Pacific Health Brokers

I don’t know how excited I am, but what I do know is that this will be California’s reality in 10 months!! Below is the ”LOGO” for the CA Exchange health insurance program for 2014.

What I want to share with you all is the website for Covered California.

There are so many questions with this new program, we at Pacific Health Brokers will personally help you through this process and always be here to answer questions, or help with the application. We stand by you 100% of the time when you and your family go through our agency. We embrace this new change and look forward to 2014 and the new chain of the Health Insurance process.

We will continue keeping you informed via our blog, but please feel free to contact us (800-858-0563) with any questions you may have as you to try and swallow this BIG CHANGE.

Today, there is a wide range of health insurance policies offering different benefits and access to different doctors, hospitals or other providers. Starting in 2014, all health insurance plans will share some common characteristics. The federal Affordable Care Act now requires that all health plans offered in the individual and small group markets must provide a comprehensive package of items and services, known as Essential Health Benefits. These benefits fit into the following 10 categories:

I ran across this well spoken woman Alicia Caramenico who wrote this article about our medical professionals and I want to share her thoughts with you as she stated in Fierce Healthcare, here ya go…

Amid calls to improve care, a new study suggests physicians and nurses may give themselves higher marks than they deserve for care quality for hospital patients prior to a serious complication, Reuters Health reported.
After examining 47 patient records, Dutch researchers revealed a disconnect between the quality of care found by independent experts and the quality of care providers thought they delivered.
The nurses and doctors said they were good at identifying a patient’s deteriorating condition, giving themselves high marks in communication, cooperation and care coordination, according to the study published in the journal Critical Care Medicine.
However, researchers found a delay in spotting deterioration in 60 percent of the patients, and 38 patients providers should have considered “at risk” in the two days leading up to complications.
Physicians’ and nurses’ misperceptions might explain why providers sometimes hesitate to implement patient safety efforts, the researchers noted.
Meanwhile, healthcare leaders also are overestimating the care provided at their organizations, noted Becker’s Hospital Review.
According to a recent Studer Group survey, for hospitals where 75 percent to 100 percent of leaders said their organization “did well” at delivering quality care, HCAHPS survey scores didn’t match up.
Such disconnects are alarming. “If you overrate performance, you’re not going to improve it,” Quint Studer told Becker’s. “Or rather, if you don’t know something is broken, you won’t be empowered to fix it.”

On Tuesday, the state Department of Insurance released information on rebates being sent out by California health insurers this week under a federal health reform law provision.

Background

Under the reform law’s medical-loss ratio rule, private insurers must spend at least 80% in the individual market or 85% in the group market of premium dollars on direct medical costs.

Insurers that do not comply with the ratio must issue rebates to consumers.

About 1.8 million Californians are expected to receive a total of $73.9 million in rebates.

The average rebate amount in California is about $65 per family.

Rebates Issued by California Insurers

According to DOI, California insurers sending MLR rebates include:

* Aetna Life Insurance, which is issuing $3.4 million in rebates to large-group employers covering 84,428 policyholders, with an average rebate of $40.50;

* Anthem Blue Cross, which is issuing $38.6 million to 182,214 small-group policyholders with an average rebate of $212.

* Anthem Blue Cross Life and Health Insurance, which is issuing $1.3 million to 407,429 individual policyholders with an average rebate of $3.16;

* Blue Shield of California Life & Health Insurance Co., which is issuing $10.8 million to 239,595 individual policyholders with an average rebate of $45.15;

* Connecticut General Life Insurance, which is issuing $3.4 million to large-group employers covering 89,575 policyholders with an average rebate of $37.70;

* Kaiser Permanente Insurance, which is issuing $277,034 to 21,823 individual policyholders with an average rebate of $12.69;

* PacifiCare Life and Health Insurance, which is issuing $789,615 to large-group employers covering 63,600 policyholders with an average rebate of $12.42; and

* United HealthCare, which is issuing $3.8 million to 22,260 small-group policyholders with an average rebate of $173.

The Supreme Court’s validation of President Barack Obama’s landmark health law sets off a scramble up and down California to find enough primary care doctors and other professionals to serve an estimated 3million newly insured patients by 2014.

California already rates below average in the number of doctors per capita.

But the state – rural and inland counties in particular – will face additional headwinds as health reform slashes the ranks of its 7 million uninsured.

California has an unusually large number of doctors heading into retirement years. It expects a much higher-than-average rise in the health-intensive 65-and-older population. And it has one of the lowest reimbursement rates in the country for Medi-Cal, the state’s primary program offering health coverage for the poor.

Especially for communities already struggling with doctor shortages, the court’s somewhat unexpected endorsement of the Affordable Care Act suddenly presents a steep challenge.

“The Affordable Care Act will add hundreds of thousands of people to the rolls of the insured. That’s good,” said Dr. G. Richard Olds, founding dean of the UC Riverside School of Medicine. “But where are the primary care physicians going to come from to serve that population?”

According to a 2009 study by the California HealthCare Foundation, only 16 of 58 California counties had sufficient primary care doctors as measured against standards set by the American Medical
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Association. The Association of American Medical Colleges has warned the nation could reach a shortfall of nearly 100,000 doctors by 2020.

Many of California’s most acute shortages are in the Inland Empire and the San Joaquin Valley, where communities struggle to attract and retain doctors. They also have some of California’s highest uninsured rates – exceeding 30 percent of residents in some counties, according to a 2009 UCLA study.

That could mean the same counties already fighting doctor shortages could see big increases in the insured starting in 2014.

Asked if local providers in San Luis Obispo County were numerous enough to accommodate the new patients created by health reform, county health officer Dr. Penny Borenstein had a definitive answer: “No. Simply.”

“We may have the possibility of adding 10,000, 15,000, 25,000 people into the health care system who have not used it very much,” she said.

Lee Kemper, executive director of the County Medical Services Program, a consortium of 34 rural counties that are implementing the Medi-Cal expansion together, said a mixture of innovation and increased funding was key to meeting the demands of health reform - now a mere 18 months away.

“We’re going to have to get creative,” Kemper said on Friday. “Strike teams” of medical specialists from urban areas could be brought into rural hospitals and clinics on a set schedule, he said. And tele-health systems could be strengthened to allow far-away specialists to consult, and even treat patients, with an online connection.

Kemper added that Medi-Cal reimbursement rates for doctors in rural areas must be increased so practitioners have incentive to set up shop in the far corners of the state. Statewide, barely more than half of primary care doctors are willing to see new Medi-Cal patients.

James Hay, a family physician in Encinitas and president of the California Medical Association, is among those who decline Medi-Cal patients.

“In my office, we figure it probably costs us $50 to $55 to see any patient on average,” he said. “If Medi-Cal pays us $23 to see a medical patient for a routine office visit I would be spending $32 per visit to see that patient.”

In California, Hay said, that’s why much of Medi-Cal primary care is done in federally qualified clinics, which are paid a higher amount for patient care because they also have to cover certain tests and other costs.

Can those community clinics handle the new wave of Medi-Cal patients?

“Absolutely not,” Hay said. “I think there will be a huge access problem.”

The Affordable Care Act does provide some help on this front, sending $700 million to California so that Medi-Cal reimbursement rates rise to the level of Medicare payments for two years. But the health industry worries that the underlying problem won’t go away, and that both state and federal politicians will be tempted to cut Medicaid reimbursements even more.

Senate Health Committee chairman Ed Hernandez, D-West Covina, plans to make the health care workforce, which he said is inadequate, one of his top priorities. “What good is it in 2014,” when millions of uninsured Californians will gain coverage “when they don’t have access to providers?” he asked.

One of his key but controversial proposals will be legislation to expand scope-of-practice definitions for some health care providers such as nurse practitioners and physician assistants.

Janet Coffman, assistant professor of health policy at UC San Francisco, said California lags many states in this area because most residents live in urban areas where doctor shortages aren’t as much of a problem. Because of the Affordable Care Act, she said, “I would say scope of practice is on the radar screen.”

Hernandez, who said he is holding committee hearings on workforce issues, will also try to boost the number of medical students in the state and bring medical residency programs to underserved areas.

Even before the health law was passed in 2010, the shortage of primary care physicians in California catalyzed a far-flung campaign – by educators, doctors, government leaders – to train new doctors in the state and encourage them to practice in under-served regions, including the Inland Empire.

That drive led to plans for all-new medical schools at UC Riverside and UC Merced, with an emphasis on primary care. Plans called for eventually enrolling 400 students at each school, both of them aiming to coax graduates to stay in the region.

But the state budget crisis has delayed both projects. This fall, 11 students, all ethnic minority students from the Central Valley area, will be enrolled in a UC Merced program with ties to UC Davis and UCSF-Fresno. Pending accreditation approval, UC Riverside hopes to open in 2013 with an initial class of 50.

Some California health insurers are proposing to raise small-business rates more than 10% next month, drawing scrutiny from state regulators. Aetna inc., which drew the ire of state insurance officials for a rate hike earlier this year, wants to increase premiums 10% on average, and as high as 24% for some employers.

Anthem Blue Cross the state’s largest for-profit insurer and a unit of WellPoint Inc., has proposed boosting rates 13%. Blue Shield of California is looking to charge some small employers up to 6% more.

Byron Tucker, a spokesman for the state Department of Insurance, said the agency is having discussions with the three companies about whether the proposed rate hikes are too high. Separately, the California Department of Managed Health Care said it is reviewing other proposed rate increases going into effect in July or August. But no matter what their decision is, neither agency has the power to deny increases. They can only urge the companies to cut rates and publicly criticize them if they don’t.

In April, insurance department officials objected to other small-business rate hikes as high as 21% by Aetna and called them “excessive.” But Aetna went ahead with the higher charges.

Aetna spokeswoman Anjie Coplin said its rates “are based on actuarially sound data and a reasonable projection of future cost.” The company also noted that some of its small-business customers will see a decrease in rates starting July 1.

Overall, about 3 million Californians get their health insurance through small businesses with fewer than 50 workers. But rising premiums and the recession have taken a toll. The percentage of California employers offering coverage has declined from 73% in 2009 to 63% last year, according to the California Healthcare Foundation.

California Insurance Commissioner Dave Jones is pushing for an initiative on the November ballot that would give him the authority to reject excessive rate increases for policies sold to individuals and small businesses. Insurers say the measure would give an elected official too much power and wouldn’t address the underlying costs driving up premiums.

In filings to regulators, insurers said the proposed increases are justified based on escalating medical expenses, in particular higher charges for hospital care and prescription drugs. They also cited slightly higher costs for new government-mandated benefits related to maternity and autism care.

Kaiser Permanente, the state’s largest nonprofit health plan, has proposed raising rates as much as 9% for certain small businesses. Joe Smith, vice president of small business for Kaiser, said his company isn’t immune to the industrywide pressures driving up medical costs, even with its coordinated approach of running its own hospitals and network of physicians.

“We still feel the same pressure on utilization, the aging population and new medical technology, which can drive increases in costs,” Smith said. “No small employers are happy. The market is still very tough.”

Tulsa Rib Company, a barbecue restaurant in Orange, has offered health benefits to its employees since 1983. But owners Steve and Liz Parker say they aren’t sure they can afford to do so much longer.

Liz Parker said she switched from Health Net Inc. to Kaiser Permanente in 2010 after her company’s premiums shot up more than 30% annually. She and her workers have been satisfied with Kaiser’s medical care, she said, but the insurer is raising her premiums 8% in August. That comes on top of higher costs for food and gasoline in their restaurant and catering business.

“We continue to be squeezed and squeezed and we can’t pass along all those costs to our customers,” she said.

The Parkers and some other small-business owners are hopeful a new online marketplace for health benefits set to launch in January 2014 will help them secure lower rates. Two years ago, the restaurant stopped paying all of the premiums for workers’ family members and boosted annual deductibles for individuals to $2,000 to reduce its costs.

“I hope the exchange will put my 50 people on a level playing field with companies that have 5,000 people,” Liz Parker said.

The California Health Benefit Exchange is designed to negotiate the best rates with insurers and to help consumers and small businesses purchase health plans using federal subsidies and tax credits.

Enrollment is set to begin in October 2013. The exchange board is scheduled to discuss its small-business program Tuesday in Sacramento.