Ga., Calif. Hospitals Sue Blue Cross Plan For Sending ER Reimbursements To Patients

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Blue Cross and Blue Shield of Georgia faces separate lawsuits accusing it of sending reimbursement money for emergency room care directly to patients — and not to the hospital because it isn’t part of the insurer’s network.
That’s costing the hospitals money since patients don’t always turn over the funds, according to the lawsuits, filed by Polk Medical Center in northwest Georgia and Martin Luther King, Jr. Community Hospital in Los Angeles — 2,000 miles apart. Each suit also says some patients have sought to profit from receiving the direct payments for their ER care.
By sending money directly to patients, Polk Medical Center says the insurer forces the hospital to find ways to collect it. Even though patients are obligated to pay the facility the amount sent to them by Blue Cross, in some cases they have spent the money, according to the lawsuit.

The Polk lawsuit said that Blue Cross, in its new payment process, was pursuing “retaliation’’ for the Cedartown, Ga., hospital’s not agreeing to “unreasonable and unfair” terms in order to be part of the insurer’s network. Hospital officials said the payment shift has hurt the hospital financially.
“Blue Cross insures a significant number of individuals in Polk County,’’ said Tommy Manning, the attorney for the Floyd Medical Center system, of which Polk Medical Center is a part.
Manning said that Blue Cross has sent ER payments to patients for several months.
And he said he was unaware of the Los Angeles lawsuit prior to the filing of the Polk complaint.
The lawsuit from Martin Luther King, Jr. Community Hospital alleges that “most of the MLK patients who receive checks from [Blue Cross of Georgia] are unaccustomed to receiving payments in such large amounts. Some of these patients do not know that they are required to endorse those checks over to MLK. Other patients know that they should endorse those checks over to MLK but instead use such funds to pay for their personal expenses. When MLK attempts to collect the amounts from these patients, the money is often spent.”
In the case of patient “B.G.,’’ the suit alleges that the patient went to the MLK emergency room 11 times between Oct. 19 and March 27 for various ailments, including complaints of chest or back pain. Blue Cross of Georgia paid the patient a total of more than $70,000 for these visits to MLK, according to the lawsuit.
The lawsuit said the practice overall has caused MLK to suffer damages in excess of $350,000.
Blue Cross declined comment on the lawsuits, citing pending litigation.
Patients are protected under federal law when seeking care in hospital emergency rooms. Under the Emergency Medical Treatment and Labor Act (EMTALA), they must at least be stabilized and treated, regardless of their insurance status or ability to pay.
Manning said this month that he’s not aware of any other insurer in Georgia paying the patient instead of the hospital.
At least one other major hospital that is not part of the suits has reported difficulty in getting payments from Blue Cross when it was out of the insurer’s network. Officials at Grady Memorial Hospital in Atlanta said that when it was out of Blue Cross’ network for the four months ending in March 2015, the insurer sent reimbursement payments to some patients and not to Grady.
Daron Tooch, a Los Angeles attorney representing MLK Hospital, said other Blue Cross plans in the United States use similar tactics. The Los Angeles patients worked for a company that has Blue Cross of Georgia coverage, he said. MLK is out of network for the Blue Cross plans in California.
“This is not unique to MLK,’’ said Tooch. “This happens to all out-of-network providers for Blue Cross of Georgia.”
Going after the patients for payment instead of the health plan simply hasn’t worked, attorneys for MLK said. The patients “are typically unable or unwilling to pay MLK for the medical services received,” according to the suit.
Manning agreed. “We will continue to pursue collection with patients, but filing numerous lawsuits would not be fruitful, particularly given that Blue Cross Blue Shield is the party ultimately at fault,” he said.
Asked about the Blue Cross of Georgia payment strategy, the national Blue Cross Blue Shield Association, through a spokesman, declined comment. Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group, said that those types of reimbursement arrangements would vary by plan and by contract. She added that she did not have details on other plans that may do the same.
Paying patients directly is an insurer tool used more commonly in the West, “particularly when non-network facilities are unwilling to negotiate reimbursement related to out-of-network service,’’ said Janet Guptill of the Tatum firm, which provides interim chief financial officers and other executives to health care organizations.
“The insurer takes the position that the provider claim is a private pay issue between the provider and the patient, so the facility has the responsibility to collect the payment from the patient,’’ Guptill said.
Guptill said that when a hospital isn’t in network, its charges for ER and other care tend to be higher than the charges from facilities in the insurer’s network.
For insurers, paying patients directly is “a clever and probably effective tactic,’’ said Chris Kane, a consultant with DHG Healthcare. The hospital, he said, may already be dealing with other collection challenges, including those involving high-deductible health plans.
A hospital attempting to collect the money may end up alienating the patient and thereby discouraging future visits, Kane said.
And patients pocketing the money is another problem, he added. “It’s more troubling if a patient views this as a source of cash.’’
This story was done in partnership with Georgia Health News.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

As Marijuana Legalization Initiative Heads For Calif. Ballot, Health Groups Weigh In

With an initiative to legalize marijuana in California likely heading to the November ballot, medical providers, health care experts and industry groups are sharply divided over the controversial measure.
It is already legal in California to use cannabis with a doctor’s prescription. The Adult Use of Marijuana Act would allow adults 21 years and older to possess up to one ounce of it and grow up to six plants for non-medical use. The initiative also would impose a 15 percent tax on recreational marijuana sales.
California would follow Colorado, Washington, Alaska and Oregon in allowing the recreational use of marijuana if the measure is approved. Proponents say they have collected the required number of signatures to qualify for the November ballot. State officials are verifying those signatures, and the measure could be approved for the ballot within the next two weeks.

The state’s Democratic Party endorsed the measure two weeks ago, but California’s doctors, hospitals and health advocates remain split over whether to legalize marijuana.
The California Medical Association, the influential doctors’ lobby group, now supports the initiative despite years of opposing marijuana legalization. The California Hospital Association opposes it.
Other health experts remain concerned about the health effects of legalizing marijuana for adults, even as they acknowledge some benefits of the initiative.
“There is some good stuff in the initiative,” said Rachel Barry, a researcher at the University of California, San Francisco. But the measure lacks sufficient protection for public health, she said.
Barry coauthored an analysis of the ballot measure, which concluded that the toxicity of marijuana smoke is similar to that of tobacco. This includes the harm caused by secondhand smoke.
A more fitting ballot initiative, according to Barry’s report, would be one that treated marijuana in the same way as tobacco — legal but undesirable.
“This initiative does not accomplish the goal that would prevent a public health catastrophe, because it doesn’t focus on prevention strategies,” Barry said. And the priority of the marijuana industry will be to make money by increasing consumption, she added.
Supporters say marijuana legalization and regulation is a proven success in other states. They point to millions of dollars in tax revenue for state and local governments. But opponents say it depends on whom you ask.
“What we have found from the Colorado experience is that there are more patients in the emergency rooms,” said Bill Emmerson, vice president of government relations for the California Hospital Association. “We already see [overcrowding] in our emergency rooms as a result of the Affordable Care Act and mental health issues.”
The current initiative fails to take into account the burden on hospitals, Emmerson added.
A study by Northwestern Medicine and the University of Colorado School of Medicine, published earlier this year, found a spike in Colorado emergency room visits by out-of-state visitors.
Marijuana-related visits to the emergency room by non-residents more than doubled between 2012 — when recreational marijuana was first legalized in Colorado — and 2014.
The medical community’s views on marijuana have evolved over the years.
The California Medical Association called the measure “comprehensive” and said that while it does not encourage the use of marijuana, controlling and regulating it is the most effective way to protect public health.
“The perception has changed,” said Donald Lyman, a retired physician and chair of the group’s Council on Science and Public Health. “We know it is not a useless substance; there are medical uses and it is time to look at the regulatory system.”
“Because it is a legitimate product, there should be a legitimate access point,” Lyman argued.
How the availability of recreational marijuana might affect California’s medical marijuana industry remains to be seen. It’s possible that marijuana for medical reasons might be discounted, although the measure does not address that. But if pricing for recreational marijuana is similar to that of medical marijuana, the medical cannabis industry may eventually disappear, Lyman said. That’s something that market forces will decide, he said.
“The CMA did not support the initiative with the intent to drive [the medical cannabis industry] out,” Lyman said. “But if that were the case, most physicians would not be unhappy.”
He said physicians often find themselves stuck in between state law, which allows for cannabis recommendations, and federal law, which says it’s illegal.
Last year, Gov. Jerry Brown signed a package of bills to regulate the 20-year-old medical marijuana industry. The new rules, which include licensing requirements, help doctors ensure that when they make a recommendation for medical cannabis their patients are getting a safe product, Lyman said.
The marijuana legalization measure appears to extend those rules to the recreational market. With similar rules for both recreational and medical marijuana, the state will be able to compete against the black market, Lyman said.
The CMA’s support of the Adult Use of Marijuana Act reflects its own evolving position on marijuana. In a 2011 policy statement, the organization said marijuana should be treated like alcohol and tobacco, and removed from the U.S. Drug Enforcement Agency’s list of drugs with no accepted medical use. Reclassifying cannabis would facilitate clinical research to evaluate its risks and benefits, the CMA said.
Dr. Barth Wilsey, an associate physician at UC San Diego’s Center for Medicinal Cannabis Research, said that just as alcohol prohibition ended during the Great Depression, it would not be surprising to see marijuana be legalized as the state and nation continue to climb out of the Great Recession. Governments want the tax revenues, he said, especially during times of economic distress.
If it passes, the Adult Use of Marijuana Act is expected to bring in several hundred million dollars annually to state and local governments, according to the Legislative Analyst’s Office.
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Most Americans Want More Federal Money To Stop Zika: Poll

A large majority of Americans want the federal government to increase funding to prevent Zika’s spread in the U.S. and also help women at risk in affected areas get access to abortion, contraception and family planning services, according to a poll released Thursday.
The virus, which has reached epidemic levels in Latin America and the Caribbean and is likely to spread further this summer, has been linked to serious birth defects in babies born to infected mothers.
The Kaiser Family Foundation’s survey revealing broad public support for federal Zika spending landed as Congress remains in a months-long stalemate over allocating emergency funds to combat the mosquito-borne virus. On Tuesday, a Senate vote that was split along party lines left a $1.1 billion proposal in limbo. (KHN is an editorially independent program of the foundation.)
There have been more than 800 confirmed cases of the Zika virus in the U.S. — including 265 pregnant women — and all stemmed from travel outside the country, according to the Centers for Disease Control and Prevention. But in Puerto Rico, CDC figures show, more than 1,800 people have caught the virus, including from locally infected mosquitoes in the territory. The virus also can be spread through sexual contact.

More than 70 percent of the public favors investing more money in research on Zika, according to Kaiser’s poll. That sentiment is relatively consistent across party lines –- 81 percent among Democrats, 73 percent for Independents and 68 percent for Republicans.
Similarly, there’s agreement on spending more money to prevent Zika’s domestic spread. On that issue, Kaiser found support ranges from 80 percent among Democrats to 66 percent among Republicans.
The partisan divide is widest on the matter of federal funding to give women access to reproductive health choices and services, according to the survey.
Overall, 65 percent of Americans supported that as did 81 percent of Democrats and 65 percent of Independents. Among Republicans, backing dropped to 46 percent.
The Senate’s vote Tuesday on a GOP-drafted measure was opposed by Democrats and failed on a 52-48 vote — short of the 60-vote, veto-proof majority required to advance it. Democrats faulted Republicans for packing the bill with provisions designed to deny new funding for Planned Parenthood clinics in Puerto Rico. It is unclear if the parties will be able to come to an agreement before Congress adjourns for summer starting next month.
The Obama administration in February requested $1.9 billion in Zika funding and Republicans originally proposed about half that amount.
Public knowledge of Zika varies widely, Kaiser’s poll found. While about six in 10 correctly said that the virus is associated with birth defects in babies born to infected mothers, only half were aware the virus can be sexually transmitted.
While 85 percent of Americans are familiar with Zika, just 13 percent say it poses a major threat to them personally, the Kaiser poll found. Seventy-four percent said it poses a major threat to pregnant women.
The poll of 1,201 adults was conducted June 15-21 and has a margin of error of +/- 3 percentage points.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

If You Read One Article About Services, Read This One

Seeking Help from A Dentist Besides day-to-day flossing and brushing, you can help secure your dental health by seeing your dental office consistently for examinations. It’s recommended that many folks have dental checkups for every six months, however your dentist could possibly advocate more recurrent or less sessions, dependent upon your oral health background. In many instances, a orthodontic hygienist… More →

Will Louisiana’s Medicaid Expansion Be A Harbinger For Georgia?

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Louisiana and Georgia have many political similarities. Both states face significant health challenges affecting their populations. And until recently, both states had identical approaches to Medicaid expansion.
Georgia Gov. Nathan Deal, a Republican, has rejected expansion since he took office in 2011, and GOP lawmakers have repeatedly backed him up. They point to concerns about the future cost of expansion, saying it would eventually put too much strain on the state budget.
But on Friday, Louisiana will become the 31st state — and only the third Southern state — to expand the government program, which is jointly financed by state and federal governments. Gov. John Bel Edwards, a Democrat elected last fall, on his second day in office reversed the course set by his predecessor, Republican Bobby Jindal, by signing an executive order that began the process. Already, more than 200,000 state residents have been signed up.

“This isn’t just about expanding health care coverage and saving money,’’ Edwards said earlier this month when addressing reporters at a seminar sponsored by the Kaiser Family Foundation. “We want healthier people in Louisiana.” (KHN is an editorially independent program of the foundation.)
And there are small signs of a crack in the opposition to expansion in Georgia.
Georgia state Sen. Renee Unterman (R-Buford), who chairs the Senate Health and Human Services Committee, recently made headlines calling for Georgia to “re-examine’’ the possibility of Medicaid expansion, perhaps looking at a “waiver’’ plan similar to the Arkansas expansion program.
“We have to open that box and look just a little bit and see what’s available,” Unterman told WABE, the NPR affiliate in Atlanta. “Hopefully, if you draw down federal dollars, you can free up some of those state dollars. Right now, we’re just pumping out state dollars to stay in the midst of the crisis.”
A task force created by the Georgia Chamber of Commerce is formulating proposals that would extend coverage to more of the state’s uninsured but not along the lines of a conventional Medicaid expansion.
Yet Georgia state Rep. Sharon Cooper of Marietta, the Republican chairwoman of the Georgia House’s Health and Human Services Committee, told Modern Healthcare that she and her colleagues will entertain the proposals, but added that she doesn’t believe an expansion plan will solve the problem of access to care.
“The problem with expansion is, ‘Who is going to treat these people?’ ” Cooper said. “We don’t have the physicians, nurse practitioners or physician assistants to care for them in rural areas of the state.”
Since the beginning of 2013, five rural hospitals have closed in Georgia.
A Tale Of Two Southern States
America’s Health Rankings puts Louisiana 50th among states — 10 spots behind Georgia. The state has high rates of obesity, hypertension and diabetes, and a high mortality rate from cancer. For Georgia, the rankings note its large number of low-birthweight babies.
Louisiana also has a very high share of people living in poverty, but Georgia has a larger percentage without health insurance (16 percent).
One key difference between Georgia and Louisiana is the Peach State’s much stronger fiscal situation. Louisiana, where the energy industry is very important, has been hit hard by a decline in oil prices. Edwards inherited what he calls a record state deficit.
But ironically, that deficit eased the road for expansion, officials say. “The budget crisis was a catalyst for the Legislature to come aboard,” said Dr. Rebekah Gee, secretary of the Louisiana Department of Health.

A study found that the expansion would produce net savings of $184 million for Louisiana, including in-state money paid to hospitals and moving some current Medicaid patients into a better federal matching rate of 95 percent.
Part of Louisiana’s push to enroll new people in Medicaid has come through a unique mailing to 105,000 food stamp recipients, like Aretha Frison, of the New Orleans area, who works at an animal hospital part time and battles depression.
She said she “had been hitting a lot of brick walls” when trying to get psychiatric care but now “it seems like Medicaid is the golden ticket.”
About 180,000 other people were ‘’auto-enrolled’’ from a previous “waiver’’ program that did not provide coverage for hospital services or prescription drugs.
Help For Hospitals
Advocates for Medicaid expansion in Georgia often tout the expected benefits for the state’s hospitals, many of which are financially stressed. Though hospitals in other states have reported substantial revenue gains as a result of expansion, Louisiana’s complicated system of funding for hospitals may not yield many clear winners.
Louisiana has had an unusually heavy reliance on ‘’disproportionate share’’ funding, which the state pays out to those hospitals serving a large number of indigent or uninsured patients.
While the giant Ochsner Health System said Medicaid expansion would be slight improvement for the system financially, Baton Rouge-based Our Lady of the Lake Hospital said expansion may bring a payment cut overall with the loss of disproportionate share funds.
But low-income residents should benefit greatly.
More than half of the 4,000 medical patients at the New Orleans CrescentCare health center are expected to qualify for Medicaid under expansion, which may lead to better care options.
For example, Alicia Honomichl, a registered nurse there, said expansion will help more people obtain PrEP, a medication that can prevent a person from getting HIV from an infected individual, whether through sexual contact or sharing of drug-injection equipment.
Dr. Peter DeBlieux, chief medical officer of the brand-new University Medical Center New Orleans, said the Medicaid change is “earth-shattering’’ for his patients.
Patient access to regular medications will be “low-hanging fruit’’ that will come from expansion, and “I expect [cancer] screenings to skyrocket,” he said.
This story was done in partnership with Georgia Health News.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Old Motels Get New Life Helping Homeless Heal

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Just up the freeway from Disneyland, in the Orange County city of Buena Park, Paul Leon stood outside the beat-up remnant of a seedy motel. Above him, a faded pink sign advertised the Coral Motel, whose rooms back in its prime cost 35 bucks a night.
“This particular motel was going to be taken back by the city of Buena Park, because of the drugs, alcohol, prostitution,” Leon explained.
But Leon, CEO of the Irvine-based Illumination Foundation, a homeless services nonprofit, had a different idea. He proposed turning the motel lobby into a triage center and converting the rooms into clean recovery facilities for homeless people recently discharged from the hospital. And that’s what he did.

It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.
Recuperative care centers are pricey to set up, but the motel model was just the opposite, Leon says.
“The beauty of this [is] it’s the poor man’s recuperative,” he said. “They’re not the Hyatt or the Hilton, but they do serve a purpose for us. The costs to run it are much less.”
The motel recovery room costs about half as much as a hospital would — about $2,000 less a day for each patient. And it’s like being at home. In fact, it may be even better than home, because it has a nurse on staff to help supervise care and handle complications.
Leon, who was trained as a public health nurse, launched the Illumination Foundation to provide precisely this type of care and links to the community.
The foundation now has expanded the motel model to six sites in four counties — Orange, Los Angeles, Riverside and San Bernardino.

Elvin Quiñones, one of the patients at the Coral Motel, padded across the motel parking lot in flip-flops to show off his previous home — a small white Datsun B210 sedan.
“I’ll show you my house,” he said, “it’s not very big.”
Quiñones is a large man, and it’s hard to picture him crammed into the car along with his two dogs. In the days immediately following his gall bladder operation, he had to fit a bunch of medical gear, too.
“I’ll be honest, I was sleeping in front of the 24-hour Walmart, because they had a bathroom,” Quiñones recounted. “I still had a tube stuck inside me that was draining, so I needed someplace where I could empty out the drain.” Being homeless and helpless, he added, is something he’ll never forget.
“It’s surreal. You think you’re going to wake up and it’ll all be a nightmare. And you wake up and it’s not,” he said. “It’s just the next day.”

A week after his medical release, the hospital called and helped place him in the motel.
“This is a new model of care for Orange County,” said Ginny Ripslinger, vice president of network of care at St. Joseph Health System.
Hospitals and health insurers help fund the motel-based care centers, Ripslinger said, because they save money by stabilizing these patients. The dollars they contribute are in addition to any payments from Medi-Cal, the state- and federally funded health program for people with low incomes.
Beyond the financial interest of hospitals, providing funding for this motel-based care is “just the right thing to do,” Ripslinger said. “We don’t want to discharge them to the street, and there’s an obligation on the hospitals to provide continuity of care and safe discharges.”

There’s also an added benefit to accommodating these homeless patients in motel rooms for two or three weeks.
“You might say they’re a [captive] audience,” Riplinger said. “We can then provide the social services and the linkages to the community for stable housing and get them in a protected environment.”
Leon said he has been working with dozens of cities across the country to establish similar models elsewhere.
“If you’re just starting and you don’t have a recuperative care program,” he said, “one easy quick method is to use motels. They could basically start within days to house some of the patients that are the most vulnerable.”
Every city has a homeless problem, Leon added, and every city has its own version of the beat-up Coral Motel. It’s a rare opportunity, he said, to turn two big problems into one solution.
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.
This story is part of a partnership that includes KQED, NPR and Kaiser Health News.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

HHS Proposes To Streamline Medicare Appeals Process

The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases.
The measures “will help us get a leg up on this problem,” said Nancy Griswold, chief law judge of the Office of Medicare Hearings and Appeals.
If there was not a single additional appeal filed and no changes in the system, it would take 11 years to eliminate the backlog, Griswold said in an interview.
Her office has faced increased criticism from health care providers and beneficiary advocates lately for its inability to speed up appeals and reduce the backlog. The latest critique came earlier this month in an investigation from the Government Accountability Office.

This latest effort still falls short of what is needed, said Tom Nickels, executive vice president at the American Hospital Association. “We are deeply disappointed that HHS has not made more progress in addressing the delays despite the more than two years since the delays began,” he said.
The new proposals, as well as increased funding requests, are expected to eliminate the backlog by 2021 by streamlining the decision-making process and reducing the number of cases that go to the third level of appeals, where many cases linger waiting for a hearing and then a decision from an administrative law judge. From the day of the hearing, it currently takes an average of slightly more than two years for a decision in appeals from hospitals, nursing homes, medical device suppliers and other health care providers.
Among the proposed changes:
Designate some decisions from the Medicare Appeals Council, the last of four stages of appeals, as precedents that decision-makers at lower levels would have to follow. That could eliminate redundant appeals and resolve inconsistencies in interpretation of Medicare policies.
Allow senior attorneys to handle some of the procedural matters that come before the administrative law judges, such as dismissing a request for a hearing after the appellant has withdrawn the request, Griswold said.
Revise how the minimum amount necessary to lodge an appeal is determined. Under current rules, an appeal must involve payment of at least $150, based on the amount the provider charged. HHS is proposing to use Medicare’s allowed amount instead, which tends to be lower, and that could reduce the number of claims that could be appealed.
Eliminate some steps in the appeals process to simplify the system.
Although advocates have sought changes to speed up the appeal process, Alice Bers, an attorney at the Center for Medicare Advocacy, was skeptical about some of the proposals. The effort to set up a system of precedents, she said, “could restrict coverage for needed items and benefits for seniors that they are entitled to by law.”
And the change in calculating the minimal amounts “could make it harder for beneficiaries to reach that threshold,” said Bers. It might not sound like a lot of money, Bers said, “but for an elderly woman living on Social Security that’s several meals or co-pays for medicine.”
The proposals do not address what hospital representatives say is a key cause of increasing appeals, independent audit contractors who can reject payments to hospitals. The American Hospital Association contends that those contractors unnecessarily cut off many payments and that hospitals frequently win the appeals.
According to the GAO study, audit-related appeals decided at the administrative law judge stage — the third level of appeals — increased 37-fold from 2010 through 2014, compared to only 1.5 times for appeals of other kinds of claims.
But Griswold said that currently only about a third of the pending cases at this stage involved recovery audit contractors, after settlements were reached with appellants who agreed to accept partial payment. As a result of these agreements, 4,245 cases from just 16 appellants were withdrawn from the system as of May 12, according to government statistics.
Griswold also said Medicare will continue to process beneficiary appeals before those from hospitals, doctors and other health care providers. The practice began in 2014.
The proposed changes will be posted on the Federal Register website and open to comments through Aug. 29.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

‘Digital Health’ Not Just For Well-Heeled Fitness Fiends

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When we hear the phrase “digital health,” we might think about our Fitbit, the healthy eating app on our smartphone, or maybe a new way to email our doctor.
But Fitbits aren’t particularly useful if you’re homeless, and the nutrition app won’t mean much to someone who struggles to pay for groceries. Same for emailing your doctor if you don’t have a doctor or reliable internet access.
“There is a disconnect between the problems of those who need the most help and the tech solutions they are being offered,” said Veenu Aulakh, executive director of the Center for Care Innovations, an Oakland-based nonprofit that works to improve health care for underserved patients.
At most digital health “pitchfests,” it’s pretty much white millennials hawking their technology to potential investors.
“It’s about the shiny new object that really is targeted at solving problems for wealthy individuals, the ‘quantified-self’ people who already track their health,” Aulakh said. “Yet … What if we could harness the energy of the larger innovation sector for some of these really critical issues facing vulnerable populations in this country?”
A small but growing effort is underway to do just that. It’s aimed at using digital technologies — particularly cellphones — to improve the health of Americans who live on the margins. They may be poor, homeless or have trouble getting or paying for medical care even when they have insurance.
The initiatives are gaining traction partly because of the growing use of mobile phones, particularly by lower-income people who may have little other access to the internet.

The Affordable Care Act and the expansion of Medicaid have added millions of previously uninsured people to the nation’s health care system, including community health clinics that serve poor and largely minority populations, according to a California Health Care Foundation report. (California Healthline is an editorially independent publication of the California Health Care Foundation).
In California alone, the number of people on Medi-Cal, the state’s version of the Medicaid program for the poor, rose from 7.5 million in 2010 to 12.4 million by early 2015. Many Americans remain uninsured, however, because they live in states that have declined to expand Medicaid eligibility.
Health advocates say it’s important to tailor digital health technologies to lower-income people not only to be fair, but because they’re more likely to have chronic illnesses, like diabetes, that are expensive to treat.
Health-care providers have incentives as well. They are being rewarded financially under the Affordable Care Act, Medicare and Medicaid for keeping patients healthy, and this goes beyond simply performing medical procedures and prescribing drugs.
For now, experiments targeting low-income people are a tiny part of the digital health industry, which racked up an estimated $4.5 billion in venture funding in 2015 alone. Entrepreneurs are still trying to figure out how they’re going to get paid by serving this population, and government health programs like Medicaid and Medicare are taking a while to figure out how they’re going to pay providers for approaches that don’t involve a doctors’ visit.
But Jane Sarasohn-Kahn, author of the California Health Care Foundation report, says investors are getting more interested in digital health initiatives for low-income patients simply because there are so many of them.
Investors are eyeing the “fortune at the bottom of the pyramid,” she said, much as Walmart profits from selling low-priced items to millions.
“It’s now sexy to scale,” she says. “If you can have impact [on many people], inexpensively, you can make a lot of money. If we get it right, we can do well and do good.”
Some initiatives are simple and cheap, like Text4Baby. The free text-messaging service for pregnant women and new moms offers English- and Spanish-language information about prenatal care, labor and delivery, breastfeeding, developmental milestones, and immunizations — all timed to the baby’s due date.
Operated by the nonprofit ZERO TO THREE and the mobile health company Voxiva, Inc., Text4Baby has reached nearly 1 million women since starting in 2010. In one survey, more than half of them reported yearly incomes of less than $16,000.
Other experiments are far more elaborate. In California and Washington state, San Francisco-based Omada Health is testing a version of Prevent, a diabetes and heart disease prevention program that’s been modified for “underserved” populations — basically people on Medicaid or who are uninsured. The free program offers patients a digital scale as well as behavior counseling and education, access to a personal health coach and an online peer network.
To adapt the program, the company made it available in Spanish and English and lowered its reading level from 9th grade to 5th grade. Bilingual health coaches were hired, and the educational materials now acknowledge potential food access, neighborhood safety and economic issues that participants may face, said Eliza Gibson, Omada’s director of Medicaid and safety-net commercial development.
The scale doesn’t require a wireless connection, and the patient just needs to be able to access the internet for one hour each week, Gibson said.
Omada is enrolling 300 community clinic patients in Southern California and rural Washington in a year-long clinical trial of Prevent, in hopes that the program can demonstrably slow the progress of diabetes.

Patients at other community clinics in California will try out the program but won’t be included in the clinical trial, Gibson said. Omada Health is also offering a version called Prevent for Underserved Populations that specifically targets low-income community clinic patients.
Among the people trying out the program is Susy Navarro, an elementary school substitute teacher who lives in the Spring Valley community east of San Diego. After being diagnosed with prediabetes, Navarro, 28, set an ambitious goal to lose 100 pounds. In the meantime, she is taking medication to stave off Type 2 diabetes.
“You name it, I’ve probably tried it — Weight Watchers, low-fat, low carb, pills, injections, acupuncture,” Navarro said. “The first time I try things it goes very well, I feel like I’m very successful, then I wean off and I’m not successful. This program focuses more on life choices that are going to help us out long-term, not just for a little bit.”
Navarro described the scale she was given as “sophisticated looking — all black, flat, digital.” It has been programmed to her weight profile — she is considered obese — and transmits her weight every morning to the program’s counselors.
The program, with its daily weigh-ins, helps her pay attention to what she eats, and her blood sugar levels are declining, Navarro said. She also appreciates the ability to connect online with fellow patients on her “team.” “It’s very awesome — you get to know the other members and feel like it’s a team effort.”
As they continue to explore digital health possibilities for underserved patients, developers are learning more about what works and what doesn’t, says Sarasohn-Kahn. For example, apps chew up a lot of cellphone data, so many community clinic patients prefer lower-cost text messaging.
At the Petaluma Health Center, a network of community clinics in Sonoma County, Calif., staffers offered free, simplified “loaner” digital devices to patients after a hospital stay to help them avoid complications that could land them back in the hospital.
They first offered an Android tablet to allow for a video visit with a health professional, but patients were reluctant to take it, saying it was hard to hide and could be stolen, said Dr. Danielle Oryn, the network’s chief medical informatics officer.
Then they tried iPhones, in which everything was locked down except the ability to call 911 and a single button triggering the video visit. Those were more acceptable. Still, there were challenges. Would patients, some recuperating at homeless shelters, have access to electricity to charge their phones? Oryn said they had to learn by trial and error. She was surprised and pleased to see seniors accepting the technology. Every loaner iPhone was returned to the clinic.
Oryn’s advice to the captains of the digital health industry?
They should “not necessarily come in with too many assumptions. They should come with an open mind and a willingness to listen,” Oryn said. “Safety-net people are very excited to have these companies interested in them and to share their experiences.”
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.