Category Archives: Health Care

Blues dropping ObamaCare in much of TN

BlueCross BlueShield of Tennessee will not sell insurance plans on the Obamacare exchange in the state’s three largest metro areas next year, reports The Tennessean.

The insurer made “an extremely difficult but necessary decision” to leave the Nashville, Memphis and Knoxville markets as it tries to manage its number of members to hit a break-even point amid three years of losses, said Roy Vaughn, chief communications officer of BCBST.

“It’s not something we want to do but we believe we must look out for the health care and financial security for all the members that we serve,” Vaughn said in an interview with The Tennessean.

(The Times-Free Press reports the total of 214,000 Tennesseans impacted is more than half of those enrolled through BCBS statewide.)

The company formally made the change to its 2017 plans in a Friday filing with the U.S. Department of Health and Human Services — roughly a month after it raised the possibility of scaling back. Earlier this summer, BCBST requested — and was granted — state approval for an average 62-percent premium increase. The rate hike is still pending federal approval.
By the end of 2016, BCBST anticipates losses from three years selling on the exchange established by the Affordable Care Act will approach $500 million.

…The Chattanooga-based insurer, which was the only insurer that originally planned to sell statewide, expects to shed about 112,000 people from its rolls under the change and keep about 80,000 primarily in rural areas. Shoppers in the three metro areas will not be able to buy either on-exchange plans, where tax credits may be used, or off-exchange plans, which are not eligible for tax credits.

The decision will reshape open enrollment, which begins Nov. 1, for people who buy individual plans in the state’s three largest markets — and where Cigna or Humana, or both, are expected to sell plans. According to BCBST, 52,000 people in Nashville, 31,000 in Knoxville, and 29,000 in Memphis, will have to look to another insurer for coverage in 2017.

Vaughn said the structure of its 2017 footprint was designed to make sure there was at least one insurer in every part of the state. The 95 counties are divided among eight regions. In 2016, BCBST and UnitedHealthcare were the only two insurers to sell statewide.

BCBST’s decision increases the number of counties in which people may choose from a single company to 73 counties — up from 57.

(Note: A BCBS map showing county coverage in 2017 is HERE.)

Andy Miller company settles Florida fraud claim for $7.75M

The wealthy Republican donor who took campaign money as investments from now-expelled lawmaker Jeremy Durham has agreed to pay $7.75 million to settle allegations he and his brother defrauded a federal military health care program through their pharmaceutical business in Florida, reports The Tennessean.

Andy Miller and his brother Tracy Miller operate Healthmark Investment Trust, which has an ownership stake in a Florida company called QMedRx Inc., according to a settlement agreement from Middle District of Florida U.S. Attorney A. Lee Bentley III.

Bentley’s office accuses the Millers and QMedRx of submitting fraudulent claims for reimbursement from TRICARE, a federal health care program for military members and their families.

The government sought penalties and fines from the owners who participated in the fraud, according to a news release issued Sept. 14.

“The United States attorney’s office is committed to protecting TRICARE and other federal health care programs from fraud,” Bentley said in a news release. “Those who violate the anti-kickback statute to generate business will be held accountable.”

A spokesman for the office declined to comment beyond the information included in the settlement agreement. The agreement — which indicates the settlement is neither an admission of guilt from the Millers nor a concession of a weak case from the federal government — shows the pattern of a kickback fraud scheme.

Bentley’s office says QMedRx violated the federal “anti-kickback statute,” a law that bans the exchange of anything valuable in order to receive a referral for business with a federal health care program. The settlement says people were paid incentives to get from doctors costly compound prescriptions, made through combining several different medications. Those prescriptions were then paid for by the federal government through the TRICARE program.

…Miller said the people who obtained the prescriptions from the doctors were classified as contract workers, and the government said they were employees of QMedRx.

“The claims resolved by the settlement are allegations against QMedRx only, and there has been no determination of liability, but to avoid delay, uncertainty, inconvenience and expense of protracted litigation, we agreed to settle for a portion of our profits,” Miller said in an email to The Tennessean.

…Miller and his family own several health care companies and are big donors for some Republican candidates. That includes Durham, who also invested some of his own campaign funds into one of Miller’s companies. State campaign finance regulators found out about the investment while investigating Durham’s campaign finances, which show a $191,000 discrepancy between his campaign finance report and his bank accounts.

Alexander, other GOP senators, propose Obamacare ‘options’

News release from Sen. Lamar Alexander’s office
WASHINGTON, Sept. 14—A group of eight United States Senators today introduced emergency, one-year legislation that would give states the authority to allow Americans who rely on Obamacare subsidies to have more options to buy health insurance unavailable on the failing Obamacare exchanges, and waive any penalty if they do not find a plan that suits their or their family’s needs.

Senate health committee chairman Lamar Alexander (R-Tenn.) said: “If you aren’t on Medicare or Medicaid and don’t obtain your health insurance through your employer, you are probably one of the nearly 11 million Americans who purchase their insurance on their own through the Obamacare exchange in your state.

“And you’ve probably read in the news that rates may be 60 percent higher next year than they were this year for the same insurance policy. And come November, nearly a third of the nation’s counties will have only one insurer for you to choose from when you have to buy health insurance on the regional Obamacare exchange as the market collapses and insurance companies are leaving the Obamacare exchanges in droves. This legislation would allow your state to give you the option of buying health insurance wherever you can find it whether on or off the Obamacare exchange.”

“This one-year solution is not a substitute for the long-term need to repeal and replace Obamacare with step-by-step reforms that transform the health care delivery system by putting patients in charge, giving them more choices and reducing the cost of health care so that more people can afford it,” he continued. “That would require a Republican president next year, but it gives Americans a real solution for next year and lets them know that we are on their side. Even if we have a Democratic president next year, we cannot continue without making big, structural changes soon to avoid a collapse of our nation’s health insurance markets.

Sen. Kelly Ayotte (R-N.H.) said: “More than 11,000 people in my home state recently learned that they would have to find a new health care plan after an insurer announced that it would be leaving the New Hampshire partnership exchange next year. Higher premiums and fewer choices are impacting real people today, and hardworking Granite Staters can’t afford to keep taking these hits. Our legislation would provide a temporary means to lessen the burdens of ObamaCare on New Hampshire families and individuals by allowing eligible individuals to use a subsidy to purchase health insurance outside of the exchanges, which may offer less expensive options than plans available through the exchanges.  This bill will help bring back some much-needed flexibility and choice in the health insurance marketplace, both of which ObamaCare has limited.”

Sen. John Barrasso (R-Wyo.) said: “In more than half of all counties in America, there will be only be two or fewer carriers offering coverage on the Obamacare exchange. Hard-working families facing higher premiums because of Obamacare deserve relief.  This legislation will give families more choices in 2017, as Republicans work to replace this failed law with real reforms that will make health care more affordable for all Americans.”

Sen. Thad Cochran (R-Miss.) said: “Time has shown that Obamacare is resulting in fewer and more expensive choices for the American people.  This legislation would increase options for families in Mississippi and elsewhere to obtain health insurance without being locked into troubled Obamacare exchanges,”
Sen. Ron Johnson (R-Wisc.) said: “I have worked for years to limit the damage and harm done to real people by Obamacare, a partisan policy that promised marketplace competition and higher quality health plans at lower costs and instead delivered the exact opposite. This bill would provide necessary relief to Wisconsinites who, under Obamacare, would be penalized for not purchasing a product that they cannot afford or does not meet their needs. It will allow the state to provide Wisconsinites receiving subsidies more options that just those offered on the Obamacare exchanges for 2017.”

Sen. Rob Portman (R-Ohio) said: “Ohioans need immediate relief from the skyrocketing cost of Obamacare. Premiums have increased in Ohio more than 90% since the President’s health care law went into place. This bill would provide individuals who have suffered under the high costs and fewer choices of Obamacare more options to receive coverage—which means more competition which in turn brings down costs. After eight years of stagnating wages, slow economic growth, and a rising cost of living, Ohioans deserve the relief this legislation would provide, not a health care system they can’t afford.”                                                             
The legislation, introduced by U.S. Sens. Lamar Alexander (R-Tenn.), Kelly Ayotte (R-N.H.), John Barrasso (R-Wyo.), Thad Cochran (R-Miss.), Ron Johnson (R-Wisc.), Mark Kirk (R-Ill.), David Perdue (R-Ga.), and Rob Portman (R-Ohio), would:

        Give states with a failing Obamacare exchange the authority to allow residents to use their Obamacare subsidy to purchase any health plan of their choice, even those off the exchange, for the 2017 plan year.

        If the state chooses to use this authority to allow residents to use subsidies outside of the exchange, the legislation will waive the Obamacare law’s requirement that you must buy a specific health care plan or pay a fine of as much as $2,000 for a family of four next year.

A summary of the State Flexibility to Provide Affordable Health Options Act is available online HERE.

Task force can’t resolve doctors-versus-nurses turf war

A divisive “turf war” between doctors and nurse practitioners has broken out across Tennessee and a state task force created by state legislators to find common ground has, thus far, only illuminated the depth of the schism, reports The Tennessean.

The dispute centers on exactly what types of treatment can be provided by advanced practice registered nurses (APRN), and under what level of oversight. Tennessee is among the dozen states with the most restrictive scope of practice laws — and the reform debate is a recurring flashpoint in legislative sessions. The nurses contend they are equipped to administer many of the same primary care and preventative treatments as doctors. Further, they point to a growing primary care physician shortage across the region.

Doctors, meanwhile, question whether nurse practitioners can offer the same level of care and have opposed efforts to expand the scope of treatment, preferring legislation to reinforce physician roles in primary care.

The task force created by Sen. Becky Massey, R-Knoxville, and Rep. Jeremy Faison, R-Cosby, was designed to give doctors and APRNs — nurse anesthetists, nurse practitioners, nurse midwives and clinical nurse specialists — a forum outside of legislative session to find consensus on how to reform the rules governing treatment. The resulting recommendations could result in legislation that impacts how Tennesseans receive primary care — a key step toward improving the state’s dismal health.

Yet the debate has devolved into a fight between doctors and nurse practitioners, with both sides becoming entrenched and the task force’s meetings becoming forums for people to air individual frustrations and opinions.

“Reluctantly I say no (we haven’t made progress). We’ve met twice and we’re closer to the beginning than the end,” said Dr. John Hale, a primary care doctor in Union City, who is co-chair of the panel alongside Carole Myers, a registered nurse and associate professor at the University of Tennessee College of Nursing.

3-Star Healthy draft to be submitted soon

Rep. Cameron Sexton, chairman of the 3-Star Healthy task force, says the group expects to submit a draft TennCare expansion pilot proposal to the U.S. Centers for Medicare and Medicaid Services in a week and he’s optimistic about approval, reports The Tennessean.

In a meeting Monday at Tennessee Tower, presenters with expertise in telehealth and a specific workforce training program called “individual placement and support” told task force members and interested health care officials about how the initiatives could bolster the TennCare expansion proposal as well as existing programs. Continue reading

Northeast TN methadone clinic gets state OK

GRAY, Tenn. (AP) — State officials have approved East Tennessee State University and Mountain States Health Alliance’s application for a methadone clinic in Gray.

Media outlets report that the Tennessee Health Services and Development Agency voted 8-0 Wednesday to grant a certificate of need to the addiction treatment clinic.

ETSU and MSHA said in a statement that it is “regrettable” that the need for the clinic exists, but that they have a responsibility when it comes to the health and well-being of the community.

Several local residents and leaders spoke out against the clinic at the meeting, many citing concerns over the clinic’s proximity to three schools.

Next, the Johnson City Commission will vote on a rezoning request for the proposed site’s location before the clinic can open in Gray Commons Professional Park.

TN regulators OK big Obamacare insurance hikes

Tennessee regulators have approved the full amount of the rate increases requested by the three health insurers still offering exchange plans under ObamaCare, pushing up rates by the biggest amount since the program began three years ago, reports the Times-Free Press.

BlueCross BlueShield of Tennessee, the state’s biggest health insurer, will raise individual rates by 62 percent in 2017, or nearly double the 36 percent rate increase adopted this year by BlueCross. Small group rates in the marketplace exchange will rise by only 6.5 percent, however.

Cigna got state approval to raise its individual rates for its ObamaCare plans by 46.3 percent, while Humana got the OK for a 44.3 percent jump in premiums for individual plans next year.

The increases for the marketplace plans were the biggest of the rate increases approved by the Tennessee Department of Commerce and Insurance, according to an announcement released this morning.

U.S. Sen. Lamar Alexander, R-Tenn., the chairman of the Senate health committee, said the increases prove that ObamaCare is not working. Alexander said the record increases under the program for 2017 are “only the most recent proof that Obamacare is spiraling out of control. Continue reading

Counseling service bilked TennCare for $300K

MEMPHIS, Tenn. (AP) — The owner of a Memphis counseling service has pleaded guilty to defrauding TennCare of more than $300,000 by billing for services that were never performed.

According to a news release from the U.S. Attorney’s Office in Memphis, Vicky Fox began contracting with Tennessee’s Medicaid program in 2008 for grief counselling and psychotherapy services at her Rainbow Center for Children and Adolescents.

After one of Rainbow Center’s licensed clinical social workers left in January 2012, Fox continued to use that worker’s provider number to bill for phantom services.

The Tennessee Bureau of Investigation began looking into the billing in August 2014 at the request of the Bureau of TennCare.

Fox pleaded guilty on Friday to one count of health care fraud. She is scheduled to be sentenced in November.

Hepatitis-infected TN prisoners sue the state

Tennessee inmates infected with hepatitis C on Monday filed a federal lawsuit against state prison officials, asking the court to force the state to start treating all inmates who have the potentially deadly disease.

Further from the Tennessean:

The lawsuit, filed by attorneys with the ACLU and other advocates in U.S. District Court in Nashville, says the Tennessee Department of Correction officials knowingly denying inmates care for their hepatitis C, also known as HCV, constitutes cruel and unusual punishment. It alleges the department is denying care because the best available medication is too expensive.

“In reality, (department officials) ignore the medical needs of (inmates) and class members in order to save costs. (The department’s) written politics for HCV diagnosis, assessment and treatment utilize outdated standards of care and normalize the practice of refusing treatment for unjust and medically unsound reasons,” the lawsuit states.

Inmates Charles Graham, also known as Charles Stevenson, and Russell L. Davis are named as plaintiffs in the lawsuit. Attorneys representing the inmates include Thomas Castelli from the Nashville office of the ACLU, Karla Campbell of Nashville-based law firm Branstetter, Stranch and Jennings and Elizabeth Logsdon of advocay organization Disability Rights Tennessee.

Note: The ACLU press is below, including link to the text of the lawsuit. Continue reading

AG joins lawsuit against insurance company merger

News release from Tennessee Attorney General’s Office
Attorney General Herbert H. Slatery III today announced that Tennessee has joined the U.S. Department of Justice and attorneys general from 11 states and the District of Columbia in litigation to block the merger between health insurance companies Anthem and Cigna, alleging that the transaction would increase concentration and harm competition in Tennessee and across the country.

The Justice Department and state attorneys general filed the merger challenge in the U.S. District Court for the District of Columbia. The complaint alleges that the merger, valued at $54 billion, would harm seniors, working families and individuals, employers, and doctors and other healthcare providers by limiting price competition, reducing benefits, decreasing incentives to provide innovative wellness programs, and lowering the quality of care.

“In what instance would Tennesseans want 4 instead of 5 competitors from which to choose insurance products or negotiate services? That is the question raised by the merger, whether one is a national employer comparing benefits and premiums, a health care provider like a hospital or physician practice, or an individual selecting a policy on an exchange. There are too many unanswered questions and too much at stake in reducing competition for Tennessee to support this merger,” Attorney General Slatery said.

Eleven states – California, Colorado, Connecticut, Georgia, Iowa, Maryland, Maine, New Hampshire, New York, Tennessee, and Virginia – along with the District of Columbia joined the department’s challenge of Anthem’s $54 billion acquisition of Cigna.

The suit against Anthem and Cigna alleges that their merger would substantially reduce competition for millions of consumers who receive commercial health insurance coverage from national employers throughout the United States. The complaint also alleges that the elimination of Cigna threatens competition among commercial insurers for the purchase of healthcare services from hospitals, physicians, and other healthcare providers.

Anthem, Inc. is headquartered in Indianapolis, Indiana. It is the nation’s second-largest health insurer. It operates in every state and the District of Columbia, and provides health insurance to 39 million people. In 2015, Anthem reported over $79 billion in revenues.

Cigna Corp. is headquartered in Hartford, Connecticut. It is the nation’s fourth-largest health insurer. It operates in every state and the District of Columbia, and provides health insurance to 15 million people. In 2015, Cigna reported $38 billion in revenues.