By Kerry Young, CQ HealthBeat Associate Editor

July 15, 2014 -- Paid and volunteer workers helped about 10.6 million people navigate the health law's at times complex process of buying medical coverage, a report found.

Consumers in many cases struggled with even some of the more basic jargon of the health insurance field, such as "deductible" and "network service," according to the recent report by the nonprofit Kaiser Family Foundation.

Then, there were the well documented technical glitches with the federal and some state insurance exchanges created by the health law (PL 111-148, PL 111-152). Very often, workers in assister programs spent one to two hours helping each consumer, the Kaiser report said.

"Explaining rules and options to people with limited understanding of the ACA and health insurance took time," the report said, referring to the Affordable Care Act. "So did waits on hold with marketplace call centers and frozen computer screens."

The report drew on a survey of the helpers involved in getting people enrolled in new insurance through state and federal exchanges. These include the Navigator programs that contracted directly with the Centers for Medicare and Medicaid Services to provide free outreach.

The report estimates that a total of about 4,400 assister programs operated nationally during this first enrollment period for the new marketplaces, with an estimated 28,000 full-time staff and volunteers. That suggests that each assister helped more than 370 people on average during the six-month open enrollment period that ran from Oct. 1 through March 31.

The report was is the first nationwide assessment of the number and type of assister programs and the number of people they helped, according to Kaiser. Many consumers needed more help even after enrolling, the report said. About nine of 10 assister programs has been contacted by people with follow-up questions after enrolling.

"Post-enrollment problems range from consumers not having received their insurance card, to not understanding how to use new health insurance or how to appeal a denied claim," the report stated.

The role of these assister programs will continue beyond the initial enrollment period, the report stated. The Congressional Budget Office has estimated that as many as 13 million people could enroll in the marketplaces in 2015, 5 million more than signed up during the first run. There will be work to be done in keeping current enrollees in the program, and also reaching out to Americans who have not yet signed up for health insurance.

"If the first wave of enrollment in 2014 was comprised of those consumers who were the most resourceful and motivated to seek coverage, then investment in consumer assistance will be all the more key in the year to come," the report said.

By John Reichard, CQ HealthBeat Editor

July 17, 2014 -- Collaboration and planning are the early watchwords of Karen DeSalvo's recently launched tour of duty as the federal government's top health IT coordinator.

The goal is to lessen divisions that have developed among the different players in health care over a realistic schedule for moving to a truly "interoperable" health care system–one in which a growing volume of electronic medical data moves quickly and easily among patients, doctors, hospitals, labs, pharmacies and public health agencies.

But behind that methodical approach–one that risks criticism that DeSalvo isn't pushing interoperability hard enough – the new coordinator signaled impatience with vendors and health IT providers that drag things out too long.

"We're keenly interested in seeing that that data starts to flow," DeSalvo said, hinting that providers may be more capable of making that happen then they've been letting on.

In her first extended Washington, D.C., press briefing since becoming national coordinator for health information technology at the Department of Health and Human Services (HHS) six months ago, DeSalvo sketched out the activities of her office for the rest of the year, including "refreshing" the federal strategic plan for health IT.
"We've been trying to go really deep into interoperability really quickly," she said. "This is going to take everybody's input, and as much of everybody as we can include in the country."

"This is a thorny problem that we have yet to completely solve," she said.

In June, her office released a 10-year vision for achieving interoperability and invited public comment on developing a shared agenda in five areas: core technical standards allowing IT systems to talk to each other; certification of products as interoperable; privacy and security of medical data; "supportive" business, clinical and regulatory environments; and the development of governance structures.

The collaborative approach will establish three, six, and 10-year goals in each of the areas, she said.

Health IT systems have advanced to the point where medical data is "ready to be shared," she said. There also are "a series of bright spots around the country" that show it's possible to move data in a way that makes health care more convenient and easier to deliver, she said.

DeSalvo named a number of states that have created interoperability standards and attended to privacy and security concerns to allow information to flow. They include Maine, Massachusetts, Maryland, Minnesota, Tennessee, Kentucky and Colorado. She singled out communities such as Rochester, N.Y. for exemplary work.

DeSalvo said she plans meetings with advisory groups in the fall and wants to come out with a 10- year interoperability roadmap by January "that is specific enough that people will know what to do when."

DeSalvo has established a council in which the various agencies at HHS and also other federal agencies such as the Federal Trade Commission can work together to set priorities.

She'll also host listening sessions across the country in coming weeks to make sure that the federal government's health IT priorities "align with what the country thinks."

The revised federal health IT strategic plan will place a priority on "health" as distinct from improving "health care." The idea is to promote health "where you live, learn, work, and play," she said. "Wearables" are an important part of that.

"It's an opportunity to completely transform the delivery of health care and to give people an opportunity for things like dignified aging in the community," she said.
Wearables go well beyond products that count the steps one takes in a day to devices that monitor blood glucose and oxygen levels. Providers would be able to monitor a patient remotely, notice if the person might be having climbing steps and adjust medication accordingly.

Kids could have a GPS feature on asthma inhalers that would allow public health agencies to find out where they are having asthma attacks–say in a school that has a mold problem–and take action.

DeSalvo also touched on regulatory topics. Providers are supposed to attest by the end of the year that they have health technology that complies with "stage two meaningful use" requirements that determine whether they will receive higher Medicare payments. She said her office has data on the ability of hospitals to do so, and that 2014 edition health IT products needed to comply with stage two are now beginning to move into the marketplace.

DeSalvo also expressed impatience with proprietary systems that block the flow of medical data.

"We're keenly interested in seeing that that data starts to flow," she said.

July 15, 2014 -- California officials hope to reduce the unprecedented number of people stuck waiting for the state to process their Medicaid applications from 900,000 people to 350,000 people by mid-August, according to a 17-page response that the state sent to federal officials.

California—which has the biggest backlog in the nation—was one of a dozen states that recently received letters from the Centers for Medicare and Medicaid Services (CMS) questioning why they were taking so long to get people enrolled in the federal-state health program for the poor.

Half of those states responded by Monday night to requests sent June 27 from CMS to come up with plans to solve the problem. The other six states were warned in July 9 letters that federal officials want to review their enrollment processes to find out the causes and extent of the problems before the next steps are determined.

At least 2.9 million people nationwide were waiting for Medicaid officials to process their applications, according to a CQ Roll Call count published on June 3. Some of the people who applied had given up on their original applications and sent in new forms directly to state Medicaid offices in the hope that the duplicate applications would be processed sooner.

In addition to the formal letters sent to 12 states, CMS officials have been having direct phone calls with state officials to inquire about Medicaid backlogs.

"States are working to get through their backlogs," said Matt Salo, executive director of the National Association of Medicaid Directors. "It's going to take some time."
The states that received June 27 CMS letters demanding that they take corrective steps were Alaska, California, Kansas, Michigan, Missouri and Tennessee. The states that were asked to provide more details included Arkansas, Georgia, Illinois, Indiana, North Carolina, Virginia and Wyoming.

The slow processing times are due to several factors, including the volume of people applying, technical difficulties and state resources.

California officials answered questions from CMS about major issues that will affect the huge backlog there. State officials estimated that the number of people waiting had fallen from 900,000 to 600,000 by late June.

About 2.2 million additional people enrolled in Medicaid from Oct. 1 through the end of June, bringing the state's total Medicaid population to 10.9 million people, said California Department of Health Care Services officials in their July 14 letter.

Technical problems remain a big factor in the California enrollment difficulties.

"Additional work is still needed to improve and complete certain system functionality," wrote Medicaid Director Toby Douglas in the letter. The state is trying to update its computer systems as quickly as possible and use workarounds for technical problems.

The state will soon send letters to consumers to tell consumers how to expedite their enrollment. State computer systems will add automated process to identify and get rid of duplicate applications, and self-service portals that consumers use to enroll will be updated to catch errors, said state officials.

Other states that responded to CMS spelled out their plans to fix the issues. Alaska, Kansas, and Michigan received letters because they were not yet able to receive applications from healthcare.gov, the federal website that handles enrollment in 36 states.

Alaska officials said there are about 4,000 applications still stuck at the federal marketplace website but some of the people who tried to enroll have signed up through other ways. A new portal is supposed to go live this month.

Kansas officials said they will start implementing a contingency plan, based on techniques used in Iowa and Ohio, that will allow them to start getting applications from healthcare.gov as early as July 25.

"Michigan has already begun accepting the full backlog of records and we will continue to work closely with CMS in meeting this final success factor so that we can complete the processing of these files," said Medicaid agency spokeswoman Angela Minicuci in an email.

In the states that used healthcare.gov, technical problems prevented the transferring of applications for months. The ability for the federal marketplace to send states applications and for states to receive them was supposed to go live Oct. 1, 2013. But initially the federal website had problems transferring the files and later some states continued to struggle with technical problems in receiving them. Those so-called "account transfer" problems led to at least temporary backlogs in many states.

"The receiving state agencies were all being built independently and from different starting points so it shouldn't be surprising that the 'ear' hearing that message, so to speak, will be different in each state. So the problems that one state might have would legitimately be different than in other states," said Salo.

One state official that received a letter, the Medicaid director in Tennessee, has argued that CMS is unfairly targeting the state. In the June 27 letter to Tennessee, the agency said that the state has resisted calls to create a mitigation plan and increase the level of state resources needed to work on applications that are sent in directly to the state instead of through the federal website.

But Medicaid director Darin Gordon said in an op-ed published in The Tennesseean newspaper that the state has done its best.

"To make this second outlet in Tennessee available to all applicants, an entirely new eligibility system is required," he wrote. The health care law "dramatically changed the eligibility determination process, but the lead time states were given to develop their new eligibility systems was extremely short. This was further complicated by constantly changing federal requirements. As a result of these factors, as well as other challenges encountered by our systems vendor, Tennessee's new eligibility system is behind schedule."

Gordon argued that the delay "has not prevented Tennesseans from enrolling." He said that record numbers, more than 125,000 individuals since Jan. 1, have been able to enroll in Medicaid.

CMS officials have checked in to verify that applications are being processed more quickly in states that say that their backlogs have declined precipitously in recent months.

"In our calls we have kept them apprised of our experience with the account transfer problems, which was the source of our backlog," said Monica Coury, assistant director of the Office of Intergovernmental Relations for the Arizona Medicaid agency. "So as we whittled that down, there has been less to talk about."

A CMS spokeswoman said that the agency did not have any information on whether additional letters would be sent.

July 18, 2014 -- Fifteen years ago, a landmark Institute of Medicine report concluding that up to 99,000 Americans needlessly die each year from medical errors grabbed the health policy community by surprise and prompted a national push to improve patient safety.

But despite steps undertaken since then such as checklists to prevent infection, wider reporting of infection rates and payment incentives to reduce unsafe care, the latest estimates of preventable deaths are far higher.

Patient safety advocates hope to launch a new round of policymaking to address the problem.

"Many individuals, hospitals and other health care institutions are working to eliminate medical errors," Lisa McGiffert of Consumers Union told a Senate hearing last week. Nevertheless "millions of Americans are at risk for death and serious injury," she said. "The response by our leaders fails to match the scope of this epidemic."

McGiffert and other witnesses at the Senate Health, Education Labor and Pensions Primary Health and Aging Subcommittee hearing chaired by Bernard Sanders, I-Vt., offered a long list of policy prescriptions. They ranged from establishing a "National Patient Safety Board" akin to the National Transportation Safety Board to a Securities and Exchange Commission-like entity to develop uniform quality of care measures and expanded reporting on rates of preventable medical harm by the Centers for Disease Control and Prevention.

The new effort seems sure to encounter resistance from the hospital industry, which says lawmakers already have granted ample authority to develop quality measures ensuring patient safety.

American Hospital Association spokeswoman Jennifer Schleman said various agencies have taken steps to reduce medical errors and have authority to develop new measures. She cited as examples the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, CDC and the Office of the National Coordinator for Health Information Technology.

Witnesses said that despite progress made since the 1999 report, current efforts are too limited and are sometimes ineffective.

Prominent at the hearing was an estimate by John James, founder of Patient Safety America, that up to 440,000 Americans die each year from preventable medical errors in hospitals. Sanders said errors are the third leading annual cause of death in the United States today, behind heart disease at 597,000 and cancer at 574,000.

McGiffert pointed to three studies done in 2010 and 2011 that she said provided "some solid estimates of how often errors and patient infections happen." A Department of Health and Human Services (HHS) inspector general's study found that unsafe care in hospitals contributes to the deaths of 180,000 Medicare beneficiaries in hospitals annually.

A New England Journal of Medicine study in North Carolina found that one in four hospitals patients is harmed by substandard care during a stay. And an April 2011 Health Affairs study found the one in three hospital patients is harmed.

Patient safety expert Peter Pronovost of Johns Hopkins Medicine in Baltimore said "we do not know exactly how many people die needlessly." But he estimates that more than 220,000 preventable deaths occur yearly from unsafe treatment. He acknowledged heavy federal spending to improve adoption of health information technology to improve care but sees little payoff in safety.

Pronovost and his colleagues developed a simple five-item checklist for teams of doctors and nurses follow to prevent "central line" infections in the intensive care unit. Adopted in 100 intensive care units in Michigan, it cut infection rates to essentially zero, according to a study he published in the New England Journal of Medicine in 2006. That checklist is now followed by hospitals nationally and is credited with saving tens of thousands of lives each year.

Pronovost testified that infections linked to a tube inserted into the chest to carry medications are one type of harm from over a dozen harms. Every type of harm has a checklist, every checklist has five to 10 items and each item may occur three or more times per day. "None of the electronic medical record vendors, despite spending billions, displays this information," he said.

Harvard Medical School professor Tejal Gandhi, president of the National Patient Safety Foundation, emphasized that plenty of medical harm occurs outside the hospital.

"Most care is given outside of hospitals, and there are numerous safety issues that exist in other health care settings," Ghandhi said. The biggest problems in primary care are medication safety, missed and delayed diagnoses and transitions of care.

University of Minnesota School of Nursing professor Joanne Disch stressed the importance of engaging patients and their families in the care process, particularly in keeping medical instructions straightforward and in making sure patients follow them when they go from the hospital to the home, for example.

Sanders said he plans measures to address preventable hospital deaths but didn't outline any plans for legislation.

July 14, 2014 -- Federal officials recently announced that they will provide up to $100 million in funding states will be able to tap to improve the quality and efficiency of treatment in Medicaid.

States can suggest ways the money could be used to improve care, but Centers for Medicare and Medicaid Services (CMS) brass will contract with outside consultants to do much of the work involved.

States can get several types of technical assistance.

One is financial modeling to analyze ways of ways of paying doctors and hospitals that save the most money without jeopardizing the quality of care.

Officials want to test out ways to care for patients with very high medical costs and minorities whose health outcomes often are not as good as the rest of the population. CMS hopes to apply to a broader swath of the Medicaid population approaches that worked in smaller parts of that population or for people who have other types of coverage. States also could work with CMS and outside consultants to examine data from Medicare and Medicaid to find more efficient ways of delivering care.

Another focus is to improve quality of care measures and find ways to more effectively disseminate information to states about what works best. Funding also could pay for faster federal evaluations of existing state efforts such as their increased use of managed care.

CMS said it wants to coordinate communication so state officials don't have to make repeated calls to the agency about the same issue.

The new project stems in part from recommendations by National Governors Association (NGA) in February. Health and Human Services (HHS) Secretary Sylvia Mathews Burwell met July 13 with governors at their summer meeting in Nashville.

The co-chairs of an NGA task force on health care—Tennessee GOP Gov. Bill Haslam and Oregon Democratic Gov. John Kitzhaber—praised the HHS announcement.

"We are very pleased by this new effort to develop performance partnerships with states that can deliver better health outcomes at a cost we can afford," said Kitzhaber.

"I appreciate the continued conversations CMS has had with us about these areas," said Haslam.

CMS officials are taking suggestions about how to identify a small group of states that would be interested in experimenting with new technical tools or ways of offering care. Those states' experiences would be shared with other states, according to a "frequently asked questions" document posted online.

Known as the Innovation Accelerator Program, the new effort is similar to the CMS State Innovation Models project. But the latter uses cooperative agreements with states to fund projects while the new initiative emphasizes federally-funded technical assistance. The innovation project involves broader initiatives that can include other issues or more than one payer, while the new project is focused on Medicaid.

July 16, 2014 -- House Budget Committee members fixated on a slowdown in Medicare spending asked Congressional Budget Office (CBO) Director Doug Elmendorf at a hearing last week how long the relief would continue and whether it is due to the 2010 health care law.

Projections CBO recently released found that spending in 2014 for Medicare, Medicaid, the Children's Health Insurance Program and health law subsidies to buy insurance will total about 4.8 percent of the nation's economic output. By 2039, funding for those programs will rise to 8 percent of the gross domestic product. That's lower than projections. "What's happened since that point is everyone has observed a great slowing in federal health care costs and private health care costs," Elmendorf told committee members.

The effect on federal spending is significant since Medicare consumes such a large portion of the budget. The change in projections means that budgeteers think the federal government will save more than a trillion dollars in federal health spending for the decade that started in 2010 compared to what they previously thought. The reasons for the slowdown in spending growth are less clear, Elmendorf said.

"It's hard to know what's happening," he said.

Elmendorf said there isn't a consensus among economists about how much of the slowdown is due to the sluggish economy.

"We don't think it's totally explained because we had a recession," he said. Medicare spending in particular is not influenced significantly by the health of the economy, he said.

The CBO believes that the health care law (PL 111-148, PL 111-152) will produce net savings, in part because of Medicare and Medicaid cuts that help pay for it. But Elmendorf was careful not to say that the law is a primary reason why spending growth has been held in check.

And the biggest uncertainty is how long the lower-than-typical growth will continue.

"The question for us and for everyone is for whether they can keep that going," said Elmendorf. He noted that in the 1990s, the nation saw a marked slowdown, in part because of the increased use of managed care plans that held down costs. But then in the following decade, spending growth rose again.

"We don't know yet how persistent this slowdown will be," he said.