Wednesday, December 11, 2013

Obamacare enrollment in Florida: 17,908 and counting

About 110,000 eligible Americans selected a health plan in November using the federal online insurance exchange at 
The Miami Herald

About 110,000 eligible Americans selected a health plan in November using the federal online insurance exchange at — more than four times the rate for October, the U.S. Department of Health and Human Services reported on Tuesday.

Florida led the way, with 17,908 people signing up since Oct. 1. Nationally, a total of more than 364,000 eligible Americans have selected a health plan using the federal- and state-based online insurance exchanges that are central to the Affordable Care Act, according to government estimates that were embargoed until 9 a.m. Wednesday.

More than one in three individuals who selected a health plan, or 137,204 people, did so using, which serves 36 states, including Florida. The majority of people who signed up, or 227,478, used state-based websites that serve 14 states and the District of Columbia.
The improved numbers for the federal exchange reflect extensive technical upgrades to and a “tremendous demand” among consumers for affordable health insurance, Michael Hash, director of HHS’s office of health reform, told reporters during a conference call Tuesday night.

“Through end of November,’’ Hash said, “the federal and state sites have received more than 39 million visitors.’’

Hash noted more than 800,000 Americans have been found eligible for Medicaid or the Children’s Health Insurance Program, which are state-federal healthcare programs for the poor and disabled.

Another 1.9 million people have applied for and have been determined eligible for a health plan sold through the exchange but have not yet selected a plan, Hash said.
Included in the number of people who selected a plan are those who have paid the first month's premium to activate their plan, and those who have not.

The enrollment data did not include demographic details about applicants, such as age and ethnicity, information that Hash said may be more important in determining the success of the health law than the number of individuals who enroll.

“It’s really about who signs up and where,’’ he said.

The White House has set a 2014 enrollment goal of 7 million Americans, a figure first projected by the Congressional Budget Office.

Tuesday’s enrollment report is well below the pace needed to reach that goal by March 31, the close of open enrollment. Dec. 23 is the deadline for individuals to buy health insurance that will take effect on Jan. 1, 2014.

Obama administration officials have repeatedly said that they expect enrollments to rise as the March 31 deadline nears, and as their aggressive outreach and education efforts begin to produce results.

“We fully expect these numbers to grow over time,’’ said Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services, the federal agency that oversees
The federal online exchange is designed to handle as many as 800,000 consumers a day.
Despite the improved functionality of, a team of technicians continues to work on significant “back-end” issues with the complex system, such as the transmission of direct payments, and so-called 834 forms containing consumer data, from to insurers.
Bataille said CMS officials, insurers and technical experts are meeting daily to fix the 834-form problems.

“Our top priority,’’ she said, “is making sure that every 834 form both past and present is accurate.’’

Problems include the system’s failure to generate 834 forms for consumers who enroll in a plan, the generation of duplicate forms and data errors, such as incorrect spousal or parent-child relationships and misspelled names.

As many as one in four of all 834 forms generated through the federal online exchange from Oct. 1 to Nov. 30 may contain errors, Bataille said last week.

Since the site’s relaunch on Dec. 1, however, that error rate dropped to one in ten of 834-form transactions, Bataille said, largely due to a repaired “bug” in that was causing 80 percent of the form errors by failing to transmit Social Security numbers for consumers.
Tempering Tuesday’s improved numbers is the fact that only about 41 percent of Americans determined eligible to enroll in an exchange plan also qualified for financial aide to help pay their montly premiums.

The Congressional Budget Office had estimated that about 90 percent of Americans who enroll in an exchange plan would be eligible for financial assistance, which is available only to those earning up to four times the federal poverty level, which was about $46,000 a year for an individual and $94,000 for a family of four in 2013.

Nancy DeLew, a CMS administrator speaking on Tuesday’s conference call, acknowledged that fewer people were eligible for subsidies than expected, but that it was still early in the enrollment period.

“We don’t know if that will change by the time we get to the end of the six-month period,’’ she said.

Among the states using the federal online exchange, Florida leads the way in the number of applications completed (150,142), number of individuals applying for coverage (281,517), and the number of plans selected (17,908.)

The Sunshine State is home to an estimated 3.8 million uninsured residents younger than age 65, the second-highest rate in the nation behind Texas, according to the U.S. Census.

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In era of health reform, retail clinics become part of the health care delivery system

Sylvana Yalda, M.D., a family medicine physician at Henry Ford Medical Center-Troy and a MinuteClinic medical director
Sylvana Yalda, M.D., a family medicine physician at Henry Ford Medical Center-Troy and a MinuteClinic medical director, said nurse practitioners at the retail clinics are good at calling her if they have questions about patient care.
Fast facts about retail clinics
• 12 percent to 14 percent of all visits to emergency departments can be seen in retail or convenient-care clinics.

• Average treatment costs are lower at retail clinics ($60 per visit) than urgent clinics ($124), physician offices ($127) and emergency departments ($356).

• Services include acute care; immunizations; wellness and preventive services; chronic-disease care; school, camp and sports physicals; and minor office procedures.

• Quality is comparable to other medical locations. For example, retail clinics had 92.7 percent compliance with quality for children with pharyngitis (inflammation of the throat), compared with a HEDIS (Healthcare Effectiveness Data and Information Set) average of 74.7 percent.

• Patient satisfaction scores are 93 percent for convenience and 90 percent for quality.

Source: Convenient Care Association, Philadelphia
A contract between Detroit-based Henry Ford Health System and MinuteClinic, a division of CVS Caremark Corp., is one example of how retail clinics are becoming a larger part of the health care delivery system in Southeast Michigan to meet an expected increase in patient demand next year under the Affordable Care Act.

Under the contract, Henry Ford provides at least five physician medical directors to 14 CVS MinuteClinics in metro Detroit to oversee clinical operations and supervise nurse practitioners. CVS plans to add three or four more MinuteClinics here and more than 150 nationally next year.
Paul Szilagyi
Paul Szilagyi
"Our physicians serve as medical directors to meet with nurse practitioners at MinuteClinics on a regular basis to review quality," said Paul Szilagyi, Henry Ford's vice president of primary care and medical centers. "They are a phone call away if the nurse practitioner has a question about a patient."
MinuteClinic locations
Ann Arbor, Canton Township, Farmington Hills, Fraser, Grosse Pointe, Macomb Township, Milford, Northville, Rochester Hills, Shelby Township, Southfield, Walled Lake, Waterford Township, Wyandotte
The contract also allows patients of the Henry Ford Medical Group to use the MinuteClinics as if they were one of the 27 Henry Ford-owned medical centers and nine affiliated physician offices.

Two years ago, officials at Henry Ford Health System recognized they needed additional access points for patients and others seeking care from Henry Ford doctors.

"The only way to get into the Henry Ford Health System was through (hospital) emergency departments or our ambulatory care clinics," Szilagyi said. "We wanted to create more doors to enter the system."

Henry Ford considered creating retail clinics on its own, he said, but concluded it would be better to seek an established company.

Because Woonsocket, R.I.-based MinuteClinic already had contracts with more than two dozen other health systems and physician group practices, including the Cleveland Clinic — and evidence showed that MinuteClinic quality was high and medical malpractice incidents low — Henry Ford decided to join forces with the retail clinics.

"CVS had already made a commitment to Detroit, and we felt they had the same commitments to access, quality and connections (to primary care doctors) as we did," Szilagyi said.

Another bonus for Henry Ford patients, Szilagyi said, is that MinuteClinic offers expanded evening and weekend access to care and affordable primary care prices.

Sylvana Yalda, M.D., a family medicine doctor at Henry Ford Medical Center-Troy and a MinuteClinic medical director, said the delivery of care has been convenient and high-quality.

"The nurse practitioner sees the patient, and we do chart reviews," Yalda said. "They call me for consultations and a second opinion if they have questions about a patient.

"Nurse practitioners are very good at following (national clinical care) guidelines, but some situations require a doctor's point of view."

Since January 2012, when Yalda became a MinuteClinic medical director at the Waterford Township, Rochester Hills and Southfield CVS centers, some of her patients have been seen by nurse practitioners at MinuteClinics, she said.
Sylvana Yalda, M.D.
Sylvana Yalda, M.D.
Nurse practitioners fax patient encounter notes to primary care physicians, Yalda said.

"I have received quite a few," she said. "It is very helpful to know the care my patients have received."

To improve the sharing of patient records with primary care doctors, Henry Ford Health and MinuteClinic are working to link electronic medical record systems, Szilagyi said.

Next year, Henry Ford should have MinuteClinic fully integrated with the health system's Epic electronic medical records, Szilagyi said, which will provide visit tracing and opportunies to do chronic disease management.

Retail clinic, urgent care growth

Because of health insurance expansion and the need to offer lower primary care costs, the number of retail clinics is projected to double over the next five years in the U.S. to 3,000, said Tine Hansen-Turton, executive director of the Philadelphia-basedConvenient Care Association.

Hansen-Turton said the Affordable Care Act is stimulating growth because 40 percent to 50 percent of the people who use retail clinics don't have a primary care physician, and many are uninsured.

"We expect to increase services as people become insured and seek lower-cost options of retail clinics," Hansen-Turton said. Costs for comparable services at retail clinics are 40 percent lower than in physician offices and urgent care centers and 80 percent less than emergency departments, she said.

"People will be more cost-sensitive because they will have higher out-of-pocket costs before they hit their deductibles," she said.

Like retail clinics, urgent care centers — which provide higher levels of care than retail clinics but less than hospital emergency departments — are also growing in numbers in Southeast Michigan to accommodate expected demand, said Mohammed Arsiwala, M.D., president of the Lansing-based Urgent Care Association of Michigan.

Under the Affordable Care Act, over the next several years, nearly 900,000 uninsured people in Michigan are expected to either purchase private health insurance through or qualify for Medicaid.

"We won't see much more growth in the next year," Arsiwala said. "But the second year, 2015, we will start to see growth" in patient volumes at urgent clinics, he said. It will take time for newly insured patients to learn how best to access the health care system.

One concern has been that the influx of newly covered patients will overload the primary care delivery system. Primary care physicians, hospitals and other providers have been ramping up care recently for the expected increase in volume.

Besides CVS, pharmacies including those inside Walgreen Co. and Rite Aid Corp. stores have started retail clinics in various ways to take advantage of national changes in health care that are projected to add 16 million privately insured patients and 16 million Medicaid beneficiaries starting in 2014.

In a 2-year-old pilot program that began in Detroit, Rite Aid has established virtual NowClinics in nine stores in Michigan. NowClinic uses computers and telemedicine to link customers with remotely based advanced-practice nurses and physicians.

"Our online clinics have computer kiosks adjacent to the pharmacy in a private room with a computer," said Ashley Flower, senior manager of public relations for Camp Hill, Pa.-based Rite Aid.

Flower said customers can talk with nurses for free, but a 10-minute consultation with a physician costs $45. Customers also can consult with medical providers using their home computer, she said.

While Deerfield, Ill-based Walgreen doesn't currently operate its Take Care retail clinics in Michigan, the nation's largest pharmacy chain operates more than 400 clinics in 21 states — including Illinois, Indiana, Ohio and Pennsylvania — as well as the District of Columbia, said Jim Cohn, a Walgreen spokesman.

The company also has contracted with 15 health systems to integrate its clinics with system hospitals. Those health systems include Baltimore-based Johns Hopkins Health System and Indianapolis-based Community Health Network.

Convenient, not comprehensive

Retail clinics are positioned to meet the needs of people who don't have a doctor or can't get a convenient appointment, Cohn said.

But Arsiwala of the Urgent Care Association of Michigan cautioned that retail clinics are limited in the types of care they can provide.

"Urgent care centers offer comprehensive medical care for people who need it urgently and cannot be seen by primary care doctors," said Arsiwala, who also is CEO of 10-center Michigan Urgent Care Centers.

"Pharmacy retail clinics are a very commercial side of the business," Arsiwala said. "They have nurse practitioners working for them. They don't have X-rays or comprehensive testing. They treat very minor complaints like earache or sore throats."
Nancy Gagliano, M.D.
Nancy Gagliano, M.D.
Nancy Gagliano, M.D., MinuteClinic's chief medical officer, said retail clinics can take on a large range of basic primary care services. Those include treating strep throat, bladder infections and pink eye and offering vaccinations for flu, pneumonia, pertussis and hepatitis.

Gagliano said patients do a good job deciding the appropriate care location for their medical issue.

"We send patients to ERs every once in a while," she said, "but working with health systems like Henry Ford helps us deliver the type of care that patients need. Doctors are seeing MinuteClinics as a place to augment primary care."

Gagliano said retail clinics stay within the boundaries of what nurse practitioners and physician assistants can do.

Yalda, the Henry Ford doctor and MinuteClinic medical director, said nurse practitioners at the clinics are well-trained in established clinical guidelines and refer more complicated patients to physicians or hospital emergency departments.

"If there is a sore throat and it is complicated, they will be referred," she said. "They know if a patient is not appropriate for the guidelines. They refer them right away. I get calls from them."

Although MinuteClinics lack the sophisticated diagnostic equipment found in hospitals and urgent care clinics, nurse practitioners can perform diabetic evaluations that include simple foot examinations to check for circulation problems or infections and can conduct blood sugar and blood pressure tests, Yalda said.

Gagliano said 50 percent of patients who come to a MinuteClinic do not have a primary care physician, and 50 percent of those patients visit during evening or weekend hours.

"Patients tell us if it weren't for us, they would go to an emergency department," Gagliano said. "We are reducing overall health care downstream costs."

mHealth Alliance Honors Mobile Health Visionaries in First-Ever Awards Ceremony at mHealth Summit

The mHealth Alliance, an organization dedicated to advancing the use of mobile technologies to improve health outcomes in low- and middle-income countries, announced this evening the winners of the Holly Ladd mHealth Pioneer Award and the mHealth Alliance Collaboration Award. This marks the first time that the Alliance has extended these honors. Dr. Richard Gakuba of Rwanda received the Holly Ladd mHealth Pioneer Award, while the Ananya partnership of Bihar, India, received the mHealth Alliance Collaboration Award. The awards were presented at a dinner celebrating the Alliance's fifth anniversary, which coincides with the fifth annual mHealth Summit, of which the Alliance is an organizing partner.
"These awards are designed to honor visionaries in the field of the mHealth - individuals and organizations whose work serves as a shining example of what is possible when we use mobile technologies strategically to improve health outcomes in developing countries," said Dr. Patricia Mechael, executive director of the mHealth Alliance. "We are delighted to have the opportunity to honor these outstanding members of the mHealth community, and we're grateful to the co-sponsors that have made it possible to recognize them."
The Holly Ladd mHealth Pioneer Award is co-sponsored by the mHealth Alliance, FHI 360 and the Rockefeller Foundation, and it includes a $5,000 cash prize and covers travel expenses to bring Dr. Gakuba to the mHealth Summit.
The Holly Ladd mHealth Pioneer Award
Dr. Richard Gakuba, the former national e-Health coordinator of Rwanda, received the Holly Ladd mHealth Pioneer Award - named in honor of Holly Ladd, a champion of community building and skills transfer in mHealth. The award recognizes an individual who is advancing sustainable solutions for personal and community health empowerment through the use of mobile technology.
"In just a few short years, the mHealth Alliance has been instrumental in making mHealth ubiquitous in global health. It demonstrates how philanthropic dollars, leveraged at the right moment, can catalyze entire fields," said Dr. Judith Rodin, President of The Rockefeller Foundation. "This progress has been further possible through visionary champions around the world like Dr. Richard Gakuba, who recognized the potential of mHealth and eHealth, and demonstrated how it can help transform health systems anywhere."
Dr. Gakuba was honored for his pioneering work, which has led to the creation and implementation of a national e-Health strategy for Rwanda. This strategy has created a regulatory environment that is enabling mHealth projects and programs to flourish and scale. Dr. Gakuba's work has helped to optimize the effectiveness of health care delivery and made health services more affordable in Rwanda.
"FHI 360 is honored to support the Holly Ladd mHealth Pioneer Award this year," said Albert J. Siemens, Ph.D., Chief Executive Officer of FHI 360. "The award acknowledges Holly's vision of how communication technology can transform the lives of millions of people around the globe. It celebrates her outstanding leadership and passion that have been an inspiration for so many."
Holly Ladd was the Director of SATELLIFE, which pioneered access to peer-reviewed medical and public health information for health care workers in developing communities via electronic-based information technology and low-earth orbit satellites. A true innovator in the development of systems to support health workers and strengthen health systems, Holly trusted the passion of health care workers to overcome a lack of familiarity with computers. When SATELLIFE joined FHI 360 in 2011, Holly redoubled her commitment to using mobile technology to expand knowledge, build human capacity and improve lives. The Holly Ladd mHealth Pioneer Award celebrates her innovation, compassion and magnanimity.

The mHealth Alliance Collaboration Award
The mHealth Alliance Collaboration Award was presented to the partners in the Ananya project, which is using mobile technologies in Bihar, India, to extend health information and services to families living beyond the reach of formal health facilities. The Collaboration Award recognizes individuals and/or organizations whose work through partnership has contributed significantly to advancing the field. The mHealth Alliance, itself, was created based on the vision that deepened collaboration and convening among members of the mHealth community could help overcome key obstacles in bringing effective mHealth products, projects, policies and programs to scale.
Ananya was honored for its ground-breaking model, including integrated approaches to achieving the Millennium Development Goals related to maternal and child health. The Government of Bihar (the Social Welfare Department and the Health Department), the Bill and Melinda Gates Foundation, BBC Media Action, CARE, Dimagi, the Grameen Foundation and World Health Partners will be recognized collectively for their innovative work that stands out as a leading example of an effective mHealth project operating at scale.
Note: Dr. Richard Gakuba will speak at mHealth+SocialGood, an event being held at the mHealth Summit on Tuesday, December 10th at 12 p.m. EST. This event will also be live streamed via Several members of the Ananya partnership will also be speaking at an mHealth Summit session held on Tuesday, December 10th at 5 p.m. EST. Both events will offer opportunities to hear directly from the award recipients and learn more about their work.