PORTLAND, Ore. – Ha sido un año de sucesos emblemáticos para Health CO-OP de Oregon, la organización no lucrativa creada bajo la Affordable Care Act (Ley de Cuidado Asequible) como alternativa a las aseguradoras tradicionales. Primero, el organismo recibió 57 millones de dólares en abril, para iniciar operaciones; en junio contrató un nuevo director ejecutivo CEO; y se ha dedicado a desarrollar nuevas políticas de seguros, con base en sondeos de opinión levantados por todo el estado.
Oregon obtuvo este mes la aprobación federal necesaria para “Cover Oregon”, la nueva opción comercial de seguros médicos que ofrece a los individuos y a los pequeños negocios una alternativa para comparar y comprar seguros de salud. Además de las pólizas tradicionales de seguros, las personas interesadas encuentran nuevas opciones. Este año, los directivos de Health CO-OP de Oregon han invertido mucho tiempo investigando qué esperan los oregoneses de su seguro médico. El Dr. Ralph Prows, Director Ejecutivo de Oregon Health CO-OP, dice que la lista de indispensables de los entrevistados incluye simplicidad, buen servicio al cliente y precio accesible.
“Pero además del puro precio, realmente les interesa un plan de salud que equilibre la promoción de la salud y el bienestar, de tal manera que sea al menos equivalente al énfasis que pone en sólo cubrir los servicios médicos básicos. Así, la promoción de la salud y el bienestar es un magnífico trato.”
El término “CO-OP” son las siglas en inglés de Planes Orientados y Operados por los Consumidores (Consumer Operated and Oriented Plans), que es una organización sin fines de lucro; dos tercios de los directivos también serán usuarios de CO-OP.
Prows dice que una manera de que los planes de CO-OP mantengan bajos los precios es cambiar la manera en que se manejan las reclamaciones de seguros.
“Actualmente gastamos 20 dólares por cada reclamación, en mucha complejidad administrativa innecesaria. Podemos organizar un sistema mejor que eso, que elimine el desperdicio y la naturaleza incómoda de nuestro proceso de facturación y pago.”
Prows agrega que el intercambio “Cover Oregon” está en buena forma, comparado con otros estados que fueron lentos ante la posibilidad de adoptar la Affordable Care Act (Ley de Cuidado Asequible). La inscripción comienza en octubre del año próximo, para coberturas a partir de enero del 2014. Él dice que entre hoy y esas fechas las aseguradoras estarán muy ocupadas.
“Hay toneladas de trabajo por hacer para asegurarse de que todo esto fluya adecuadamente y que el consumidor pueda tomar una decisión con base en información que le sea presentada de manera sencilla y clara. En esto vamos considerablemente más avanzados que cualquier otro estado. Es fácil subestimar lo complicado que es organizar bien todo esto.”
Sitio Web de CO-OP: ORHealthCO-OP.org. Sitio Web de Cover Oregon: CoverOregon.com.
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A recent report examined how some rural Tennessee hospitals have managed to stay afloat despite financial challenges.
The report includes interviews from staff at five different rural hospitals, which range in size from 25 to 125 beds.
Judy Roitman, executive director of the Tennessee Health Care Campaign, said some of the hospitals are drowning in uncompensated care. She explained as part of their research, they did an interview with a CEO from a rural hospital in Kentucky who expressed the importance of Medicaid expansion.
"Kentucky has expanded its Medicaid program and Tennessee has not," Roitman pointed out. "He said that's the key to our stability is actually having the funds coming in to treat these patients. And the CEOs and others in Tennessee hospitals said it would make a huge difference to have that federal funding."
Roitman added the federal government is offering Tennessee a nine-to-one match. If Tennessee were to expand Medicaid, at least 330,000 people would gain access to coverage.
Roitman pointed out the report suggested further steps hospitals could take, including examining how they are reimbursed for services provided. She noted private insurance plans tend to provide the highest reimbursement rates, and said more funding is needed to support TennCare, which does not cover enough of the cost.
"TennCare is all managed by managed-care organizations," Roitman explained. "They negotiate with every hospital about how they're going to reimburse and the big hospitals have some leverage to demand better payment and the smaller hospitals are just, they're just not getting paid."
Roitman added the report credited strong community engagement and effective hospital leadership as key factors in staff retention. Robust management and maintaining an engaged workforce significantly affect a hospital's viability, according to the report.
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Medicare and Medicaid are key sources of health coverage for many Americans and some people qualify for assistance under both programs. With lagging enrollment for the unique plans, outreach efforts are underway.
According to KFF Health News, only about three in 10 people who qualify for Dual-Eligible Special Needs Plans were enrolled in 2021. Experts said the option is designed for people who need additional help because of disabilities, certain health conditions or their age.
Dr. Gina Williams, associate medical director for UnitedHealthcare, said the plans try to take a dynamic approach to serving those eligible.
"Everything from managing your wellness to managing your behavioral health needs and then everyday needs," Williams outlined. "It's kind of a more comprehensive package for people who need a little bit more support."
Everyday needs include meal benefits and bathroom safety devices. The National Council on Aging said D-SNPs aim to provide a more streamlined coordination of care because there is assistance in arranging the services. Wisconsin's enrollment numbers are similar to the national rate, at 28%.
Christine Huberty, lead benefit specialist and northern region supervising attorney for the Greater Wisconsin Agency on Aging Resources, said a tricky component of the plans is navigating provider network restrictions. A rural resident might have to travel farther to see a doctor covered under the plan and she cautioned it warrants careful research when enrolling.
"I would say first and foremost, look at the provider network restrictions," Huberty advised. "Look at what's available in your area."
Meanwhile, Williams noted the push to get more eligible people to sign up coincides with more awareness around preventive care in a post-pandemic world.
"Everybody's kind of going into a phase where they're not only thinking about acute illness, but they're thinking about overall care," Williams observed. "What was the impact of the pandemic from a psychological standpoint? Do you need more support and then you also need more coordination of benefits?"
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In Mississippi and across the country, Community Health Centers are getting a funding increase, thanks to Congress passing a bipartisan spending package.
Community Health Centers in Mississippi serve patients without regard to their insurance status or ability to pay. More than 20 locations in the state provide medical care to more than more than 380,000 people.
Joe Dunn, senior vice president of public policy and advocacy for the National Association of Community Health Centers, said roughly one in 11 Americans gets their care from this type of clinic.
"Community Health Centers are the largest primary care network in the nation, providing care for 31 million Americans," Dunn pointed out. "This network is critically important, because they provide primary care, behavioral health, dental; just an array of services that are so critically needed."
Dunn emphasized more can be done. Research shows more than 100 million Americans need better access to primary care. Community Health Centers in Mississippi also support more than 4,000 jobs and about $678 million dollars in economic activity in the communities where they're located.
Dunn noted the increased funding from Congress will help the clinics provide more comprehensive care and reach more underserved patients, especially in rural communities, which ends up saving the state money.
"By incentivizing people to go get primary care, you alleviate more downstream costs," Dunn emphasized. "There's fewer hospitalizations and complications from chronic conditions, based on preventive screening and care at the outset."
The Congressional Budget Office reports the increase in funding for Community Health Centers just through the end of this year will reduce federal spending on public health insurance programs by more than $700 million.
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