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AAOS Now

Published 6/1/2019

Second Look – Advocacy

Distribution of private health insurance enrollment

According to a report from the Government Accountability Office (GAO), just a few health insurance issuers held the majority of the market in 2015 and 2016. In at least 37 states, the three largest issuers dominated more than 80 percent of the market. In individual market exchanges, three or fewer issuers controlled at least 80 percent of the market in 46 of the 49 states for which GAO had data. For small employers, three or fewer issuers dominated 80 percent or more of the market in 42 of 46 exchanges in states where data were available. The most recent data are similar to those of previous years, as reported by GAO.

CMS’ AI challenge

The Centers for Medicare & Medicaid Services (CMS) announced its Artificial Intelligence (AI) Health Outcomes Challenge. The goal of this three-tiered contest is to bolster the development of AI and further its capability to predict unplanned admissions to hospitals and nursing facilities. Selected winners during the final two stages of the challenge will be eligible for a monetary award.

Charges filed in orthotic brace fraud case

Authorities filed charges against doctors, telemarketers, and owners of medical equipment companies behind a $1.2 billion scam in which hundreds of thousands of older and disabled patients were encouraged to purchase unnecessary orthotic braces. Officials said the case is one of the nation’s largest healthcare frauds. According to the Medicare antifraud unit, at least 130 medical equipment companies submitted more than $1.7 billion in claims and received more than $900 million.

Doctors charged with illegal opioid prescribing

Sixty medical professionals—including 31 doctors—were charged after prescribing opioids and other drugs to patients in exchange for sexual favors and money. The charges, including illegal prescriptions and healthcare fraud, spanned numerous states, including Kentucky, Tennessee, Ohio, West Virginia, Alabama, Louisiana, and Pennsylvania.

CMS releases open enrollment report

The Centers for Medicare & Medicaid Services (CMS) issued its “Health Insurance Exchanges 2019 Open Enrollment Report.” Plan selections in the exchange across all 50 states plus Washington, D.C., were at 11.4 million—an estimated decrease in plan selections of 300,000 from a year ago. The average total premiums for plans chosen through HealthCare.gov decreased for the first time since the exchange began operation five years ago, going down by 1.5 percent.

Medicaid expansion associated with financial stability in health centers
Since the Affordable Care Act (ACA) went into effect, health centers located in Medicaid expansion states were more likely to report financial stability improvements compared to those in nonexpansion states (69 percent versus 41 percent, respectively). Additionally, expansion states were more likely to have an improved ability to provide patients with affordable care (76 percent versus 51 percent, respectively), according to a survey from The Commonwealth Fund. Facilities in expansion states were also more likely to use a value-based payment model.

Medicare costs predicted to surge by 2038
A report from the Medicare Board of Trustees estimated that total Medicare costs will jump from 3.7 percent of gross domestic product (GDP) in 2018 to 5.9 percent by 2038. The report also projected that the Hospital Insurance Trust Fund will be able to pay full benefits until 2026. The rise in spending and GDP growth can be attributed to the growing Medicare population, as well as an increase in volume and intensity of healthcare services.

Outpatient versus in-office costs
Patients receiving treatment in the outpatient setting may be paying more than they would for the same service during in-office treatment, according to a report from the Health Care Cost Institute. Between 2009 and 2017, the share of outpatient services increased from 11.1 percent to 12.9 percent, and those were more expensive compared to in-office services. Cost increases varied by procedure. During the eight-year period studied, the average level five drug administration price increased 15 percent in the office setting—from $220 to $254—and increased 57 percent in the outpatient setting—from $423 to $664.

Justice Department says ACA is unconstitutional
In late March, the Department of Justice broadened its stance on the ACA and said the law should be completely eliminated. The new position reflects a December 2018 ruling by U.S. District Judge Reed O’Connor, who said that without the ACA’s individual mandate penalty, the entire law cannot stand. The Justice Department said it “is not urging that any portion of the district court’s judgment be reversed” and intends to file a brief at a later date.

When is shared-risk value-based health care expected?
According to a survey conducted by the HealthCare Executive Group and Change Healthcare, 90 percent of medical leaders believe shared-risk value-based health care is still at least one year away. More than a third of respondents (39.8 percent) said it will take three to five years, and just over a quarter (26.7 percent) believe it will take one to two years. According to the survey, barriers to shared-risk value-based health care include limited data sharing, a lack of consensus on outcome measures, and no incentives for payer-provider collaboration.

ACA exchanges on the rise
More Americans have access to ACA exchanges this year compared to previous years, according to a report from the Urban Institute. Today, 37.5 percent of Americans live in a rating region with one or two insurers compared to 33.8 percent in 2017. In 2018, 45.1 percent of Americans lived in areas with almost no marketplace insurer competition. Marketplace competition largely differs based on region: In 2019, no Northeast rating region has fewer than two marketplace insurers, and 40.7 percent of the Northeast population lives in rating regions with at least five marketplace insurers, whereas the South is reportedly almost the opposite.

‘Medicare for All’ to cost $3.89 trillion
According to a RAND report, a “Medicare for All” healthcare plan with extensive, long-term benefits would cost $3.89 trillion this year—an increase of 1.8 percent relative to expenditures under the current law. The federal government’s healthcare spending would increase by 221 percent—from $1.09 trillion to $3.50 trillion.