Two divergent Circuit Court rulings last week on the legality of ACA subsidies could spur the Supreme Court to consider the case, with potentially lethal implications for the law’s mandates.

The Affordable Care Act provides for subsidies, or tax credits, to qualifying individuals purchasing healthcare plans on an online exchange. These subsidies have since been given to consumers on both state-run and federal exchanges, greatly increasing the ability of those individuals to purchase coverage that would otherwise be too expensive.

In two separate cases, Halbig v. Burwell (D.C. Circuit panel) and King v. Burwell (Fourth Circuit, Texas), judges considered whether the ACA’s rule on subsidies is applicable to all qualifying individuals or only those who purchased their insurance on state-run exchanges. Last Tuesday, each court handed down a decision based on its interpretation of the rule in question.

The Fourth Circuit ruled that the subsidy should be available to all consumers, whether their state’s exchange was state-run or federally administered. Their ruling is based on the legal doctrine of deference, which allows federal agencies to carry out a law as it sees fit if the language is ambiguous. The D.C. Circuit, however, relied on a literal reading of the law’s text to limit subsidy qualification to only the states that run their own exchanges.

Before the issue proceeds to the Supreme Court, the Department of Justice will request a review of the ruling by D.C.’s three-judge panel by the entire D.C. Circuit bench. It is possible that an en banc review will overturn the panel’s decision and bring the ruling in line with the Fourth Circuit.

This ruling has critical implications for not only the availability of subsidies, but also the individual and employer mandates of the ACA. Only 14 states chose to create their own healthcare exchanges; if the Supreme Court steps in and upholds the original D.C. ruling, as many as 90 percent of individuals in the other 36 states lose access to an affordable health care option.

Those who will be unable to purchase an affordable plan will also be exempt from the individual mandate, including the significant demographic of young and healthy consumers that are necessary to balance insurance costs. Furthermore, employers in the affected states may be exempt from their mandate.

As with other provisions of the ACA in dispute, it will likely be some months before there is a concrete decision. We will provide updates as they become available.

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Several months ago, Senator Mark Begich (D) of Alaska proposed that the Obama administration add a new tier to the Affordable Care Act’s available healthcare plans. While the administration and other legislators weigh the benefits, significant potential issues have presented themselves.

The new “copper” plans would feature lower premiums than those for bronze plans – currently the least expensive full coverage available – and would cover 50 percent of consumers’ health costs. Patients would be required to pay the balance out of pocket. Copper plan subscribers would likely have a higher spending limit on out-of-pocket expenses than the current $6,350 individual/$12,700 family cap but would also be eligible for tax credits and subsidies.

Higher out-of-pocket costs are just one major concern with the idea of copper-level plans. Another associated issue is whether copper plans would be able to offer lower prices and still offer the comprehensive coverage required by the ACA. Jay Angoff of the Department of Health and Human Services questions whether passing on half of the cost of care to consumers can legitimately constitute “decent coverage”.

Furthermore, enrollment statistics through the March 31 deadline this year indicate that consumers are not particularly fond of low premium-high deductible plans. Approximately 65 percent of consumers chose subsidized or unsubsidized silver plans in the marketplace, while only 20 percent enrolled in bronze plans. Enrollment in catastrophic plans was even lower, at only two percent.

Copper plans would also pose a threat to healthcare spending in facilities and systems, turning back the reductions in spending reported by many systems thanks to newly enrolled patients. As copper plans are meant to attract young adults and others who have found even the bronze plans to be unaffordable, the risk of defaulting on higher deductibles is akin to the risk of non-payment by uninsured patients.

If the administration allows the creation of copper plans, consumers should expect to wait until at least the 2016 enrollment period to see these plans for purchase on the marketplace.

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As health insurance companies begin establishing premium rates for the 2015 enrollment year, some insurers are pursuing substantial hikes while others are proposing modest increases and even some reductions.

Increases proposed by CareFirst in Washington, D.C. range from as little as four percent for higher-tier plans to more than 24 percent for a catastrophic plan. Other providers are also proposing mixed updates to increase certain plan premiums and reduce others. At the same time, UnitedHealthcare is proposing a reduction in all of their rates. Meanwhile, the average increase in New York is around 13 percent according to the state’s Financial Services Department.

Rate proposals in these and other states appear to be heavily tied to a number of factors, including the number of buyers who chose plans on different tiers during this year’s open enrollment period and the rising cost of medical care. Many insurers are attempting to compensate for larger populations of sick patients who use more care and for differences in health care markets.

However, some states’ proposals are more encouraging for consumers. Georgia, for example, has one statewide provider on their healthcare exchange but will welcome two more for the 2015 enrollment period. In addition, the current provider – Blue Cross and Blue Shield – has proposed statewide rate decreases.

Initial rate proposals are typically revised downward during pre-approval reviews by state regulators, so it is unlikely that the highest rates among those reported will go through as proposed. Also, patients who qualify for federal insurance subsidies through the healthcare marketplace will likely see those subsidies rise to match any rate increases.

Small business owners are likely to see at least modest increases in healthcare rates for 2015, among other rising costs of care. If you need a boost in working capital to meet these expanded operating costs, healthcare factoring with PRN Funding can close the gap. Explore the many healthcare factoring options for your company and contact us today to get started.

Home Care Minimum WageA pending extension of the Fair Labor Standards Act has significant potential implications for home care agencies.

Starting January 1, 2015, the U.S. Department of Labor will require all direct care workers employed by home care agencies and other third parties to be covered by minimum wage and overtime protections.  Caregivers will be limited to 40 hours a week without overtime, which must be at least one and one-half times the standard hourly rate. In addition, agencies must offer a minimum wage of $7.25 per hour (the current federal rate) or the current minimum wage in their state, whichever is higher.

A particular element of the Department of Labor’s final rule, published in September of 2013, will also narrow the application of the “companionship services” designation and prohibit “third-party employers, such as home care agencies, from claiming the companionship and live-in exemptions.”

What could this rule change mean for agencies, caregivers, and patients?

Agencies

Home care agencies face an almost guaranteed increase in operating costs: in the first place, if they do not already pay their caregivers at minimum wage they will have to meet that standard. Second, agencies will have to either allow overtime at a higher rate for their nurses to continue working more than 40 hours or hire additional staff to close coverage gaps from a limited 40-hour work week.

Many agencies will have to increase their rates to match their rising costs.

Caregivers

While caregivers will be earning more for the hours they work, many agencies will likely choose to restrict their weeks to 40 hours. Many caregivers typically work as many as 80 hours in a week, meaning that such a restriction would effectively cut their paychecks in half. Another concern: if agencies lose patients due to increased prices, there may be even less work for a caregiver to perform.

Caregivers who face losing a substantial portion of their pay may be forced to take a second job to supplement their income.

Patients

While most of the coverage of this rule change so far has centered on home care agencies and caregivers, there are also meaningful potential consequences for patients who rely on home care. As mentioned above, home care agencies may be forced to raise their prices for care or, alternately, provide fewer services to current and future clients. Patients who pay out of pocket or from a trust for their services may quickly be priced out, as would those who have long-term care insurance. Nonmedical home care is not covered by Medicare.

Case Study

There is already an indication of how this rule will impact home care agencies, based on new legislation enacted in California earlier this year.  The California guidelines set a threshold of 45 hours for regular work time and feature a $9 minimum wage as of July 1.

The New York Times profiled one California home care agency, Select Home Care, and highlighted the owners’ options for continuing to operate. In addition to the options presented earlier in this article, co-owner Dylan Hull also presented the option to turn their employees into independent contractors. This option would almost certainly reduce operating costs for Select Home Care, even when factoring in the additional caregivers they would need to recruit.

However, the contractor path opens Select up to periodic audits from the government to ensure that they are in compliance with the IRS definition of an independent contractor. To meet that description, Select would lose the ability to dictate the quality of care they expect and to hold their employees to that standard. According to feedback from other industry professionals not affiliated with Select, the most promising option is to charge more for services and hire additional staff to accommodate a new shift structure.

The Good News

Fortunately, home care agencies do not have to struggle with increased operating costs alone. Factoring for home care agencies can provide immediate working capital to cover the hiring, training, and payroll costs associated with bringing on new staff. Home care factoring also offers additional benefits that can help home care agencies structure their businesses for continued success. PRN Funding has nearly 15 years of experience providing outstanding service to home care agencies across the country – could you be our next success story? Apply online today to get started!

That the nursing industry is changing is indisputable. Social and economic pressures are transforming the industry and will have a continuing impact on new nurses looking to establish themselves in the industry. Where are the nursing jobs? What state offers the best standard of living for its nurses?

WalletHub released a recent analysis of the industry nationwide (including the District of Columbia) with a breakdown of the best – and worst – states for nurses along a variety of criteria. Depending on your area of focus and your career goals, below you will find out which states to pursue…and which to avoid.

Jobs

Nursing is an overall high-demand field, particularly given the impact of the Affordable Care Act on the insured population. However, some states have more openings than others and provide a more ideal destination for the newly minted nurse in search of a job.

Most job openings: District of Columbia

Least job openings: Alabama

Most healthcare facilities per capita: Oregon

Least healthcare facilities per capita: Delaware

Salary

Even the most rewarding position should come with a salary that covers the cost of living and, hopefully, allows an experienced nurse to invest in the future. What kind of price tag comes on your dream job? Find out where you’re likely to get it, and where you may need to pass. (Salary rankings are adjusted for cost of living.)

Highest annual salaries: Texas

Lowest annual salaries: Hawaii

Demographics

A nurse’s dream job location also depends on his or her specialty. Many specialties – including pediatrics, labor & delivery, and elderly care – are concentrated in a single age group, and choosing a location with low numbers of patients in that demographic means finding the right job will prove difficult. WalletHub projected the concentration of patients over 65 in each state by 2030.

Highest percentage of population over 65: Florida

Lowest percentage of population over 65: Utah

This is just a sample of the data and perspectives available in WalletHub’s survey. For more information, visit their site.

Many nurses choose to start their own nurse staffing agencies to serve hospitals and other healthcare facilities. If you are starting a nurse staffing agency and need working capital to get off the ground, contact PRN Funding to start nurse staffing factoring today.

If you reside firmly in the 21st century you are likely very familiar with bundling. You can bundle your car insurance with your home and life insurance policies, your cable with internet and phone services – even your soda with your pizza. Hospital billing is picking up on the trend, and soon bundled hospital bills may become the norm.

Typical hospital billing involves individual charges for each element of a given stay or procedure, down to individual doses of ibuprofen. Provider services are billed separately. In a bundled billing plan, however, hospitals would consolidate these charges to a single fee for everything involved in a typical procedure.

Not only do bundled payments offer savings to patients, but they also provide an incentive to hospitals to provide efficient, high-quality care. Hospitals would keep the net funds remaining after a procedure completed under cost, but would be required to absorb any additional costs for extra care or complications.

Medicare is working with more than 300 health care organizations to provide bundled hospital payments for large-scale procedures such as heart surgeries, and other facilities are expected to follow. In the future bundled payments may include those for chronic conditions as well. Rob Lazerow of Advisory Board Co. points out bundled price tags can help hospitals “compete on cost and quality” for patients shopping around.

Hospitals that shift toward bundled payments will need to work with high-quality vendors to provide the best care to their patients. If you want to expand your healthcare company to work with these hospitals, PRN Funding’s healthcare factoring programs can provide the working capital you need to get everything in order. Contact PRN Funding to learn more about healthcare factoring in every sector and to get started today!

Despite nationwide reports of healthcare systems eliminating jobs, the sector added 34,000 jobs last month according to the Bureau of Labor Statistics.

The healthcare sector has added jobs for 131 consecutive months, or nearly 11 straight years, despite the recession and fears that the Affordable Care Act would cause the sector to shrink. Last month’s growth was twice the standard rate at nearly three percent, most of which was concentrated in ambulatory services.

One element of continuing job growth is the increase in demand for services created by larger numbers of insured patients. At the same time, the decrease in uninsured patients due to marketplace policies and Medicaid expansion has reduced healthcare spending for charity care and covering self-pay patients.

Year over year spending has dropped significantly from 2007-2008 levels, but has remained consistent over the last several years.

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CareerBuilder recently conducted a survey about the nursing profession, in which they measured nurses’ sense of loyalty and satisfaction with their field, the training they find essential to success, and their opinion of the impacts that changes in health care have had on their effectiveness.

Responses from approximately 900 nurses across the country can help health care executives make better decisions about recruiting, retaining, and properly rewarding their nursing staff.

The full results of the study are currently available, and CareerBuilder will present a free webinar discussing how healthcare organizations can integrate those results into their ongoing strategies. In the meantime, below are five of the study’s most interesting results:

5) 58 percent of nurses believe that health care changes have made the workplace less efficient.

4) Half of nurses surveyed believe technology helps them do their jobs faster.

3) Two out of three nurses reported having a mentor on the job – mostly in hospitals and hospice settings.  In facilities without a nurse mentoring program, 41 percent responded that management has not picked up on the idea and 43 percent say that potential mentors are too busy.

2) 67 percent of nurses reported that on the job training was as helpful as or more helpful than their formal training.

1) More than 80 percent of nurses would recommend a career in nursing to others. (Is your job satisfaction that high?)

For more in-depth applications of the study’s information, we recommend taking advantage of CareerBuilder’s webinar scheduled for June 5.

If you provide nursing staff to hospitals and other healthcare facilities, don’t let poor cash flow stop you from keeping them satisfied. PRN Funding can customize the ideal nurse staffing factoring program to meet your needs – contact us today to learn more and get started!

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Virginia insurance carriers have already filed their plan adjustments for 2015, indicating expected rate increases.

Early predictions of 2015 insurance rates had insurers raising premiums by exorbitant amounts to compensate for higher costs and restrictions imposed on their fee structures by the Affordable Care Act, as well as the greater health needs of previously uninsured enrollees who obtained healthcare during the open enrollment period. However, if Virginia filings are representative of how the nation will go then average rate increases will fall short of expectations.

Average increases will not apply equally to policyholders across the board, and range from just above three percent to nearly 15 percent depending on the provider. Those averages, meanwhile, will vary greatly in their individual application. Some providers are adjusting for average enrollee ages that skew higher, as age is one factor that allows them to differentiate. Providers are no longer able to price their premiums based on the enrollee’s current health unless s/he is a smoker.

Some states such as Washington may release their 2015 rates within the next several weeks, though most will complete their projections by the end of the summer.

Rising insurance rates are nothing new but may precipitate slow payments and other rising costs of healthcare. If you need to close the gap between service and payment in your healthcare company, consider PRN Funding’s comprehensive healthcare factoring programs. We work with healthcare vendors providing services to hospitals and other medical facilities – learn more and apply to get started today!

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A survey completed by the American College of Emergency Physicians shows that emergency room visits have increased since January 1.

Approximately 46 percent of ER respondents noted an increase in patient visits and another 27 percent reported constant rates. Nearly a quarter of respondents reported decreased patient visits. According to the survey, the patient demographic is shifting toward fewer patients with private insurance but more patients with Medicaid coverage. The increase is also not restricted to certain states or any geographic area.

While proponents of the Affordable Care Act hoped that the law would decrease ER visits by expanding insurance coverage, studies of Oregon’s and California’s healthcare system overhauls in the last several years indicate that the expectation may have been unrealistic. At the same time, the survey suggests that the ACA has in fact played a role in the shifting numbers over the last three months.

The first and most significant reason is that coverage does not equal or lead to access. Many newly insured patients have little access to a primary care physician or clinic for regular care, either because they are not informed about their options or because PCPs in the area are already overwhelmed with volume. The Association of American Medical Colleges estimates that the PCP-patient gap will reach 30,000 next year and continue growing after that.

Emergency care is equally difficult to access in many states. The American College of Emergency Physicians released their 2014 Report Card which gave 21 states an F rating in the “Access to Emergency Care” category.

That said, patients who do have access to emergency rooms – insured or uninsured – may choose the setting because they cannot be turned away; because they are experiencing potentially serious symptoms; or because they need immediate care when other providers are unavailable (that is, on evenings and weekends).

A potentially significant drawback of the ACEP’s survey is the limited number of respondents: many states had too few responses to register as a percentage of the total responses, and in the top participating state – California – only 10 percent of facilities submitted responses. This indicates a great deal of missing data that could impact the survey’s findings. In addition, the survey’s focus on only the first three months of 2014 makes it insufficient to make any far-reaching assumptions about continuing trends.

If ER visits continue to increase it could create greater demand for healthcare vendors to cover staffing and equipment shortages. PRN Funding’s healthcare factoring programs can prepare your healthcare company for future growth by giving you immediate access to working capital. Learn more about our healthcare factoring services and apply today to get started!

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