Lifetime Caps Research Articles

Impact of the Affordable Care Act on Referral to Care for People Living with HIV in Appalachia.

IntroductionThe Affordable Care Act (ACA) enacted on March 23, 2010 significantly impacted access to healthcare for people living with HIV (PLWH). Expansion of care was accomplished in three areas: eliminating exclusions for pre-existing conditions, elimination of lifetime caps on healthcare expenditures, and expansion of Medicaid eligibility.PurposeThis study evaluated the impact of state implementation of the ACA Medicaid expansion on referral to HIV care at a Ryan White federally funded clinic in Kentucky (University of Kentucky Bluegrass Care Clinic [UK BCC]).MethodsRetrospective chart review of all newly enrolled patients at the UK BCC between March 2010 and June 2017. Data included patient demographics and referral source, and were divided into two groups to compare enrollments before and after Kentucky implemented the ACA Medicaid expansion. Data were collected from 2018–2019 and analyzed in 2020.ResultsFollowing Medicaid expansion there were statistically significant changes in the patterns of referral to federally funded HIV care. These included a significant decrease in the proportion of referrals from state and local health departments, and an increase in both proportion of referrals from outpatient clinics and transfers from different HIV care providers.ImplicationsThese results have implications for engaging more PLWH into HIV care, particularly in states where patients have increased access to screening and assessment of risk at primary care encounters through implementation of the ACA Medicaid expansion.

APA, Five Other Groups Oppose Administration’s Efforts to Undermine ACA

APA, Five Other Groups Oppose Administration’s Efforts to Undermine ACA

King v Burwell

In King v. Burwell, the U.S. Supreme Court once again saved the Affordable Care Act (ACA) by upholding subsidies (tax credits) offered to low- and middle-income individuals for insurance bought on federal exchanges. A contrary opinion would have put at risk health insurance for 6.4 million Americans and threatened to destabilize insurance markets for millions more.The ACA is supported by four interlocking reforms, each of which are necessary to realize its promise of expanding health care coverage: (1) guaranteed issue (prohibiting discrimination based on pre-existing conditions), (2) community rating (barring insurers from imposing higher premiums based on health status and prohibiting lifetime caps), (3) tax subsidies to offset the cost of premiums for low- and middle-income individuals, and (4) Medicaid expansion. King v. Burwell threatened to undermine the third pillar. Buried deep within the law, the ACA states that subsidies are available to “Exchange[s] established by the State.” Not imaging that their residents could be denied subsidies, 34 states chose to allow the federal government to run their exchanges. The Supreme Court ruled in favor of the government, recognizing that Congress would not have given states the option of having the federal government run their exchanges, while simultaneously dooming those exchanges to dysfunction.With the ACA now safe from its latest — and it is to be hoped last — existential judicial challenge, attention must now turn to the law’s unfinished business. First, a confluence of judicial interpretation and political impasse has created a new Medicaid “donut hole,” with many earning too much to qualify for Medicaid but too little to receive ACA subsidies. States should close this hole, both to protect their most vulnerable citizens and to boost their own economies. Second, the law has left out approximately 11 million undocumented immigrants to the U.S. More than half are uninsured, leading to poor health outcomes, needlessly straining emergency services and safety-net hospitals, and endangering public health. Some localities have experimented with ways of expanding coverage, but national action is needed to guarantee universal health coverage.

Prescription and repair rates of prosthetic limbs in the VA healthcare system: implications for national prosthetic parity

Purpose: To quantify prescription and repair rates of prosthetic limbs in the Department of Veterans Affairs (VA) and explore differences by level, type, and age. Methods: Veterans (N = 32 440) with an initial prosthetic prescription between 2000 and 2010 were classified by amputation level and type. Annual rates of prescription and repair were calculated using person-time and compared by group. Results: Veterans with upper limb amputation had lower annual prescription and repair rates (0.28 and 0.21) compared with those with lower limb amputation (0.40 and 0.56). Myoelectric devices users had higher prescription rates. However, body-powered users had higher repair rates. Prescription and repair rates for microprocessor knee joints were higher than for fluid and friction devices. Veterans under 65 had 0.07 and 0.16 higher rates of prescription and repair than those over 65 (p < 0.0001). Conclusions: Because the VA is unconstrained by co-pays or caps, data on prosthetic prescription and repair can be used to estimate rates that might occur if national prosthetic parity laws were adopted. Given the rates found, it is likely that annual costs would exceed the typical annual and/or lifetime caps in most insurance plans. In states without prosthetic parity laws, such costs likely limit access to needed devices.Implications for RehabilitationFor the almost 2 million people in the United States living with an amputation or congenital limb loss, purchasing and maintaining a prosthetic limb can be costly, with insurances often imposing annual or lifetime caps.Data on prosthetic purchasing and repair is limited and reliant on self-reported information.Because the VA is unconstrained by co-pays or caps, claims data on prosthetic prescription and repair can be used to estimate rates that might occur if national prosthetic parity laws were adopted.Given the rates found, it is likely that annual costs would exceed the typical annual and/or lifetime caps in most insurance plans. In states without prosthetic parity laws, such costs likely limit access to needed devices.

ABO/Rh Testing, Antibody Screening, and Biometric Technology as Tools to Combat Insurance Fraud: An Example and Discussion

In 2012, more than 47 million Americans lacked health insurance1; this is a serious problem because everyone will need access to healthcare at certain times in their lives. The main reason for lack of health insurance before the passing of the Patient Protection and Affordable Care Act (PPACA) in the United States has been reported to be affordability.1 In March 2010, the Patient Protection and Affordable Care Act was signed into law. The PPACA was especially enacted to reduce the number of uninsured Americans by providing affordable, quality health insurance and to curb healthcare spending.2 Reducing the number of uninsured is to be accomplished by expanding public (Medicaid) and private insurance as well as making health insurance more affordable by providing subsidies to eligible applicants, instituting mandates, providing tax credits and insurance exchanges.2 The Medicaid expansion clause is optional for states and as a result, some states choose not to expand eligibility. The PPACA law has a provision for a health insurance market place, which has allowed uninsured individuals, along with those who purchased their own insurance to compare and buy health insurance at affordable premiums with the help of subsidies.3 The law calls for insurance companies to accept all applicants regardless of any pre-existing conditions or gender and eliminates annual or lifetime caps on healthcare benefits. In addition, Members’ coverage cannot be terminated due to illness. All these provisions allow for addition as well as retention of individuals with health insurance coverage.2 Individuals living in states that have expanded Medicaid eligibility and have incomes below the poverty level are more likely to obtain health insurance coverage through Medicaid.3 Even with the relative affordability of health insurance, some individuals will not still purchase health insurance for various reasons. States that do not …

The impact of the economic downturn and health care reform on treatment decisions for haemophilia A: patient, caregiver and health care provider perspectives

Little is known about the impact of the recent US economic downturn and health care reform on patient, caregiver and health care provider (HCP) decision-making for haemophilia A. To explore the impact of the recent economic downturn and perceived impact of health care reform on haemophilia A treatment decisions from patient, caregiver and HCP perspectives. Patients/caregivers and HCPs completed a self-administered survey in 2011. Survey participants were asked about demographics, the impact of the recent economic downturn and health care reform provisions on their treatment decisions. Seventy three of the 134 (54%) patients/caregivers and 39 of 48 (81%) HCPs indicated that the economic downturn negatively impacted haemophilia care. Seventy of the 73 negatively impacted patients made financially related treatment modifications, including delaying/cancelling routine health care visit, skipping doses and/or skipping filling prescription. Treatment modifications made by HCPs included delaying elective surgery, switching from higher to lower priced product, switching from recombinant to plasma-derived products and delaying prophylaxis. Health care reform was generally perceived as positive. Due to the elimination of lifetime caps, 30 of 134 patients (22%) and 28 of 48 HCPs (58%) indicated that they will make treatment modifications by initiating prophylaxis or scheduling routine appointment/surgery sooner. Both patients/caregivers and HCPs reported that the economic downturn had a negative impact on haemophilia A treatment. Suboptimal treatment modifications were made due to the economic downturn. Health care reform, especially the elimination of lifetime caps, was perceived as positive for haemophilia A treatment and as a potential avenue for contributing to more optimal treatment behaviours.

American Diabetes Association Postgraduate Meetings—2011

At the American Diabetes Association(ADA) Postgraduate Meetings held 25–26 February 2011 in New York, a discussion of health-care reform and diabetes was opened by Herbert Pardes, chief executive officer of New York-Presbyterian Hospital, who stated that “the focus on health care by the entire country … and the world has never been so great.” His medical center is one of the largest hospital networks in the country, with 2,300 beds and two medical schools, and is the largest private enterprise in New York. He discussed the Naomi Berry Diabetes Center, treating >10,000 diabetic individuals, with one of the largest pediatric diabetes practices in the U.S. At the Weill Cornell Hospital, surgical treatment for diabetes is being studied. Safety programs are being developed in hand washing and in error prevention. Information technology is being expanded, with (as an example) software tools to reduce deep vein thrombosis. More online access to medical records by patients and initiatives such as health information exchanges are being studied to avoid “costly, redundant tests.” Hospitals around the country are, along with politicians and the general public, focusing on health-care reform because of increasing costs, large numbers of uninsured individuals, and increasing numbers of individuals with chronic diseases, in part because of increasing longevity. Cost-effectiveness is an issue, with the U.S. ranking first in per capita spending but far lower in health outcomes. “A lot of populations,” Pardes said, “are not getting the kind of care that they should.” Health-care reform efforts include measures to increase coverage, eliminate exclusions for preexisting illnesses and “lifetime caps,” allow older dependent children to remain on parents’ plans, and to eliminate costs to patients for annual preventive care. All these concepts are relevant to the treatment of diabetes. Quality has also become an important focus, with proposals that “the provider needs …

Mental health parity.

Probably the most far-reaching legislation that affects nurse therapists today is that of mental health parity. Officially designated Decade of the Brain, the 1990s brought unprecedented federal and state legislation to end health insurance discrimination against individuals with mental illnesses. Federal Parity Mental Health Parity Act of 1996. The Mental Health Parity Act of 1996 became effective January 1, 1997, and will sunset on September 30, 2001. It requires employers that offer mental health benefits to set annual and lifetime caps equal to those for medical and surgical benefits. The measure excludes businesses with 50 or fewer employees, and allows all employers to be exempted from the law if their costs rise more than 1% as a result of complying with the requirements. The law allows health insurance plans to set different benefit levels for copayments, deductibles, out-of-pocket payments, inpatient hospital days, and outpatient visits. Relationship to state law. A state law requiring more comprehensive coverage is not weakened by the federal parity law, nor does the federal law preclude a state from enacting stronger parity legislation. On April 14, 1999, U.S. Senators Pete Domenici (R-NM) and Paul Wellstone (D-MN) introduced the Mental Health Equitable Treatment Act of 1999, which would require full health insurance parity for the most severe, biologically based mental illnesses. This legislation would prohibit unequal restrictions on annual and lifetime mental health benefits, inpatient hospital days, outpatient visits, and out-of-pocket expenses. Variations and amendments to this federal bill are being considered. Overview of State Parity Laws After the Mental Health Parity Act of 1996 was signed into law, the momentum shifted to the states. A firestorm of legislative activity created a patchwork quilt of various parity laws around the country. A total of 28 states now have some degree of mental health parity, with fairness bills pending in many other state legislatures. Depending on the state, mental health parity may include any combination of the following two items: 1. Equalization of insurance benefits in relation to annual and lifetime caps 2. Equalization of benefit levels for copayments, deductibles, out-of-pocket payments, inpatient hospital days, and outpatient visits. In 1999, 11 states (California, Hawaii, Indiana [expansion of '97 law], Louisiana, Missouri [expansion of '97 law], Montana, Nebraska, Nevada, New Jersey, Oklahoma, Virginia) and two territories (Guam, Puerto Rico) passed parity legislation. In 1998, four states (Delaware, Georgia, South Dakota, Tennessee) passed parity legislation. In 1997, nine states (Arizona, Arkansas, Colorado, Connecticut, Indiana, Missouri [managed care only], South Carolina, Texas [expansion of earlier requirement], Vermont) passed mental illness parity legislation. Between 1991 and 1996, seven states (Maine, Maryland, Minnesota, New Hampshire, North Carolina [state employees only by administrative order], Rhode Island, Texas [state employees only]) effected mental illness parity measures. As each state passes some form of parity legislation or expands existing law, managed care networks are opening up to accept additional therapists to handle the increased workload. The NAMI website gives a state-by-state breakdown of mental illness parity laws. At this site it is possible to find out the specific provisions each state has passed, if any, and when the law has or will become effective. If you reside in a state that has recently passed or amended parity legislation, you are in a window of opportunity that will not last long. Once networks reach their provider quotas, it will be very difficult to gain entry. To take advantage of this window of opportunity, here are several steps you can take: 1. …

AMA Reaffirms Commitment To Parity For MH Care

AMA Reaffirms Commitment To Parity For MH Care

Can Health Care Plans Afford Hemophilia Costs? Yes.

Hemophilia care has high annual recurring costs. 80–90% of these costs are to cover replacement therapy. Managed care programs have, in general, not recruited specialists to help determine the guidelines of care, the use of hemophilia treatment centers (HTC) by their patients or the multiple sources and charges for acquiring these expensive biologics. Aetna has 700–750 hemophilia patients in a typical year whose medical costs are upward of $60 million. These patients represent only.005% of the total membership, and 0.198% of the health care dollars spent. A hemophilia specialist was asked to evaluate these patients vis-á-vis site of care, optimal treatment plan, and potential savings for covered members, payers and employers.Methods: working with the Aetna nurse case managers, individual patients were evaluated for the above issues.Results: From June 2004 to June 2005, 190 patient files were reviewed. Of these, 18% had lifetime caps, and 30% were not treated in an HTC. 16% of these patients decided to transfer to an HTC for either their care or product procurement. The remainder decided not to pursue this path.Table IPatientsIssue1)4.5 %Altered regimen, product or product procurement2)3 %Contemplating altered regimen, product or product procurement3)17 %Physician contacted regarding optimal therapy4)9.5 %Prices of product negotiated downward5)12 %Product procurement switch to PHS pricing6)3 %Adhering to previous regimenTable II$ Savings (using above categories)RealPotential1)2,978,0282)---353,9723)04)1,157,5045)4,334,5236)---1,904,360Total8,470,0552,258,332The potential savings represent those who are either contemplating change but, in the main, are physicians and/or patients who chose not to accept the recommendations made. Realized annualized savings of more than $8 million affect all aspects of the care system. It is particularly revelant to those with lifetime caps. If this model were expanded for other high cost disorders, medical expenses could diminish and premium inflation could eventually decrease. Hemophilia biologics have continued to increase in costs from cryoprecipitate in the 1960s to current recombinant products. Fostering access to HTCs substantially improves quality of care and reduces medical expenditures. In conclusion, we believe that by using this approach, hemophilia care and its costs can be appropriately managed.

A Note on Hybrid Mortgages

We extend previous research on traditional one-year adjustable-rate mortgages (ARMs) by analyzing the performance of 3/27 hybrid instruments. Under this contract innovation, which first appeared in the mid-1990s, note rates are fixed for three years after which they convert to a traditional one-year adjustment schedule with periodic and lifetime caps. We find high rates of prepayment, particularly at time of initial rate adjustment, and relatively high rates of default, as would be consistent with the payment shock that often affects adjustable-rate loans.

The slippery slopes of advanced reproductive technologiesPresidential address

The slippery slopes of advanced reproductive technologiesPresidential address

DB Efforts Help Pass Mississippi Parity Bill

Back to table of contents Previous article Next article Government NewsFull AccessDB Efforts Help Pass Mississippi Parity BillChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:18 May 2001https://doi.org/10.1176/pn.36.10.0004Mississippi is the 32nd state to enact mental health parity legislation. To ensure the law’s passage, the Mississippi Psychiatric Association (MPA) and its coalition partners worked with key legislators, and Gov. Ronnie Musgrove (D) signed the bill last month.APA President Daniel Borenstein, M.D., said in a press release, “We applaud the Mississippi legislature and Gov. Musgrove for breaking down the barriers for the people of Mississippi from receiving treatment and recovery from mental illness.”APA’s Commission on Public Policy, Litigation, and Advocacy approved funding for MPA’s advocacy efforts last month, subject to approval by the Board of Trustees.APA’s Division of Government Relations held a one-day advocacy training session last year for MPA members and provided resource materials on parity.Sudha Madakasira, M.D.: “We were told by politicians that a parity bill would not pass given the opposition by key legislators.”MPA President Sudha Madakasira, M.D., said in an interview with Psychiatric News, “We were told by politicians that a parity bill would not pass given the opposition by key legislators. We decided not to ask for full parity and met with insurance committee chairs in the House and Senate and the insurance industry. Once we agreed on the provisions, the chairs sponsored the bills and shepherded them through their chambers.”Madakasira estimated that the law, which becomes effective next January, will affect 500,000 individuals in group health insurance plans. The legislation requires employers with more than 100 employees to provide mental health coverage for “clinically significant mental illnesses.” The law doesn’t list or define those illnesses.The mental health coalition also succeeded in not having lifetime caps on mental health benefits included in the bill.Specifically, HB 667 mandates that group health plans provide the following mental health benefits:• A minimum of 30 days of inpatient services annually• A minimum of 60 days of partial hospitalization annually• A minimum of 52 outpatient visits annuallyThe group health plans must cover a minimum of 50 percent of the cost of outpatient visits but are not required to pay more than $50 a visit. Group health plans can opt out of the new requirements if they result in increasing the plans’ costs by more than 1 percent.MPA lobbyist and executive director Angela Ladner told Psychiatric News, “In addition to having a 15-member mental health coalition that included the state psychological, medical, and hospital associations, we had representatives from the state department of health insurance giving us advice.”Ladner said the coalition took the department’s advice to craft a bill based on the mental health benefits in the health insurance plan for state employees. “We decided the state’s benefits were pretty good and that we could argue persuasively that everyone else should have the same benefits as state workers.”Ladner praised Mary Ann Stevens (D), chair of the House Insurance Committee and a previous opponent of parity, with meeting with the mental health coalition and agreeing to sponsor the bill.“Once we had the insurance industry on board, she did everything in her power to ensure the passage of this legislation.”Ladner credited Senators Billy Thems (D) and Robert Huggins (R), as well as Lt. Gov. Amy Tuck (D), who presides over the Senate, with pushing the bill through the Senate.Madakasira added that the law is a good first step toward full parity and that the mental health coalition plans to work toward having its provisions expanded. ▪ ISSUES NewArchived

Anatomy of an ARM: The Interest-Rate Risk of Adjustable-Rate Mortgages

This article analyzes the dynamics of the commonly used indices for adjustable rate mortgages and systematically compares the effects of their time-series properties on the interest-rate sensitivity of adjustable-rate mortgages. Our ARM valuation methodology allows us simultaneously to capture the effects of index dynamics, discrete coupon adjustment, mortgage prepayment, and both lifetime and periodic caps and floors. We can, moreover, either calculate an optimal prepayment strategy for mortgage holders or use an empirical prepayment function. We find that the different dynamics of the major ARM indices lead to significant variation in the interest-rate sensitivities of loans based on different indices. We also find that changing assumptions about contract features, such as loan caps and coupon reset frequency, has a significant, and in some cases unexpected, impact on our results.

The Valuation and Analysis of Adjustable Rate Mortgages

Securities whose payoffs depend upon the actual path of the underlying state variables pose problems for standard backward-valuation techniques. In this paper, we show that there is a method of solving such problems that requires the addition of but a single auxiliary state variable. The technique is illustrated by examining an adjustable rate mortgage (ARM) with yearly and lifetime caps. The ARM amortizes and can be prepaid at any time. We also handle other prominent features of ARMs including points and teasers. This method of using a single auxiliary state variable to handle path dependencies is a general one, applicable to more complex models of the economic environment and to other financial contracts.

The Relative Termination Experience of Adjustable to Fixed‐Rate Mortgages

ABSTRACTOur study uses a multinomial logit model to analyze the concurrent termination experience of adjustable‐rate and fixed‐rate mortgages. A new set of ARM‐specific interactive determinants expands the conventional FRM specification to isolate the unique termination behavior of ARMs. We find that expected rate adjustments and large lifetime caps are positively related to ARM termination probabilities while long adjustment frequencies are inversely related. Caps, both periodic and lifetime, have a secondary, inverse effect on termination probabilities when interest‐rate movements exceed cap limits. The model also shows that interest‐rate expectations affect FRM terminations more strongly than ARM terminations.