Instruction: create a high quality summary of the given input

Input:
SIF sets out action plan to integrate sustainability in insurance
 A new report has been released by the global network of insurance supervisors and regulators Sustainable Insurance Forum (SIF) to outline the necessary action to tackle sustainability challenges within the insurance sector.

A new report has been released by the global network of insurance supervisors and regulators Sustainable Insurance Forum (SIF) to outline the necessary action to tackle sustainability challenges within the insurance sector.

SIF, created by UN Environment in December 2016 in San Francisco, is a global platform for knowledge sharing, policy dialogue, international collaboration, and identification of best practices for a sustainable insurance system.

The report – Sustainable Insurance, The Emerging Agenda for Supervisors and Regulators – details the need for the insurance industry to scale its efforts to integrate sustainability factors within the regulation and supervision of insurance companies by 2020.

The UN initiative Principles for Sustainable Insurance leads the efforts in tackling sustainability challenges across underwriting and investment.

The report reads: “In its role as risk manager, risk carrier, and investor, the global insurance sector plays a cornerstone role in the management of sustainability-related risks and opportunities.”

The report outlines five steps for insurance professionals: initial assessment; deepening risk analysis; improving information; market transformation; and making systemic linkages.

Understanding how sustainability challenges apply to the core institutional objectives including the solvency of firms, policyholder protection, or broader implications for financial stability is the main challenge for insurance practitioners, according to the SIF report.

Output: The Sustainable Insurance Forum (SIF), a global network of regulators and insurance supervisors, has created a report detailing the actions required to integrate sustainability factors in the supervision and regulation of the insurance firms by 2020. The report outlines five steps, including deepening risk analysis, improving information and making systemic linkages. The SIF suggests that understanding the impact of sustainability challenges on core institutional objectives and financial stability is a key challenge for insurance practitioners.


Instruction: create a high quality summary of the given input

Input:
FBI warns companies against using Kaspersky security products
 The FBI has been briefing private sector companies on intelligence claiming to show that the Moscow-based cybersecurity company Kaspersky Lab is an unacceptable threat to national security, current and former senior U.S. officials familiar with the matter tell CyberScoop.

The briefings are one part of an escalating conflict between the U.S. government and Kaspersky amid long-running suspicions among U.S. intelligence officials that Russian spy agencies use the company as an intelligence-gathering tool of global proportions.

The FBI’s goal is to have U.S. firms push Kaspersky out of their systems as soon as possible or refrain from using them in new products or other efforts, the current and former officials say.

The FBI’s counterintelligence section has been giving briefings since beginning of the year on a priority basis, prioritizing companies in the energy sector and those that use industrial control (ICS) and Supervisory Control and Data Acquisition (SCADA) systems.

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In light of successive cyberattacks against the electric grid in Ukraine, the FBI has focused on this sector due to the critical infrastructure designation assigned to it by the Department of Homeland Security.

Additionally, the FBI has briefed large U.S. tech companies that have working partnerships or business arrangements with Kaspersky on products — from routers to virtual machines — that touch a wide range of American businesses and civilians.

In the briefings, FBI officials give companies a high-level overview of the threat assessment, including what the U.S. intelligence community says are the Kaspersky’s deep and active relationships with Russian intelligence. FBI officials point to multiple specific accusations of wrongdoing by Kaspersky, such as a well-known instance of allegedly faking malware.

In a statement to CyberScoop, a Kaspersky spokesperson blamed those particular accusations on “disgruntled, former company employees, whose accusations are meritless” while FBI officials say, in private and away from public scrutiny, they know the incident took place and was blessed by the company’s leadership.

The FBI’s briefings have seen mixed results. Companies that utilize ISC and SCADA systems have been relatively cooperative, one government official told CyberScoop, due in large part to what’s described as exceptional sense of urgency that dwarfs most other industries. Several of these companies have quietly moved forward on the FBI’s recommendations against Kaspersky by, for example, signing deals with Kaspersky competitors.

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The firms the FBI have briefed include those that deal with nuclear power, a predictable target given the way the electric grid is increasingly at the center of catastrophic cybersecurity concerns.

The traditional tech giants have been less receptive and cooperative to the FBI’s pitch.

Earlier this year, a U.S. congressional panel asked federal government agencies to share documents on Kaspersky Lab because the firm’s products could be used to carry out “nefarious activities against the United States,” Reuters reported. That followed the General Services Administration removing Kaspersky from an approved-vendors list in early July and a congressional push to pass a law that would ban Kaspersky from being used by the Department of Defense.

Kaspersky, which has long denied ever helping any government with cyber-espionage efforts, reiterated those denials.

“If these briefings are actually occurring, it’s extremely disappointing that a government agency would take such actions against a law-abiding and ethical company like Kaspersky Lab,” a company representative told CyberScoop. “The company doesn’t have inappropriate ties with any government, which is why no credible evidence has been presented publicly by anyone or any organization to back up the false allegations made against Kaspersky Lab. The only conclusion seems to be that Kaspersky Lab, a private company, is caught in the middle of a geopolitical fight, and it’s being treated unfairly, even though the company has never helped, nor will help, any government in the world with its cyber-espionage or offensive cyber efforts.”

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The U.S. government’s actions come as Russia is engaged in its own push to stamp American tech giants like Microsoft out of that country’s systems.

Russia’s Quid Pro Quo

In the briefings, FBI officials also raise the issue of Russia’s increasingly expansive surveillance laws and what they charge is a distinct culture wherein powerful Russian intelligence agencies are easily able to reach into private sector firms like Kaspersky with little check on government power.

Of particular interest are the Yarovaya laws and the System for Operative Investigative Activities (SORM), among others, which mandate broad, legally vague and permissive Russian intelligence agency access to data moving inside Russia with retention periods extending to three years. Companies have little course to fight back. U.S officials point to the FSB, the KGB’s successor, as the cryptography regulator in Russia, and say it puts an office of active agents inside Russian companies.

A Kaspersky spokesperson emphasized that all information received by the company is “is protected in accordance with legal requirements and stringent industry standards, including encryption, digital certificates, firewalls and more” and insisted that “the company is not subject to these laws and other government tools” like SORM.

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The law unquestionably does, however, impact Russian internet and communications providers, which Kaspersky uses. And, after all, it’s the Russian “legal requirements” that raise so many eyebrows.

“If it comes to the case of Kaspersky being induced to do something which is undocumented and illegal, it’s only then we’re in a slightly different domain [than in the West] and yes, you can assume the Russian government would have ways to induce private industry to do what it wants,” Keir Giles, a Russia expert with the British think tank Chatham House, told CyberScoop. “This is extremely hard to pin down because by this very nature this official encouragement is clandestine.”

They show up, say ‘You’re already breaking the law, now what are you going to do for me?’”

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By design, there is little visibility and public understanding of this opaque world. Many of the accusations pointed at Russia are met — by Kaspersky’s defenders as well as by civil liberties activists and technologists critical of what they view as gross U.S. government overreach — with fingers pointed right back at U.S. military and spy agencies.

Eva Galperin, the director of cybersecurity at the Electronic Frontier Foundation, believes Western intelligence agencies are engaged in many of the same tactics and must be similarly criticized but that “the legal and political landscape in Russia is very different.”

“The Yarovaya laws and many of the other internet-related laws in Russia were never meant to be implementable,” she told CyberScoop. “They were always meant to be overbroad, overreaching and impossible to comply with because this gives the Russian government a place to start whenever they come calling for your data. They show up, say ‘you’re already breaking the law, now what are you going to do for me?'”

Galperin’s observations on the Russian legal and political landscape mirrors what U.S. officials say in private about intentionally vague laws allowing intelligence officers to have broad abilities and authorities to conduct what U.S. officials see as malicious activity.

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Throughout Kaspersky’s leadership ranks, including CEO and founder Eugene Kaspersky, the company is populated with Russian former intelligence officials, some of whom are accused by Western intelligence agencies of continuing in all but name to work for the Kremlin. This is a major point of contention, because Western cybersecurity firms are largely populated by ex-intelligence community employees as well.

While much of the public focus has understandably been on Eugene Kaspersky, the U.S. intelligence community places great focus on other executives, including Chief Legal Officer Igor Chekunov. Prior to joining the company, Chekunov was a KGB officer. A Kaspersky spokesperson stressed that Chekunov’s time was “obligatory military service” equivalent to “working for customs and border protection (CBP), which is under the Department of Homeland Security (DHS).” U.S intelligence officials say in briefings they believe the list of individuals within Kaspersky cooperating with Russian intelligence is far longer, but they’ve offered no public evidence as proof.

“Once you serve in the [Russian] intelligence services, you’re always kind of linked to them,” Zachary Witlin, a Russia analyst at the Eurasia Group, told CyberScoop. “Kaspersky is an interesting case though. Eugene built this entire company there, he and plenty of other Russians want it to succeed as a global cybersecurity company because it showcases that Russia does have the talent to have world-class software products. I don’t think they would be immune from the same sorts of oversight that incredibly powerful Russian intelligence agencies have on the rest of the country, but they would have to make a calculation about whether or not they would be putting a major company like that at irreparable risk. In a situation like this, I’m not so sure.”

Purely Political?

In closed congressional hearings, senators have responded with some punch to the FBI’s work. The chief criticism from Congress, which is anxious to take legislative action, is that the U.S. intelligence community didn’t speak up sooner about the problem. Earlier this year, senior U.S. intelligence officials slammed Kaspersky in an open congressional hearing; Eugene Kaspersky blamed it on “political reasons” rather than any wrongdoing by his own company.

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In the years since suspicion has crept up against Kaspersky, the firm has repeatedly denied that it poses a threat to U.S. security or that it cooperates with Russia or any other government to spy on users. Efforts to reach out to American authorities have repeatedly been ignored or dismissed, the company told CyberScoop.

“CEO Eugene Kaspersky has repeatedly offered to meet with government officials, testify before the U.S. Congress and provide the company’s source code for an official audit to help address any questions the U.S. government has about the company, but unfortunately, Kaspersky Lab has not received a response to those offers,” a company spokesperson said.

“The company simply wants the opportunity to answer any questions and assist all concerned government organizations with any investigations, as Kaspersky Lab ardently believes a deeper examination of the company will confirm that these allegations are completely unfounded.”

The issue of a code audit was dismissed as a “publicity stunt” earlier this year by Jake Williams, an ex-NSA employee who has called the U.S. government’s efforts against Kaspersky “purely political.”

Beyond Kaspersky, U.S. intelligence officials see a problem that encompasses all of Russia and which, more broadly, impacts relations with tech firms from other countries, most notably China. As with so many other Washington, D.C., conversations of late, however, Russia has taken nearly sole possession of the spotlight that might otherwise be spread more globally.

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Update: A Kaspersky spokesperson’s comments on the nature of Chief Legal Officer Igor Chekunov’s KGB service was added.

Output: The FBI has met with US firms throughout the year to advise against using Kaspersky's cybersecurity products, according to unnamed current and former senior US officials. The US government's allegations that Kaspersky holds deep ties with the Russian government have not been substantiated. Following cyber attacks on Ukraine's power grid last year, the FBI has focused on briefing energy companies and large tech firms. While companies in the energy sector have cooperated with the government, tech firms have resisted the FBI's advice.


Instruction: create a high quality summary of the given input

Input:
Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment
 Author Affiliation Amy Stuck, PhD, RN West Health Institute, Health Services, Successful Aging, La Jolla, California;

University of California, San Diego, Department of Emergency Medicine, San Diego, California Christopher Crowley, PhD West Health Institute, Health Services, Successful Aging, La Jolla, California Tracy Martinez, RN West Health Institute, Health Services, Successful Aging, La Jolla, California Alan Wittgrove, MD West Health Institute, Health Services, Successful Aging, La Jolla, California Jesse J. Brennan, MA University of California, San Diego, Department of Emergency Medicine, San Diego, California Theodore C. Chan, MD University of California, San Diego, Department of Emergency Medicine, San Diego, California Edward M. Castillo, PhD, MPH University of California, San Diego, Department of Emergency Medicine, San Diego, California

Introduction

Methods

Results

Discussion

Limitations

Conclusion

ABSTRACT Introduction The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization. Methods We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews. Results Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked “reduce unnecessary hospitalizations and observation stays” among their top three perceived motivators for using home-based care, and 77% ranked “no existing process in place to refer to home-based care” among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours. Conclusion The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process.

INTRODUCTION

Clinicians, researchers, and government agencies recognize the need to move toward value-based healthcare delivery that supports population health, better matches the needs of an aging population, and reduces the emerging burden of healthcare costs for the U.S.1 Since the release of the Medicare Access and CHIP Reauthorization Act (MACRA) final rule in 2016, providers are increasingly incentivized by Medicare to assume more risk, not only to save money but to provide care that is more person-centered, higher quality, and more affordable. Seniors are also shifting from traditional fee-for-service Medicare to Medicare Advantage plans, the latter of which often provide access to additional benefits such as medications and other services.2

Of the $3 trillion spent per year on healthcare in the U.S., $2 trillion is spent on chronic disease, with inpatient medical care accounting for 31% of nationwide health spending ($1 trillion per year).3 Emergency departments (ED) are the primary entry point for hospital admissions. In effect, emergency physicians (EP) act as gatekeepers in the decision to admit patients to hospitals.4 Specifically, over half of all hospital admissions and nearly 70% of senior admissions occur through the ED.5,6

Currently, EPs are generally afforded only three disposition options for patients presenting to the ED: (1) discharge, (2) observe, or (3) admit. While admission may represent the most appropriate option for many acute conditions, there also exist risks of “default” admissions, where there are simply no other options for a needed course of therapy or monitoring following ED evaluation and management. In some instances, admission may not be the best match for ongoing management of multiple chronic conditions, especially in the frail elderly where there is an elevated risk of in-hospital nosocomial infections, delirium, and falls.7

There is an emerging need to provide EPs with home-based healthcare alternatives to hospital admission, particularly for the elderly. The first objective of the study was to investigate the level of EP’s awareness about their ability to refer patients to home-based healthcare, and the EPs’ experience, if any, in invoking a home-health referral. The next objective was to uncover EP motivations for considering the use of home health for ED patients versus hospital admission, the type of patients EPs select, and time requirements for an initial home-health visit. The final objective was to gain knowledge, through conducting focus groups and interviews that paired EPs with key ED clinicians and decision makers about the incentives or barriers for using home care as an alternative to hospital admission. An analysis of the potential cost basis for home-based care as an alternative to hospitalization is presented elsewhere.8

METHODS

Study Design and Participants

We used an email survey, a focus group, and interview methodologies to explore knowledge of and willingness to use appropriate and safe home care as an alternative to hospital admission. The research setting included two EDs in an academic healthcare system. One hospital was an urban academic teaching hospital (Level I trauma center) with an annual census of 48,000 visits. The second was a suburban community hospital with an annual census of 27,000 visits. An Emergency Medicine Physician Survey was electronically distributed to all 52 attending physicians practicing in the health system’s EDs between August and September 2014. A total of 48 (92.3%) physicians responded to the survey.

Population Health Research Capsule

What do we already know about this issue?

We know that most hospital admissions originate in the ED. We also know that repeated hospitalizations for older adults elevate the risk of nosocomial infections, delirium, and falls.

What was the research question?

What is the emergency physician’s (EP) perspective on disposition to home-based care following evaluation and management in the ED?

What was the major finding of the study?

EPs are receptive to referring patients for home-based care, but few have access to processes for doing so.

How does this improve population health?

It shows the potential to reduce hospital admissions from the ED, which could allow more patients—especially seniors—to be cared for at lower cost in the comfort and safety of their own homes.

For the focus groups and interviews, study participants included three EPs, with the addition of ED leadership overseeing operations and quality, registered nurses (RNs) and social workers (SWs) employed in the ED. The focus of this research was confined to patients being evaluated in the ED.

Selection of Focus Group Participants

The answers on the physician survey were, in part, used to develop the focus group interview guides. We selected physician participants if, on the survey, they indicated previous experience with referrals to home care as an alternative to admission. Of the 48 EPs who responded, 18 (37.5%) indicated prior experience with referring patients directly from the ED. All focus group participants were selected on their availability to participate during the time frame of December 2014 through February 2015. The study was approved by the institution’s Human Research Protection Program.

Study Procedures and Data Analysis

Survey

We developed survey questions following qualitative data gathered from more than 40 telephone interviews with emergency physicians and nurses, hospital and home-health leaders, case managers, primary care physicians, and health plan administrators from across the U.S. Survey answer choices such as barriers to home-health referrals and conditions amenable to home health were gleaned from these preliminary interviews. We designed the survey questions to gauge EPs’ awareness of and prior experience with referring to home-based care as an alternative to hospital-based care. Physicians were invited to complete the survey via e-mail. The survey consisted of five questions. The first question determined whether EPs had prior experience discharging patients to home-based healthcare directly from the ED. If they answered yes, the next question asked their reasons for this decision. The following two questions ascertained what motivations EPs had for considering a home-based referral, as well as the types of clinical diagnoses they would consider eligible. Finally, the survey inquired about the necessary response time the home-based care staff would need to provide for EPs to consider care at home a safe option.

Focus Groups

The primary research team conducted three focus groups and four interviews, each approximately one hour in duration, using a discussion guide. Focus groups and interviews were audiotaped and then transcribed verbatim. The research team conducted thematic analysis using a horizontal approach.9 Four members of the research team independently read all focus group and interview transcripts to identify patterns of recurrent concepts. The team then sorted and coded the transcriptions, categorizing comments into major and minor themes based on frequency of similar comments from participants. Major themes and concepts were finalized by consensus.

RESULTS

Emergency Physician Survey

Of the 48 respondents, 30 (62.5%) EPs indicated no prior experience ordering home-based care from the ED. When respondents were asked to indicate the three most important reasons or concerns that might influence their decision to discharge patients to home-based care (10 options were provided), the most common concern reported was “no existing process in place to refer to home-based care,” with 37 (77.1%) physicians rating this in their top three responses. The second most common response was “unavailability of a care coordinator/case manager”; 35 (72.9%) physicians rated this reason among their top three. See Figure 1.

Figure 1 Other reasons listed: Feasibility to get PICC line and appropriate antibiotics delivered (1); Just not something that most of us are familiar with (1); Lack of emergency physician support to execute plan (1); Takes too much time to arrange in a busy ED (1); Unclear if patient’s funding covers services (1).

Next, physicians were asked to indicate the three most important motivators (or advantages) when considering home-based care (five options were provided). The most common motivator reported was to “reduce unnecessary hospitalizations and observation stays,” with 43 (89.6%) physicians rating this advantage among their top three. The second most common motivator was “reduce risks associated with hospitalization,” with 38 (79.2%) rating this in the top three. See Figure 2.

Figure 2 Other motivators listed: Lower cost for equivalent care (1); Patient preference for care location (1); Preferred by patients and families (1); Reduced healthcare costs (1).

Physicians were then asked to indicate the top three medical conditions they would consider for home-based care (six options were provided). The three most common medical conditions reported were cellulitis (43 respondents, 89.6%), urinary tract infection (38, 79.2%), and diabetes (33, 68.8%). See Figure 3.

Figure 3 COPD, chronic obstructive pulmonary disease; UTI, urinary tract infection.

The final question asked physicians to indicate how soon a home-based follow-up evaluation by a clinician would need to occur (four options were provided). The most common response indicating the specific time frame within which a physician believed a follow-up evaluation would need to occur was “within 24 hours” (21 respondents, 43.8%), followed by “within 8 hours” (13, 27.1%). See Figure 4.

Figure 4 Other time frames listed: within 12 hours (4); next day (1); case dependent, for example, airway issues (pneumonia/congestive heart failure/chronic obstructive pulmonary disease) likely require earlier care at 8–12hrs, cellulitis 24–48hrs, etc. (1).

Focus Group Thematic Analysis

Three focus groups were convened with three participants each: (1) with three EPs, (2) with three EP leaders and, (3) with two SWs and one RN. The four individual interviews were conducted with three EPs and one ED RN. The majority of participating EPs had at least some experience in transitioning patients to home health following evaluation in the ED and believed it was a good option to have available. The major themes derived from the focus groups are discussed below and categorized in the table.

Knowledge and education regarding: Efficacy and outcome data for: Streamlined ED processes Responsive and qualified home care Alternatives to admission Short- and longer-term clinical outcomes Easy to initiate Providers can respond within a short time What home care can provide Patient and family satisfaction Efficient ED workflows Clinicians have skills and expertise to deliver quality care Accessing home care alternatives Patient safety Effective clinician hand-offs TableFour areas of need identified by focus groups queried about the feasibility of transitioning patients from the emergency department to home-based healthcare.

Recognition of a Need for Awareness and Education Regarding Alternatives to Admission

Participants indicated a gap in education of EPs and nursing staff regarding what options exist for home care and the types of services and treatment that can be provided, stating, for example, that “there is a simple lack of awareness [that] we can do it this way” and “awareness is a major factor.” In addition, clinicians wanted to know how to access these services from the ED. One participant stated, “There is no book on case management. There are concepts, there’s a lot of on-the-job training, and it is very situationally different.”

Participants identified the need, due to staff turnover, for ongoing education of new employees and ED residents in regard to home-based care options. Most agreed that to sustain momentum the education also needed to include frequent reminders because “learning goes away after a few months.” The prevailing message was summed up by this physician participant: “In the event of a patient who everyone agrees doesn’t necessarily need to be admitted, but has no good alternative, we, the ED physicians, are also not wanting to admit these people. We would love to have an adequate alternative.”

Data on the Short- and Longer-Term Benefits of Home-Based Care

Participants felt there were short- and longer-term benefits of home- and community-based care, stating, for example, “Whatever can be addressed at home should be”; “From a social perspective, people do, in my opinion, tend to heal better at home, assuming they have a normal home”; and “There is a realization of so much of what we do in the hospital can really be done at home with appropriate care-takers, and keeping them in the hospital wasn’t going to do a whole lot different than sending them home with some help.” Recognized benefits of home-based care were accompanied by acknowledgment of risk in sending home patients who still need monitoring or interventions. Most physicians felt the patients would be safe as long as they were assured of timely follow-up. “If I could know they’d be seen the next day, I still would [send them home],” and “If I feel that the family and patient are comfortable, I’m not that concerned about medical/legal ramifications.”

The Need for Streamlined ED Processes to Transition Patients Home

Participants acknowledged the critical need for streamlined processes to transition patients home from the ED. Currently both process and operational barriers exist. In particular, ED operations include time constraints, and participants indicated adding on time-consuming or complicated processes significantly reduces the likelihood the practice would be adopted. ED-to-home transitions must be easy, streamlined, and time-efficient. One physician stated, “A lot of our patients can be taken care of at home, but just due to logistics … sometimes it becomes a challenge.” Another EP said, “Often, we’re really busy down there, and we often take the path of least resistance.” Others expressed standardized order sets, protocols, or algorithms would be helpful.

The strongest recommendation for streamlining was that EDs have someone on site to arrange the transition. The availability of ED case managers—a hard-to-fill position in the hospital due to lack of applicants—was said to be a real problem.

Many explained they’d had difficulty getting assistance even from inpatient case managers. These were several of the comments: “The physical presence of a case manager or social worker in the ED is critical”; “We can avoid the inpatient admission with a series of home health visits. We can actually do this. But without the intermediary of a case manager or social worker involved in the ED, this is very difficult to orchestrate”; “I think we just need a steady case manager presence”; and “Some of them [case managers] have amazing concepts of what can be done at home.”

The Need for Home-Based Care that is Responsive and Provides Qualified Staff

The need for home-based care to be responsive and provide qualified staff was viewed as extremely important. Some participants discussed challenges in ensuring a qualified home-health workforce. Concern over current compensation structures that may be driving less experienced staff to seek home care jobs was expressed: “Maybe home health doesn’t pay well. Maybe they need to be more comparable to hospitals to have good employees.”

Additional concepts that arose were clinical oversight immediately following the ED encounter, avenues for reimbursement, and regulatory limitations.

Participants also discussed barriers that exist in the broader healthcare ecosystem. Regulations and reimbursement can influence where patients are treated. In order to create new options, participants said, for example, that we “must figure out financial incentives.” Participants articulated that disposition alternatives are limited by what services and treatments get reimbursed and what is easily accessed. Traditional community-based healthcare options (e.g., home health agencies and infusion clinics) typically operate during regular business hours, with little or no responsiveness during the evenings, nights, or weekends. Participants indicated that providing needed care in the most appropriate setting, ED-to-home options need to be available 24 hours a day, 7 days a week. Participants admitted that currently “EDs do not have other good alternatives to admission,” and until those options exist EPs will more often than not default to a hospital admission, even if patients do not require hospital-level care. Participants with experience in ED-to-home transitions found the process “easier if the home health agency is part of the health system.”

The need for a supportive hospital administration was also seen as key to overcoming system barriers because admissions are the main revenue source for hospitals, and efforts to reduce admissions may not be met with support.

In the focus groups, one broad category of possible candidates for home healthcare instead of admission were patients needing intravenous antibiotics for diagnoses such as cellulitis, uncomplicated community-acquired pneumonia, and urinary tract infections. Other diagnoses often mentioned were congestive heart failure and lower extremity deep vein thrombosis. Others indicated that in general the elderly would do better at home whenever possible, and that home care would be a good alternative for patients who were refusing admission and requesting to go home. Most participants agreed that at present the decision to arrange for home care to avoid an admission is made on a case-by-case basis.

DISCUSSION

Substituting more acute home-based care for hospital-based care has been widely adopted in single-payer systems overseas and to a lesser extent domestically within integrated delivery networks and Veterans Administration hospitals.10-12 Studies conducted both in the U.S. and abroad show that providing healthcare services in the home is safe, effective, satisfying to patients and clinicians, and lower in cost. 7, 13-16 One such effort is the Hospital at Home® model, which shifts acute care out of the hospital and into the home for select patient cohorts. This model substitutes hospital-level care for a similar level of home-based care.7 Broader adoption of this model, especially in non-integrated healthcare systems, has historically been hampered in the U.S. by reimbursement and regulations that have not strongly incentivized short-term, higher-intensity care in the home. Although the body of research on substitutive models demonstrated feasibility, providers seeking hospital-level reimbursement were not successful.17

Home-based healthcare, which includes home health, provides skilled nursing and therapy services following an acute hospitalization. It is a widely used lower-cost option compared to both hospitalization and in-home care by a physician. In the U.S., home health is covered as a benefit, provided to both Medicare and Medicaid beneficiaries. The Medicare home health benefit requires both a skilled need and patients meeting home-bound criteria. Although home health services in the U.S. are growing, use of this care delivery option is not widely employed as an alternative for hospital-based care directly following care in the ED. However, the benefit does provide coverage for skilled home-based healthcare services and treatments, including those necessary following ED treatment.

Prior to the present study, little was known regarding the extent to which EPs might recommend home-based delivery of acute medical care. Furthermore, it was not well known whether EPs were aware of what health services are available in the home and whether care at home is a safe and effective option. The present study provides insight into EPs’ knowledge and attitudes toward the option of using home-based healthcare directly from the ED. Nearly three quarters of physicians indicated the main barrier was a lack of processes and help to arrange the transition to home care. Given the number of sick and injured patients coming into the ED, physicians expressed a need for a well-trained support network within the ED, including staff with clear guidelines and infrastructure necessary to transition patients smoothly from ED to the home. EPs expressed a strong motivation to reduce unnecessary admissions and the associated risks of hospitalizations. They also identified the types of patients they consider candidates for home care and the time frame during which they would need the patients to be seen at home.

Focus group participants also identified several barriers that must be overcome to make the ED-to-home option more viable. A knowledge gap exists in that 12 of the physicians either did not know home-based care was an option from the ED, had never encountered the situation, or were not familiar enough with the process to be comfortable using it. Participants acknowledged they encounter patients receiving care in the hospital that could as easily be provided in the home. The main challenges were (1) a lack of time in the ED to arrange home health, (2) a lack of knowledge on how to arrange for home health, and (3) a lack of understanding of the kind of services home health can provide.

In light of recent healthcare outcomes research that has begun to quantify the hazards of hospitalization,18-20 there is growing belief that certain patients, especially the elderly, might fare better at home. If these higher-risk patients are able to avoid hospitalization, it may reduce their exposure to resistant pathogens, noise, unfamiliar environments, and risk of falls and delirium, and can reasonably be translated into better outcomes and patient satisfaction.

LIMITATIONS

Several limitations should be considered in the context of this study. First, because the sample size for the survey was small and limited to the relatively narrow setting of an academic medical center, generalizations to nationwide perspectives are beyond the scope of this study. Additionally, individuals selected for interviews that led to development of survey questions were professionals paid for their time to participate. However, these individuals were not informed that their answers would be used to create survey questions.

The survey was intended to uncover thematic areas, first in a local setting, with the potential for surveying a broader sample, and providing the potential for modification and adjustment of the questions. The interview and focus groups were a small convenience sample of self-selected individuals limited to a single institution. These included only three EPs, and therefore may similarly not be representative of the broader population of EPs and ED RNs and SWs. Regional differences in practice patterns, availability of home-based care, and variability in the number and types of personnel staffing EDs may have further biased the responses of the study participants. Surveying a larger, more geographically diverse group of EPs could provide a more balanced perspective.

CONCLUSION

This study revealed that EPs are generally receptive to referring patients for home-based healthcare following ED treatment to reduce the incidence of “default” hospital admissions. EPs also believe patients with certain diagnoses are likely to benefit and may avoid many of the iatrogenic risks of hospitalization. However, few EPs know specifically what services are available in the home and lack knowledge of the process for invoking an “ED to home-based healthcare” transition. While limited statistical inferences can be drawn from the current survey, the results of this study do serve as a conversation starter, and also form the basis for the design of a larger, nationwide survey. Because the study highlights a general willingness on the part of the EP community, future research should therefore further investigate, on a broader scale, what system-level changes could potentially realize the opportunity for EPs to be provided with a broader range of transition options from the ED. Future research should also explore patient and physician satisfaction with alternative disposition options as well as relevant outcome data (e.g. ED bounce-back rates, need for subsequent hospitalization, etc.). With the emergence of value-based payment reform, more incentives are emerging for both physicians and hospitals to provide these additional options in furtherance of high-value care in the most appropriate setting.

Footnotes

Section Editor: David Thompson, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Amy Stuck, PhD, RN, West Health Institute, Health Services, Successful Aging, 10350 N. Torrey Pines Road, La Jolla, CA 92037. Email: arstuck@westhealth.org. 6 / 2017; 18:761 – 769

Submission history: Revision received September 7, 2016; Submitted March 30, 2017; Accepted March 25, 2017

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

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3. Martin AB, Lassman D, Washington B, et al. Growth in US health spending remained slow in 2010; Health share of gross domestic product was unchanged from 2009. Health Aff (Millwood). 2012;31(1):208-19.

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8. Crowley C, Stuck AR, Martinez T, et al. Survey and chart review to estimate Medicare cost savings for home health as an alternative to hospital admission following emergency department treatment. J Emerg Med. 2016;51(6):643-7.

9. Borkan J. Immersion/crystallization. Doing Qualitative Research. 2009:179-94.

10. Mader SL, Medcraft MC, Joseph C, et al. Program at home: a Veterans Affairs healthcare program to deliver hospital care in the home. J Am Geriatr Soc. 2008;56(12):2317-22.

11. Montalto M. The 500-bed hospital that isn’t there: the Victorian Department of Health review of the Hospital in the Home program. Med J Aust. 2010;193(10):598-601.

12. Cryer L, Shannon SB, Van Amsterdam M, et al. Costs for ‘hospital at home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012;31(6):1237-43.

13. Leff B, Burton L, Mader S, et al. Satisfaction with hospital at home care. J Am Geriatr Soc. 2006;54(9):1355-1363.

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16. Marsteller JA, Burton L, Mader SL, et al. Health care provider evaluation of a substitutive model of hospital at home. Med Care. 2009;47(9):979-85.

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19. Lakhan P, Jones M, Wilson A, et al. A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals. J Am Geriatr Soc. 2011;59(11):2001-8.

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Output: Clinicians, researchers, and government agencies recognize the need to move toward value-based healthcare delivery that supports population health, better matches the needs of an aging population, and reduces the emerging burden of healthcare costs for the U.S.


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For Covered California, Uncertainty Is The New Certainty
 About Capitol Desk Capitol Desk delivers the latest in health care policy and politics from Sacramento and around the state. Have an idea? Let us know.

SACRAMENTO — Covered California’s board made several multimillion-dollar decisions Thursday, all addressing one unsettling theme: uncertainty.

Over and over, board members blamed “uncertainty” at the federal level for interfering with their ability to finalize premiums for 2018 and prepare consumers for open enrollment, which begins Nov. 1.

In response to that uncertainty, the board agreed to delay a critical decision on 2018 rate hikes, boost Covered California’s marketing budget by more than $5 million and allow its participating insurers to make higher profits in the future — under certain circumstances.

“The lack of clarity and direction at the federal level continues to be a challenge,” said Covered California Executive Director Peter Lee. “While we are doing our best to manage a difficult situation, we hope Congress and the administration will provide clear guidance on how [they intend] to stabilize the individual insurance market.”

Use Our Content This story can be republished for free ( details ).

One of the most pressing questions facing Covered California and other Obamacare exchanges across the country is whether President Donald Trump will continue to fund critical subsidies that help reduce many consumers’ out-of-pocket expenses.

The White House announced this week it would fund those so-called cost-sharing reduction payments this month but did not say whether it would continue to do so after that.

Covered California is seeking a long-term commitment to fund the subsidies, which are available only to consumers whose incomes are low enough to qualify and who purchase silver-level plans, the second-least expensive among the exchange’s four tiers of coverage. The subsidies reduce what they pay for medical expenses such as copayments and deductibles.

Earlier this month, the exchange announced proposed average statewide rate hikes of 12.5 percent for 2018. It also floated an additional average surcharge of 12.4 percent on silver plans if the federal government does not commit to making the payments.

Covered California was supposed to decide by the end of this month whether to apply the surcharge next year. But on Thursday, its board announced it will push the deadline to Sept. 30.

“Our hope is that by changing the deadline to allow Congress to act, we will not have to deal with the … surcharge,” Lee said.

The surcharge would vary by region and plan, ranging from 8 percent to 27 percent — on top of the regular annual premium increases, Lee said.

Covered California consumers who receive tax credits to reduce their monthly premiums would not bear the full brunt of the increase, however, because those credits would also rise.

Delaying the decision until the end of September doesn’t leave much time for Covered California — its health plans — to finalize rates and prepare consumers to renew their health plans or shop for new ones, said Diana Dooley, board chair and secretary of the state Health and Human Services Agency.

But the board doesn’t want to raise silver plan rates prematurely, in case Congress acts next month to fund the cost-sharing subsidies on a more durable basis, she said.

If Congress doesn’t act until the very end of September, “that will put extraordinary pressure on our system,” she said.

Charles Bacchi, president and CEO of the California Association of Health Plans, said 1.2 million renewal packets will have to be dispatched to enrollees on a very tight timeline.

“It is going to be a heavy lift, but the plans will work to do the best we can under difficult circumstances,” he said.

The board also agreed to modify its contracts with participating insurers to allow them to make higher profits in 2019, 2020 and 2021 if they lose money next year as a result of continued uncertainty or changes in existing federal policy.

For example, one way insurers could lose money is if the federal government stops enforcing the Obamacare requirement to have health insurance, known as the individual mandate, Covered California said.

The change also requires plans that reap increased profits next year — again, because of uncertainty or changes in federal policy — to lower their premiums over the next one to three years.

Lee explained that Covered California’s insurers usually make a profit of about 1 to 3 percent annually. But, for example, if one should lose money next year, its profit margin could grow to 6 to 8 percent in the subsequent three years, he said.

Any profit increase would be decided on a case-by-case basis and depend on the amount of the loss, he said.

The contract amendment would not change any laws or violate any rules, such as the Medical Loss Ratio provision of the Affordable Care Act, Lee said. That provision requires most insurance companies that cover individuals and small businesses to spend at least 80 percent of their premium dollars on medical care and the remaining 20 percent on administration, marketing and profit.

Consumer advocates testified Thursday that they were initially skeptical of the change, but they now hope it will save consumers money in the long run.

“We like the idea that it is balanced and if [there is profit], it could go to reducing premiums,” said Doreena Wong, project director at Asian Americans Advancing Justice, a Los Angeles-based civil rights group.

In another move tied to the uncertainty over federal policy, the board agreed to increase its marketing budget by $5.3 million, bringing the total to $111.5 million for 2017-18. The additional money will pay for more radio and television spots, and more direct mail to consumers.

Some of the advertising will target Covered California enrollees who are losing their Anthem Blue Cross plan next year.

Anthem will exit the individual market in 16 of the state’s 19 pricing regions, which will force 153,000 enrollees to find new plans. Anthem cited uncertainty and market instability for its pullout.

“This open enrollment is going to be our most challenging since year one,” Lee said.

Output: Covered California’s board made several multimillion-dollar decisions Thursday, all addressing one unsettling theme: uncertainty. Over and over, board members blamed “uncertainty” at the federal level for interfering with their ability to finalize premiums for 2018 and prepare consumers for open enrollment, which begins Nov. 1.


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Medicare Unveils ‘Skeletal’ Site For Hospice Comparison Shopping
 Medicare launched a website aimed at helping families choose a hospice — but experts say it doesn’t help very much.

The Centers for Medicare & Medicaid Services this week released Hospice Compare, a consumer-focused website that lets families compare up to three hospice agencies at a time, among 3,876 nationwide. Following similar websites for hospitals and nursing homes, the site aims to improve transparency and empower families to “take ownership of their health,” according to a press release.

Through the website, families can see how hospices performed in seven categories, including how many patients were screened for pain and breathing difficulties, and how many patients on opioids were offered treatment for constipation.

But the measurements of quality, which are self-reported by hospices, have limited utility, some experts say. Over three-quarters of hospices scored at least 91 percent out of 100 on six of the seven categories, a recent paper in Health Affairs found. Because so many hospices reported high marks, there is “little room” for using these metrics to measure hospice quality, argued the authors, led by Dr. Joan Teno at the University of Washington.

The Hospice Compare grades are based on hospices reporting whether they followed a specific process, such as screening for pain when the patient arrives. This type of metric may lead staff to just check a box to indicate they completed the desired process, resulting in high grades for everyone, which is not helpful for consumers or for quality improvement, the authors wrote.

Use Our Content This KHN story can be republished for free ( details ).

Meanwhile, Teno’s other research has found troubling variation in hospice quality, measured by how often hospice staff visit a patient when death is imminent.

“It’s nice that they’re at least beginning to be concerned about hospice quality,” said Dr. Joanne Lynn of the Altarum Institute, a longtime hospice physician and researcher, of CMS’ new website. But “at the present time, it’s of pretty limited value.”

Lynn said people trying to choose a hospice would be better helped by other kinds of information, such as the average caseload for hospice staff; what percentage of patients are discharged alive; and whether the hospice predominantly serves nursing home patients or devotes significant resources to at-home care.

The Hospice Compare website also doesn’t say how often hospices run awry of federal regulations: Inspection reports, which contain verified consumer complaints as well as problems uncovered during routine inspections, are not part of the website, as they are for nursing homes.

Recent hospice inspection reports may be hard to find. Until a recent federal rule change, hospices could go as long as six years without being inspected. By 2018, CMS requires states to increase the frequency to once every three years.

Common quality measures for hospitals and nursing homes, such as mortality rates, don’t translate well to the hospice setting, where people are expected to die, Lynn noted.

Although Hospice Compare is “skeletal” at the moment, Lynn said, it does enable families to search which hospices are near them, and find the hospice’s phone number to start asking questions.

“I’m hoping that it continues to improve over time,” as CMS’ other consumer-focused websites have, she said.

Next year, CMS plans to add family ratings of hospices, including how timely hospice staff were when a patient needed help. CMS is also collecting data on the number of staff visits a patient received in the final week before death. That information should be made public in late 2018, a CMS spokesman said Wednesday.

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation and its coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Output: Medicare launched a website aimed at helping families choose a hospice — but experts say it doesn’t help very much. The Centers for Medicare & Medicaid Services this week released Hospice Compare, a consumer-focused website that lets families compare up to three hospice agencies at a time, among 3,876 nationwide.


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Too Few Patients Follow The Adage: You Better Shop Around
 Despite having more financial “skin in the game” than ever, many consumers don’t make any attempt to compare prices for health care services, a newly released study found.

In a survey of nearly 3,000 adults younger than 65, about half of the roughly 1,900 who said they spent money on medical care in the previous year reported that they knew in advance what their costs would be. Of those who didn’t anticipate how much they would owe before receiving care, only 13 percent said they tried to predict their out-of-pocket expenses. An even smaller proportion, 3 percent, compared prices from multiple providers ahead of time.

It wasn’t that survey respondents were ignorant of price differences or didn’t care about them. More than 90 percent said they believed that prices vary greatly among providers, and 71 percent said that the amount they spent out-of-pocket was important or very important when choosing a doctor. Yet most respondents said they didn’t comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment.

Researchers conducted the online survey in February and March of 2015, dividing respondents into three groups: uninsured, insured in a plan with an annual deductible higher than $1,250 for single coverage or $2,500 for family coverage, or insured in a plan with a lower deductible or no deductible. The results were published in the August issue of Health Affairs.

Insuring Your Health KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs. To contact Michelle with a question or comment, click here. This KHN story can be republished for free (details).

Three-quarters of the study participants said they did not know of any resource that would allow them to compare costs, while half said that if a website showing such information were available, they would use it.

“If price shopping is an important policy goal, it will be necessary to increase the availability of information on price and decrease the complexity of accessing the information,” the researchers wrote. They noted that patients trying to figure out pricing information and their share of the cost must often know specific procedures’ billing codes, the difference between professional fees and facility fees, and the details of how their insurance plan is structured.

“Our results emphasize that simply passing price transparency laws or regulations (as over half of states have done) appears insufficient to facilitate price shopping,” they added.

Most respondents said they did not think there was a relationship between lower cost and lower quality.

One reason for the lack of shopping activity may be that consumers value the ongoing relationship they have with an existing doctor and don’t want to disrupt that, said Neeraj Sood, professor of public policy at the University of Southern California in Los Angeles and one of the study’s authors.

Another possible explanation is that despite efforts by states, employers and insurers to make price information readily available, shopping for health care services is nowhere near as user-friendly and intuitive as buying something on Amazon or Expedia.

“Maybe right now these tools are so primitive that even though there is a financial incentive to shop, people aren’t doing it,” Sood said.

People surveyed were most likely to search out prices before going to a retail or urgent care clinic compared with other care facilities. Consumers who received physical therapy or lab and imaging services were more likely than others to comparison shop for providers, the survey found.

Please visit kffhealthnews.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Output: Despite having more financial “skin in the game” than ever, many consumers don’t make any attempt to compare prices for health care services, a newly released study found. In a survey of nearly 3,000 adults younger than 65, about half of the roughly 1,900 who said they spent money on medical care in the previous year reported that they knew in advance what their costs would be.


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In Tennessee, Promoting Enrollment in Tenuous Health Care Plans
 The evidence so far suggests they won’t. The administration recently ended $23 million worth of contracts with two companies that helped people sign up for coverage. It also is cutting the enrollment period in half in most states, to 45 days. A number of advocacy groups that worked closely with the Obama administration to get the word out about open enrollment have heard nothing from the Trump administration about re-upping the partnerships this year.

All of this has Ms. Barker and other Obamacare enrollment counselors around the nation, many of whom rely on federal grants to carry out their work and to keep their jobs, revving up earlier than usual, and bracing for the strange new challenge of promoting coverage that the president is attacking at the same time. They are not even certain the law’s mandate that most Americans have health insurance or pay a tax penalty will be enforced.

A recent sticky Friday found Ms. Barker passing out fliers about open enrollment at a back-to-school fair in East Nashville. To every parent and grandparent who strolled past, she asked, “You have health insurance?” Nearby was her favorite prop: a wheel that passers-by could spin with a dial that landed on terms like “deductible” and “penalty,” which she cheerfully explained to those willing to listen.

For the law’s first four enrollment seasons, the Obama administration spent heavily on advertising, recruited celebrities like Katy Perry and companies like Uber to spread the word and scrutinized data to pinpoint potential customers. But this year, community-based enrollment groups, known as navigators, may be largely on their own.

“This is going to be the heaviest lift we have ever tried to undertake,” said Jessie Menkens, navigator program coordinator for the Alaska Primary Care Association. “We will be shouting out for people to recognize this really is not over — that regardless of what deliberations are happening in Washington, this is still truly the law of the land.“

Output: Sharon Barker isn’t used to recruiting new health insurance customers in deepest summer, long before the enrollment season for the Affordable Care Act. But this year, everything is different.


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Time Crunch Among Hurdles for Bipartisan Senate Push to Bolster ACA
 The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time.

The Senate Health, Education, Labor and Pensions Committee leaders of both parties have set a self-imposed mid-September deadline for a bipartisan agreement. To keep lingering animosity from the Obamacare repeal fight from seeping into negotiations, Chairman Lamar Alexander has made clear that what he’s seeking is far from comprehensive.

The bill will have to be “small, bipartisan and balanced,” the Tennessee Republican said in a statement Wednesday.

Above all, Democrats want to make sure insurers continue to receive payments that help them cover out-of-pocket costs for some low-income patients. President Donald Trump has threatened to cut off the payments, and the administration has kept insurers on tenterhooks by making them only on a month-to-month basis.

Without the subsidies, known as cost-sharing reductions, some insurers warn they’ll be forced pull out of the ACA markets or hike premiums. The companies need certainty about payments at the latest by Sept. 27, the final deadline for them to decide whether to sell Obamacare plans in 2018.

If the committee can reach agreement next month, it would still be a challenge to get a bill through the full Senate and House before the key deadline for insurers. And Trump would still have to sign a bill into law that extends payments he is loath to continue.

The potential for chaos was highlighted this week when the nonpartisan Congressional Budget Office released a report estimating average premiums would rise 20 percent next year and the federal deficit would grow by $194 billion by 2026 if the administration stops paying.

While some conservative hard-liners want to cut off the CSRs, Alexander and other top Republicans have shown they’re willing to work with Democrats to have Congress extend the payments.

Sen. Patty Murray of Washington, the panel’s ranking Democrat, on Thursday called for quick action.

“People across the country are facing much higher premiums next year because of uncertainty driven by the Trump Administration, so I hope Republicans will join Democrats to act quickly to protect patients and families from paying more for care they need — and then continue working in a bipartisan way to make health care more affordable, accessible, and higher quality for all,” Murray said in a statement.

Democrats also want some sort of reinsurance program, an idea that has bipartisan support and would help insurers pay for their most expensive enrollees.

But in return for extending CSRs and including reinsurance, Republicans want to give states more authority over their health care systems, and Democrats could balk at some of their proposals.

Alexander has specifically pointed to changing the ACA’s 1332 waiver program, which allows states to opt out of key ACA regulations as long as it doesn’t lead to reduced coverage, skimpier benefits, more expensive insurance or a higher federal deficit.

In remarks to reporters earlier this month, Alexander noted a proposal that would eliminate all of those requirements besides increasing the federal deficit, in order to give states “more of an opportunity to approve insurance plans.” The plan, which was included in Senate Republicans’ health overhaul bill, would also bar the administration from rejecting a waiver as long as it doesn’t increase the federal deficit.

Democrats would likely oppose that proposal, wary of allowing states to undercut key Obamacare requirements without those other conditions in place.

Sen. Tim Kaine (D-Va.) said he’s interested in a proposal from Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) to let states replace Obamacare’s most contentious provision — the mandate requiring people to purchase health insurance or pay a penalty — with a system that automatically enrolls individuals in low-cost coverage if they don’t do so on their own.

Backers of this approach argue it would offer comparable coverage to the individual mandate while being less intrusive, allowing people to opt out.

“I think that’s intriguing,” Kaine said earlier this month in a brief interview. “We ought to have that discussion, but you can’t blow the mandate without something to bring people into the program and do what insurance needs to do, which is to spread risk.”

But auto-enrollment has raised concerns among some liberal health care analysts, including over how to implement and administer such a system. The outstanding questions cast doubt on whether it could garner enough backing to be included in the stabilization bill.

Output: The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time.