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.

Cause

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.

Notice

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.

Need

“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.

Status

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 Florida: ‘Year in Review’ Celebrates 125 Years of Public Health

The Florida Department of Health (DOH) released its 2013-2014 Year in Review, trumpeting the agency’s successes for July 1, 2013 through June 30, 2014, and celebrating 125 years of public health in Florida. Over the year, Florida improved in citizens with a healthy weight compared to other states, jumping into the top 15 healthiest weight states in the country. The state attributed this to its Healthiest Weight Florida program, a partnership between the DOH, other state agencies, local governments, businesses, schools, non-governmental organizations, non-profits, and hospitals to increase the number of Floridians with a healthy weight. The report discussed some of the DOH’s other programs, and celebrated local efforts at health throughout the state.

Anniversary

In 1899, the Florida legislature created the State Board of Health in response to yellow fever epidemics plaguing the state. Due to the large number of ports in the state, Florida experienced many public health crises that the Board of Health worked to fight. To celebrate the anniversary of the DOH’s predecessor, the DOH released an online publication called Florida Public Health Heroes, which shines a spotlight on historic and present Floridians who have served the state’s public health community, showing one hero for each of Florida’s 67 counties.

Healthiest Weight Florida

According to the DOH, weight is the “#1 public health threat in Florida.” The Healthiest Weight Florida initiative was launched in 2013 to avoid the estimated $34 billion in health care costs associated with preventable chronic disease. The program has five priority strategies in its fight against unhealthy body weight:

  • Activity - Increase opportunities for physical activity.
  • Nutrition - Make healthy food available everywhere.
  • Worksite Wellness – Add effective health-focused workplace programs, policies, and environments.
  • Schools – Strengthen schools as the heart of health for healthy weight promotion.
  • Messaging – Market what matters for a healthy life.

The report listed a number of “Healthiest Weight Highlights”–programs and policies championed by municipal and county governments across the state. Examples include restaurants in Escambia offering low-fat and low-sodium entrees or substitutions for no additional cost, the development of walking trails and community gardens in Jefferson, and St. Johns’ “Healthy in a Hurry” newsletter that includes information about local fitness opportunities as well as healthy recipes. The program’s goal is to bend the state’s weight curve by 5 percent by 2017.

Other Initiatives

The Students Working Against Tobacco (SWAT) program began its “We Are Not Replacements” campaign, empowering youth to speak out against tobacco and refuse to be a new customer to replace one of the 1,200 individuals who die each day from tobacco-related diseases. The DOH worked with other entities to conduct emergency preparedness training throughout the state. The Women, Infants and Children (WIC) nutrition program implemented statewide Electronic Benefits Transfer (EBT) services, and the WaterproofFL initiative promoted levels of protection for keeping children safe around swimming pools.

Mandatory Quarantines Criticized; Monitoring Recommended for Ebola Exposure

The fight against the Ebola virus has expanded beyond the Centers for Disease Control and Prevention (CDC) into the states, a move the New England Journal of Medicine (NEJM) called “destructive.” The recent state-level steps, most of which are aimed at health care workers who return to the United States after treating Ebola patients in Africa, have expanded far beyond the CDC’s recommendations and guidances. After one quarantined health care worker accused the governors of New York and New Jersey of violating her basic human rights, the state policies have been widely criticized, and the CDC has provided additional recommendations on how to track individuals who may have been exposed to the virus.

Background

The current outbreak of Ebola virus disease, commonly known as Ebola, began in West Africa, where the first cases were identified by the World Health Organization (WHO) in March 2014. The virus is primarily spread through direct contact (through broken skin or mucous membranes) with the blood or body fluids of a person who is sick with Ebola. Symptoms include sudden fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage. Individuals are only infectious after symptoms appear, and thereafter as long as their blood and body fluids, including semen and breast milk, contain the virus. The incubation period for the virus is between two and 21 days; after 21 days have passed, individuals who may have had contact with Ebola are not at risk of infection.

The first case of Ebola on American soil was diagnosed on September 30, 2014. A man from Liberia sought care at Dallas’ Texas Presbyterian Hospital once he began experiencing symptoms. All individuals who had close contact with the man were monitored for 21 days after exposure; he died on October 8, 2014. Two health care workers who treated the man at Texas Presbyterian tested positive for Ebola; both have since been discharged as Ebola-free. According to the CDC, the highest risk of exposure to Ebola is for health care providers caring for Ebola patients, as well as others in close contact with Ebola patients such as family and friends.

In response to the initial three cases of Ebola, the CDC, working with the Department of Homeland Security, began screening travelers from Guinea, Liberia, and Sierra Leone upon arrival at five U.S. airports (New York’s JFK International, Washington-Dulles, Newark, Chicago-O’Hare, and Atlanta). The agency announced active post-arrival monitoring of travelers from those three countries, which requires travelers to report their symptoms (or lack thereof) on a daily basis for 21 days. The CDC also provided updated guidance to health care workers to help prevent further transmission from treating patients with the virus. The new guidance requires “rigorous and repeated training” in how to properly use personal protective equipment, and stresses the need for oversight and observers to ensure that all procedures are being completed fully and correctly.

New York Aid Worker

A New York man who had volunteered in Guinea as a health care worker returned to the United States without any Ebola symptoms. He cleared the airport’s enhanced screening, then returned to his home with instructions on post-arrival screening. Six days later on October 23, 2014, the man experienced a low-grade fever and reported it to local health officials. He was then transferred–by a specially trained HAZ TAC unit wearing Personal Protective Equipment—from his home to Bellevue Hospital in New York City, a designated Ebola treatment facility, where he tested positive for the virus. The CDC identified four individuals to monitor for possible infection due to close contact with the man. To date, none have presented symptoms.

States React

On October 24, 2014, the day after the New York aid worker was diagnosed with Ebola, New York Governor Andrew M. Cuomo (D) and New Jersey Governor Chris Christie (R) jointly announced additional Ebola screening protocols for the international airports in their states, JFK and Newark. One major change was the mandatory quarantine imposed upon any individual who had direct contact with an individual infected with the Ebola virus while in Liberia, Sierra Leone, or Guinea. The states specifically included medical personnel who have performed medical services for individuals infected with the Ebola virus for mandatory quarantine.

The quarantine policy was implemented immediately. That same day, the New Jersey Department of Health released a statement announcing the quarantine of a health care worker who arrived at Newark Liberty International Airport without Ebola symptoms; the health care worker was placed in isolation at Newark’s University Hospital. Kaci Hickox, a nurse who recently treated Ebola patients in Sierra Leone, contacted CNN while under quarantine to publicize the “inhumane” treatment she was experiencing. Hickox repeatedly tested negative for Ebola, despite the state announcing that she had developed a fever. Hickox states that her temperature was taken only with a forehead scanner, which is less accurate than an oral thermometer.

Christie defended the decision to place Hickox under mandatory quarantine, saying “I understand that this has made this woman uncomfortable and I’m sorry that she’s uncomfortable but the fact is I have the people in New Jersey as my first and foremost responsibility to protect their public health.” Hickox was released from University Hospital on October 27, 2014; the state announced its plan to transport her to her home in Maine, where she will spend the remainder of her 21-day quarantine. New York released a fact sheet regarding its quarantine policy, which allows in-home quarantine with unannounced visits from the state to check the individual’s health and to ensure he or she is honoring the quarantine.

Other States

In Illinois, Governor Pat Quinn (D) announced a mandatory 21-day home quarantine for high-risk individuals who have had contact with an individual infected with Ebola, including medical personnel. Chicago-O’Hare International Airport is one of the designated points of entry for individuals entering the U.S. from the countries experiencing the Ebola outbreak. The state issued a guidance clarifying its position for determining whether an individual is “high-risk.” Similarly, Florida Governor Rick Scott (R) signed an executive order requiring mandatory twice-daily monitoring for all individuals returning from Liberia, Sierra Leone, and Guinea. Despite the absence of a designated screening airport in the state, Scott maintained the necessity of his action because “four individuals have already returned to Florida after traveling to Ebola-affected areas.”

Criticism of States

Physicians and other health experts have heavily criticized the mandatory quarantines that states are implementing. The NEJM criticized these policies as “not scientifically based,” “unfair and unwise,” and “more destructive than beneficial.” It argued that “hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source”—therefore, skilled health care workers must not have additional barriers making it harder for volunteers to return home. The NEJM lauded the New York aid worker, saying that returning workers can follow his example of alerting public health officials if they develop symptoms. Dr. Anthony Fauci, Director of the National Institute of Allergies and Infectious Diseases at the National Institutes of Health (NIH), warned against mandatory quarantines, saying that “draconian” requirements may have unintended consequences, such as preventing aid workers from going to Africa. He recommended treating returning people with respect, and told the states to “go with the science.”

Continued CDC Action

On October 27, 2014, the CDC released an interim guidance for monitoring and movement of persons with potential Ebola virus exposure and a corresponding fact sheet. It recommends monitoring depending on an individual’s risk level: active monitoring, where an individual monitors himself or herself and reports any symptoms to the public health authority, for individuals at low-risk, and direct active monitoring, in which a public health official directly observes the individual daily to review symptoms and monitor status, for those with some or high risk. Individuals who may have been exposed to Ebola virus should limit their travel to “controlled movements”—no long-distance commercial conveyances, such as planes, trains, or buses, and should ensure that any movement allows the continuation of active or direct active monitoring.

Ongoing updates to the governmental response are available at www.whitehouse.gov/ebola-response and http://www.cdc.gov/vhf/ebola/index.html.

Philadelphia Smokers Cough Up More For Benefits

The City of Philadelphia has ramped up its efforts to curb smoking with two major changes to its employee benefits programs. First, beginning January 1, 2015, all pharmacies in its Preferred Health Network (PHN) must be tobacco-free; employees who fill prescriptions at an out-of-network pharmacy will pay an additional copayment on top of the copayment for the medication. City employees and their spouses who have used tobacco in the previous year also will pay an additional $500 for health insurance, although the amount will be reduced if they complete an approved smoking cessation program by May 1, 2015.

CVS Caremark is both a pharmacy benefits administrator (PBA) and the second largest chain of pharmacies in the nation; only Walgreens is larger. The company announced in February 2014 that its pharmacies would no longer sell tobacco products. The PBA recently began to offer optional tobacco-free pharmacy networks as part of its benefit program. The City of Philadelphia is the first employer to adopt the option, which applies to non-union workers.

Philadelphia’s Network

The City announced on Friday, October 24, 2014 that together with its pharmacy benefits administrator, CVS Caremark, it has recruited 135 independent pharmacies and the CVS, Target, and Wegmans chains to participate in the tobacco-free PHN. Covered employees and spouses who fill their prescriptions at an out-of-network pharmacy will make a copayment of $15 per prescription in addition to the copayment for the drugs. Mayor Michael A. Nutter noted that the PHN and benefit changes were part of a multifaceted effort called “Get Healthy Philly.” Other components include coverage of smoking cessation medications and a new $2 per pack tax on cigarettes.