MA Plans Could Not Drop Physicians Without Cause Under Proposed Legislation

Rep. Rosa DeLauro (D-Conn.) and Senator Richard Blumenthal (D-Conn.) discussed the importance of legislation that they introduced that would prohibit Medicare Advantage plans from dropping physicians, providers, and other suppliers from the their networks with little or no notice to Medicare beneficiaries during a conference call sponsored by Medicare advocacy groups. The Medicare Advantage Participants Bill of Rights Act puts in place numerous requirements an MA plan would need to meet before it could remove a physician, provider or other supplier from its network.


Under the legislation a physician, provider, or other supplier could only be dropped from the MA’s network for cause. The MA plan has cause to remove a provider of service if the HHS Secretary determines that the physician, provider or other type of supplier is (1) medically negligent; (2) in violation of any contractual requirement with the MA plan; or (3) is otherwise unfit to furnish items or services. In addition to meeting the definition of cause, an MA plan would have to have the HHS Secretary determine that cause exists before the physician, provider or other supplier could be dropped from its network. The legislation requires the Secretary to establish an appeal process for providers who are removed from an MA’s network.


The legislation also requires that notice be given to beneficiaries enrolled in the MA plan 60 days prior to the date on which the MA plan will no longer cover services from a physician, provider, or other supplier. The notice is to include (1) the last date of coverage for services from the physician, provider or other supplier; (2) the name and telephone number of other physicians, providers or other suppliers in the MA’s network who offer the same services and supplies as the physician, provider or supplier who is no longer in the MA’s network; and (3) a customer service telephone number. In addition, the legislation would require MA plans to establish their networks 60 days before the beginning of the annual open enrollment period and to include that information in their annual bid and on their website.


“This landmark legislative proposal was inspired by the thousands of patients who need a bill of rights to protect them against bait and switch abuses like United Health Care used last year when they dropped hundreds of doctors from their Medicare Advantage networks in Connecticut,” said Senator Blumenthal during a conference call on the legislation sponsored by The Medicare Rights Center and The Center for Medicare Advocacy. “When UnitedHealth dropped an unprecedented number of providers right at the beginning of last year’s Medicare open enrollment period, the stories from seniors in my district were staggering,” said Representative DeLauro. “People were not only worried about their physical health, but had to deal with the mental strain and stress of not knowing whether they were going to have their doctors,” she said.


The Medicare Rights Center reported that 10,000 individuals signed a petition urging Congress to support the bill and enact legal protections to maintain doctor-patient relationships. The legislation was introduced in both the House of Representatives and the Senate on June 26, 2014. It was referred to the Ways and Means and the Energy Committees in the House and to the Finance Committee in the Senate. The legislation has not yet received a hearing in any of the committees.

Highlight on Georgia: Residents Favor Medicaid Expansion, Still Oppose ACA

Although certain implementation of the Patient Protection and Affordable Care Act (ACA) has been set in motion over the past year, a survey undertaken by the Healthcare Georgia Foundation observed Georgia residents’ division of support for the ACA with 42 percent approving and 46 percent disapproving of it. The survey of 400 adults also found that more than 70 percent of Georgia residents believe that there has been no difference in their access to health care and quality of services over the past year, which saw the full rollout of the ACA. Generally, the Georgia residents’ disapproval of the ACA stemmed from the key provision related to penalties for not purchasing health insurance. Conversely, there was noted support for the ACA’s prohibition of health insurers denying individuals coverage for pre-existing health conditions and the requirement for insurers to cover some preventative care services at no cost to the patient.

Regarding ACA implementation, the state of Georgia made two key policy determinations: (1) no to expansion of Medicaid and (2) no to offering a state marketplace for health insurance. The survey found that 90 percent of Georgia residents believe that Medicaid was important for healthcare in Georgia, with 75 percent finding that Medicaid was very important. Not surprisingly then, 60 percent of surveyed Georgia residents expressed their disapproval of the state’s decision not to expand Medicaid. In contrast, Georgia residents were evenly split on the state’s decision not to  offer a state marketplace for insurance, with 44 percent approving and 44 percent disapproving.

In August, Gallup reported that states with the largest declines in uninsured rates from 2013 to mid-year 2014 expanded Medicaid and established a state-based marketplace exchange or federal partnership. These states reduced their uninsured rates three times more than states that did not implement these mechanisms. For instance, the state with the largest reduction, Arkansas, saw a 10.1 percent decline in its number of uninsured residents, from 22.5 percent to 12.4 percent. In contrast, Georgia saw its uninsured percentage only drop 2.2 percent from 22.4 percent to 20.2 percent.

However, Georgia is unlikely to take up Medicaid expansion in the foreseeable future.  Georgia lawmakers did not expand Medicaid during the 2014 legislative session, instead passing legislation (HB 990) that prohibited Medicaid expansion without prior legislative approval. The governor and other state officials opposed to Medicaid expansion cite added costs to the state, with estimates of more than $2 billion over 10 years.

The Georgia Budget and Policy Institute (GBPI), factoring in new state revenues that the expansion would trigger, puts the figure much lower, at an estimated net expansion cost of about $350 million over the same time frame. In September, the GBPI had argued that almost 50,000 uninsured Georgia residents in a 10-county region could get guaranteed health coverage if the state accepted new federal money to expand Medicaid eligibility. The number of uninsured residents covered would be the third largest number of residents in any of Georgia’s 12 state-designated regions. Without Medicaid expansion, many uninsured Georgia residents with income below the federal poverty level will remain stuck in a coverage gap, according to the GBPI, as their income is above Georgia’s current Medicaid threshold, yet too low to qualify for new federal insurance subsidies. The institute noted that throughout the state, more than 400,000 uninsured adult residents fell into the coverage gap.

Georgia’s decision not to expand Medicaid has played a role in how residents access healthcare services. Forty-two percent of respondents in the Healthcare Georgia Foundation survey reported that they wanted to seek care for a health-related issue, but chose not to for some reason, including cost, distance to doctor’s office or time spent. Cost was cited as a major reason by 68 percent of these respondents. In part, this focus on cost not surprisingly results in the survey finding a majority of residents favoring Medicaid expansion.





Post-Sequester Caps Hamper Control of Infectious Diseases: Sen. Harkin

Senator Tom Harkin (D-Iowa), Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee and the Appropriations Subcommittee on Labor, Health and Human Services and Education has called for an Omnibus bill providing sufficient resources to all federal agencies involved in the control of Ebola and other infectious diseases in the U.S. and overseas. To pay for this, Harkin calls for the lifting the post-sequester caps that return next year when the Murray-Ryan budget deal expires.

Cap Problem

According to Harkin, the post-sequester caps put the government “on autopilot, hampering the work of the [Centers for Disease Control and Prevention] CDC and agencies on the frontlines of controlling Ebola. We must increase resources for CDC, not just to continue their work in the three countries most affected, but also to ramp up surveillance in the 11 countries surrounding the outbreak.”

More CDCs Needed

Harkin believes that every country needs a CDC and that the U.S. must help them develop their own. To that end, Harkin has championed the National Public Health Institutes (NPHI), which currently helps five countries around the world increase surveillance and laboratory and outbreak response capacity to improve the detection of public health threats. Harkin wants NPHI funding increased to expand the program to all 24 of the countries that wish to participate, including 11 in Africa.

CDC’s Role in NPHI

Through leadership and direct engagement with Ministry of Health officials, CDC and partners help countries develop a strategic plan aligned with public health priorities, determine necessary policy changes, create a sustainability plan, and execute a project which includes linking NPHIs with other established NPHIs or U.S. State Health Departments that can provide additional public health expertise. CDC’s role in NPHI emphasizes: (1) high impact investments to maximize an NPHI’s self-reliance; (2) the leveraging of existing partnerships; and (3) the sharing of scientific expertise through a time-limited engagement of 3 to 5 years.

On the Homefront

According to Sen. Lamar Alexander (R-Tenn.) “we must take the deadly, dangerous threat of Ebola in West Africa as seriously as we take the ISIS threat in the Middle East. The spread of this disease requires a more urgent response from the U.S. and other countries.”Alexander urges President Obama to immediately: (1) begin screening at all U.S. airports any person who is traveling to the U.S. from one of the countries with an Ebola epidemic; and (2) designate a single cabinet member to coordinate the response among the agencies involved and the other countries of the world. The U.S. screening would be in addition to any screening received when they leave the country of outbreak.

Harkin believes that in the U.S. we need to: (1) better train doctors in what to look for; (2) strengthen our quarantine stations at the 20 busiest entry-points to the U.S.; (4) fund basic research for better future treatments; and (4) fund clinical trials for potential vaccines and therapies that are currently in the pipeline now.

Dental Therapists Could Be End to Oral Workforce Decay

By Lisa A. Weder

In a push for states to expand their dental workforce, Families USA has launched its Access to Dental Care Initiative, which focuses on improving awareness of dental care access for low-income families and expanding the use of mid-level providers, such as dental therapists, in more states. The initiative attempts to heed the call of underserved populations in which 14 million low-income children went without dental care in 2011, according to Pew Charitable Trusts (Pew). Pew attributes the workforce problem to an unbalanced distribution of dentists across the country and the small network of dentists who participate in Medicaid. Families USA says this impacts more than 49 million Americans.

The initiative centers on expanding dental teams to include dental therapists in order to reach more patients. Reaching more dental patients allows dentists more time to focus on treating patients with complex care needs.

Families USA sees dental therapists as a means to cost-effective and patient-centered care allowing dental practices to increase productivity and revenue because dental therapists earn lower salaries, take a shorter amount of time to train (receiving two to three years of hands-on training), and are able to provide routine preventive and restorative procedures including dental exams, cleanings, x-rays, fluoride treatments, sealants, fillings, and basic extractions under the general supervision of a dentist. They also provide much needed prevention and education services within communities where dentists are scarce.

Dental therapists already provide care in more than 50 other countries, as well as in previously underserved communities in Alaska and Minnesota. Maine passed legislation in 2014 allowing dental therapists to provide care within dental practices, and 15 other states are considering the move as well.

Three nonprofit dental programs reaped benefits of using dental therapists:

  • People’s Center Health Services, a federally qualified health center (FQHC) in Minnesota, targets Minneapolis’ diverse, low-income population. In April 2012, the FQHC became the first to hire a dental therapist to increase the number of patients who could be served. She saw 1,756 low-income, uninsured patients in the first year.
  • Norton Sound Health Corporation, a tribally owned and operated nonprofit health care organization, deploys dental health aide therapists to distant rural locations. According to Mark Kelso, D.D.S., the group’s dental director, dental therapists who provide routine care have given its dentists more time to attend to unmet needs for higher-level procedures. One dental therapist contributed to saving approximately $95,000 in Medicaid outlays for travel by providing early preventive care and treatment.
  • The Virtual Dental Home is a demonstration project operated by the University of the Pacific School of Dentistry at sites throughout California. The project tests delivery of health-related services and information via telecommunications technologies to provide dental care to populations that would otherwise not receive care. It targets patients in community settings such as elementary schools, Head Start programs, and nursing homes in low-income areas. The dental therapists collect dental information that is sent electronically to a supervising dentist, who creates a treatment plan for the hygienist to implement.

Families USA would like to see more states investigate expanding their oral health workforce to meet the needs of all of their residents, but in particular to meet the needs of underserved children. “Improving children’s oral health will involve many policy and public health changes, and strategies to expand the oral health workforce are a critical component of these changes.”