that they were left with hundreds of thousands
of dollars. Owe beyond that, it's very important as we
develop better measures evaluative measures, that the information be easy to understand,
consumer's union we do consumer reports and have the blogs and you don't have to be an
expert in automobiles to get some sense of comparative value on a number of measures.
You can look across. We put out other information for people who
don't want to read two page charts with 69,000 things on it and that say if you're interested
in a camera, here are the top three buys and here is why.
People not inclined or not that level of depth of analysis, so that it is easier but valid.
It's so important that the information provide second degree reliable and timely because
once a person relies on some information in the exchange and then turns out it isn't true,
it really undermines and especially the way people feel about distrust of government information
as it is so it's extremely important. There's always lag times on data.
And I think that that is an issue that we have to worry about in terms of providing
really useful information in terms of making decisions.
-- Incredibly important point. In the population that we're talking about
in the exchange, it's such a diverse population, you have people of all sorts of incoming who
have never really interacted with government, state or federal on healthcare issues.
Ever before. Phil, you wanted to add a point?
-- I wanted to pick up on this point to agree that it's really not the first thing on a
person's mind, picking a healthcare plan. Unless you really happen to need that plan.
State of Wisconsin has very highly educated population.
Yet less than 50% of our people use our report cards, there are caps report cards use those
to select a plan. It is, is my doc there and what will it cost
me. So arguing then taking that a step further
in terms of active versus passive manage you have to have an exchange I think that will
provide the person who was made their choice but now is caught in the wheels.
Some ability to have somebody go to bat for them.
I this I the exchange can do that if they're actively managing and working with health
-- I think it will be important there is a function where there's consumer feedback and
a chance to understand as I was sitting in the audience before this panel I got -- had
an email from a person that I'm in a book group with.
The question was, who is a good eye doctor? That happens and people do that.
For individuals that done have friend that they can send a blast email out asking for
a certain provider, it's helpful to have feedback on the side.
-- Yeah. And I think like I was saying, you have people
who are going to have access to the web who that's something that is very familiar to
them and others where that's not how they're going to try to get information so different
types of outreach, different types of education for all sorts of people interacting with the
exchange as we move forward. I would certainly like to hear from the rest
of the panel, what are the appropriate minimums as we think about marketing standards and
marketing these qualified plans when we're talking about various populations.
Medicare advantage, certainly saw some plans having issues as seniors, people with disabilities
having trouble understanding the differences between the plans.
So I would like to ask you to comment a little bit about what kinds of standards there should
be. And enforcement.
-- I think people do understand things differently. It is extremely important that whatever materials
that are made focus group tested focus group testing the NAIC disclosure form being developed,
just to get consumer input, what makes sense, what doesn't.
That should be routine in any of these things. All health plans I'm sure do that on their
own but in terms of setting standards, language capacity, literacy capacity are very important.
When I was running medicaid we had the health plans judge each other's marketing materials.
Trying to monitor we set up a council all the plans sat on it and they would raise issues
as to the problems with each other's marketing not meeting the standards of people and I
think it's a way to get okayer ship on the part of the health plan.
-- Ruth can I ask you to comment?
-- Part of the marketing effort needs to be the consumers really make an informed choice
about what the plan is, what it contains in terms of scope of benefits but also cost sharing.
You mentioned maybe doing scenarios on costs that might be incurred.
I think when we display the cost of the plan along with premiums, and deductibles or out
of pocket max, it doesn't provide the kind of definition that many consumers need.
For instance with the plans and certain levels of deductibles, some apply that deductible
after the first office visit. Other plans say no, actually there are three
or four office visits you can have outside the deductible before that comes into place.
Those scenarios are useful for the consumer to have access to understand what they're
buying. I would also stress the importance of delivery
networks because there's a lot of ways that difference plans come into the exchange can
keep their premiums down by restricting, further delivering that work available with that product.
So I would say to the administrators look carefully, make sure the network is adequate
to make sure that the person who is purchasing that plan is not just purchasing the benefit
but find out it's very difficult to find a doctor connected with that product.
Finally on benefits, I know we have talked about sort of choice of benefits it is difficult
for a consumer to try to compare different benefits because there's lots of ways that
you can differentiate as a health plan on the scope of benefits.
Perhaps over time you might move towards standardization of that although you need to weigh that obviously
with the advantage of having some flexibility around benefit design to consider new changes
in delivery of care and to make sure consumer preferences are really kept to the forefront.
Massachusetts had a good approach because they said, well, let's start with something
then see which of the benefits the consumers really prefer and over time standardize towards
those types of benefits. So again you have to be careful and make sure
that you can have some flexibility because you don't want it too rigid.
Otherwise you can't accommodate the new changes in care delivery techniques.
Those are some of the things I think would be very important for consumers to see.
Christina, do you have anything to add to that?
-- I a agree with everything said and I think the most important thing in this exchange
is that consumers understand what they're buying.
And consumers don't necessarily speak in a language of insurance companies or people
in this room. There are key concepts like balance billing.
People need to understand when buying a plan when to see the doctor and the doctor can
charge more than what the health plan is going to reimburse so I have these out of pocket
balance billing charges. I think the NAIC right now is doing important
work on creating a dictionary of terms for consumers because it is important that there
are some core terms the consumers understand. I also think the standard comparison of exchange
they're going to create is important but it's also important to recognize price is not the
only component of that and quality means different things to different people.
When I shop for a car, I look for the safety, because I want my kids to be safe and my husband
looking for horse power which I think is useful and counter productive given the number of
tickets he has, but he finds that an important quality aspect so I think when we come up
with these standard templates, we need to make sure the added value services that health
plans are developing are portrayed in this an it's not two dimensional.
Finally I would say that the other thing about marketing is to be careful you don't overly
regulate marketing exchange capabilities. One thing that's critical to health reform
is the balanced risk pool, it's important to get people in that need the kidney transplant,
it's important to recognize that $143,000 or whatever it is now that a kidney transplant
costs we have to enroll enough other people to offset costs.
The people that are hurt are the people in the exchange paying these premiums and the
small employers. And marketing is going to be a key to a balanced
risk pool and it's something the exchange needs to think about because it's tough to
sell health insurance. I was talking to my 11-year-old and 9-year-old
who are really young and they say what do you do, I think people should by health insurance.
They said if you have a choice between driveing a car nine years old like mommies and you
buy health insurance, or you have a chance to buy a really nice new car I'm sorry, you
know what I'm saying here. The point is my 11-year-old she immediately
got it and said I would buy the new car because mom, I only go to the doctor once a year.
I'm healthy, I never get sick and I don't need health insurance and she got it immediately.
My nine-year-old is sweet, she said mom, I would buy your health insurance.
When we think about the marketing criteria, having a balanced risk pool is important,
having consumers understand and think ahead about what this is going to do for me when
I'm sick is important too. A balanced risk pool is important unless you're
going to let the insurer charge what they need to cover claims.
That's where the contribution as with call it or the subsidy formula, a high cost plan
that manages those people well, then it's not going to show up in the cost of the premium
to the person making that decision. So that's another way to approach it.
-- Balancing the risk pool because it is important to make sure as we move into a world where
we want to make sure everyone is buying health insurance who wants it that you have the healthy
and those who need care today getting coverage through the exchanges.
So I want to open it up to the whole group to provide comments and ask questions at this
point. if you want to get started, please introduce
yourself.
-- I'm with the national association of public hospitals and health systemsch thanks for
a great panel. It's important to remind ourselves that the
folks eligible for participation in the exchange in terms of premium subsidies will be 400%
of poverty so a specialized group of individuals they certainly have oftentimes specialized
the need for specialized care and extenuating circumstances that it may get sometimes difficult
to access healthcare which is where safety net providers come in and we're pleased that
the law acknowledge this in terms of ensuring that in the context of the exchange qualified
health plans had negotiated with essential community providers.
I was hoping someone could speak to that specifically and how that might shake out, and it might
not be as sufficient as we talked an't in the earlier panel having the right physician
or care group that attends to asthma treatment but also to those type of individuals who
have to work evenings and weekends who don't have transportation to the doctor, et cetera.
-- Would anyone like to comment?
-- We certainly also were supportive of that provision and many of the safety net health
plans are owned by providers such as the public hospitals in the community health centers
so they obviously have the strong bond with them.
That's a reason we want to make sure these plans are eligible because you can have the
requirements that there's a contract but that doesn't mean health plans will send beneficiaries
to them or encourage them to go so we think those health plans that actively have a relationship
with those types of providers that it's important one that they be in the exchange and the risk
adjustment process work appropriately because we're going to attract folks especially plans
owned by public hospitals or other academic medical centers likely to attract sicker beneficiaries
so that's certainly a concern of our health plans to make sure the risk adjustment process
works well.
-- Over here.
-- I'm Barbara SOFUL with the American federation of state county and municipal employees.
Most of our 1.6 million members have healthcare coverage.
Some there are a few who don't in selected occupations but we got into healthcare reform
because we want not only for coverage to be expanded and universal but also because we
wanted to get ourselves to a high value healthcare system.
So the healthcare dollar our members and their employers were paying was buying good quality
healthcare coverage. I wanted to comment on the topic of setting
standards and negotiating with health plans that enter the exchange.
From our perspective if we want to keep the healthcare system we have got and expan it
then we continue to have no standards or low standards but if we want a high value system
we think that we need to have standards established by the exchange and we need to have active
negotiations not just on price but on quality as well.
-- I'm Barbara corn BLAU from the American for people with disabilities.
When you speak of access we think of access to care or to insurance coverage.
But people with disables have a concern about access to care.
We're very concerned that the plans include information for consumers that explain which
physicians have accessible exam tables and which physicians are trained to deal with
the needs of people with disabilities. We have women get pelvic exams, women and
men who can't get colonoscopies because physicians don't know what to do with them.
O so we're concerned since Social Security encourages people -- there's all kinds of
incentives but at the same time insurance is a problem to come off medicaid and Medicare
because we done have providers that can treat us.
So we want that to be include in the quality reporting and to be something that is shared
as an incentive and why you should purchase a particular plan.
Thank you.
-- It's very important as we talk about coverage that it is about getting to the doctor, getting
the service you need so appreciate that.
-- I'm Emily Newport, executive director of the steel workers health and welfare fund.
My question is directed more towards Christina and Ruth big carriers out there.
And how you see the exchange impacting delivery of care.
We spent a lot talking about quality outcomes and providing consumers with information they
need to be able to make good choices which goes deeper than plan design and provider
networks. It's medical policy, is his condition covered
and how and those sorts of things. How in your business plan, is that going to
impact what's in the exchange versus outside the exchange?
I'm waiting for a carrier to speak how you're going to provide plans in the exchange.
-- -- Kaiser Permanente does support exchanges.
One of the reasons we support exchanges is we think the exchange is provide a real opportunity
to transform the way care is delivered in this country today.
As I side, we need to figure out how to make care more afford, it centers on the way care
is delivered so if the exchange can go ahead and promote things like team based care, like
higher quality standards, like better chronic care management, I think it has a real opportunity
to show the rest of the system here is how you can go ahead and deliver high quality
affordable care. So we're excited about the opportunity and
hope the exchange and administrators will be excited about this opportunity as well.
-- We all do. Thank you.
-- Larry McNeilly, U.S. public research group. I'll start with a question that I think we
can would be the basis for some common ground between the consumers we represent and payers
on the dice. It's quite simply this, looking to take a
position to encourage secretary of HHS to explicitly acknowledge in the criteria for
certification, that to consider whether plans are adopting proven approaches to creating
value. That means encouraging teams, primary care
and that means integrated delivery. So the first part of my question, is that
something that folks around the table see some promise in, see some interest in?
My second is something where I differ with some folks on the dice.
That fundamentally we feel having an active purchasing role for state and exchanges in
the state is important because of the value we place on these new approaches to generating
value. We have to deal with cost growth and healthcare
for the sake of consumers. And we see active purchasing not as a way
of just driving down premiums no matter what but being a vehicle to drive those reforms
so I would be interested to get reaction to both of those.
-- Anyone want to comment on that?
-- Sure. We think that having standards in the exchange
for entry are going to be really important. They should be transparent, up front, in advance
so you know and can plan for what criteria you have to meet in order to be a participant
in the exchange. We also think it's important for criteria
to evolve over time. As we years ago disease management was a real
new thing. Now disease management is a core competency.
Chronic care management is a core competency. And there's going to be additional things
that maybe right now are still experimental, we're figuring how to do it.
But eventually could work their way into being core criteria for entry into the exchange.
-- I think integrated systems and insurers are the best way to deliver those both the
quality and the cost concerns can be addressed by that.
The comment was made earlier that PPO is while people may wish to have them they don't compete
well with limited network plans. In our experience that is absolutely true.
Yet as people become more familiar with the limited network plans, our settings are extremely
high. If you can marry the concern with letting
all insurers participate with the desire to get provider groups working with insurers
who ultimately provide that care, we think that's a better outcome.
-- I would be remiss if I didn't comment, being with Kaiser Permanente, the largest
integrated delivery systems in the country, yesk we absolutely believe integrated delivery
systems are the promise for keeping costs affordable long term.
Whether integrated real time or virtually. There are ways of doing this outside of having
the integration we have within our system but we believe that that is the way to go
in the future.
-- (inaudible) from the national centers consortium. Mike talked about innovation early on.
We know even with insurance today we probably don't have an adequate primary care work force
at this point. I think early on we heard from others who
mentioned other types of providers. But how do we guarantee and how do we assure
that we have an adequate provider network that includes physicians nurse practitioner,
physician assistance, community health centers, retail based clinics or retail clinics so
there is access points for everybody because that's critical.
For innovation, what mic talked about. Second part is in terms of credentially process
of providers is something that's come up before. Is there some thought exchange to set some
standards how provider enters an exchange because I think both the cost on the administrative
side to get credential contracting with insurance agencies is burden densome for all providers
and I think insurance companies do. So perhaps second question, are there thoughts
about how those procedures could be streamlined. With exchangers.
-- On the work force issues that's critical. You see that playing out as more people are
eligible for med medicaid. The fact there's not enough providers in place
to serve everyone adequately. This is where I thicker teen coordination
comes into place. And we can use our teams more effectively
if we really work on integrating the different components of that together.
Within Kaiser Permanente we have had a number of successes by taking front line workers
who have direct interaction with the member and have them help them understand, oh, look,
you're coming in for an exam but you actually need a mammography.
Can I set up an appoint while you're here? And we get that done and we have actually
had members come back to us and say that mammogram you people told me to get, was found out I
had early stage breast cancer, got that treated right away.
And it's made all the difference in my life. So we do need to think about how we can use
all of the work force within the system to make sure people get the adequate care they
need.
-- Over here.
-- (indiscernible) from the national council of (indiscernible).
If we are to keep consumer needs in mind, we absolutely think there needs to be some
active role of the exchanges. We want to encourage innovation and design
of plans that don't currently exist that meet needs but secondly encouraging plans that
do meet consumer needs to get into the exchange and negotiating the purchase into the exchange.
Case in point we know a number of insureds have announced they're going to drop child
only coverage plans. Those are something critically important for
the population that I represent. A third of children -- Latinos are under the
age of 18. In addition we know about 4 million of those
kids definitely will have a parent who is not eligible to access either the exchange
or medicaid. Which means we need the plans in the exchange.
We believe there should be a very active role in choosing these plans and make sure consumers'
needs are met.
-- My name is Bobby KOURT. I'm a board member of APB.
I have three different perspectives. The strength of nation is defined on the ability
to take on all of its citizens. As APD board member I echo the comment by
Barbara about the quality of care. A person with disabilities face a lot of lack
of inclusiveness when it comes down to medical appointment and equipment and so quality of
care definitely needs to be marketed and impact on the reform package.
But also now focusing from adapt perspective. long term support in the package.
People with disabilities need to be taxpayers and tax users.
What prevents us from entering the work force is lack of healthcare and healthcare packages.
In the inform bill there was the bill that Kennedy introduced.
That was a great impact toward getting people with disabilities back to work.
But there is no long term -- right now there is no impactful long term care support system
under insurance so any response from the panel that could speak to how long term care services
and supports are going to be addressed upon the insurance packages or coverage.
-- Is there anyone that wants to comment on that?
-- Extremely important issue but I think that it's beyond the scope of the health insurance
debate. Long term care and support in terms of being
able to provide people with access to services that ultimately will save healthcare dollars
is a -- a very important question. I think insurance has been so engrained in
to the active medical provision of services, versus the long term care non-professional,
custodial, whatever you want to call it, that I just think it's a bit of a reach for this
particular program, particular issue.
-- I think you referenced it but in the legislation there were some changes made to the medicaid
program to try to encourage states to cover more services in the long term care area.
I will be a key issue as exchange issues are enrolling and more people are coming and hearing
about coverage they need and it maybe that private insurance coverage paired with something
else maybe one of the better options. But it is a very important issue.
Thank you. Are there any other questions or comments
people want to make? I think we had a diverse group of opinions
on our panel and I want to thank our panelists for joining us today.
[Applause]
-- Thank you, Chiquita. Thank you to all of our panelists…