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Healthcare Reform Update - May 13-19 2010


Email Alert

May 19, 2010

Compiled by Scott Mertie*

Medical Spending Spiking In Once Thrifty Areas
By Jordan Rau
KHN Staff Writer
May 18, 2010

Provo, Utah—If there is any place that should have medical spending under control, this is it.

Residents are among the healthiest in the country. Many are Mormons who don't smoke or drink, and outdoorsy folks devoted to active lives. The biggest hospital is run by Intermountain Healthcare, a medical system lauded by President Barack Obama for providing high quality care while restraining costs.

Until recently, Provo seemed to be a model for the nation. But spending on Medicare patients here has accelerated rapidly, as it has in many other areas of the country also known for cost-efficient care. The region's transformation calls into question initiatives—including some in the new health care law—to encourage more profligate regions to learn from their frugal counterparts.

A major reason: Medicare recipients are receiving certain kinds of surgeries more frequently and are admitted for longer periods to intensive care units during their final days.

"It's very discouraging to see costs increasing rapidly in those low-cost areas we believe to have good care," says Paul Ginsburg, president of the Center for Studying Health System Change, a Washington-based research group. "They appear to be succumbing to the same forces that have led to high costs elsewhere."

Experts say Medicare spending trends often parallel those in the country's overall health system. In 2007, average Medicare spending per person in the greater Provo hospital market was $8,064. That was below the national average of $8,682, but far higher than it had been a few years before.

Between 2000 and 2007, Medicare spending in the Provo region rose on average 8.6 percent a year, nearly double the average national rate of 4.7 percent, according to data from the Dartmouth Atlas of Health Care, which analyzes geographic variations in health spending.

Spending Rises Elsewhere

Provo's spending increases aren't an aberration. Annual average spending grew at 7 percent or more in other traditionally low-cost areas, including Oxford, Miss.; Wausau, Wis;, and Durham, N.C. Even in Rochester, Minn., home of the highly regarded Mayo Clinic, and Salt Lake City, where Intermountain is headquartered, Medicare costs grew faster than the national average, according to Dartmouth. On their own, these areas aren't big enough to bankrupt Medicare. Still, the spending increases are particularly worrisome in places such as Provo where many providers have already made changes experts hope can hold down costs. These include adopting electronic medical records, focusing on prevention and increasing cooperation between doctors and hospitals. But Harvard professor Michael Chernew noted in a recent article that "even the most efficient delivery systems must wrestle with the adoption of expensive new technologies." Indeed, Provo's regional hospital market, which stretches south of Salt Lake City down the Wasatch mountain range and includes more than 26,000 Medicare beneficiaries, has embraced some of the less admired traits of expensive health care markets, with dueling providers competing to offer the same kinds of high-tech services.

"The first surgical center in Utah County was built by a physician from the hospital," says Rulon Barlow, a former county health board commissioner who runs the student health center at Brigham Young University in Provo. "So what did the hospital do? It built a surgery center. It wasn't too much longer that another outfit came in across the street."

Much of this kind of rapid expansion is fueled by the Medicare's traditional fee-for-service payment system, which rewards doctors who offer more services, health care experts say. Patients, for their part, seem only too happy to get the latest that medical technology has to offer, as close to home as possible. Physicians in the Provo region performed 17.3 percent more procedures on Medicare patients in 2008 than they did in 2000, outpacing the median national increase of 13.7 percent, according to a Government Accountability Office study.

The largest physician-owned practice in the state is the Provo-based Central Utah Clinic, which has grown fivefold over the decade and now houses more than 110 doctors, mostly specialists. Last year, it earned gross revenues of $200 million, clinic administrator Scott Barlow says, and its doctors saw 208,000 patients. That's a remarkable number given that only 556,000 people reside in the Provo-Orem metropolitan area.

Central Utah Clinic's sprawling campus, which sits across the street from Intermountain's Utah Valley Regional Medical Center, has opened its own open heart program, chemotherapy center and a high-dose radiation machine so powerful that it operates behind 70,000 pound steel doors in a room called "the vault." The clinic is home to some of the only providers in the area in a number of specialties, including cardiology.

The physicians have attempted to make it a one-stop shop for patients, even building a pharmacy on the lot. The physician-owners benefit financially from the use of these machines and facilities (except the pharmacy, which Utah law prohibits them from owning), but the clinic's officials insist they guard carefully against performing unneeded procedures. Dr. Scott Bingham, a cardiologist at the Central Utah Clinic, says area cardiologists have been performing fewer of the most expensive tests and surgeries in the last few years, which Dartmouth has not yet analyzed. "The only thing that I see increasing in Provo is the number of patients we see," he says. Competitors are skeptical. "The gastroenterologists owning their own CT scanners, the oncologists owning their own radiation machines," says Dr. Wendell Gibby, a radiologist who owns his own imaging clinic. "If you've got a million dollar scanner, you end up using it," he says.

Intermountain also faces competition from HCA, the for-profit hospital chain. In 1998, HCA, welcomed into the area by commercial insurers feeling captive to paying whatever Intermountain charged, built Timpanogos Regional Hospital in Orem, the city just north of Provo. HCA also owns a hospital in the south. Timpanogos opened its own heart surgery program in 2007, and last year added two stories on top of the existing two floors. Dr. Mike Kennedy, a family doctor and the chief of staff at Timpanogos, speculates that the area's higher Medicare costs are due to better care. "You're probably seeing more aggressive treatment earlier on in disease stages," he says. "If we want excellent care, it's going to cost excellent money."

"Trying not to cave"

To some, it's inevitable low-cost areas such as Provo will catch up to their more expensive peers as a greater proportion of medical spending goes toward expensive machines and nursing salaries, which are rising, says Greg Poulson, senior vice president at Intermountain. Aggressive marketing of the latest technology also is making it more likely that patients everywhere are demanding the same novel treatments, even ones that aren't proven to work better, Poulson says. "We're seeing a homogenization of practice," Poulson says. He says "at Intermountain we're trying not to cave into things that we think are value diminishing. An example that I find frustrating is the use of robotics for surgery."

Yet Intermountain has embraced the technology, too, announcing in 2008 that its surgeons in Salt Lake City "performed the first robotic surgery using the most advanced robotic surgical system in the world that utilizes 3-D technology and high definition (HD) vision that virtually extends the surgeon's eyes and hands deep into the surgical field." Utah Valley Regional has been busy growing in many areas. It's added four MRI machines; expanded its intensive and critical care units; upgraded its trauma center; doubled the size of its emergency room; and built an outpatient center.

Amid all this new construction, Medicare patients in the region have been getting more and more medical attention. Dartmouth data covering 2000 through 2005 show some treatments were performed more frequently in Provo while decreasing nationally. Those included operations to clear blocked leg arteries and replace heart valves. Repairs of aortic aneurisms and hospitalizations for hypertension and asthma also rose faster than the national average. While many procedures are still performed less frequently than elsewhere, a Dartmouth study released in April singled out Provo for having the highest shoulder replacement rate in the country.

Commercial insurers say prices in Provo and the rest of Utah still remain lower than the national average. But some experts say that could change, too.

"We take some comfort that we have less of problem in Utah than elsewhere," says Dr. Kim Bateman, vice president for medical affairs at HealthInsight, a Salt Lake City-based nonprofit that Medicare has authorized to find ways to improve the quality of care in Utah and Nevada. "But really I think we're just behind them on the same curve—that we're going to be subject to the same kinds of cost pressures as everyone else."

New Health Law Throws Lifeline to "Uninsurables"
By Michelle Andrews
May 18, 2010

If you're sick—or have ever been sick—and can't get insurance, the new health-care law promises fast relief: access to guaranteed coverage through a special federally funded insurance program starting in July. The goal is to provide comprehensive and affordable coverage to more people.

But as the starting date approaches, uncertainties abound. Details have yet to emerge about the costs and benefits of the "high-risk pools" to be set up under the program. Not everyone who qualifies will be able to afford the premiums. And while many states have said they will set up their own pools, with help from Washington, others have balked, opting to let the federal government run the program in their states.

Debra Keown, a 52-year-old resident of Kalamazoo, Mich., is the type of "uninsurable" person who might be helped by the new program. A lung cancer survivor with severe asthma, she and her husband, 50-year-old Kerry, have been without insurance since his concrete-construction company dropped their coverage nearly two years ago, then laid him off several months later. Even if they could afford health insurance on his unemployment check, no private insurer would accept them because of their preexisting medical conditions.

Keown has cobbled together some of the care she needs: A local specialist treats her asthma for free, and she gets Advair, an asthma medication, and an emergency inhaler at no cost through manufacturer programs for the needy. But she's paying out-of-pocket for three other medications, and she has cysts on her breast, kidney and ovary that need to be checked. She's interested in the new insurance program but fears she won't be able to afford the premiums.

"We live paycheck to paycheck," she says. "We're never late on rent, but there's not much left after that." Thirty-five states already run high-risk pools for people who can't get insurance because of health problems such as heart disease and diabetes. About 200,000 people are enrolled, but many others can't afford the premiums. In the existing pools, premiums are sometimes twice as high as the standard rates that commercial insurers charge for individual policies. Premiums in the new pool will be limited to the standard rate.

That doesn't mean coverage under the new program will be cheap: Premiums could still amount to several hundred dollars a month. As a result, the high-risk pools "won't be an effective strategy for a lot of people," Health and Human Services Secretary Kathleen Sebelius acknowledged in a recent speech.

The health-care overhaul law provides $5 billion for the new program—both for pools administered by the states and ones set up by the federal government—to help pay the costs of coverage, holding down premiums for consumers.

Many policy experts, however, believe the amount won't be sufficient to fund the pools until they shut down in 2014. (At that point, insurers will be barred from turning away people or charging them more because of health problems.) "Nobody believes that the $5 billion is enough to cover a significant number of people for four years," says Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network. Twenty-nine states have said they'll run the new high-risk pools themselves, either by incorporating them into their existing pools or by setting up separate pools that meet the new standards, while 19 have said they'll let the federal government do the job.

One reason some states give for refusing to run their own pools is that they fear $5 billion isn't enough and they'll be forced to come up with more money to ensure affordable coverage.

There's another potentially dicey issue that's looming. Under the new law, people must be uninsured for six months before signing up for the new pool—a restriction, experts say, that's intended to target help to those who need it most. But the upshot is that members of existing state pools won't be permitted to switch to the new ones, where coverage will likely be cheaper and more comprehensive.

Given the potential for confusion, not to mention dissatisfaction among those already in a pool, some states have decided "it'll be easier if we just let the feds do it," says Sandy Praeger, the Kansas insurance commissioner. Some states, however, are eager to set up their own pools. In Maine, there's no existing high-risk pool because the state already guarantees insurance coverage, including to people with medical problems. Officials hope to open up the state-run Dirigo health plan to people who would be eligible for coverage under the new federal law. "We have a proposal that would allow us to start serving people in August," says Trish Riley, director of the governor's office of health policy and finance.

In Kansas, the managers of the existing pool say they could have a new one up and running in July. Much will depend on HHS rules, Praeger says, adding, "The devil is in the details, as always."

Insurance Regulators Wrestle With Definition Of "Unreasonable" Rate Increases
By Julie Appleby
KHN Staff Writer
May 17, 2010

When Wellpoint proposed up to a 39 percent premium increase for some of its California customers, it touched off a storm of criticism that helped boost passage of the new health care law. Now, state and federal officials are wrestling with how to define "unreasonable" premium increases, a thorny issue Congress has handed regulators.

The definition is critical because the law requires review and justification for premium increases deemed unreasonable, starting this year. Federal regulators do not have authority to outright deny rate increases, although the provision could help them pressure insurers to hold down premiums.

But just what is unreasonable? While consumers might object to any increase over the rate of inflation, that's likely too simple a test to make it into final regulations.

Even the National Association of Insurance Commissioners, representing appointed and elected state regulators, could not reach consensus on a single definition. Instead, the NAIC sent a letter last week to the Department of Health and Human Services suggesting 11 options for defining a "potentially unreasonable" premium increase.

"We didn't think it would be reasonable to have a discussion on whether X is 2 percent or 10 percent or 30 percent, but to say, here are the alternatives," said Julia Philips of the Minnesota Department of Commerce, during a call Tuesday with NAIC members studying the issue.

The association is playing a key role in helping shape these and other regulatory issues arising under the new law, including consulting with HHS on how insurers calculate and report the amounts they spend directly on medical care.

Under the law, states retain authority to oversee health insurance premiums. Regulation now varies widely: Some states review rates and may deny increases before they go into effect, the NAIC letter said. Others allow insurers to put new rates into effect and examine them only if questions are raised. States also differ on the types of insurance regulated. Typically, they do not review rates for large, self-insured employers, which pay medical bills themselves. Those employers are also exempt from the rate review regulations in the new federal law.

Insurers say many factors determine premium increases, primarily how much insurers must pay doctors, hospitals and drug companies. They also consider how long customers hold their policies: As customers age or fall ill, they become more expensive. Many insurers, including Wellpoint, blame rapidly rising health care costs for recent double-digit premium increases. The insurer withdrew its proposed rate increases after a special review uncovered incorrect estimates of future costs.

America's Health Insurance Plans, the largest industry group, has warned NAIC against adopting a definition that is "arbitrary."

It encouraged regulators to evaluate whether a rate is "reasonable," based on such factors as an insurer's ability to pay estimated claims costs.

On the definition of unreasonable, the NAIC letter to HHS said that, in the states that review rates, most simply look at all rate increases, not just those that fail some sort of test. Special consideration is sometimes given to newer or smaller insurance companies, the NAIC said, because they may need larger increases to offset start-up expenses or higher-risk policyholders who have big medical costs.

Still, the NAIC offered federal regulators a number of options for flagging "potentially unreasonable" increases. Those included: Average increases above a certain percentage; those that exceed the consumer price index by a particular percentage; rates that cause an insurer to lose money, but gain market share, and those aimed at covering excessive administrative costs.

In hesitating to pick one standard or a certain percentage, Philips noted that even a zero increase might be unreasonable, if an insurer was at the same time cutting benefits offered in the policy.

The letter also noted several "practical considerations" regulators will face:

  • Tough review of rate increases might increase year-to-year variability if rejection of an unreasonable increase leads an insurer to lower rates one year, then boost rates far more the next.

  • States may have to review their own laws for consistency once the secretary of Health and Human Services decides upon a nationwide definition of unreasonable.

  • Existing policies sold to individuals and small businesses are exempt from premium rate review because they are "grandfathered" under the law so long as substantial changes aren't made to them.

Coming up with a definition of unreasonable—along with some of the other standards called for by the new law—is difficult in part because insurance plans and current state rules vary so much, said Kim Holland, Oklahoma's insurance commissioner.

"One of the greatest challenges we will encounter is developing uniformity without trying to force everything into a one-size-fits-all," Holland said.

Lobbyists Have Long Wish List For New Health Rules
By Julie Appleby, Mary Agnes Carey, and Phil Galewitz
KHN Staff Writers
May 14, 2010

Now that the health care bill is law, an array of groups—representing doctors, insurers, small businesses and others—have switched to their post-passage game plans. Among their top goals: Helping shape the all-important regulations being written by the Obama administration. Here's a sampling of their priorities and who will be pushing them.

Group: National Federation of Independent Business Represents: 350,000 small businesses
Making The Case: Amanda Austin, director of federal public policy Priority: Simple tax credit rules and flexibility

Many small businesses are eligible this year for tax credits to help pay the cost of insuring workers. But if getting the credits is too complicated then the tax breaks "might as well not exist," Austin says. Business owners also want flexibility and clarity on a "grandfathering" clause that exempts existing policies from some new rules that could add to the costs of insuring workers, as long as the businesses don't make significant changes in their policies. "If a business owner changes a deductible," she asks, does that mean that the policies aren't grandfathered?

Group: AARP, the biggest seniors' group with 40 million members
Making The Case: Nancy LeaMond, executive vice president of social impact
Priority: "Doughnut hole" money, coverage for the uninsured

The government begins to close the so-called doughnut hole, or coverage gap, in the Medicare drug plan with a $250 payment this year to participants. Checks are scheduled to go out in June, a fast-approaching deadline AARP will be watching. AARP also will be monitoring how benefits are defined in a new temporary insurance plan for people who have been denied coverage for health reasons. Given that Congress has set a $5 billion limit on the federal contribution to the plan, officials have to strike a balance between giving a lot of people a little coverage and giving a few people a lot of coverage.

Group: American Nurses Association
Represents: About three million registered nurses
Making The Case: Michelle Artz, chief associate director, government affairs
Priorities: Expanding nurses' responsibilities

With more Americans getting insurance amid a growing shortage of primary care physicians, nurses want to take on a larger role in providing medical care. Nurse practitioners will be permitted under the new law to direct medical teams in a demonstration project providing home-based care to Medicare beneficiaries with chronic diseases. Nurses want similar authority in areas where their training and state laws permit, such as in "medical homes," which are primary care practices designed to coordinate patient services. "We want to make sure that nurses are recognized appropriately as providers of services that they are educated and trained to do and is within their scope of practice," says Artz.

Group: Families USA
Represents: Consumer groups
Making The Case: Ron Pollack, executive director
Priorities: Aggressive enrollment of consumers

Enroll America, a new initiative led by his group, is working with drug makers, hospitals, insurers, physicians and others to make it as easy as possible for Americans to enroll in Medicaid or sign up for subsidies and private insurance. The group is pushing for enrollment sites at hospitals and community health centers, and for application forms that are readily understood and printed in a variety of languages. "There's been so much mythology" about the bill, he says. "The more people understand the specific provisions in the legislation, the more they are actually going to like it."

Group: National Governors Association
Represents: The nation's governors
Making The Case: Kathleen Nolan, health division director
Priorities: Guidance on high-risk pools; authority to experiment

A new federal program to offer coverage to people who are uninsured because of medical problems must be set up by the end of June. Twenty-eight states and the District of Columbia have elected to run their own programs, called high-risk pools; in other states, the federal government will create one. "Even as we speak, states are having to make decisions about this, but there's very little information about how the (new program) will work and who is on the hook for it," says Nolan. Down the road, NGA wants states to have broad authority to try new ideas for, say, cost control or quality improvement, across several programs: state employee plans, Medicaid and exchanges where insurers will market policies.

Group: America's Health Insurance Plans Represents: Approximately 1,300 health insurers
Making The Case: Karen Ignagni, president and chief executive officer
Priorities: Spending requirements, benefits design

New rules requiring insurers next year to spend at least 80 percent of premiums for medical benefits for patients—as opposed to administration and profit—could cause problems in the individual market, Ignagni says. That's because of the cost of payments insurers make to sales agents who sell the policies on their behalf. Some are multi-year agreements that could still be in place when the 80 percent requirement begins. "You just can't tear up those contracts," Ignagni says. And when the health insurance exchanges begin in 2014, insurers want the package of benefits to be comprehensive but not make insurance so expensive that it's unaffordable.

Group: American Hospital Association
Represents: More than 5,000 hospitals and health care systems
Making The Case: Linda Fishman, senior vice president for public policy analysis and development.
Priorities: Insurance exchanges; Medicaid payment rates

Hospitals want a say in how state-based insurance exchanges are set up in 2014. The exchanges are marketplaces where individuals and small businesses can buy coverage. How many insurers are approved to sell in an exchange, and rules governing benefits and other issues, ultimately can affect hospitals. That's because insurers negotiate with hospitals over payment rates and participation in provider networks. Hospitals also want to boost payment rates for Medicaid, the state-federal program for the poor, which will be greatly expanded. Currently, Fishman says, the program pays hospitals an average of 88 cents for every dollar of medical costs.

Group: American Medical Association
Represents: About 250,000 doctors
Making The Case: Dr. J. James Rohack, president
Priorities: Medicare spending board; physician payment cuts

The AMA wants to make sure that a new panel created to recommend ways to control Medicare spending doesn't result in physician pay cuts; Rohack says they would hurt patients' access to care. The group has been battling for repeal of an existing pay formula that has repeatedly called for cuts in doctors' pay. Congress steps in almost every year to block the cuts, but the situation remains a major sore point with physicians. The AMA also will urge regulators to help simplify physicians' dealings with insurers, hoping to cut costs. And it wants to weigh in on the design of pilot programs to explore alternatives to medical liability lawsuits.

Health Law Guarantees Protections For Emergency Room Visits
By Maggie Mertens
May 13, 2010

When Kelly Arellanes fell off a horse and suffered a severe head injury in rural Arkansas, medics said she would need to be airlifted immediately to the nearest hospital—150 miles away in Fort Smith. There, emergency surgery saved her life—but at a cost.

The hospital wasn't in her insurance network, so she and her husband ended up with $20,000 in out-of-pocket expenses that they wouldn't have incurred at their network hospitals 150 miles away in Little Rock. Under the new health law, insurance companies must extend several new protections to patients who receive emergency care. One of the biggest guarantees: Patients who need emergency treatment will have their costs covered at the same rate, regardless of whether they are treated at "in-network" or "out-of-network" hospitals.

The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the "prudent layperson" rule. For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense. The provisions go into effect for every health plan issued after Sept. 23—six months after the law was enacted—that offers emergency coverage.

For years, insurance plans have been denying ER claims for a variety of reasons. Although there is little data on the overall scope of the problem, a 2004 RAND Corp. study found that at least one out of every six claims for emergency department care was denied by two large HMOs in California.

One Hour To Live

When Kelly Arellanes' husband, David, and daughter, Jo, rushed by car to the hospital after the accident six years ago, the neurosurgeon gave them two options. "He said, 'You need to make a decision: either we go into emergency neurosurgery now and save her life, or we don't and she'll have an hour to live,'" David recalled.

Kelly, who had a portion of her brain removed that day, has since then learned how to speak, eat and walk again. The Arellanes' finances haven't fared as well. David and Kelly had health coverage through their jobs at Southwestern Bell Telephone Co., now part of AT&T, one of many large corporations that is self-insured. In such plans, the employer sets the benefits package and pays workers' claims and benefits itself. Southwestern Bell's plan was administered by United Healthcare.

According to the plan's 2004 policy guidelines, provided by David Arellanes, emergency claims incurred at an in-network hospital were completely covered, while those at an out-of-network hospital were covered at the "non-network" rate of 80 percent, unless patients contacted their primary care provider within 24 hours.

Arellanes, 56, said he did call to report the accident within the designated period, but that was disputed in an appeals process. Originally, the plan denied coverage for many of the emergency bills, Arellanes said, but after he appealed, it picked up 80 percent of most of the expenses.

Kelly, now 50, has gone through intense rehabilitation and needs tests and checkups every few months. Without her salary and battered by the bills from the emergency room and continuing medical costs, the family burned through their savings, retirement accounts, investments and their daughter's college fund. With medical debts of more than $100,000, they filed for bankruptcy in 2005.

AT&T and United Healthcare would not comment on Kelly Arellanes' case because her family did not give permission to make her medical file public for comment. Her current plan through AT&T has different rates of emergency care coverage, depending on whether the hospital is in network. Under the new law, that will no longer be allowed.

Reluctant To Seek Care

The inclusion of coverage guarantees for emergency care in the new law "was a major victory for us," said Angela Gardner, president of the American College of Emergency Physicians. "People often can't stop to check to see if a particular hospital or doctor is in- or out-of-network when they are having an emergency," she said.

Research suggests concerns about costs can keep people from going to the emergency room. A recent study in the Journal of the American Medical Association found that insured patients without financial concerns were more likely to seek emergency care within two hours, but almost half of uninsured patients or patients with financial concerns waited six hours or more to seek care.

A spokeswoman for the insurance industry, however, said problems with emergency coverage are not widespread and the law's provisions generally follow what insurers already offer in their own plans. "I do not think this represents a major change for our members," said Susan Pisano, a spokeswoman for America's Health Insurance Plans. "It is already the standard most places now, if not universally," she said.

Consumer groups disagree. Cheryl Fish-Tarcham, deputy director of health policy at Families USA, a nonprofit consumer health advocacy group, said that since some states don't have regulations on the issue, the federal law will set a uniform standard.

Yet, even when states do have such laws, there have been consumer complaints about insurance company practices. For instance, last December, Pennsylvania insurance officials, working with the state attorney general, determined that 631 consumers had their emergency claims improperly denied between 2001 and 2007 by HealthAmerica, a Pennsylvania-based insurer. The company settled with state officials, admitting no wrongdoing but agreeing to reprocess the claims.

"The federal law gives us more teeth to enforce what we already thought was the right thing to do," said Dan Honey, Arkansas's deputy insurance commissioner.

*We would like to thank Scott Mertie, Esquire (Kraft Healthcare Consulting LLC, Nashville, TN), for selecting the articles for this week's update.

This information was reprinted from with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.

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