This year, his effort may get a boost on the national scale. U.S. Senator Dianne Feinstein has been designated the chief spokeswoman on the issue, according to an article by Marc Lifsher of the Los Angeles Times. Sen. Feinstein was the first person to sign a new petition to put state regulation of premium increases on the ballot this November, a campaign that will require 505,000 signatures to succeed. She then spread the word on the issue by emailing the petition to about two million constituents, encouraging them to sign it as well.

Sen. Feinstein’s email focused on you – the individual market – as the main group of consumers who the bill would protect from rising premiums. People enrolled in employer-sponsored plans, she explains, are less affected by rate increases since their premiums are at least partially subsidized. Her website’s healthcare section goes into more detail, citing some of the highest proposed rate hikes of the recent past and the fact that about two-thirds of states and the District of Columbia already have the authority to regulate premium increases.

This isn’t Sen. Feinstein’s first involvement with the issue. Last August, according to a press release on her website, she testified before a Senate Committee on a proposal that would prevent health insurance companies in all states from increasing rates without justifying them.

Readers, do you think that bringing national attention to the issue will help the California proposal? Do you agree that health insurance premium increases should be approved by the state?

But that’s starting to change. In an article for the Connecticut Mirror, Arielle Levin Becker reports that Anthem Blue Cross and Blue Shield, a major insurer in the state, plans to start paying doctors for these non-visit activities. And Anthem is not the only one to do so, she explains, but rather the latest example of a new trend. Just this week, Aetna announced a similar program in which certain doctors who actively manage their patients’ care will receive monthly payments for that work.

It’s all part of a move toward the medical home model, which we’ve covered before in this blog. According to the American College of Physicians, this model places the personal doctor at the center of a web of continuous and coordinated care for patients, throughout their lifetime. This personal doctor organizes referrals to specialists and other providers when needed. Those who support this model, Ms. Becker writes, say that it reduces costly emergency room visits and improves the quality of care – a win-win situation.

The details of Anthem’s program have yet to be determined. So far, it includes rewards for primary care practices that show improved health outcomes and lower costs. Eventually, like in Aetna’s program, doctors who play an active role in coordinating their patients’ care will receive a monthly payment. Anthem’s goal is that one day, all primary care doctors will fit that description.

• AB154, which passed 47-18, and would require health insurance companies to cover the diagnosis and treatment of almost all mental illnesses. This includes nearly 400 conditions.
• AB171, which passed 45-13, and would require insurers to cover developmental disorders, such as autism. This is already a requirement, but is not always followed.
• AB137, which passed 67-0, and would require insurers to cover mammograms for all patients who need it, regardless of their age.
• AB1000, which passed 51-15, and would require insurers to cover oral chemotherapy as extensively as they cover intravenous chemotherapy. Similar laws already exist in 13 states and the District of Columbia.

Proponents of the expansions to coverage say that people with mental health conditions are often unable to get treatment, and so they cost taxpayers money through public health programs and when they need emergency care. Assemblyman Jim Beall, who proposed AB154 and AB171, believes that this is a more cost-effective approach because patients will be treated before an emergency takes place, Ms. Lin writes. Plus, supporters say, physical and mental health are equally important to overall well-being, and thus should be covered at similar levels.

Opponents argue that these bills place a large burden on health insurance companies and will drive up their costs, which will be passed on to consumers in the form of higher premiums and fees. They also say that it may encourage abuse of prescription drugs such as medical marijuana.

These four bills are now headed for the state Senate.

But on Friday, the Obama administration announced to the Supreme Court that most of the law can still survive, even if the individual mandate is thrown out. Those portions include cost control measures and public health efforts that are unrelated to insurance coverage, explains James Vicini in an article for Reuters. Plus, they say, the Supreme Court has never before struck down a comprehensive law like health reform because one provision was unconstitutional.

If the individual mandate is invalidated, two parts of the law will have to be eliminated: first, that insurers cannot refuse to cover a person with pre-existing medical conditions, and second, that insurers cannot base a person’s premium cost on his or her medical history. This would protect insurance companies, who need the income from healthy customers’ premiums to pay for the medical costs of the less healthy. Without the individual mandate, those healthy customers may choose not to maintain coverage.

For more information and previous coverage of this debate on our blog, please read:

• Jan. 6, 2012: Cameras in the Courtroom: Will Supreme Court’s Hearing of Health Reform be Televised?
• Nov. 14, 2011: Confirmed: Supreme Court Will Rule on Health Reform
• Nov. 11, 2011: D.C. Appeals Court Rules in Favor of Individual Mandate
• Nov. 4, 2011: Insurers Worried about Potential Repeal of Individual Mandate
• Additional posts about health insurance policy and regulation

When the U.S. Department of Health and Human Services (HHS) unveiled these forms in August, the goal was to have them ready by March 23 of this year. But several health insurance companies, who would be the ones developing the forms, wanted more time, according to an article by Susan Jaffe of Kaiser Health News. Insurers argued that the March deadline would force them to duplicate efforts and create both styles of forms for plans available in 2012: once, in the usual format, for continuing enrollment at the end of 2011; and again, in the new format, for those enrolling in March or later. If the deadline were pushed back, they said, they could use the old format for 2012 and begin using the new one in 2013.

Now, writes Ms. Jaffe in a new article, questions still remain about how exactly the forms should be used. HHS is still reviewing public comments on the sample forms. Given that the March deadline is less than two months away, it’s likely to be pushed back. But advocates for consumers and seniors urge HHS and the Obama administration not to weaken it. Several organizations, including the American Cancer Society, Consumers Union, and AARP, have written and signed an open letter to the president asking for the forms to be available by this fall, in time for enrollment for 2013. The letter also asks that the forms include premium and cost information as well as examples, and that they be required for group and individual market plans.

Now, notes Elizabeth Stawicki of Minnesota Public Radio, there is a new trend among health insurance companies: ahead of the 2014 launch of the government-run exchanges, several insurers are starting their own exchanges. Unlike the public exchanges, these sites may offer plans from only one insurer, allowing some comparison-shopping but only between the plans offered by that insurer.

But why? According to Ron Rowe of Blue Cross Blue Shield Kansas City, quoted by Ms. Stawicki, the aim is to get customers used to the format of an online exchange and familiarize them with the coverage a given company offers before the public exchanges force insurers to compete directly. Because switching plans often requires finding new doctors and hospitals, which can be unpredictable and a hassle, insurers hope that customers will develop loyalty to their plan by the time 2014 rolls around, rather than shop around for something new.

Readers, what do you think of this approach? We often suggest that you evaluate your coverage every year to make sure it’s still the best value and package for you (here and here, for example), but having to switch providers is a very real barrier to that. When you read about the plans that are out there, what factors would make you consider a switch?

According to an article by David Morgan of Reuters, 14 states have established their authority to set up exchanges, whether by a new law or one that previously existed, and 14 have taken steps to show that exchanges are useful. The health reform law set a deadline of January 1, 2013 for states to either move toward a state-based exchange or agree to participate in a national one, with the option of later establishing a state-based system. The exchanges must be up and running by the beginning of 2014. But given the uncertainties and Supreme Court hearings scheduled for this spring, some states have decided to wait and see what happens.

However, all states have made some changes since the law was passed. For example, writes Meghan McCarthy of the National Journal, 44 states have strengthened their review of increases to health insurance premiums. In addition, most states have accepted federal grants to help them plan for the exchanges, says Louise Radnofsky of the Wall Street Journal’s Washington Wire blog. According to Julie Appleby of Kaiser Health News, those grants total more than $729 million in 49 states and D.C. (only Alaska has not sought funding). Some states, however, do not plan to use their grants and will return the money.

Now, the formal repeal of CLASS is proceeding through the legislature. In November, the House Energy and Commerce Committee voted in favor of repeal. And yesterday, writes Sam Baker of The Hill, the House Ways and Means Committee voted the same way. The next step is a House floor vote, which will take place next month.

While Congressional Republicans are largely against the program and the health reform law in general, Mr. Baker says, Democrats say that CLASS targeted a serious problem – the fact that most Americans are unprepared for the expenses of long-term care – and that while this particular program was not viable, the government should continue to search for an alternative that is more financially sound.

Although CLASS was dropped, not everyone supported its outright repeal, Mr. Volsky elaborates. Many of those who supported the intent of the program were against its repeal, arguing that it could instead be modified and its financial model strengthened. But those in favor of repeal believe that it needed to be removed formally and legally, rather than simply abandoned, Mr. Baker writes.

Neither home care nor nursing home residency are covered by Medicare. While CLASS is no longer an option for those who may need long-term care, a variety of affordable long-term care insurance plans are available on the individual market. If you’re interested, our reference page on long-term care is a good place to get started.

Many insurers in Massachusetts are tackling that very challenge by creating ‘tiered’ health insurance plans. In a traditional plan, like an HMO or PPO, patients are urged to keep their costs down by visiting certain providers who belong to the plan’s network, and have to pay extra for providers outside the network. In a tiered plan, insurers place providers into groups based on quality and price data. Customers can see those groups and use them to choose who they go to for a particular treatment, with lower co-payments for providers in the low-cost group. Also, premiums for tiered plans tend to be lower than those for traditional plans.

But all that flexibility is causing some confusion, writes Martha Bebinger of WBUR. Potential customers are drawn in by the lower premiums that tiered plans offer. When calculating their expected health costs, however, and trying out different scenarios based on the providers they’re likely to visit, some customers are finding that the premium savings aren’t as high as they expected. For example, going to a high-cost provider for just one emergency treatment could wipe out a year’s worth of premium savings.

To add to the confusion, Ms. Bebinger explains, different plans may put the same provider in different groups. This happens for multiple reasons, such as basing the groups on different outcomes data and measuring quality and price in different ways. Depending on their agreements with doctors and hospitals, different health insurers may pay different amounts for the same procedure by a given provider. This variation makes shopping for a tiered plan extra complicated.

Soon, insurers will be required to use the same set of quality criteria when rating hospitals and physicians, simplifying the shopping process a little bit. However, they may still weigh the criteria differently and have varying reimbursement agreements with providers.

A new approach known as value-based insurance design (VBID) takes those factors into account. Ms. Edlin writes that the VIBD model includes adjustments to copayments and coinsurance, shared decisionmaking, network design, incentives for maintaining health, and disease management. Insurers are currently working on value-based health insurance plans with financial incentives for healthy behaviors.

Transparency of information on costs and outcomes for various patient groups is key to VBID, because this data helps patients and providers decide which treatment course to take.

Rewards for good health are another important piece of the model. Starting in 2014, employers will be allowed to reimburse employees who reach certain health and wellness targets up to 30% of their premiums. Other incentives include reducing or eliminating coinsurance for in-network providers and deposits into employees’ health savings accounts.

Ms. Edlin describes another approach to VBID known as “reference pricing,” in which there is a standard price for any treatment (including medication), and plan members cover any costs beyond that standard. Reference prices are best suited to procedures with little variation in quality that, for some reason, vary widely in cost. But when a more expensive provider does offer better quality and outcomes, they are less useful and may in fact mislead patients.

Readers, how do you define the value of a health care procedure? How do you decide whether a treatment is worth it?