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Highmark: Value-based program saved $260 million

Highmark headquarters, in Pittsburgh.

Pittsburgh-based Highmark Inc. said its value-based payment program saved the insurer more than $260 million within its first year.

The nonprofit insurer said that  its value-based program for primary-care physicians cut hospital readmissions 16 percent last year, which potentially saved $224 million. Further, it reported, an increased focus on prevention, including screenings and vaccinations, helped saved an estimated $38 million in avoidable emergency room visits.

This seems to be a trend. For instance, UnitedHealthcare expanded its bundled-payment program in May after it netted $18 million in savings from a total of 115 employers in the program since 2016.

To read Highmark’s press release, please hit this link.

To read FierceHealthcare’s report, please hit this link.


Harken ending insurance-care combine


Harken Health is ending its unusual combination of health insurance and  clinic care in Illinois and Georgia.

The insurer began selling insurance plans for customers at its clinics in Illinois and Georgia in 2015. A subsidiary of gigantic UnitedHealthcare, Harken offered its members unlimited free physician visits at its health centers, as well as such wellness programs as acupuncture, yoga and meditation.

Rewarding ‘metric-centric’ practices in value-based contracting


In  a Physicians Practice piece on practices involved in value-based initiatives, Scott Hewitt, vice president for value-based care contracting for UnitedHealthcare, says that most of the small- to medium-sized practices that his company  engages with in value-based care contracts are in what he calls its “metric-specific programs” that reward practices when they can show that they’re proactively managing the health of their patients.

Among his suggestions to practices:

• “Engage with payers to ensure that you have mutually aligned goals. ‘You can better care for members when you know how [you] can work together to achieve that,” Mr. Hewitt told the publication.

• “Get as much patient data as possible from payers.”

• “Implement processes within the practice to provide the highest level of care.”

• “Determine with payers where there may be inefficiencies in the delivery of care. ‘Everyone thinks they’re providing the most efficient care. Unfortunately, that’s not always the case.”‘

To read the whole piece, please hit this link.

UnitedHealthcare is launching a national ACO

UnitedHealth Group‘s UnitedHealthcare unit,   America’s largest health insurer, will launch a nationally branded Accountable Care Organization as part of its push to value-based care aimed at luring self-funded employers.

UnitedHealthcare’s NexusACO will be available in 2017 in 15 markets to self-funded employers with 100 or more workers during this fall’s open enrollment period. The company said that NexusACO already has a dozen employers signed on, but  it wouldn’t disclose  names, Forbes reported.

“This (ACO) will have a much more national view with consistency across how the product is designed,” Jeff Alter, UnitedHealth’s CEO for employer and individual coverage,  told Forbes.  “It’s sold as a product that happens to have a unique network attached to it.”

The NexusACO has a national network of UnitedHealthcare’s “tier1” physicians who, UnitedHealth says, are already meeting the insurer’s quality and efficiency measures.

UnitedHealthcare said NexusACO is different from regional ACOs, which generally have contracts with providers only in certain markets. UnitedHealthcare, for example, already has contracts with more than 800 ACOs across  America —  double what it had two years ago.

Forbes noted that UnitedHealthcare’s rivals are also expanding arrangements with ACOs. Aetna, for example, has increased its ACO agreements to 275 since 2011, and that figure is expected to grow even more in the next year as the company shifts 50 percent of what it pays providers from fee-for-service  to value-based arrangements.

To read the Forbes article, please hit this link.

Optum’s big push



UnitedHealth Group’s Optum division is making its biggest push yet into patient care in Minnesota. It  will open up to 19 new urgent-care centers  in the “Land of 10,000 Lakes” by the end of 2017. The centers are under the MedExpress name.

Optum is the direct-health-services unit of Minnetonka, Minn.-based UnitedHealth Group, which runs UnitedHealthcare, America’s largest private-sector health insurer. The  huge insurer’s move into clinics recalls the move by some hospital systems into becoming insurers.

Optum itself is the nation’s largest provider of urgent-care services.

Survey of healthcare billers finds Medicare remarkably popular


The market-research firm Peer60 surveyed nearly 800 ambulatory-care leaders (36.8 percent of whom were physicians;  participants also included practice administrators and financial and nurse leaders) on which insurer they liked the  most.  Peer60 found that Medicare was surprisingly popular.

To the surprise of everyone, Medicare—allegedly “slow, inefficient, broken and inflexible,” ranked number two (with 16 percent of the vote), behind Blue Cross Blue Shield, which ranked first, at 22 percent, and way ahead of (UHC), which ranked a distant third, at 9 percent.

The study said that survey respondents  cited Medicare’s  fast reimbursement, efficient precertification, low staff time required to file claims, ease of negotiating with, low amount paperwork required,  fewest denied claims and the best customer service.

To read an article on this, please hit this link.


Phil Galewitz: Your doctor will see you at the kiosk


For Kaiser Health News


On the day abdominal pain and nausea struck Jessica Christianson at the office, she discovered how far telemedicine has come.

Rushing to a large kiosk in the lobby of the Palm Beach County School District’s administrative building where she works, Christianson, 29, consulted a nurse practitioner in Miami via two-way video. The nurse examined her remotely, using a stethoscope and other instruments connected to the computer station. Then, she recommended Christianson seek an ultrasound elsewhere to check for a possible liver problem stemming from an intestinal infection.

The cost: $15. She might have paid $50 at an urgent-care center.

The ultrasound  that Christianson got later that day confirmed the nurse practitioner’s diagnosis.

“Without the kiosk I probably would have waited to get care and that could have made things worse,” she said.

Endorsements such as  Christianson’s demonstrate how technology and positive consumer experiences are lending momentum to telemedicine’s adoption in the workplace.

Less than a decade ago, telemedicine was mainly used by hospitals and clinics for secure doctor-to-doctor consultations. But today, telemedicine has become a more common method for patients to receive routine care at home or wherever they are — often on their cellphones or personal computers.

In the past several years, a growing number of employers have provided insurance coverage for telemedicine services  letting employees connect with a physician by phone using both voice and video. One limitation of such phone-based services is physicians cannot always obtain basic vital signs such as blood pressure and heart rate.

That’s where telemedicine kiosks offer an advantage. Hundreds of employers — often supported by their health insurers — now have them installed in the workplaces, according to consultants and two telemedicine companies that make kiosks, American Well and Computerized Screening, Inc.

Employers and insurers see the kiosks as a pathway to delivering quality care, reducing lost productivity due to time spent traveling and waiting for care, and saving money by avoiding costlier visits to emergency rooms and urgent care facilities.

Jet Blue Airways is adding a kiosk later this year for its employees at John F. Kennedy International Airport in New York. Other big employers providing kiosks in the workplace include the city of Kansas City, Mo.

Large health insurers such as Anthem and UnitedHealthcare are promoting telemedicine’s next wave by testing the kiosks at worksites where they have contracts.
“This technology should make it more affordable for employers of many sizes,” Jesser said.Anthem has installed 34 kiosks at 20 employers in the past 18 months. John Jesser, an Anthem vice president, said kiosks are a good option for employers too small or disinclined to invest hundreds of thousands of dollars in creating an on-site clinic with doctors and nurses on standby.

Kiosks are typically used for the same maladies that lead people to see a physician or seek urgent care — colds, sore throats, upper respiratory problems, earaches and pink eye. Telemedicine doctors or nurse practitioners can email prescriptions to clients’ local pharmacies. Employees often pay either nothing or no more than $15 per session, far less than they would pay with insurance at a doctor’s office, an urgent care clinic or an emergency room.

Despite kiosks’ growing use in telemedicine, it’s unclear whether they will be supplanted as smartphones, personal computers and tablets enable people toaccess health care anywhere with a Wi-Fi connection or cell service. Some employers already offer kiosk and personal device options, including MBS Textbook Exchange in Columbia, Mo., which has 1,000 workers.

Workplace kiosks’ appeal is they are quiet, private spaces to seek care. Consumers can get their ailments diagnosed remotely because the kiosks are equipped with familiar doctors’ office instruments such as blood pressure cuffs, thermometers, pulse oximeters and other tools that peer into eyes, ears and mouths. The instrument readings, pictures and sounds are seen and heard immediately by a doctor or nurse practitioner.

“The kiosk gives the doctor more tools to diagnose a wider range of conditions,” Anthem’s Jesser said.

The downside is that the machines cost $15,000 to $60,000 apiece, which may still be too much for some employers.

“Telemedicine kiosks look promising and may still take off, but I don’t see explosive growth,” said Victor Camlek, principal analyst with Frost & Sullivan, a research firm.

While kiosks are now found in more workplaces, usage is still relatively low because employees are not sure how they work, said Allan Khoury, a senior consultant with Willis Towers Watson.

Employers’ experiences are mixed.

Officials in Kansas City, Mo., estimate that the kiosk placed in city hall almost a year ago has saved the local government at least $28,000. That’s what Kansas City hasn’t spent because employees and dependents chose the telemedicine option instead of an in-person doctor visit. The city also estimates it has gained hundreds of productive work hours — that’s the time employees saved by not leaving work to see a doctor.

In contrast, fewer than 175 of the 2,000 employees at the Palm Beach County School District headquarters have used the kiosk there in its first year, said Dianne Howard, director of risk management.

Howard remains hopeful: “This is the future of health care.”

The district’s kiosk was supplied at no cost by UnitedHealthcare, as part of a test also involving two other employers in Florida.

Those kiosks connect employees to nurse practitioners at Nicklaus Children’s Hospital in Miami. The hospital employs an attendant at each kiosk location to help workers register and use some of the instruments, such as the stethoscope.

Other telemedicine kiosks, such as those made by America Well, are designed to be totally self-service for employees. They also offer users immediate access to a health care provider. American Well has deployed about 200 kiosks and is in midst of rolling out 500 more, mostly to employers, the company said. It also places kiosks in retail outlets and hospitals.

Telemedicine’s increasing sophistication is winning over some traditional-minded physicians.

The WEA Trust in Madison, Wis., a nonprofit that offers health coverage to public employers, installed a kiosk for the benefit of its 250 workers last fall.

Tim Bartholow, M.D., a family doctor by training and chief medical officer for the trust, said he was cautious about physicians treating patients they haven’t seen in person. After observing employees using it, Bartholow is convinced it can help them get good care.

“I don’t think telemedicine is making a doctor being on site quite agnostic, but it is certainly reducing the premium on being in the same space as the patient,” Bartholow said.

Insurers declare they are moving carefully, too, recognizing that telemedicine has its limits and they must depend on practitioners to tell patients when they have to see a doctor — in person.

“We have to rely on their experience and judgment,” Jesser said.

UnitedHealthcare’s exit from many exchanges worries patient advocates


For Kaiser Health News


UnitedHealthcare’s decision to quit insurance exchanges in about 30 states next year has patient advocates concerned that fewer options could force consumers to pay more for coverage and have a smaller choice of network providers.

The company’s departure could be felt most acutely in several counties in Florida, Oklahoma, Kansas, North Carolina, Alabama and Tennessee that could be left with only one insurer, according to an analysis by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

To sell policies next year on the health law’s exchanges, also called marketplaces, insurers must apply within the next few weeks and get state approval this summer.

Two counties in southwest Florida — Lee and Collier — will be most affected. With UnitedHealthcare’s departure, the 80,000 consumers in those counties could be left with only one option: plans offered by Florida Blue, the Blue Cross and Blue Shield company. Two counties in Oklahoma — Oklahoma and Tulsa — which had about 60,000 enrolled on exchanges this year, could be left with only the Blue Cross and Blue Shield of Oklahoma, the Kaiser analysis found.

Lynne Thorp, regional director of the Health Planning Council of Southwest Florida, which helps consumers enroll in plans, said the impact depends on how Florida Blue handles its monopoly. While most enrollees get subsidies that keep their monthly premium low, many are concerned about possible increases in copayments and other cost-sharing on physician visits and drugs. Florida Blue offered the plans with the lowest premiums in the region last year.

“Absolutely there are concerns with United leaving,” said Andrea Stephenson, executive director of Health Council of Southeast Florida, which also assists consumers with enrollment. “Having another big carrier pull out of the market will be a real challenge,” she said.

While Florida Blue has a strong reputation, her group did hear complaints that the insurer did not offer enough choice of specialists. Without having a company compete against Florida Blue for exchange customers, Stephenson worries those networks could remain tight or get even narrower. If customers can’t find a robust choice of doctors, they may decide to remain uninsured. “Even with the individual mandate, the value proposition has to be there,” she said.

UnitedHealth Group cited escalating losses on the Obamacare plans — $475 million in 2015 and $650 million expected this year — as a reason the company planned to quit most marketplaces. United operated in 34 states this year but has committed to staying only in New York, Virginia and Nevada for 2017. United’s independent subsidiary, Harken Health, is expected to continue operating in Atlanta and Chicago.

So far, UnitedHealthcare is the only large carrier to announce it was quitting the marketplaces in multiple states.

While UnitedHealth is the nation’s largest health insurer overall, most of its business historically has not been in the individual market, which the exchanges serve.

Jodi Ray, director of Florida Covering Kids & Families, which has the largest federal navigator contractor in the state to conduct enrollment assistance, played down the impact of UnitedHealthcare leaving. “United is not a low-premium issuer … and most consumers are price driven,” she said. “Consumers will adjust accordingly no matter who the issuer is.”

Denise Cyzman, executive director of the Kansas Association for the Medically Underserved, said UnitedHealthcare will be missed even though it only had about 10 percent of marketplace enrollees. She said she hopes another carrier comes in to give the Blue Cross and Blue Shield plan some competition. “It’s good for consumers to have choice,” she said.

Kansas Insurance Commissioner Ken Selzer is meeting with companies to try to entice one into the marketplace, a spokesman said.

Having just one insurer left in counties near Winston-Salem and Wilmington is concerning, said Sorien Schmidt, North Carolina director for Enroll America, but she’s confident another player will step in. She said marketplace enrollment was still strong last year even after the Blue Cross plan raised rates an average of 32 percent. But she said the more companies in the marketplace, the better chance to drive down premiums and get the word out about options under the health law.

In Florida, Thorp said, the biggest challenge is still educating people that many can get government assistance to buy coverage. “It’s still surprising how many people we find who don’t know that.”

Ala. handing Medicaid managed care to nonprofits


For Kaiser Health News

Despite having one of the strictest eligibility requirements in the country, Alabama has struggled to control the rising costs of Medicaid, which provides health coverage to more than 1 million residents.

Alabama Gov. Robert Bentley, M.D., a popular two-term Republican governor, and a dermatologist, is offering an unusual cure.

The state last week won federal approval to shift most of its Medicaid recipients into managed-care organizations, which are paid a fixed monthly fee from the state for each person in the plan. It’s a strategy employed by about three dozen states, many for decades, to provide more predictable spending.

Yet, Alabama’s shift to Medicaid managed care has features not typically seen elsewhere. Most notably, the state isn’t relying on big for-profit insurance companies like UnitedHealthcare and Aetna to manage the program. Instead, it’s turning control over to new nonprofit organizations mostly run by the state’s hospitals and other local providers. Oregon has also pulled in healthcare providers to help run its Medicaid program, but that approach, begun in 2012, also included private insurance plans.

Hospital leaders applaud the move, saying they know their communities’ needs and are best positioned to care for the patients. And they hope it’s a step that leads the governor and legislature to expand Medicaid under the Affordable Care Act, which would make an additional 300,000 people eligible. Bentley has said he would not consider expanding Medicaid until his proposed reforms of the program go into effect.

Alabama is one of 19 states, mostly in the South, that have refused to accept the health law’s provision to extend Medicaid to everyone earning less than 138 percent of the federal poverty level, or $16,400 for an individual. The federal government pays the full cost of the expansion through this year and then gradually reduces its share to 90 percent in 2020. Alabama’s Medicaid program is mostly used by children and disabled residents. Parents are only eligible if their income is under 18 percent of the poverty level, or about, $4,000 a year for a family of four.

Courtesy of Huntsville Hospital Health System

Huntsville Hospital Health System is tentatively planning to run two of the new regional care organizations in the northern and western parts of Alabama.

— Photo courtesy of Huntsville Hospital Health System

The state and the federal government split the costs of the program, with the federal share nearly 70 percent in Alabama.

The Obama administration’s decision to approve Alabama’s managed-care system will bring the state an additional $328 million in federal funding over three years — money that will help set up the new entities the state calls Regional Care Organizations. Most of the funding will be used to build information-technology and computer systems to help the hospitals work as insurers. Under the waiver, Alabama could also qualify for an additional $420 million in federal money over a five-year period to further support the transformation.

Without the waiver, Alabama hospitals feared the state would have cut Medicaid benefits and reimbursements to the hospitals. Alabama’s total Medicaid spending has increased from $5.2 billion to $5.8 billion in the past four years as enrollment rose more than 15 percent.

Hospitals say the money they will receive through managing the regional care collaborations will give them incentives to keep people healthy. That’s quite different from the traditional fee-for-service Medicaid system in which hospitals get paid more money by providing the most expensive health services.

The effort will allow hospitals to change their mission from treating disease to improving the health of the population — and share in the savings, said Frederick Isasi, director of the health division of the National Governors Association, which worked with the state on the waiver. “Alabama is creating a more efficient system,” he said.

The Regional Care Organizations, or RCOs, will be rewarded for keeping spending on budget and they will have their care rated by a doctor-controlled state board that will look at dozens of quality and customer service measures. The RCOs will work to help people with chronic diseases such as diabetes and asthma so they can avoid costly hospital stays.

Hospitals say they are happy they won’t have for-profit managed care companies dictating their Medicaid reimbursement and can have more control over how the program’s dollars are spent.

“Anyone who realizes where health care is going in the country knows you want to be high up on the hierarchy where the premium dollars are being paid,” said Burr Ingram, spokesman for Huntsville Hospital Health System, which is tentatively planning to run two of the RCOs in the northern and western parts of the state.

Some health insurers will still provide a supporting role for the program, such as providing back office support or helping hospitals meet their financial requirements.

Insurers say the state is wasting money having hospitals and other providers learn how to operate as managed care companies when insurers have been doing that elsewhere for years.

“The state bought half a loaf,” said Jeff Myers, CEO of the Medicaid Health Plans of America, a trade group of large insurers. He applauds Alabama for moving to managed care, but he said it could have saved money using experienced insurers that know how to build provider networks, pay claims and manage risk.

The state has tentatively contracted with at least two regional care organizations in each of five regions of the state. Each RCO will set up its own provider networks, which Medicaid recipients must use to get the cost of their care covered. The program expects to enroll 650,000 Medicaid patients. Nursing home patients are excluded.

“We see this as a huge milestone,” Danne Howard, executive vice president for the Alabama Hospital Association, said of the federal waiver approval. “We hope this will pave the way for more serious discussion of expansion.”

While the managed care strategy is a victory for hospitals, the Medicaid expansion would have helped them even more by reducing their uncompensated care. “Having a bigger pie would be better to carve up,” said Meredith Kilgore, chair of the healthcare organization and policy department at the University of Alabama at Birmingham. “But that would be seen as caving into Obamacare.”

6 new ACO-type pacts


Herewith, from Becker’s Hospital Review, a list of  six accountable-care and shared-savings agreements signed in November and December:

“1. Saint Francis HealthCare Partners, UnitedHealthcare team up for accountable care: 3 things to know
Hartford, Conn.-based Saint Francis HealthCare Partners, a joint venture between a network of primary care and specialty physicians and Saint Francis Hospital and Medical Center, and UnitedHealthcare are collaborating through a new accountable care relationship.

“2. Delaware Valley ACO expands partnership with Humana
Philadelphia-based Delaware Valley ACO and Humana expanded their accountable care relationship after seeing favorable results in the first year of their partnership.

“3. Humana, Collaborative Health Partners launch value-based care program
Lynchburg, Va.-based Collaborative Health Partners and Humana signed a value-based care agreement for 4,000 Humana Medicare Advantage members in the Lynchburg area.

“4. Lee Memorial, Florida Blue launch ACO
Ft. Myers/Cape Coral, Fla.-based Lee Memorial Health System’s affiliated physicians teamed up with Florida Blue to launch an ACO for businesses and individuals with commercial plans.

“5. Aetna, CHOP to collaborate on ACO
Aetna has announced a first among its ACOs — It is launching a pediatric accountable care program with The Children’s Hospital of Philadelphia.

“6. Cigna rolls out 2 new collaborative care arrangements in Chicago
Cigna is teaming up with two Chicago area physician groups, Alexian Brothers Clinically Integrated Network and Midwest Center for Women’s HealthCare, on collaborative care programs similar to ACOs.”



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