The Cleveland Clinic, one of the largest hospitals in the country, has cut its charity care spending — or the cost of free care provided to patients who can’t afford to pay — to $101 million in 2014 compared with $171 million in 2013.

Hospital officials credited the federal health law for the improvement. “The decrease in charity care is primarily attributable to the increase in Medicaid patients due to the expansion of Medicaid eligibility in the State of Ohio and the resulting decrease in the number of charity patients,” the hospital’s year-end financial statement reported.

That 40 percent drop spotlights a trend in how payments are changing for all providers since the health law rolled out the Medicaid expansion and subsidies that help some lower-income people purchase policies on the new insurance marketplaces, said John Palmer, spokesperson for Ohio Hospital Association.

“Now that you’re starting to see that shift from uninsured or underserved on over into health care programs such as Medicaid and the exchange, that has had a good impact,” he said. “And, obviously, it is reflective of what hospitals are experiencing with uncompensated care in the areas of charity care especially.”

The clinic is not alone. The federal Department of Health and Human Services announced last week that the number of uninsured and self-pay patients has fallen substantially in Medicaid expansion states since the program went into effect last year. In addition, states with expansion saw significant reductions in uncompensated care costs – which includes charity care and bad debt, such as when an insured patient doesn’t pay her share of a hospital bill. Hospitals in those states had an estimated savings of $2.6 billion over that seen in non-expansion states.

Even so, Moody’s Investors Service released a negative outlook for the nation’s nonprofit health care sector. It pointed out that while the increased insured population will funnel dollars into the hospitals, that may not make up for federal cuts in Medicare and other programs.

Ohio is one of 28 states and the District of Columbia to expand Medicaid under the federal health law. More than 492,000 Ohio residents have enrolled through expansion. In addition, another 234,341 people in the state selected or were automatically re-enrolled in a private plan on the state’s federally run exchange.

“This has been good for patients because now they are insured through the State of Ohio’s adoption of Medicaid Expansion and can go anywhere for the care they need,” a spokeswoman wrote via email.

Another financial report, released by the clinic in early March, indicates that total uncompensated care fell 27 percent to $211 million in 2014. That number includes both charity care and bad debt costs.

The clinic, however, announced in the earlier March report that 2014 was an “extraordinary” financial year with operating income up 60 percent to $466 million on total revenues of $6.7 billion.

Dr. Toby Cosgrove, the clinic’s chief executive, noted then that the economic improvement came from a reduction in expenses, with cuts in energy use, employee health insurance costs and staff.

“Everybody in the organization contributed from whether we were turning off the escalators at night or not doing duplication of lab studies,” Cosgrove said. “But it was a total organization involvement in this and it was very gratifying to see people step to the plate.”

This story is part of a partnership that includes WCPN/Ideastream, NPR and Kaiser Health News.

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

Online tools and resources available to help states use health IT to improve health care quality and lower cost

Readers continue to have questions about how the health insurance marketplaces work and coverage requirements there. This week I answered some recent queries.

I purchased health insurance in Ohio through the marketplace in April. I then moved to Missouri and applied for marketplace coverage there that began in October. I had assumed that the Ohio marketplace would cancel my coverage there, but that didn’t happen. What should I do?

When people relocate, it’s up to them to inform the marketplace and their insurer, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

If you don’t inform the marketplace that you’re cancelling your subsidized plan, a 90-day grace period will begin the first month that you don’t pay your premium. The grace period is intended to protect consumers from losing coverage immediately because of a late payment. During the first 30 days, insurers are required to continue coverage and pay claims. For the next 60 days, if consumers still haven’t paid up, insurers may delay paying claims. During this period, consumers can still pay their back premiums and continue their coverage if they wish. After 90 days, the insurer can cancel coverage.

You could be on the hook for the entire premium for the first month of the 90-day period, according to officials at the Centers for Medicare & Medicaid Services. Although consumers would not generally be responsible for repaying any premium tax credit for that first month, in some circumstances they might have to pay that back when they file their taxes, CMS says.

Solomon’s advice: “Call the Ohio marketplace and ask them to retroactively cancel her coverage.”

I help people apply for marketplace policies and I’ve noticed that some of the plans sold on the state marketplaces don’t cover tobacco cessation medication and other products for free as a preventive service. Isn’t that required? 

Under the health law, most health plans have to cover without cost sharing by patients the preventive services that are recommended by the U.S. Preventive Services Task Force, a nonpartisan group of medical experts. The only exception is for plans that are grandfathered under the law.

The task force recommends that doctors ask patients whether they smoke and provide smokers with cessation interventions. In an FAQ last May, the administration spelled out what would be covered:  at least two stop-smoking attempts annually that include at least four counseling sessions and all FDA-approved tobacco cessation medications, both prescription and over the counter options.

Only 17 percent of insurers on the state marketplaces cover tobacco cessation medications without cost sharing, according to a report released Tuesday by the American Lung Association.

Stingy smoking cessation coverage is short-sighted, says Brian Hickey, director of federal government relations at The Campaign For Tobacco-Free Kids, an advocacy group.

“It’s not overutilized and it’s not particularly costly, especially when you consider its ability to reduce future medical costs,” he says.

If a plan doesn’t offer comprehensive coverage, Hickey recommends bringing it to the attention of the state insurance commissioner.

As a small employer, I believe that my employees may be better off if I dropped our group health plan and let them get coverage from the public exchanges. Is there any way for me to provide my employees pre-tax reimbursement for the premiums they pay on the exchanges?

No, that’s not possible. As a small employer, you won’t be fined if you don’t offer health insurance on the job to your employees. In contrast, employers with 100 or more workers face penalties of up to $3,000 per worker for not offering good coverage and those with more than 50 employees will have the same penalties next year. But no matter how many people you employ, you’re not allowed to give workers cash for the purpose of buying their own policy on the exchange, according to published guidance from the Obama administration. That arrangement would count as a group health plan, and under the law those arrangements can’t be integrated with individual exchange coverage.

However, as a small business owner, “you can always pay more in cash to the worker and the worker can take the cash and use it as he wants, whether to buy health insurance or for something else,” says J.D. Piro, a senior vice president at Aon Hewitt, who leads the benefits consultant’s health law group. As an employer, you just can’t earmark that cash for health insurance.

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.

The National Institute of Mental Health unveiled a five-year strategic plan emphasizing research it hopes will ultimately give clinicians a better understanding of what mental illness looks like inside the brain — before a patient shows outward symptoms.

NIMH is part of the National Institutes of Health.

The plan signals investment to figure out the genes associated with mental illness, develop new treatments based on those findings, make sure research findings are eventually implemented into practice and find brain patterns for a range of disorders.

These four objectives form a broad roadmap – part of what NIMH director Thomas R. Insel, M.D., describes as a “path to discover” – beginning with the fundamental science of the brain and behavior, and ending with public health impact. An estimated 9.6 million Americans have a serious mental illness that impairs daily functioning.

One of the hopes is that the research will enable health professionals to identify people who are at risk and begin treatment early in the disease process.

“Just as brain tumors are detected through CAT scans and diabetes is diagnosed through blood sugar testing, NIMH is focused on employing brain imaging to detect common mental disorders and severe mental illnesses before full-blown clinical presentation,” said Al Guida, the president of Guide Consulting Services, a Washington-based government relations firm that specializes in behavioral health.

Early diagnosis would make a big difference on a variety of levels, allowing people to finish school, find jobs and lead more productive lives.

Shelli Avenevoli, chief of NIH’s Developmental Trajectories of Mental Disorders Branch, says NIH already has research going on that seeks to get help for people right after their first psychotic break. The trial results have been so promising that Congress required each state, starting last year, to implement a program based on the findings.

“For those of us in this area, it’s an aspirational goal: to identify those at risk as early as possible and hopefully before onset of full syndrome so that we can then not just treat something, but prevent it,” Avenevoli said.

But even with private and public research investment, it could be decades before the scientific advances are applied so that a child could be screened for mental illness with a CT scan or some other such tool, said Paul Gionfriddo, president and CEO of patient advocacy group Mental Health America. He added, though, that science already shows that early signs of mental health problems — sleep problems, unusual risk taking, disorganization and difficulty forming friendships — need to be taken into account when diagnosing mental illness.

“Long before the first psychotic break, these symptoms worsen over time and affect school success, relationships with siblings and parents, and inclination to self-medicate,” Gionfriddo said. “We didn’t wait until we had a cure for cancer before doing early identification and starting to fight it, and we can’t afford to wait until we have a cure for psychosis before fighting that either.”

Shifting resources from treating people when they have a full-blown illness to when they are just presenting symptoms or have an irregular brain scan will mean a change in how the mental health system works, said Ken Duckworth, medical director for patient advocacy and lobbying group the National Alliance for Mental Illness. “NIMH is helping to drive a culture change,” he added.

But despite the promise, some experts also offer reminders that even with such advances there will still be room for error.

“They’re looking for a perfect indicator before intervention, but is anyone noticing what’s going on with mammograms and other imperfect early indicators that work well enough, but have flaws? Elevated cholesterol levels don’t necessarily mean you’ll have a heart attack,” and the same will be true for mental illness, said William McFarlane, director at the Center for Psychiatric Research at the Maine Medical Center in Portland, Maine.

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

Whether a patient is in the hospital for an organ transplant, an appendectomy or to have a baby, one complaint is common: the gown.

You know the one. It might as well have been stitched together with paper towels and duct tape, and it usually leaves the wearer’s behind hanging out.

“You’re at the hospital because something’s wrong with you –  you’re vulnerable – then you get to wear the most vulnerable garment ever invented to make the whole experience that much worse,” said Ted Streuli, who lives in Edmond, Okla., and has had to wear hospital gowns on multiple occasions.

Put another way: “They are horrible. They are demeaning. They are belittling. They are disempowering,” said Camilla McRory of Olney, Md.

The gowns are among the most vexing parts of being in the hospital. But if efforts by some health systems are an indicator, the design may be on its way out of style.

The Cleveland Clinic was an early trendsetter. In 2010, it introduced new gowns after being prompted by the CEO, who often heard patient complaints when he was a practicing heart surgeon. That feedback led to a search for something new, said Adrienne Boissy, chief experience officer at the hospital system.

The prominent academic medical center ultimately sought the help of fashion icon Diane von Furstenberg, settling on a reversible gown with a front and back V-neck, complete derriere coverage, and features such as pockets, softer fabric and a new bolder print pattern.

Patients “loved the gowns,” Boissy said. “People felt much more comfortable in the new design, not just physically but emotionally.” In recent years, she added, “hospitals are looking at everything they do and trying to evaluate whether or not it contributes to enhancing the patient experience.”

It’s all part of a trend among hospitals to improve the patient reviews and their own bottom lines – fueled in part by the health law’s focus on quality of care and other federal initiatives. The Centers for Medicare & Medicaid Services increasingly factors patients’ satisfaction into its quality measures, which are linked to the size of Medicare payments hospitals get.

Sometimes the efforts involve large capital improvement projects. But they can also mean making waiting rooms more comfortable, improving the quality of food served to patients or, as in this case, updating hospital gowns.

Ultimately, this focus leads to “a better patient experience,” said John Combes, senior vice president of the American Hospital Association.

The Detroit-based Henry Ford Health System is in the process of updating its gowns, an initiative that began when the system’s innovation institute challenged students at the city’s College for Creative Studies to identify and offer a solution to one hospital problem.

The students responded with the suggestion to redo the garment that has often been described by patients as flimsy, humiliating, indecent and itchy. The process took three years, but last fall, the institute unveiled a new and improved version. It’s made of warmer fabric – a cotton blend – that wraps around a patient’s body like a robe and comes in navy and light blue, the hospital’s signature colors.

Patient expectations are part of the calculus. They “are demanding more privacy and more dignity,” said Michael Forbes, a product designer at the Henry Ford Innovation Institute.

When the institute tested his gown design, Forbes said, patient-satisfaction scores noticeably increased in a few days.

The new gown “was emblematic … of an attitude that was conveyed to me at the hospital – that they cared about me as a whole human being, not just the part they were operating on,” said Dale Milford, who received a liver transplant during the time the redesign was being tested. “That was the subtext of that whole thing, was that they were caring about me as a person and what it meant for me to be comfortable.”

But replacing the traditional design is no easy task. What patients wear needs to be comfortable yet allow health professionals proper access during exams, meaning it must open and close easily. The gowns also need to be easily mass-manufactured, as well as efficiently laundered and reused.

New designs, though, can be expensive. After Valley Hospital of Ridgewood, N.J., switched to pajamas and gowns that provide extra coverage, costs went up $70,000 per year, said Leonard Guglielmo, the facility’s chief supply chain officer, because the new garments cost more to buy and maintain.

Beyond cost, more ingrained cultural expectations might also play a role in what hospitals think patients should wear, said Todd Lee, an assistant professor of medicine at McGill University, who co-authored a 2014 study in the journal JAMA Internal Medicine, examining whether gowns were important and whether patients might be fine wearing their own or hospital-provided pants, instead of or along with gowns.

Often, doctors reported that pants or undergarments beneath gowns would have been okay, but patients said they were never given those options. Traditional gowns make it easier to examine patients quickly, and several doctors Lee spoke to seemed shocked at the idea that patients might wear garments other than the open-backed gown during their stay.

But the most common challenge isn’t necessarily doctor expectations or costs. It’s navigating hospital bureaucracies, said Dusty Eber, president of the California-based company PatientStyle, which designs and sells alternative gowns. In his company’s experience, hospital decisions are often made by committees, not individuals.

“There’s a lot of bureaucratic runaround,” Eber said.

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

HHS gave around $12 million to BioCryst Pharmaceuticals of Durham, North Carolina, for the advanced development of a promising experimental drug for Ebola, including preparing for large-scale manufacturing of the drug and conducting related studies.