Supreme Court's McCutchen Decision Is Good News for Health Plan Sponsors
"A well-drafted provision should address first-dollar recovery, whether the plan is going to share in the legal fees incurred in pursuing the recovery, and many other issues.... [P]lan sponsors should keep in mind the reality that a completely one-sided reimbursement provision will give a participant (and the participant's attorney) little incentive to bring a lawsuit against a third party which, in turn, will mean no reimbursement for the plan."
(Faegre Baker Daniels LLP)
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Defining Equitable Relief and Health Plan Terms
"[F]or subrogation and reimbursement cases, health plans should make sure they have very specific subrogation and reimbursement language to avoid challenges on an equitable basis. But the broader concept is an affirmation that plan terms mean what they say. In a time when we are revising and redrafting plans to comply with PPACA, it is important to keep in mind that we have to say exactly what we mean. To avoid 'equitable' interpretations of plan language, be specific and detailed."
(Fox Rothschild LLP)
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Equity Cannot Trump ERISA Plan Terms in Health Plan Reimbursement Case
"The U.S. Supreme Court ... strengthened the ability of employer health insurance plans to recoup payments for medical expenses paid for an injured plan participant who later sues to recover damages from a third party.... This decision helps resolve a conflict among the federal courts of appeal over whether principles of fairness, ... can trump a health plan's terms ... The decision also will allow companies to draft their contracts to ensure full reimbursement and to avoid having to pay legal fees." [US Airways, Inc. v. McCutchen, No. 11-1285 (U.S. Supr. Ct. Apr. 16, 2013)]
(Lane Powell PC)
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Supreme Court Upholds Plan Sponsor's Recovery of Participant Damages Award
"As a condition to enrolling in a group health plan, plan participants and beneficiaries may be required to agree that in a scenario where the medical expenses are a result of an injury caused by third parties, any recovery from those third parties must be shared with the group health plan. The plan language could also be explicit about which party bears the cost of the attorneys' fees. The Supreme Court's decision implies that a plan does not have to share in the costs of the participant's lawsuit if the plan provisions expressly state that the plan recovers first, without regard to attorneys' fees that must be paid."
(Leonard, Street and Deinard)
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Help Is at Hand: New Health Insurance Tax Credits for Americans (PDF)
"In order to maximize the number of people who receive the new tax credits, states across the country will need to develop robust outreach programs to educate consumers about this new help. The state marketplaces will need to offer insurance shoppers consumer-friendly, simple online enrollment processes, and they'll need to build complementary networks of assisters who can provide in-person, one-on-one help to anyone who needs it."
(Families USA)
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Want to Cut Health Costs? Show Doctors a Price Tag.
"Providers ordered just over 1.1 million lab tests during the study period, and there was indeed a significant difference when the system displayed price information. For the 30 tests where providers saw cost data, the number of tests ordered dropped from 458,297 to 416,805. That worked out to the hospital spending $3.79 less per person per day on medical tests."
(The Washington Post)
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'Big Data' Contest Looks to Solve Healthcare Puzzles
"Healthcare innovators looking to fuel their big data analytics dreams have a new source of inspiration -- and money. The Care Transformation Prize Series will provide at least three quarterly prizes of $100,000 to the teams that develop the best solutions to challenges to be selected by the public and vetted by a panel of judges."
(HealthLeaders Media)
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Most Health Insurance Subsidies to Aid Working Families
"About 25.7 million people who fall between 138% and 400% of the poverty level -- or below $46,000 for a single adult and $94,000 for a family of four -- will be eligible for funds that will go directly to an insurance plan that they choose. According to the Congressional Budget Office, those subsidies will cost about $350 billion from 2010 to 2019, but taxes and savings built into the law will offset them."
(USA TODAY)
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Doctors Flee Puerto Rico for U.S. Mainland
"A medical exodus is taking place in the Caribbean territory as doctors and nurses flee for the U.S. mainland, seeking higher salaries and better reimbursement from insurers. Many of their patients, frustrated by long waits and a scarcity of specialists, are finding they have no choice but to follow them off the island."
(The Washington Post)
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2012 U.S. Group Disability and Group Term Life Market Survey (PDF)
"This annual survey now covers the Group LTD, STD, Term Life and AD&D industries in a single report, tracking sales and in-force results for 2012. In addition, Voluntary results, Supplemental Term Life premium, ASO, Lapse Rates and Renewal results are provided for companies who reported this information. In all, 32 carriers participated in the survey representing roughly 95% of the Group Disability insurance marketplace, and over 85% of the Group Term Life insurance market."
(GenRe)
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Get Well Soon: It's Health or Consequences
"Among the 83 percent of employers that reported offering incentives for [programs that help employees become more aware of their health status], 79 percent offer incentives in the form of a reward; 5 percent offer incentives in the form of a consequence; and 16 percent offer a mix of both rewards and consequences. Looking ahead, 58 percent of respondents said that, in the next three to five years, they plan to impose consequences on participants who do not take appropriate actions for improving their health."
(Human Resource Executive Online)
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Health Insurance Actuaries in the Hot Seat on 'Rate Shock'
"[A] study published last month by the Society of Actuaries (SOA) [predicted] that ... medical claims per member will rise 32 percent in the individual plans expected to dominate the ACA exchanges next year.... Undisclosed in the SOA report was the fact that about half the people who oversaw it work for the health insurance industry that is warning about rate shock."
(Kaiser Health News)
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Health Reform: A Guide for Employers (PDF)
"This guide highlights the areas of health reform that most impact employers. [It was] developed ... as an employer resource to help you understand the principal changes enacted by the health reform legislation."
(Word & Brown)
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Top Senate Democrat Sees 'Train Wreck' Ahead for ACA
"Senate Finance Committee Chairman Max Baucus, D-Mont. ... is the first top Democrat to publicly voice fears about the rollout of the new health care law ... 'The administration's public information campaign on the benefits of the Affordable Care Act deserves a failing grade,' he told [HHS Secretary Katherine] Sebelius. 'You need to fix this.'"
(InsuranceNewsNet.com)
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Supreme Court in McCutchen: Clear Plan Terms Win Over Equitable Remedy
"[T]he Court affirmed that equitable theories, such as make-whole, common fund, unjust enrichment and double-recovery doctrines should not be allowed to override a plan's clear language reserving its right to full reimbursement for benefits it paid when all other contractual conditions are met. The reason cited by the High Court in its 5-4 decision is that the plan's reimbursement agreement is mutual, whereas after-the-fact carve-outs to protect a plan participant from equitable defenses such as windfall, unjust enrichment, etc., are unilateral."
(Thompson SmartHR Manager)
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Want to Know the Future of Obamacare? Take a Look at Fort Dodge, Iowa
"UnityPoint Health (which was, until this week, named Iowa Health System) is one of the 32 Pioneer Accountable Care Organizations that volunteered to have part of their Medicare payments tethered to a set of quality metrics.... The most difficult part of preparing to move to a system that pays for value rather than volume in Fort Dodge was asking doctors to rethink how they do their jobs. They would be encouraged to delegate relatively routine care, for example, to other advanced practitioners, while focusing their own work on care management."
(The Washington Post)
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Judge Orders Arizona Worker Be Offered Reinstatement, Paid Back Wages and Expenses Under FMLA
"The U.S. Department of Labor's Wage and Hour Division found that DS Waters of America Inc. discriminated against the driver when it failed to reinstate him at the end of an approved FMLA-covered leave period.... The department's investigation determined that ... the successor company had a legal obligation to allow this employee to complete his leave and then restore him to an equivalent position as required by the act."
(Employee Benefits Security Administration)
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The Relationship Between Occurrence of Surgical Complications and Hospital Finances
[Excerpt from summary of findings:] "In this hospital system, the occurrence of postsurgical complications was associated with a higher per-encounter hospital contribution margin for patients covered by Medicare and private insurance but a lower one for patients covered by Medicaid and who self-paid. Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications."
(JAMA; subscription required for full article)
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Senators Question HITECH Implementation, Suggest Delaying 'Meaningful Use' Program
"The report cites interoperability as the key to achieving the efficiencies in health care delivery that have been promised by the meaningful use program and federal grants for health IT projects. But the report questions whether the meaningful use program is focused enough on interoperability rather than one-size-fits-all technology adoption among hospitals and providers."
(Bloomberg BNA)
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Some Families Who Purchased Health Coverage Through The Massachusetts Connector Wound Up With High Financial Burdens
"[F]amilies participating in unsubsidized plans offered in the Massachusetts Commonwealth Health Insurance Connector Authority, an exchange created prior to the 2010 national health reform law, [demonstrated] high levels of financial burden and higher-than-expected costs among some enrollees. The financial burden and unexpected costs were even more pronounced for families with greater numbers of children and for families with incomes below 400 percent of the federal poverty level. those with lower incomes, increased health care needs, and more children will be at particular risk after they obtain coverage through exchanges in 2014."
(Health Affairs)
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Bill Proposes Insurer Fee to Expand Medical Residencies in California
"An Assembly committee yesterday approved a plan to provide a major boost to California's physician-training residency programs by generating roughly $100 million a year with a $5-per-covered-life fee to be imposed on health care insurers. The new bill is one of several legislative efforts to address a provider shortage in California that's likely to intensify when the [ACA] is implemented and Medi-Cal is expanded starting in 2014."
(Kitsap Sun)
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Developing Subannual Estimates of Health Insurance Coverage from the American Community Survey: Challenges and Promising Next Steps (PDF)
"[S]ubannual estimates, whether monthly, quarterly, or semi-annual, would further enhance the value of the ACS to policy, research, and government audiences, as well as to the media and public, by providing more timely updates on health insurance coverage. Subannual estimates would provide a closer link between the timing of state decisions and insurance outcomes, which is particularly important for understanding the relationships between state policy choices under the ACA and health insurance coverage ... [S]ubannual ACS estimates would support a more in depth understanding of state-level insurance trends within and across years."
(Urban Institute)
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[Opinion]
Questions for HHS Secretary Sebelius
"Secretary of Health and Human Services Kathleen Sebelius has been making the rounds on Capitol Hill, testifying in favor of President Obama's proposed budget and generally trying to assure members of Congress that all is well with ObamaCare implementation.... Since everyone else is pestering Sebelius with questions, [here are] some questions [the author] would like to hear her answer."
(Cato Institute)
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[Opinion]
Public and Private Payment of Hospital Complications
"In reporting this JAMA article on surgical complications and hospital finances, headlines throughout the nation are stating that hospitals profit from surgical errors. The story that should be reported is that private insurers have been richly rewarding hospitals for surgical complications, whereas Medicare has largely avoided paying these rewards."
(Physicians for a National Health Program)
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[Opinion]
The Path to Continuously Learning Health Care
"Health care payment policies strongly influence how care is delivered, whether new scientific knowledge and insights about best care are diffused broadly, and whether improvement initiatives succeed. The prevailing approach to paying for health care, based predominantly on paying set fees for individual services and products, encourages wasteful and ineffective care.... Although evidence is conflicting on which models work best and under what circumstances, it is clear that a learning health care system would incorporate incentives aligned to encourage continuous improvement, identify and reduce waste, and reward high-value care."
(Issues in Science and Technology)
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Benefits in General; Executive Compensation
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Germany to Enact Say-on-Pay Rules by Summer
"Debate in Germany gathered pace after Swiss voters on March 4 backed pay limits including a binding annual shareholder vote on executive compensation at listed companies and a ban on big payouts for new hires and for managers when they leave. German opposition parties hailed the Swiss referendum.... [Merkel's party agreed] to seek legislation that would give shareholder meetings of listed German companies the 'mandatory task' of making binding pay recommendations to the supervisory board, according to a government statement at the time."
(Bloomberg BusinessWeek)
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Executive Compensation Design: Some Early Reflections on the 2013 Proxy Season
"So far, it's been a relatively quiet proxy season, with continuing high levels of shareholder support for say-on-pay votes and continuing incremental changes in pay design and pay levels. However, one potentially troubling trend ... is growing conformity, which may call for a shift to more tailored approaches to executive pay."
(Towers Watson)
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[Opinion]
Text of ERISA Advisory Council Report to DOL on Beneficiary Designations in Retirement and Life Insurance Plans (PDF)
"The Council recommends that DOL (1) develop educational materials to help plan participants understand the importance of beneficiary designations, how they work and the importance of updating them when life events occur, (2) develop suggestions and guidance for employers, plan administrators and service providers on how to improve plan design and administrative practices to diminish disputes in the area of payments based on beneficiary designations, and (3) issue guidance for plans, plan administrators and plan fiduciaries in several areas that would aid in the resolution of beneficiary disputes."
(ERISA Advisory Council, via The SPARK Institute)
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[Opinion]
How to Fix Our Broken Proxy Advisory System
"Limit proxy voting requirements of mutual funds and pension funds so that those institutions will be the sole arbiters of when it makes sense to vote using active analysis of the question at hand.... End extraneous proxy requirements such as Say-on-Pay votes."
(Mercatus Center, George Mason University)
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