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  • AMA Issues Top 10 Least, Most Competitive States for Insurance

    The American Medical Association's (AMA) latest ratings of health insurance competitiveness across the United States finds that in 17 states, a single health insurer commands 50% or more of the market in each state, and that in 45 states 2 insurers have captured over half or more of each state’s share.

    The AMA's Competition in Health Insurance: A Comprehensive Study of US Markets (summary available for free) uses commercial enrollment data from 2012 to create lists of the country's most and least competitive states for insurance companies, and to assess competitiveness in 388 metropolitan areas.

    The 10 least-competitive states are, in order, Alabama, Hawaii, Michigan, Delaware, Louisiana, South Carolina, Alaska, Illinois, Nebraska, and North Dakota. States that have the most competitive markets are, in order, Oregon, Wisconsin, Pennsylvania, New York, Colorado, Missouri, Washington, Ohio, California, and Florida.

    The AMA analysis of metropolitan areas found a "significant absence" of competition in 72% of the areas studied, and identified a single insurer as capturing 50% or more of the market share in 41% of the areas.

    Overall, Wellpoint Inc was found to be the largest insurer in most markets, with a "commanding position" in more than 20% of metropolitan areas—more than double the number of the next 2 largest insurers, Health Care Services Corporation and UnitedHealth Group.

    Carmen Elliott, senior director of payment and practice management at APTA, thinks the shrinking competitiveness contributes to a larger picture of insurers looking to reduce costs and control utilization.

    "The lack of competition is a reality," she said. "At the same time, insurers are trying to keep costs down by doing things like narrowing the network of providers covered by the system, increasing copays and deductibles, and implementing utilization management programs. The insurers argue that some of these efforts, like the shift of a greater payment burden to patients, will make consumers more accountable around health care costs and lifestyle choices, but the real challenge is to reduce costs while ensuring high-quality care. That can be a difficult balance."

    Keep up with the insurance industry as it continues to evolve. Check out the APTA Private Insurance webpage to find resources including toolkits, videos, podcasts and FAQs on topics ranging from payment methodologies to patient and client advocacy.

    'Severe' Restriction on Compression Devices on Indefinite Hold

    A planned change to Medicare coverage of pneumatic compression devices (PCDs) that would have severely restricted patient access to the devices at home has been put on indefinite hold, thanks in part to the efforts of an alliance that includes APTA.

    Had it been implemented, the final local coverage determination (LCD) would have imposed restrictions for PCDs that would only allow their use after a 6-month period of "chronic and severe" lymphedema, and would have attached other requirements including the presence of lymphedema into the trunk or chest, the use of manual lymphatic drainage prior to PCDs, and the use of medications. Additionally, the new policy would have denied PCDs to patients who experience any kind of improvement through conservative therapy. The requirements were set to become effective on November 1.

    In an October 13 statement to the Medicare Durable Equipment Medicare Administrative Contractors (DME MACs) responsible for the change, the Alliance of Wound Care Stakeholders wrote that "many of the new requirements have no basis in either published medical literature or professional standards of practice," and that the proposed LCD "virtually eliminates access to medically necessary equipment for a significant portion of Medicare beneficiaries" who need the devices for treatment of lymphedema and venous ulcers. APTA is a member of the alliance.

    The alliance also asserted that the final policy released in October was "significantly different" from the draft policy released in 2011, and that no additional public comment period was provided.

    On October 16, the DME MACs announced that the change would be placed on indefinite hold. The brief announcement stated only that "Additional clinical information published since the release of the draft policy is being reviewed."

    "This is a significant victory for beneficiaries who need PCDs and the physical therapists who are providing treatment," said Gillian Leene, JD, senior regulatory affairs specialist at APTA. "In the end, the alliance was able to halt a policy that not only lacked support in medical literature, but also would have been damaging to patients and severely restricted access to an effective home treatment option for this progressive and chronic condition.”