Sweeping proposals disclosed Tuesday would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, which proposed the rules.

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid — state programs for the poor run partly with federal dollars — now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85 percent of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the health law for other plans — but with a key difference. Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85 percent.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator. CMS is a division of the Department of Health and Human Services.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio standard, which supporters promote as ensuring plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program, or CHIP, which aids families with children with moderate incomes, with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

Advocates for the poor have complained that HHS’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by HHS’ inspector general found that half the doctors listed in official plan directors weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In Tuesday’s rules CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, an industry lobby, said in a prepared statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However Wachino said it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the health-law marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published Tuesday are only proposals. HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

NAPLES, Fla.— It wasn’t until the Maffuccis found themselves living on cups of coffee, and coffee alone, that they finally called a food pantry for help.

The couple had sold their suburban New Jersey home where they had raised three children and set out to pursue the glossy dream of an easy-going retirement in sunny southwest Florida. But Mina and Angelo Maffucci quickly ran out of money—overtaken by illness, bad luck and an economic crisis that claimed their Florida dream home to foreclosure. They soon found themselves staring at an empty cupboard.

“You open up the closet and all we had was coffee,” said Angelo Maffucci, 82, who had been a drywall installer in New Jersey. “I never thought we would be down on our hands and knees like that, but it happened fast.”

While the U.S. economy adds jobs and the financial markets steadily improve, a growing number of seniors are having trouble keeping food on the table. In 2013, the most recent data available, 9.6 million Americans over the age of 60 —or one of every six older men and women—could not reliably buy or access food at least part of the year, according to an analysis from researchers at the University of Kentucky and the University of Illinois.

Enid Borden, president of the National Foundation to End Senior Hunger in Alexandria, Va., which commissioned the report, said the country was doing a “worse job in trying to end senior hunger in America,” noting that the number of seniors who “face the threat of hunger has gone up every single year since we started doing the research on this.”

“And that’s not good,” she said.

Across the country, the rate of food insecurity—the academic term for a disruption in the mundane yet vital task of maintaining a basic, nutritious diet—among seniors has more than doubled since 2001, according to the National Council on Aging. And it is projected to climb even further as the Baby Boom generation gets older.

The precise conditions fueling the increase in senior hunger are unclear: the poverty rate for seniors, in fact, fell from 2001 to 2005, though it has risen every year since, according to the Employee Benefit Research Institute. And, all the while, the rate of food insecurity among older Americans has ticked upward.

But researchers who study the trend say the causes are complicated and overlap. There are the logistical challenges of getting to a grocery store when many seniors can no longer drive, either because of physical disability or because they cannot afford a car. Long rides on public transportation are difficult to endure for seniors suffering from illness, disability and dementia. And those maladies alone can rob seniors of the ability to feed themselves.

Out-of-pocket medical expenses, which increase steadily as people age, often use up large portions of monthly income for seniors, monies that otherwise might be used on groceries.

The descent into privation for seniors accustomed to middle-class life is usually swift and unforgiving, say the advocates who aid them, and it is often also triggered by failing health, the inability to work or the death of a spouse.

For Sarah Knight, 75, that moment arrived when her husband, a former jeweler from New Jersey who has Alzheimer’s disease, left his job at a Naples supermarket. As his disease robbed her husband of his faculties, the couples’ budget also suffered.

“He’s just falling apart,” Knight said of her husband.

Just one of his medications costs $125 a month, she said, and there is little left from their Social Security check for essentials like food and toilet paper. She found assistance at Jewish Family and Community Services of Southwest Florida, which gives her $100 a month for food and gas and helped her apply for food stamps. Knight was awarded $16 a month, but she says that help comes with a psychological cost.

“All my life, I’ve struggled. So, now, in my 70s, I have to struggle all, all over again?” said Knight. “You know how ashamed I get?”

That sentiment is echoed by Joanne Bartolomeo, 95, who retired from Philadelphia to Naples and continued to work at an upscale dress shop in the tony Venetian Village until just a few years ago. But after an emergency surgery, Bartolomeo could no longer work; she couldn’t keep up with her rising rent and money for food became scarce. Her life was swept into disarray.

“That’s the thing that bothers me,” said Bartolomeo. “At one time, I was in control.”

Pride is one the central reasons, experts say, that only one-third of eligible seniors are enrolled in food stamps, compared to three-quarters of the eligible general population.

“It’s a different generation,” said Thomas Felke, an assistant professor of social work at Florida Gulf Coast University. The idea of relying on government benefits “may not be something that they admit to,” he added, especially after what “they thought was going to be their life in paradise.”

And many seniors, who have perhaps never before navigated the sometimes complicated public services safety net, don’t know where to look for help or mistakenly believe they don’t qualify for food stamps or other assistance programs, including the Commodity Supplemental Food Program.

“If you’re a single senior sitting in an apartment, you don’t know what to do, you don’t know where to go,” said Al Brislain, president of Harry Chapin Food Bank in Fort Myers, Florida.

To help reach potential hungry seniors, Brislain employs social workers who scour local apartment buildings, senior centers and elsewhere to get the word out about food pantries, home-delivery services like Meals on Wheels and government programs.

When the discussions reveal deep embarrassment over a senior’s plight, Brislain says he reassures older Americans “that they deserve this help, that it’s neighbors helping neighbors, that it’s the government supporting you in your time of need.”

In Naples, the prospect of poverty and hunger hiding amid the towering beachside condominiums and acres of golf courses has been a blow to the city’s image as a ritzy retirement destination and vacation playland. Just a short drive from the upscale Fifth Avenue shopping district, with its impressive palm trees and faux-colonial architecture, are gated communities where researchers, using Census data, have detected surprisingly high rates of poverty. But following up door-to-door to find out more about the well-being and food insecurity has proved challenging.

“These gated communities don’t want people coming around asking questions about poverty,” said Felke. “It’s really hard to find out who is hungry, who is struggling.”

With the help of a Naples food pantry and a weekly ration of $34 in food stamps, the Maffuccis’ cupboards are no longer bare. But nor are they filled with nutritious food. A recent delivery included flavored Dunkin’ Donuts coffee, Uncle Ben’s rice, matzos and pasta.

Angelo Maffucci’s doctor has long urged him to lose weight, especially by eating more vegetables and fish, but it can be a challenge.

“Where you gonna get the money to buy the fish? Fish is expensive!” he said. “If you have it once a week, you’re lucky.”

So on most days, the couple eats pasta instead. “You can cook a pound of pasta for less than $2, and you get a meal,” he said. “So that and a cup of coffee, we get through the day.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Actress Rita Wilson, who was diagnosed with breast cancer and underwent a double mastectomy recently, told People magazine last month that she expects to make a full recovery “because I caught this early, have excellent doctors and because I got a second opinion.”

When confronted with the diagnosis of a serious illness or confusing treatment options, everyone agrees it can be useful to seek out another perspective. Even if the second physician agrees with the first one, knowing that can provide clarity and peace of mind.

A second set of eyes, however, may identify information that was missed or misinterpreted the first time. A study that reviewed existing published research found that 10 to 62 percent of second opinions resulted in major changes to diagnoses or recommended treatments.

Another study that examined nearly 6,800 second opinions provided by Best Doctors, a second-opinion service available as an employee benefit at some companies, found that more than 40 percent of second opinions resulted in diagnostic or treatment changes.

But here’s the rub: While it’s clear that second opinions can help individual patients make better medical decisions, there’s little hard data showing that second opinions lead to better health results overall.

“What we don’t know is the outcomes,” says Dr. Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston, who co-authored both those studies. “What is the real diagnosis at the end? The first one or the second one? Or maybe both are wrong.”

That doesn’t mean second opinions are a bad idea. Experts estimate that diagnostic errors occur in 10 to 15 percent of cases.

“There’s no getting away from it, diagnosis is an imprecise thing,” says Dr. Mark Graber, a senior fellow at RTI International who also co-authored the studies. Graber is the founder and president of the Society to Improve Diagnosis in Medicine.

Second opinion requests were related to diagnosis questions in 34.8 percent of cases in the Best Doctors study. These included 22.5 percent of patients whose symptoms hadn’t improved, 6.3 percent who hadn’t gotten a diagnosis and 6 percent who had questions about their diagnosis.

In Wilson’s case, she wrote that after two breast biopsies she was relieved to learn that the pathology analysis didn’t find any cancer. But on the advice of a friend, she decided to get a second opinion, and that pathologist diagnosed invasive lobular carcinoma. Wilson then got a third opinion that confirmed the second pathologist’s diagnosis.

Getting a second opinion may not involve a face-to-face meeting with a new specialist, but it will certainly involve a close examination of the patient’s medical record, including clinical notes, imaging, pathology and lab test results, and any procedures that have been performed. Some people choose to have that second look done by physicians in their community, but other patients look for help elsewhere.

In addition to employer-based services like Best Doctors or Grand Rounds, medical centers such as the Cleveland Clinic and Johns Hopkins in Baltimore also offer individual patients online second opinions.

“It really does give people relatively easy access to expertise,” says Dr. C. Martin Harris, chief information officer at the Cleveland Clinic.

The medical center’s MyConsult service doesn’t accept insurance. A medical second opinion costs $565, while a consultation with a pathology review costs $745.

Face-to-face meetings with specialists who provide a second opinion and review a patient’s medical record are more likely to be covered by insurance than an online consult, but nothing is guaranteed.

“Usually it’s not the second opinion where the hiccup is,” says Erin Singleton, chief of mission delivery at the Patient Advocate Foundation, which helps people with appeals related to second opinions. “It may be that the MRI that they want to do again won’t be approved.”  Many insurers won’t pay for diagnostic or other tests to be redone, she notes.

Patients seeing an out-of-network specialist for a second opinion may encounter significantly higher out-of-pocket costs, particularly if they want to subsequently receive treatment from that provider. In those instances, the foundation can sometimes work with patients to make the case that no specialist in their network is equally experienced at treating their condition.

Of course, asking for a second opinion doesn’t necessarily mean accepting the advice. In the Best Doctors survey, 94.7 percent of patients said they were satisfied with their experience. But only 61.2 percent said they either agreed or strongly agreed that they would follow the recommendations that they received in the second opinion.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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