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Calif. risk-corridor program looks good

October 28, 2015by Robert Whitcomb in Uncategorized tagged , , , ,

 

Here’s happier news on risk-corridor results from the Centers for Medicare and Medicaid Services.

As this HealthAffairs piece notes, “In many states, some insurers did not project premium rates at sufficient levels to account for the risk of the newly insured population. Thus, there were insufficient risk corridor ‘payables’ available from conservatively priced plans to cover all risk corridor ‘receivables’ for underpriced plans to compensate for risk corridor-eligible losses.

“However, this phenomena is highly state-specific. In contrast to most of the country, Covered California, California’s health insurance exchange, had much greater success enrolling a diverse population and did not have a market that allowed the continuation of low-risk, remaining ‘transitional’ plans once the ACA  {Affordable Care Act} was implemented. As a result, the health risk scores of enrollees for individual plans in the exchange have stabilized in the second year (regressed to the mean), with risk being more evenly distributed across all of the plans.”

Maybe states should break up Medicaid management systems

October 23, 2015by Robert Whitcomb in Uncategorized tagged , , ,

Tod Newcombe, writing in Governing magazine’s Web site, notes that the  technology upon which most states run their Medicaid programs “is old, clunky and slow. To make matters worse, the expansion of Medicaid in a number of states under the Affordable Care Act has only put more pressure on these aging systems. Now nearly a quarter of states are looking to modernize them…. But officials aren’t eager to risk a lot of money on another system that will be old, clunky and slow by the time it’s completed.”

Mr. Newcombe  suggests that states looking for a better way to manage to manage their Medicaid programs might look at breaking up their Medicaid Management Information Systems “into pieces and turn some of those pieces into a service.”

He notes that in in April, “the Centers for Medicare and Medicaid Services proposed updating the polices that govern the certification process for building a MMIS, and thus making it easier to develop separate modules for, say, claims management or pharmacy benefits, instead of building the entire system at once. The federal agency is also revising its development requirements so that states will find it easier — and less risky — to adopt alternatives, such as contracting for a service.”

 

 

Peril to patients seen in EHR firms’ ‘gag clauses’

September 13, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

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Politico reports that that some of the biggest electronic health record companies have inserted “gag clauses” in their taxpayer-subsidized contracts. These clauses effectively bar healthcare providers from “talking about glitches that slow their work and potentially jeopardize patients.”

The news service reports that “Vendors say such restrictions target only breaches of intellectual property and are invoked rarely. But doctors, researchers and members of Congress contend they stifle important discussions, including disclosures that problems exist. In some cases, they say, the software’s faults can have lethal results, misleading doctors and nurses who rely upon it for critical information in life-or-death situations.”

The article says that the  Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services, which are responsible for the EHR subsidy program, have ”done little about the clauses, though providers and researchers have been grumbling about them since the 2011 Institute of Medicine report warning that ‘[t]hese types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks.”’

 

Huge rise in Part B premiums may loom

September 6, 2015by Robert Whitcomb in Uncategorized tagged ,

 

Healthcare consultant Kip Piper says that among the healthcare matters that Congress may take up when it reconvenes this week is that:

“Congress will face a new problem when [the Centers for Medicare and Medicaid Services] announces the Medicare Part B premiums for 2016. Because of the intricacies of the statutory formula and the fact that about 70% of beneficiaries are protected to some degree from big increases in premiums, about 30% of beneficiaries are ultimately responsible for 100% of the annual increases. This means many seniors will likely face a Part B premium increase of 40% or more.”

If that happens, expect renewed loud calls for reform of the whole Medicare system.

Hospitals play the ‘observation’ vs. readmission game

August 28, 2015by Robert Whitcomb in Uncategorized tagged , , ,

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David Himmelstein and Steffie Woolhandler write in HealthAffairs:

The Centers for Medicare and Medicaid Services (CMS) has trumpeted the recent drop in hospital readmissions among Medicare patients as a major advance for patient safety. But lost amidst the celebration is the fact that hospitals are increasingly ‘observing’ patients (or treating returning patients in the emergency department) rather than ‘readmitting’ them. But while re-labeling helps hospitals meet CMS’s quality standards (and avoid costly fines), it probably signals little real quality gain and often leaves patients worse off financially.”

Physicians, hospitals face ProPublica pressure

August 14, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

Yelp, the consumer review site and mobile app,  is expanding its pages with quality-assessment data  about physicians and hospitals from the nonprofit investigative-journalism group ProPublica.

The Sacramento Bee reports that ProPublica “will provide quarterly updates on health services at 4,600 hospitals, 15,000 nursing homes and 6,300 dialysis clinics in the United States, using data it has compiled from the federal Centers for Medicare and Medicaid Services. The information will include emergency department wait times, patient survival rates, incurred fines and physician communication ratings.”

Many in the medical community have complained that the profiles  can give an incomplete picture of hospital and physician performance.

Brian Jensen, regional vice president of the Hospital Council of Northern and Central California, told The Sacramento Bee that the profiles may not capture a complete picture of health services, even with the added quality metrics.

“I would caution that oftentimes, because of the complexities of health care and how it’s measured and all of the different services, it might not always transfer as easily to an application like Yelp as, say, your favorite Chinese restaurant. But consumers should have as much of a say as possible.”

However much physicians and hospital officials  dislike these review services, their numbers will increase.

 

CMS extends ‘2-midnight rule’ enforcement delay

August 13, 2015by Robert Whitcomb in Uncategorized tagged , ,

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To no one’s surprise, the Centers for Medicare and Medicaid Services has extended its enforcement delay for the widely hated (by hospital executives) “two-midnight” rule governing short hospital stays to fall in line with recently proposed changes to the policy.

As Modern Healthcare noted, “The agency proposed in July that the rule be modified to allow physicians to exercise judgment to admit patients for short stays on a case-by-case basis. An enforcement delay, passed by Congress in legislation replacing Medicare’s payment formula for doctors, was set to expire on Sept. 30.”

Instead, CMS will extend the delay through the end of this year.

In the end, these patients must manage own care

August 12, 2015by Robert Whitcomb in Uncategorized tagged , , , , , ,

 

A look at how it works when patients with multiple chronic illnesses must take charge of managing their own care:

As a Wall Street Journal article notes: “Managing those people’s health care is often difficult. Integrated health systems, such as Kaiser Permanente and Mayo Clinic, aim to ensure that treatment for one condition doesn’t interfere with care the patient is receiving for other diseases. Often, however, the responsibility of coordinating treatments falls on the patients themselves.”

Trying to avoid serious complications from taking different medications and dealing with the fact that too  often physicians of a patient with multiple chronic illnesses don’t talk with each other about the patient’s case are among the biggest challenges.

Maybe it will help that the U.S. Department of Health and Human Services (HHS) has issued a curriculum for training healthcare professionals and others in caring for patients with multiple chronic conditions.

HHS has taken other steps to help patients with multiple chronic conditions. The Centers for Medicare and Medicaid Services,  a HHS agency, now reimburse providers for time spent coordinating chronically ill patients’ care  outside of regular office visits.

Obviously, many experts hope that electronic health records will increasingly help  physicians keep track of their chronically ill patients.

One recommendation is that patients create  their own  medical records by, for example, keeping  updated lists of medicines that  they are taking  and bringing  them to all visits to physicians.

 

 

More systems eye entering insurance business

July 22, 2015by Robert Whitcomb in Uncategorized tagged , , , , , ,

 

northcarolina

In western North Carolina’s mountains.
One large health system in North Carolina is ready to launch a Medicare Advantage plan, and two others  in the Tar Heel state are mulling the pros and cons of becoming a payer. Cone Health, a $1.4 billion health system in Greensboro,  has received a state license to sell health insurance, and it’s in the process of receiving approval from the the Centers for Medicare and Medicaid Services to offer Medicare Advantage plans to seniors.

Modern Healthcare reports that “Health systems are increasingly jumping into the insurance space. Even though costly information technology and complicated actuarial predictions are large hurdles, organizations view health plans as the missing piece to the population health puzzle. If people in a hospital system’s service area are willing to go to those providers for care, why not offer the coverage to pay for it and keep the healthcare dollar local?””Cone Health runs a Medicare Accountable Care Organization called Triad Healthcare Network, which earned more than $10.5 million in shared savings in its first year. The early success of that ACO gave executives confidence that they could move to the more aggressive, capitated Medicare Advantage structure, in which the federal government pays private insurers lump sums for each member.”

Meanwhile, Mission Health, a $1.4 billion hospital network based in Asheville, is looking into entering the insurance business, though so far anyway,  the  system would prefer to build partnerships with established insurors rather than get into the business directly.

And Charlotte-based Carolinas HealthCare System, the largest system in the state, with almost $5 billion in annual revenue (PDF), also has no immediate plans to build a commercial insurance business.

But, Modern Healthcare reports, “Carolinas is changing how it works with insurers. The system was the first in the state to create a narrow-network product with Blue Cross and Blue Shield of North Carolina, the state’s dominant insurer. Carolinas is also participating in bundled payment programs with local employers, where Carolinas receives a fixed amount of money for certain cardiovascular procedures.”

How to reduce cost of Medicaid newcomers

July 21, 2015by Robert Whitcomb in Uncategorized tagged , , , , ,

 

Last week, the Centers for Medicare and Medicaid Services released its 2014 Actuarial Report on the Financial Outlook for Medicaid.

The  report is making headlines because the actuaries  estimate that for 2014 the newly eligible Medicaid expansion population  had costs greater than the non-newly eligible Medicaid population.

But, Emma Sandoe writes in Health Affairs, “While we still do not have final figures on how much new Medicaid enrollees spent on medical care in 2014, we do have evidence—including a recent study by Naderah Pourat and co-authors published in the July issue of Health Affairs—that primary care and care coordination can help reduce the initial care costs of Medicaid enrollees entering the healthcare system for the first time.

“After all, evidence suggests newly eligible Medicaid beneficiaries are healthier and less costly than the current Medicaid population. However, when negotiating their managed care contracts, many states estimated that the newly eligible would cost more in the first year than non-newly eligible individuals. This approach was based on the theory that the first newly eligible people to enroll would be those previously locked out of the insurance market, quickly entering the healthcare system with pent up demand. Additionally, they would be sicker and would require more healthcare services.

“But it doesn’t have to work that way. Pourat and colleagues show how, several years ago, California found a way to reduce the cost of newly insured Medicaid beneficiaries entering the healthcare system for the first time: care coordination.”

 

 

 

 

 

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