Tag: charles ornstein
Even After Open Enrollment, Activity Remains Unexpectedly High On Federal Health Insurance Exchange

Even After Open Enrollment, Activity Remains Unexpectedly High On Federal Health Insurance Exchange

by Charles Ornstein,ProPublica

This story was co-published with NPR’s “Shots” blog.

For months, journalists and politicians fixated on the number of people signing up for health insurance through the federal exchange created as part of the Affordable Care Act. It turned out that more than 5 million people signed up using HealthCare.gov by April 19, the end of the open-enrollment period.

But perhaps more surprising is that, according to federal data released Wednesday to ProPublica, there have been nearly 1 million transactions on the exchange since then. People are allowed to sign up and switch plans after certain life events, such as job changes, moves, the birth of a baby, marriages and divorces.

The volume of these transactions was a jolt even for those who have watched the rollout of the ACA most closely.

“That’s higher than I would have expected,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “There are a lot of people who qualify for special enrollment, but my assumption has been that few of them would actually sign up.”

The impact of the new numbers isn’t clear because the Obama administration has not released details of how many consumers failed to pay their premiums and thus were dropped by their health plans. All told, between the federal exchange and 14 state exchanges, more than 8 million people signed up for coverage. A big question is whether new members will offset attrition.

ProPublica requested data on the number of daily enrollment transactions on the federal exchange last year under the Freedom of Information Act because the Obama administration had declined to release this information, a key barometer of the exchange’s performance, to the public. The administration also has not put out any data on the exchange’s activity since the open enrollment period ended.

The data shows so-called “834” transactions, which insurance companies and the government use to enroll new members, change a member’s enrollment status, or disenroll members. The data covers the 36 states using the federal exchange, which include Texas, Florida, Illinois, Georgia and Michigan.

When HealthCare.gov rolled out last fall, insurance companies complained that the information in the 834s was replete with errors, creating a crisis at the back end of the system.

Between April 20 and July 15, the federal government reported sending 960,000 “834” transactions to insurance companies (each report can cover more than one person in the same family). That includes 153,940 for the rest of April, 317,964 in May, 338,017 in June and 150,728 in the first 15 days of July. The daily rate has been fairly stable over this period.

It was not immediately clear how many of the records involved plan changes or cancelations and how many were for new enrollments.

An insurance industry official estimated that less than half of the transactions are new enrollments. The rest are changes: When an existing member makes a change to his or her policy, two 834s are created — one terminating the old plan and one opening the new one.

Charles Gaba, who runs the website acasignups.net that tracks enrollment numbers, estimates that between 6,000 and 7,000 people have signed up for coverage each day on the federal exchange after the official enrollment period ended. Gaba’s predictions were remarkably accurate during the open enrollment period.

“That doesn’t account for attrition. That doesn’t mean that they paid,” Gaba said. “That’s been based on limited data from a half dozen of the smaller exchanges, extrapolated out nationally.”

The federal data obtained by ProPublica confirm some other facts about the rollout of HealthCare.gov, which was hobbled initially by technical problems. The slowest day was Oct. 18, when no 834 transactions were sent. That was followed by Oct. 1, the day the website launched, when a grand total of six records were sent to insurers.

By contrast, the busiest day was March 31, the official end of open enrollment, when 202,626 “834” reports were sent to insurers. The entire last week in March was busy.

About 86 percent of those who signed up for coverage on the federal exchange were eligible to receive government subsidies to help lower their monthly premiums. Those subsidies are being challenged by lawsuits in federal court contending they aren’t allowed by the Affordable Care Act.

Two federal appeals courts came to conflicting decisions Tuesday on the permissibility of the subsidies (one said yes; the other no). They will remain in effect as the cases proceed in the courts, the Obama administration said.

The next time that the general public can sign up for coverage through the exchanges is from November 15 to February 15, 2015.

Click here to download the data (Excel or CSV) released to ProPublica under the Freedom of Information Act.

Read our previous coverage of the Affordable Care Act and share your story.

AFP Photo/Joe Raedle

Medicare Overpays Billions For Office Visits, Patient Evaluations

Medicare Overpays Billions For Office Visits, Patient Evaluations

by Charles Ornstein,ProPublica.

Medicare spent $6.7 billion too much for office visits and other patient evaluations in 2010, according to a new report from the inspector general of the U.S. Department of Health and Human Services.

But in its reply to the findings, the Centers for Medicare and Medicaid Services, which runs Medicare, said it doesn’t plan to review the billings of doctors who almost always charge for the most expensive visits because it isn’t cost effective to do so.

The inspector general’s report estimates that overpayments account for 21 percent of the $32.3 billion spent on evaluation and management (E&M) services in 2010. The E&M category includes office visits, emergency room assessments and inpatient hospital evaluations.

This is the second time that the inspector general has singled out this area for more scrutiny. In 2012, the watchdog said physicians had increasingly billed Medicare for more intense — and more expensive — office visits over time. But that didn’t prove the claims were improper.

“The natural question that comes out of this is: Are these physicians billing appropriately?” said Dwayne Grant, regional inspector general for evaluation and inspections in the Atlanta region, who oversaw the new report. “We don’t want to pay them too much, but we don’t want to pay them too little, either.”

For this review, the inspector general gathered the medical records associated with 657 Medicare claims and asked professional coders to see whether the records justified the rates charged.

Overall, more than half of the claims were billed at the wrong rate or lacked documentation to justify the service. Sometimes physicians billed for a lower-cost service than the one they delivered, but more often they billed for a higher-cost one. The inspector general extrapolated from its sample to estimate the amount Medicare overpaid on all 2010 E&M claims.

“We have to do a better job of curbing improper payments and protecting taxpayer dollars,” Senator Bill Nelson (D-FL), chairman of the U.S. Senate Special Committee on Aging, said in a statement.

The inspector general’s findings complement a recent review by ProPublica of data recently released by Medicare on payments to individual health professionals for services in its Part B program. We found that in 2012, more than 1,800 doctors and other health professionals almost exclusively billed Medicare for the most complicated and expensive office visits for their established patients.

Office visits are the most common services provided in the program.

While most providers had a tiny percentage of visits for which they charged the highest rate, known as level 5, more than 1,200 billed exclusively at that level. Another 600 did it more than 90 percent of the time. About 20,000 health professionals billed only at the top two levels, 4 and 5.

Experts we consulted said that these billing patterns were highly implausible and could indicate fraud. Some doctors, however, said that their patients were sicker than those of their peers and required more time and attention.

ProPublica also launched a new tool called Treatment Tracker that lets users look up their doctors and see how they compare to peers on office visits and other measures.

In its report, the inspector general’s office recommended that CMS educate doctors about proper billing practices. It also suggested that Medicare pursue doctors who consistently billed for higher-level services than they actually delivered, a practice known as upcoding.

While CMS agreed with the need for education, it disagreed with the recommendation to review the physicians’ billings. It said one of its contractors recently reviewed 5,200 medical claims of high-coding physicians and the process cost more money than it caught in overpayments.

CMS said a second phase of the review — of 13,500 claims — was nearing completion. “Based on the results of this effort, CMS will reassess the effectiveness of reviewing claims for high-coding physicians” versus other efforts, such as sending these doctors reports that compare their billings to their peers.

Grant, of the inspector general’s Atlanta office, said that while the individual E&M services do not cost much, they add up — and that if CMS declares that it won’t review outliers, it could send the wrong message.

“The challenge that CMS is trying to figure out is what is the best way to get at this,” Grant said. “We see the advantage of continuing to look at these high billers. Not only are they billing high now; it could have an impact on future billings…This is not just free rein to bill whatever you want.”

Photo: Rusty Clark via Flickr

Judging Obamacare: How Do We Know If It’s A Success Or Failure?

Judging Obamacare: How Do We Know If It’s A Success Or Failure?

by Charles Ornstein,ProPublica.

One day very soon, the focus on Obamacare will turn from signing up new enrollees to quantifying the law’s success — or failure.

The six-month open enrollment period, during which consumers sign up for health plans under the Affordable Care Act, is supposed to end today. But the U.S. Department of Health and Human Services, as well as many states running their own marketplaces, are giving some extra time to consumers who’ve had trouble signing up.

It’ll probably all wrap up by April 15. Then, the final numbers will be tallied and the pronouncements will begin. Politicians on both sides of the aisle will use the same data to proclaim that they were right about the law.

Last Thursday, the Obama administration said that more than 6 million people have signed up for coverage on the health insurance exchanges, meeting the projections set out by the Congressional Budget Office. Republicans have countered by questioning how many enrollees have paid their first month’s premium, the final step necessary for coverage to be in effect.

Dr. David Blumenthal of the Commonwealth Fund recently told me that any attempt to review the success of the law must go beyond those who sign up for coverage on the exchanges. It should include those who gained coverage through the expansion of state Medicaid programs for the poor, as well as young adults who are now able to stay on their parents’ health plans because of the law.

“I think the real success of the law will be judged over five years, not six months,” he said. “In fact, this president, President Obama, has until January 2017 to establish it as a fixture in the American social policy firmament.”

That may well be true, but now seems like a reasonable time to take stock. So, how should success — and ultimately the law itself — be judged? Here’s what some experts are saying about which metrics to use and the problems with each.

What percentage of previously uninsured people are finding coverage under the exchanges?

We can’t answer this question yet because we don’t know whether those signing up for coverage were previously uninsured. In fact, some enrollees, perhaps many, had their insurance plans canceled at the end of 2013 because the plans did not meet the requirements set out by the ACA. Obama administration officials have not released any numbers on this.

That said, a recent report from the Leonard Davis Institute of Health Economics at the University of Pennsylvania and the Robert Wood Johnson Foundation compares enrollment data through the end of February (with one month left to go in the official open enrollment period) to the number of eligible uninsured people in each state.

Here’s what the researchers found:

“Overall, more than 4.2 million people have enrolled and picked a plan through the exchanges, about 14.8 percent of all potential eligibles. The enrollment rate varies from state to state, with a high of 54 percent in Vermont to a low of 5 percent in Massachusetts. We should note that Massachusetts had the lowest rate of uninsurance in the nation since its health reform in 2006; its previous success might mean that the remaining uninsured population could be especially difficult to reach.”

Here’s a graphic from the report showing the states in which the greatest share of uninsured received coverage (through February).

Enrollment Chart

Did states meet estimates from the U.S. Department of Health and Human Services?

MarketWatch had a story last week comparing enrollment in each state to the HHS projections. By that measure, Connecticut led the pack, signing up 218 percent of its projected enrollment through the end of February. It was followed by Rhode Island, New Hampshire, New York and Maine.

The problem with this approach is that the goals are “in many cases, based on little more than educated guesswork,” writes Charles Gaba, creator of ACASignups.net, which has become akin to the Bible for tracking sign-ups under the law.

He noted that CMS’ state-by-state projections were based on 7 million enrollees nationwide, the original projection of the CBO. That projection has since been revised downward to 6 million because of the problems with HealthCare.gov, the online sign-up portal for 36 states. In addition, some states provided their own figures while CMS simply sliced up the rest to fit the 7 million projection.

He elaborated in an email: “Ten states out of 50 gave their target numbers to CMS, but those numbers were higher than CMS was figuring, so they had to drop the other 40 states down so that the grand total fit the CBO’s 7 [million] total. As a result, you get some absurd numbers — both NY and KY had the same 220K (actually, KY’s was 220K, NY’s was less at 218K) even though NY’s population is much, much higher and so on.”

Gaba suggests an alternate measure more like the one used by the Leonard Davis Institute researchers, which looks at the percentage of eligible enrollees in each state.

What percentage of enrollees are young adults, aka the “young invincibles” who typically are regarded as healthier?

A number of news outlets have focused on the relative dearth of young people choosing plans through the end of February to point out that the insurance companies may not have so-called balanced risk pools, meaning enough young, healthy enrollees to offset the costs of older, sicker ones. The Washington Post noted this month:

“Strong participation by young adults is critical to the program’s success, because they tend to use less medical care. Because they are cheaper to insure, young people offset insurers’ costs of covering the sick, many of whom are eager to sign up for coverage. Under the health care law, people with preexisting medical conditions can’t be rejected.

Initially, officials had hoped that 40 percent of the sign-ups would be adults under the age of 35, but only about 27 percent of February enrollments were young adults, about the same as in January. On Tuesday, administration officials said they were nevertheless encouraged and predicted more young people would enroll closer to the deadline.”

Drew Altman, president of the Kaiser Family Foundation, is critical of such efforts to equate young enrollees to healthy ones.

“Young people benefit the risk pool because they are healthier, but it’s really the percentage of healthy people that make or break the risk pool,” Altman wrote in a column last week. “Even if enrollment of young adults stays where it is 2013 at about one-quarter instead of 40 percent, which our analysis shows they make up among potential enrollees 2013 premiums would only increase by 2 to 3 percent. Though even that isn’t quite right, since many insurers expected this and already built it into their premiums.”

What we really need to know is what percentage of enrollees are healthy vs. sick. That will take time.

What will happen to insurance premiums in 2015?

Some experts are looking beyond this year’s enrollment numbers and are focusing on what the insurance rates will be for those renewing their plans this fall — or selecting plans for the first time. Scott Gottlieb, a resident fellow at the American Enterprise Institute, told me this month that he thinks attention will quickly shift from this year’s enrollment cycle to insurers’ rates for next year.

“The rates are going to come out early spring, so that’s going to be the next big story. And I suspect they’ll go up quite a bit,” he said.

That view was echoed by an anonymous insurance executive who talked to The Hill newspaper.

Dylan Scott at Talking Points Memo isn’t convinced they will uniformly rise. He also notes that insurance rates were increasing before Obamacare and will increase after the law.

“The real data for measuring Obamacare’s success aren’t in yet, but they eventually will be. At the top of the list: What happens with premiums in 2015? Plus: Do insurance companies leave the market or enter it? And the ultimate barometer: Has the number of uninsured Americans dropped significantly?” he wrote last week. “In simpler terms: Did Obamacare, in year one, create a sustainable insurance market for the long term?”

Another problem with looking at rates is that an insurer’s increase for 2015 may mean that it didn’t set the right price for this year, not that medical costs have increased dramatically.

***

In the end, some hints of the law’s success — or failure — will be available this year, but it will take longer to assess how much it has reduced the number of uninsured and moderated health care costs (the two key metrics of success).

An article Friday in The New York Times suggests that rather than judging the success of the law nationally, it may make more sense to look at it state by state. “A review of state-by-state enrollment data and other research, as well as interviews with patients, advocates, health policy analysts, elected officials, supporters and critics of the Affordable Care Act, suggest that, for consumers at least, the state of health care under the national law depends almost entirely on where a person lives,” the article said.

At the end of his column, Kaiser’s Altman wondered if the American public would wait for the facts to make up its mind: “The problem is that it will take time to learn if the mix of enrollees is healthier or sicker, and how premium increases vary around the country, and how people feel about their coverage,” he wrote. “Meanwhile Republican politicians will lambast the law and Democratic ones will offer lukewarm support and overall popularity of the ACA probably won’t change very much. Anybody willing to wait for a judgment based on the right metrics?”

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

AFP Photo/Joe Raedle

Epic Fail: Where Four State Health Exchanges Went Wrong

Epic Fail: Where Four State Health Exchanges Went Wrong

by Charles Ornstein,ProPublica.

Much has been written (and will continue to be written) about the spectacular failure of health insurance exchanges in Minnesota, Massachusetts, Oregon and Maryland — all blue states that support the Affordable Care Act.

All were woefully unprepared for their Oct. 1 launch, and unlike HealthCare.gov, the federal marketplace, they are still having trouble getting back on their feet. As a result, enrollment in those four states has lagged behind other states, including many that actively oppose the health law.

The New York Timesrecently reported on how problems in these states could give Republican candidates an opening. “Last month, the Republican National Committee filed public-records requests in Hawaii, Maryland, Massachusetts, Minnesota and Oregon seeking information about compensation and vacation time for the exchange directors, four of whom have resigned. All five states have Democratic governors whose terms end this year. Three of them 2014 Gov. Neil Abercrombie of Hawaii, Gov. Mark Dayton of Minnesota and Gov. John Kitzhaber of Oregon 2014 are seeking re-election,” The Times reported.

One common element emerging in the coverage of these exchanges is that at least some state employees knew they were heading for disaster but didn’t take action early enough to remedy it. All the states have blamed some, if not all, of their problems on outside tech contractors. Here’s a sampling of what has been reported in each state.

Oregon

The Oregonian newspaper has done a great job chronicling the unfolding disaster with Cover Oregon. The state is the only one in which no one has been able to enroll using the website. In an article last month, the newspaper reported that a technology analyst at Oregon’s Department of Administrative Services warned last May that managers at the exchange were being “intellectually dishonest” in claiming it would be ready Oct. 1.

As the Oregonian set forth in its findings:

  • The project’s significant flaws were well documented dating back to November 2011. Multiple independent analysts repeatedly raised questions about poor management along with strong doubts that it could be operational by the Oct. 1, 2013 deadline.
  • Cover Oregon leaders wavered between despair and an almost evangelical enthusiasm that they could complete the site. In the end they charged ahead, piloting an unfinished, largely untested exchange project right up to the Oct. 1 go-live date with no backup plan ready to go.
  • Senior officials in Gov. John Kitzhaber’s office and elsewhere read at least some of these warnings but took no significant steps to intervene, apparently after being convinced by others the project was on track.
  • A key official in the massive IT project took steps to silence the critics. The Oregon Health Authority last January withheld payment from the company hired to monitor the project, claiming its persistent criticism was inaccurate and inflammatory.

The director of Cover Oregon left on medical leave in December. The Oregonian also has a good piece comparing Oregon’s failures with the successes of Kentucky, whose exchange has been lauded.

Minnesota

Blame is being spread around in Minnesota, where the MNsure exchange is sputtering and its call center is unable to keep up with demand. As news site MinnPost reported last month: “The vendors are blaming the state. Gov. Mark Dayton and state officials are blaming the private companies who built the faulty technology, and MNsure leaders are quick to point out that they weren’t around when controversial decisions were made. Republican lawmakers, meanwhile, are saying that the governor needs to take responsibility for the project.”

MinnPost reported that despite their efforts to blame vendors, state officials were responsible for key decisions:

Newly released contract documents suggest the state and MNsure leaders had a more direct role in the health exchange’s many missteps than they have publicly acknowledged.

In recent weeks, Gov. Mark Dayton and MNsure officials have increased their criticism of vendors, blaming the private technology companies for some of the underlying problems and glitches with the health exchange’s operation.

However, in early May, the state of Minnesota in effect took over responsibility from its lead contractor, Maximus Inc., for constructing MNsure’s technical infrastructure, according to contract amendments released to MinnPost by MNsure.

The new documents show that the exchange staff quietly made a significant change to its key contract for building MNsure 2014 just months after making major revisions to the timeframe and size of the project.

Dayton later said he was unsure if senior MNsure staff were keeping him apprised of the serious issues with the exchange as soon as they came up.

The Star Tribune has reported on lengthy delays at the exchange’s call center and how officials in charge of the project received bonuses before its disastrous launch.

As in Oregon, the head of Minnesota’s exchange also resigned.

Massachusetts

In many ways, Massachusetts should have been a leader in setting up its own exchange. After all, its 2006 health reform law signed by then-Gov. Mitt Romney has been cited as the model for Obamacare. But the state’s exchange, the Massachusetts Health Connector, has fumbled.

The Boston Heraldreported last month that “state officials overseeing the Health Connector website knew as early as February 2013 — some nine months before launch — that parts of the $69 million Obamacare gateway would probably be delayed, public records obtained by the Herald last night revealed.”

The Boston Globefollowed up with another report:

Massachusetts officials knew in July, three months before the launch of the state’s ill-fated health insurance website, that the technology company in charge was far behind on building the site and that there was “a substantial and likely risk” it would not be ready, according to a state official’s memo.

The website launched on Oct. 1 was incomplete and riddled with errors that frustrated consumers, blocked some from getting coverage, and required the state to move tens of thousands of people whose applications could not be processed into temporary insurance programs.

The head of the Massachusetts Health Connector Authority, which runs the insurance marketplace, was copied on the July memo. But the executive director, Jean Yang, and her staff never told the Connector board during its monthly public meetings that the project was off track, according to meeting minutes.

The Globereported in a separate story how an untold number of people who “applied for Connector plans without financial assistance have not gotten coverage, because their payments were lost or somehow never linked to their accounts.”

John J. Monahan, a columnist for the Worcester Telegram & Gazette, put it like this last weekend:

Massachusetts’ universal health care program was the model for Obamacare. And now, it seems, the Obamacare website fiasco has been modeled by Massachusetts.

The state contracted with the same software company that messed up the launch of the Obamacare website to redesign its Health Connector website for people to buy insurance. It was scheduled to be working Oct. 1 to renew insurance for Jan. 1. It still isn’t working.

Maryland

The Maryland Health Connection, like the exchanges in other states, knew well in advance that it wasn’t ready to launch, but the problems weren’t fixed in time.

The Washington Post reported last month how “senior state officials failed to heed warnings that no one was ultimately accountable for the $170 million project and that the state lacked a plausible plan for how it would be ready by Oct. 1.”

Over the following months, as political leaders continued to proclaim that the state’s exchange would be a national model, the system went through three different project managers, the feuding between contractors hired to build the online exchange devolved into lawsuits, and key people quit, including a top information technology official because, as he would later say, the project “was a disaster waiting to happen.”

The repeated warnings culminated days before the launch, with one from contractors testing the website that said it was “extremely unstable” and another from an outside consultant that urged state officials not to let residents enroll in health plans because there was “no clear picture” of what would happen when the exchange would turn on.

Within moments of its launch at noon Oct. 1, the website crashed in a calamitous debut that was supposed to be a crowning moment for Maryland officials who had embraced President Obama’s Affordable Care Act and pledged to build a state-run exchange that would be unparalleled.

Weeks later, the Baltimore Sun’s Meredith Cohn wrote a piece about just how much trouble she personally had trying to enroll:

For a chunk of two recent days, I tried to buy insurance on the Maryland health exchange.

My editors asked me to do this because Gov. Martin O’Malley recently told a national television audience that the “website is now functional for most citizens.”

They wanted to know what “functional” meant, especially after hearing stories from consumers about a glitch-prone website created under the Affordable Care Act for the uninsured and underinsured. Marylanders have described frozen screens, lost information, error messages and even mistaken identity.

My own enrollment took 5 hours and 22 minutes over two days, two calls to the exchange’s call center, seven times entering my personal information, two computers and two web browsers.

Maryland’s exchange director resigned in December. Last week, Maryland Gov. Martin O’Malley signed a law that would provide a backup method for hundreds of residents to get coverage effective Jan. 1 if they can show that they tried unsuccessfully to get coverage from the exchange.

Have you tried signing up for health care coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

Photo of Governor John Kitzhaber: OregonDOT via Flickr