You can almost set your clock by it: at least once a year, a major piece of investigative journalism documents the struggles of uninsured and underinsured people who carry heavy medical debt and are facing collection actions from hospitals and other providers. (See “From the ER to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages,” ProPublica and NPR, 2014; Steven Brill’s 2013 article “Bitter Pill: Why Medical Bills Are Killing Us,” Time, 2013 (subscription required); “Prognosis: Profit” series, Charlotte Observer, 2012.) Without fail, these stories cut to the quick of why access to affordable, high-quality health care is a moral issue. They also highlight the tensions that exist between profits and patient care, especially the long-lasting problems that arise for patients when hospital billing and collection practices don’t acknowledge patients’ financial realities. 

Just before the new year, the Treasury Department and IRS issued long-awaited final rules that directly address hospital financial assistance, billing and collections. The regulations finalize the details for a broader ACA mandate that governs how tax-exempt hospitals provide community benefit. Historically, hospital community benefit programs—including financial assistance or free care—have been a mixed bag in terms of content, governance, and level of investment; and states have taken an uneven approach to regulating hospital behavior. While the new regulations leave most of the details to hospitals to decide, they set a new federal floor that greatly increases transparency on financial assistance and collections, provides some protection against medical debt and overcharging, and offers communities greater insight and potential influence on the way hospitals understand and address broader health issues.

What Do the Rules Change?

Transparency. Transparency is at the heart of these new rules. Financial assistance, billing and collection policies will now be available for public review, with hospitals required to disclose detailed information about eligibility, how to apply for help, and how they use third-party data to screen patients for presumptive eligibility. Translation standards for printed and online financial aid materials improved, with hospitals required to translate policies into the primary language of populations to 5 percent or 1,000, whichever is less, of people “likely to be affected or encountered by the hospital facility.” Hospitals must publicly post their community benefit planning documents for public comment. These simple requirements have been hard to come by at the state level. Now, they’re the law of the land. 

Curbing no-holds-barred billing and collections. Unfortunately, the new rules don’t include an outright ban on some of the most aggressive collection actions in use today, nor do they require hospitals to observe a minimum threshold for eligibility for financial assistance—two things advocates were hoping to see. But, they do provide patients with more procedural protections against collection activity than they’ve had in the past. In addition to notifying patients and the public that financial assistance is available, hospitals have to assist patients with the application process (hospitals can perform this function themselves or outsource it to a non-profit organization or government agency). Patients have a minimum of 120 days from the first post-discharge bill without having to worry about “extraordinary collection actions,” and hospitals that begin these collection activities must suspend them if they receive an application for financial help up to 240 days after the post-discharge bill. Critically, if a patient is deemed eligible for financial help under the hospital’s policy, they can no longer be charged sticker price—“gross charges’—for care. Instead, they can only be charged the “amount generally billed” to an insured patient receiving the same services. (They’ve got to disclose their methods for determining this amount in their financial assistance policy.) This introduces some parity into a billing system that often perversely penalizes those who can least afford to pay hospitals’ high mark-ups.

Community input and better health planning. The ACA requires tax-exempt hospitals to use a health planning tool, the community health needs assessment (CHNA), to better understand community health needs. It also requires hospitals to develop an “implementation strategy” for meeting those needs. One implication is the potential to streamline community benefit investments toward priority issues within a community, avoiding an ad hoc approach that dilutes precious resources. The process encourages collaboration among hospitals, public health and community advocates, providing opportunities to take a deeper dive on systemic issues (like financial barriers, environmental problems, housing, nutrition) that impact health but defy easy solutions. The final rules mostly mirror earlier proposed rules here, though hospitals now have to include evaluation data for previous efforts in their CHNAs. Hospitals must solicit community input and consider the input they receive, though they are not required to make drafts of the CHNA or implementation strategy available for public comment. (NOTE: Most hospitals, relying on the proposed rules, have already completed one CHNA, which should be available on their websites and/or on request. Hospitals do need to consider written comments they receive in the next round of their community benefit planning.)

The buck stops here. Despite pushback from some quarters, the IRS held firm that tax-exempt hospitals can’t absolve themselves of responsibility by outsourcing their billing and collection responsibilities to third parties or selling patient debt. Furthermore, hospital boards bear ultimate responsibility for compliance with these new standards. This should raise the internal profile of community benefit, financial assistance and billing—a critical move, since so many details are left to hospitals to decide.

What Does This Mean for Our Work?

There is no question that the final rules are a step in the right direction. They provide an important tool—in some places, like many states that have not closed the coverage gap, the only tool—for addressing health and improving access to care for low- and moderate-income people and others facing high-cost care. And, they offer hospitals clarity and consistency on the federal level (states can go further than the federal rules and some have). As our health care system moves toward integrated care and capitated payment, the CHNA requirements provide a great opportunity for communities and hospitals to work together to achieve better outcomes. On the financial front, hospitals can still choose to be miserly, but the new public reporting may dampen enthusiasm for the “old ways” of collecting. 

Effectiveness will ultimately depend on hospitals making a good faith effort to comply with the spirit of the law, not just the letter. And that means advocates and community organizations must remain engaged with local hospitals, monitoring their compliance and taking advantage of opportunities to shape policy to meet local needs.

Patient-friendly billing practices don’t just help patients. Hospitals can benefit, too, from adopting better methods to collect. 

I recently participated in a panel discussion on medication safety issues with a colleague who serves as a patient advocate. We've been on panels together and make a great team—a doctor and a lawyer who are actually on the same side! This time, though, she said something that I hadn't heard her say before and that I had some trouble with. She criticized a pharmacist who suggested to a patient that a therapeutically equivalent drug could be substituted for the medication her insurance company no longer had on its formulary. She emphasized to our audience that what the pharmacist was suggesting was not the same chemical compound as the drug she had been taking. She thought this was wrong.

My colleague is a staunch consumer advocate who has courageously fought for health justice. We have been allies in numerous campaigns on behalf of the public's health against entrenched vested interests. I have nothing but the highest regard and admiration for her. Yet her criticism of the pharmacist who, following an insurer’s pharmacy benefits management plan, suggested a clinically reasonable therapeutic substitution is emblematic of a dilemma facing patient advocates. The horns of this dilemma pit the rights of individual patients to the health care they want versus the greater good of the community.

The enormous resources poured into health care in this country—about $3 trillion dollars a year—make this conflict unavoidable. The struggle to achieve universal, affordable, high-quality health care is far from over despite the enactment of the Affordable Care Act. Tens of millions of Americans remain uninsured. Those with insurance face higher and higher out-of-pocket spending through the imposition of high deductibles. Premiums continue to rise faster than wages, especially for lower wage-earning families.

High costs for health care also impede our ability to fund key social services such as food security, adequate housing, affordable daycare, safe neighborhoods and recreation that are vital to good health. It also undermines our ability address vital global challenges as well, such as global warming and the alleviation of suffering in the developing world that can lead to international terrorism.  

If we don't rein in health care spending, it is almost certain that our efforts to advance a competing, life-saving agenda will be significantly undermined. 

Bringing this lofty conversation down to more pragmatic issues, let me return to the topic of therapeutic substitution. During the summer months, my eyes itch from pollen allergy. I buy a 10-ml bottle of ketotifen eye drops over the counter for about $12. I could also get the same relief with a prescription for Patanol (olopatadine) that costs $169 for a 5-ml bottle. I've used both and find they work equally well. What's wrong with at least starting out with the less expensive alternative rather than the one that costs more than 28 times as much?

While it is illegal for a pharmacist to substitute one drug for a chemically different drug that does the same thing, public and private insurance plans achieve the same result by changing their formulary. For instance, I'm frequently confronted by a change in what Medicaid will cover for stomach-acid problems—one year it's Nexium and the next year it's Protonix, whichever the state is able to get a better deal on. In almost all cases, the drugs work equally well even though they are different chemical compounds. Rarely, a patient will find that one works better than the other, and I can obtain an exception from Medicaid to allow the patient to continue on the drug that is no longer on the preferred drug list.

Commercial health insurers are doing the same thing by using different copayments for drugs on different tiers Going back to Patanol eye-drops, for instance, my insurance company lists that drug as a tier-3 drug that requires a $45 copayment. The problem is that not all patients know that a lower-cost alternative is available. There is no generic Patanol that the pharmacist can substitute, but there is a therapeutic equivalent, ketotifen, that will probably do just as well.  Using Patanol costs the patient more ($45 versus $12) and the health plan more ($154 versus 0), which can eventually increase premium costs too.

Patient advocates are justifiably wary about policies and practices that limit patients' ability to get the health care they want. Our sad national legacy is one that all too often denied patients, especially poor patients, the care they needed. Patient advocates should continue to be champions for low-income and chronically ill people and to fight for the right to health care that is needed. But they should also recognize the need to limit wasteful health care spending, because these at-risk  patients are also the first to suffer when high costs lead to cuts in programs and benefits. Policies like therapeutic substitution, campaigns like Choosing Wisely , and initiatives like Community Catalyst’s Voices for Better Health can stem unnecessary spending while safeguarding and improving the health of the patient.

The role of patient advocates should not be one of fighting any perceived infringement of patients to any health care service or product available, but rather one of partnering with patients to secure safe, cost-effective and better organized health care. In the long run, there really is no dilemma—this is the best strategy for individual patients as well as the broader community.

Stephen R. Smith, M.D., M.P.H., Community Catalyst Physician Consultant

So long, farewell. But first, a few of my favorite things.

As I wrap up eight years at Community Catalyst, I’ve been reflecting on the momentous changes in the health care system I’ve been lucky to be part of through this work. Before I say farewell, I wanted to mention a few of my favorite things - as well as a few hopes for the future as I say goodbye to health advocacy work… for now.

1. The Affordable Care Act. I joined Community Catalyst after working on Massachusetts health reform, and for a number of years it seemed the only path to expanding coverage was a state-by-state reform model. Then the 2008 election created the momentum for national reform. The work of state advocates in that fight – organizing rallies, writing op-eds, educating policymakers – led us to a place unimaginable a few years ago. Now 9.5 million uninsured people have coverage. Millions of people do not have to worry that a pre-existing condition will keep them from treatment. Even with all the law’s implementation challenges, sometimes I have to pinch myself when I think how far we have come in such a short time.
    
2. In-person assistance.  Over the past few years, I am fortunate to have witnessed first-hand the enormous growth in training thousands of experts to assist consumers in understanding our extremely complex health system. This issue has long been a priority of Community Catalyst, and to work with a new crop of CAPs, Navigators, CACs has been gratifying. We went from having a few wonks who understood the system to building community-based capacity in every state and city to help people navigate the health system.
    
3. Growth of consumer health advocacy. When I started at Community Catalyst in 2007, most consumer advocacy organizations operated on a shoestring with a limited policy agenda. Today, Community Catalyst works with a wide range of groups on multiple fronts – to improve dental access, health equity and care for dual eligibles. Our health system and the care available to consumers are better for it.

But there is more work to be done. Here are a few areas where I hope to see further progress:

1. Discrimination.  The ACA took made huge strides in making sure people have health coverage. The next step is to dig in and use these new tools so groups that have been systematically discriminated against can get the care they need. There are exciting developments in some areas, but there’s more work to be done to ensure all people of color, people with chronic illnesses, transgender people and those who do not speak English as a first language get high quality care.
    
2. Make assistance permanent. While we have made great progress in creating a workforce of experts to enroll people, we know from Massachusetts health reform that the need for assistance with navigating the health system does not go away after the first few years of reform. The issue is now at a tipping point - there is an opportunity to use the expertise that has been created to build an on-going system of assistance that keeps people covered and troubleshoots problems.
    
3. Retain the coverage gains made. As with any significant change, health care reform still has fierce critics. The immense gains in health care access will continue to face challenges. But as we continue to build the capacity of health advocates on the ground, we will continue to move closer to fulfilling the promise of health care for all. 

This is my last blog before I move on to the Massachusetts legislature. But I plan to keep an eye on your work, and I look forward to more good things to come. I am so proud to have worked alongside those who are fighting for health care justice and hope our paths cross again soon. 

Need an escape from crowded malls, holiday meal planning and travel plans? We’ve got the solution: escape to a quiet corner of your home with steaming cup of hot coco, a warm blanket and hundreds of pages of proposed federal regulations. Tempting, right? Well, in case this activity doesn’t make it to the top of your to-do list this month, we’ve outlined the need-to-know facts and important opportunities for consumer advocates to weigh in on strengthening federal network adequacy requirements.

When consumers enroll in a health insurance plan, they are entitled to an adequate network that has a sufficient number of providers to deliver the health care services included in the plan’s benefit package. Over the past year, due to the existing feedback loops capturing consumers’ experience, advocates across the nation have reported a number of cases where consumers enrolled in new health plans through Marketplaces found that their plan did not meet their care needs as a result of limited network of providers. To ensure consumers have confidence they can access needed care in a timely manner under the plan of their choice, the Centers for Medicare and Medicaid Services (CMS) recently released a proposed regulation to strengthen network adequacy requirements. This is a step in the right direction, but there is more work to be done to ensure that consumers have access to robust networks that meet their care needs. Below are the key highlights on the new network adequacy requirements.

Essential Community Provider (ECP) Requirements: CMS expands the list of ECP’s categories and types to include ECPs that are state-owned, government, and not-for-profit facilities including family planning service sites regardless of whether they receive federal funding under specific federal programs. This expansion would further ensure that Marketplace enrollees from low-income and racially diverse communities residing in low-income zip codes or health professional shortage areas have access to needed care services in a timely manner.

Provider directory requirements: CMS requires that the provider directories must be updated at least once a month and available online to both enrollees and consumers shopping for coverage without requirements to log on or enter a password or a policy number to ensure consumers have an up-to-date, accurate and complete provider directory.

Network adequacy requirements: CMS clarifies that out-of-network providers cannot be counted in determining network adequacy. This would prevent any confusion consumers might face when accessing care. Furthermore, CMS is waiting for the results of the National Association of Insurance Commissioners (NAIC)’ revision of its network adequacy model act before proposing significant changes in these requirements.

This is an opportunity for consumer advocates to weigh in to influence the final rule. A new report on states’ oversight of health plan network adequacy conducted by the NAIC consumer representatives highlights state approaches to regulating and monitoring the adequacy of health plan provider networks. The report also includes a set of recommendations for improved oversight, such as:

(1)    Set clear quantitative standards for network adequacy to ensure consumers have access to needed care in a timely manner. These standards could include: minimum numbers and types of providers in the network, time and distance standards for services, and maximum appointment waiting times.

(2)    Develop stronger language on transparency regarding the type of plans being sold and the accuracy of plan provider directories to ensure that consumers can make the right choice when selecting health plans for themselves and their families. Consumers need reliable, easy-to-use information in order to make optimal choices – information that is not available in the Marketplaces today.

(3)    Create provisions that protect consumers from surprise “balance billing” by out-of-network providers to reduce the burden of unexpected and expensive bills consumers might face at a time when they are most vulnerable.

(4)    Create provisions that ensure continuity of care protections for consumers. Provider networks can change over the course of the plan year for any reason, including because a provider chooses to leave the network. A grace period with a provider who leaves the network before transitioning to another in-network provider would help ensure continuity of care in these situations. This would be particularly helpful for people with chronic conditions.  

This report is a helpful resource as we are working on comments to improve the proposed regulations.

If you have questions or ideas for future materials on network adequacy, please contact Quynh Chi Nguyen, Program & Policy Associate; Staff Lead, Health Equity at qnguyen@communitycatalyst.org.

The holiday season brings many traditions to look forward to, such as spending time with family and exchanging gifts. There are also some less-favored traditions, though, such as the deluge of holiday-themed advertisements. Viewing the same images and hearing the same messages repeatedly can make anyone want to put on their blinders, plug their ears, and tune them out!

When consumer health advocates began planning for the Affordable Care Act’s second open enrollment period, advocates hypothesized that consumers who hadn’t enrolled in the previous open enrollment period may feel the same way that average holiday-shoppers feel – bombarded by the same messages that simply don’t resonate with them, and moreover, cause them to stop listening. To help motivate these consumers to enroll, the advocacy community felt that new messages needed to be created that would tap into the current feelings of the uninsured about having health insurance.

During the summer of 2014, the Robert Wood Johnson Foundation worked with PerryUndem and GMMB to conduct consumer focus groups and a national poll of uninsured individuals to better understand their feelings and attitudes toward having health insurance. Separate focus groups and polling were conducted with Spanish-dominant, uninsured Hispanics as well. Although the participants agreed that having health insurance is important, many of them firmly believed that they could not fit health insurance into their budgets. Overall, they found three messages about health insurance options were the most motivating: 1) there are low-cost health plans, 2) you can get financial help and 3) in-person assistance is available.

Based on their findings, RWJF launched a new website, TalkHealthInsuranceToMe.org, which educates consumers about these three aspects of the law and provides communications resources for partners to spread the word. The site provides a roadmap that walks consumers through information about the low-cost plans available through the Marketplace, eligibility information for financial help, and ways to find local, in-person assistance. The site also provides tools to help consumers determine how much financial help they are eligible to receive.

The partner-focused side of TalkHealthInsuranceToMe.org includes an outreach toolkit full of creative and innovative communications resources for advocates, enrollment assisters and other enrollment stakeholders. These resources are all available in both English and Spanish. In addition, RWJF has launched a digital and radio advertising campaign in federally-facilitated Marketplace states to help spread the word and encourage consumers to check out their options.

While the ACA has succeeded in enrolling millions of Americans in quality, affordable health coverage, there are still many who remain uninsured, due to perceptions of health insurance being unattainable, unaffordable, or both. Messaging aimed at these consumers should incorporate their current feelings and attitudes toward health insurance in order to be effective. Thanks to the leadership of the Robert Wood Johnson Foundation, we can determine that emphasizing low-cost plans, the availability of financial help to pay for plan costs and in-person assistance to help navigate coverage options, are the messages that will be most effective at addressing attitudinal barriers to enrollment. The wealth of resources available at TalkHealthInsuranceToMe.org provides the enrollment community with ways to message ACA enrollment that will make the remaining uninsured stop tuning out and start listening.