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News Items, by Subject

Health plan costs - healthcare delivery

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Demonstrating and Rewarding Value in Health Care
"Despite the growing interest in these programs, there are strategic and operational barriers that exist today that are preventing wide spread adoption of [value-based contracts (VBCs)]. Survey participants cited the top three barriers as collecting, linking, and analyzing the necessary patient data; gaining alignment on the contract structure; and assigning how value is measured." (Deloitte)
CMS Administrator Commends Three Health Systems for Their Price Transparency
"Three health systems that have voluntarily taken steps to promote price transparency for their patients received kudos Thursday ... CMS Administrator Seema Verma named the three systems -- UCHealth in Colorado, Mayo Clinic in Minnesota, and University of Utah Health -- as exemplars, urging other hospitals to similarly go above and beyond the requirements laid out in revised price-transparency guidelines that took effect this month." (HealthLeaders Media)
Digital Health Promises Remain Unfulfilled for High-Need, High-Cost Populations
"[Of] the studies conducted on digital health products and services, most enrolled healthy volunteers. Few enrolled high-burden, high-cost patients ... Healthy volunteers made up 32% of the studies, followed by patients with amyotrophic lateral sclerosis (14%) and those with multiple sclerosis 12%. Mental health was the most common high-burden condition category studied ... There were no studies for lung cancer or smoking." (American Journal of Managed Care)
Hospital Prices Are About to Go Public
"A federal rule requires all hospitals to post online a master list of prices for the services they provide so consumers can review them starting Jan. 1. The health care industry nationally has a reputation for having little price transparency, which can make it difficult for consumers to price compare. But the hospital's master list prices, sometimes called a chargemaster, is also not a complete look, consumer advocates say." (Atlanta Journal-Constitution)
[Guidance Overview] Pathways to Success: An Overhaul of Medicare's ACO Program
"The rule is projected to achieve $2.9 billion in savings over ten years.... One key element of [this final rule] is a reduction in the amount of time that an ACO can remain in the program without taking accountability for healthcare spending.... [The] rule also increases flexibility for certain performance-based risk ACOs to encourage innovation and expand access to high-quality services that are convenient for patients, including telehealth services provided at a patient's place of residence." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of CMS Final Regs: Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017
957 pages. "The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Opinion] Telemedicine: The Promise and the Performance
"[T]he average patient spends over 100 minutes commuting, waiting, and filling out paperwork for every 20 minutes of face time with a doctor. Telemedicine offers significant relief from this burden ... While nationwide use of telemedicine increased by 643 percent from 2011 to 2016, state and federal policymakers should remove more barriers to telemedicine." (The Heritage Foundation)
Digital Tools and Solutions for Diabetes (PDF)
18 pages. "The market for digital diabetes prevention and management solutions has continued to mature ... As employers refine the mix of programs and benefit strategies they offer their employees, NEBGH has developed this updated guide to reflect changes in the market and profile a current set of digital solutions available to employers in their efforts to help employees prevent and manage diabetes." (Northeast Business Group on Health [NEBGH])
2019 Health Care Predictions
"[1] The new 'healthcare front door' won't be a physical door at all.... [2] As health needs evolve, more non-acute care will go virtual.... [3] Virtual care delivery will integrate behavioral health into the primary care setting.... [4] Virtual care moves beyond the tipping point as regulatory conditions, economic imperatives, and consumer expectations align in its favor.... [5] AI will play a valuable role in healthcare as augmented intelligence.... [6] Virtual care will curb costs by reducing barriers to care." (Teladoc)
[Opinion] Could Telehealth Increase the Price of Health Care?
"[T]he effect of telehealth on prices depends on: [1] how responsive suppliers (i.e., physicians and other health care providers) are to this changing dynamic; [2] the price of telehealth technology; ... [3] patients' perceived inconvenience cost of going to the physician; [and] [4] how third party payers (i.e., insurers) interact with the market." (Healthcare Economist)
Is the Time Now Right for Consumer Telehealth?
"Ochsner Anywhere Care debuted in November.... [T]his consumer-facing virtual platform offers live, on-demand urgent care video visits with board-certified primary care providers for $54 a session through a smartphone app or an online portal.... A look at Ochsner's strategy provides insights into why organizations should consider incorporating these programs among their offerings, and what guard rails should be put in place to ensure a successful launch." (HealthLeaders Media)
Direct Primary Care: A Segue to Direct-to-Employer?
"Direct contracting between major employers and health systems can lead to savings, but it also opens providers up to financial risk -- which may be untenable for those seeking a safer bet. While many direct contracts have shown positive results, others have fallen short of expectations for at least one party." (HealthLeaders Media)
'Virtual' Doctor Visits Are Enticing Employers. What If You're the Patient?
"About three-quarters of large firms that offer health insurance now cover such 'telemedicine,' ... up from 27 percent three years ago. And half the large employers that were surveyed by the National Business Group on Health said adopting virtual solutions was their 'top initiative' in 2019.... Fewer than 1 percent of enrollees in large employer health insurance plans used telemedicine services in 2016[.]" (The New York Times; subscription may be required)
Worksite Medical Clinics: 2018 Survey Results (PDF)
30 pages. "One-third of all organizations with 5,000 or more employees provide a general medical clinic at or near the worksite.... Two-thirds (67%) of survey respondents with general medical clinics allow members to select the clinic as their primary care provider ... Among respondents that have invested the time and resources to measure ROI ... over half ... reported a return of 1.5 or higher ... Only 28% of respondents manage their clinic with in-house resources." (Mercer)
Spurred by Convenience, Millennials Often Spurn the 'Family Doctor' Model
"Many young adults are turning to a fast-growing constellation of alternatives: retail clinics carved out of drugstores or big-box retail outlets, free-standing urgent care centers that tout evening and weekend hours, and online telemedicine sites that offer virtual visits without having to leave home. Unlike doctors' offices, where charges are often opaque and disclosed only after services are rendered, many clinics and telemedicine sites post their prices." (Kaiser Health News)
[Opinion] Patient-Centered, Value-Based Health Care Is Incompatible with the Current Climate of Excessive Regulation
"Although still a subject of debate, the fee-for-service health care payment system that reimburses providers for individual services is widely indicted for promoting care that is inefficient, uncoordinated, and too often fails to meet the needs of patients.... Unfortunately, many well-intentioned efforts to move to a more effective system are adding to the already substantial administrative and regulatory burden on physicians, hospitals, and other providers. In turn, these cumbersome new initiatives stifle innovation and obstruct meaningful payment and delivery reform." (John O'Shea, in Health Affairs)
South Carolina Expands Telemedicine to Physician Assistants, Advanced Practice Registered Nurses
"Under the new South Carolina law, PAs and APRNs may establish a relationship with a patient via telemedicine -- as long as certain standards are met. For example, an APP cannot prescribe medication over the phone when an in-person physical exam is necessary for diagnosis. A simple questionnaire without an appropriate evaluation (involving patient history, mental status evaluation, physical exam, diagnostic/testing, etc.) will not suffice. Also, the APP must make follow-up care available if needed." (Womble Bond Dickinson)
Bundled Payment Does Not Drive Hospitals to Increase Volume
"In 2013, [CMS] introduced a voluntary program for hospitals called Bundled Payments for Care Improvement (BPCI). Under this alternative payment model, CMS makes a single, preset payment for an episode, or 'bundle,' of care, which may include a hospitalization, postacute care, and other services.... [1] Participation in the BPCI program was not significantly associated with an overall change in the volume of surgeries performed. [2] The mean quarterly market volume in non-BPCI markets increased 3.8 percent after the program was launched. For BPCI markets, the increase was 4.4 percent. [3] The analysis found only one change in case mix: patients who had previously used skilled nursing facilities were slightly less likely to undergo a lower extremity joint replacement surgery at a hospital participating in BPCI." (The Commonwealth Fund)
How Can Accreditation Programs Promote Health Plan Value?
"Health plan accreditation programs can help payers highlight offerings that deliver on key quality, efficiency, and beneficiary satisfaction measures.... [P]ayers can supplement their current performance efforts with specialized accreditation programs that display a health plan's unique features and expertise for addressing specific healthcare concerns." (HealthPayer Intelligence)
Why Investigating a Health Plan's Grandfathered Status Matters to Providers
"This article explores the ACA's reimbursement scheme, the effect that grandfathering has and has had on reimbursement to providers, and the circumstances under which a plan may lose its grandfathered status.... In certain instances where an insurer is exempt from such cost-sharing protections, a provider's recovery could be effectively eliminated, as the burden of payment would be shifted to patients who are often unable to pay." (Bloomberg Law)
An Analysis of Out-of-Network Claims in Large Employer Health Plans
"Nearly one in five inpatient admissions includes a claim from an out-of-network provider ... Patients using in-network facilities can still face claims from out-of-network providers, particularly for inpatient admissions ... Inpatient admissions that include an emergency room claim are more likely to include claims for an out-of-network provider ... Enrollees using outpatient mental health services are significantly more likely to have a claim from an out-of-network provider ... Outpatient service days that include an emergency room claim are much more likely to include a claim from an out-of-network provider ... Enrollees with anesthesia or pathology claims are more likely to have an out-of-network provider claim, even when using in-network facilities." (The Peterson-Kaiser Health System Tracker)
[Guidance Overview] CMS Proposes 'Pathways to Success,' an Overhaul of Medicare's ACO Program
"CMS proposes to require that beneficiaries receive a notification at their first primary care visit of a performance year informing them that they are in an ACO and explaining what that means for their care.... CMS proposes to allow certain ACOs under performance-based risk to provide incentive payments to patients for taking steps to achieve good health.... Pathways to Success includes proposed changes ... such as allowing physicians in ACOs that take on risk to receive payment for telehealth services provided to patients regardless of the patient's location -- including at their place of residence.... Pathways to Success proposes incorporating regional spending into ACO targets earlier, starting during an ACO's first agreement period. In addition, the proposal would authorize termination of ACOs with multiple years of poor financial performance." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Medicare to Overhaul ACOs But Critics Fear Less Participation
"ACOs were expected to save the government nearly $5 billion by 2019, according to the Congressional Budget Office. It hasn't come anywhere close.... [The administration has] proposed an overhaul to the program, which was designed to encourage doctors and hospitals to work together to coordinate care by reducing unnecessary tests, procedures and hospitalizations. The move could dramatically scale back the number of participating health providers." (Kaiser Health News)
GM Aligns with Henry Ford Health System in Attempt to Cut Coverage Costs and Improve Quality of Care
"The auto maker's agreement with Henry Ford Health System covers everything from doctor visits to surgical procedures. By signing a contract directly with one health-care provider ... GM says it can offer a plan that costs employees less than other options while also promising special customer-service perks and quality standards." (The Wall Street Journal; subscription may be required)
Do Health System Mergers in Separate Geographic Markets Create Antitrust Problems?
"Within the last few years, some antitrust economists and the FTC have expressed an increasing interest in a theory of 'cross-market effects' in hospital mergers. This theory posits that mergers between hospitals in entirely separate geographic markets nonetheless can create market power that results in higher prices for health plans and, indirectly, for consumers.... But even if we assume that cross-market effects can occur as an empirical matter, do the antitrust laws prohibit cross-market transactions?" (Drinker Biddle)
Market Concentration Variation of Health Care Providers and Health Insurers in the United States
"[F]or insurers, almost all the MSAs fell into the middle categories, either being highly concentrated MSAs (54.5%) or moderately concentrated (36.9%).... Provider concentration was in a higher category relative to insurers in 58.4 percent of the MSAs, while the opposite was true in only 5.8 percent of the MSAs." (The Commonwealth Fund)
Progress Toward Value-Based Care Slipping
"[O]nly 27 percent of the respondents said the nation has a [value-based care (VBC)]-based healthcare system, down from 29 percent in 2017.... The percentage of respondents who said they believe physicians have the tools needed to succeed with VBC dropped to 42 percent this year from 46 percent last year. The percentage of respondents who said they think doctors lack enough information about their patients to make VBC work jumped to 72 percent this year from 60 percent last year." (HFMA)
[Guidance Overview] Telehealth Reimbursement May Be Coming to Medicare: CMS Proposes Medicare Payment for Virtual Visits and Review of Pre-Recorded Images
"[CMS], for the first time, has proposed payment for virtual visits to established patients regardless of such patients' location, effective January 1, 2019.... CMS is seeking comment on the types of communication technology that may be used in furnishing the virtual services, including whether audio-only telephone interactions are sufficient compared to interactions that are enhanced with video or other kinds of data transmission." (Drinker Biddle)
Medicare Billing Overhaul to Transform Documentation, Expand Telehealth
"Rather than continuing to comply with documentation guidelines from the 1990s, practitioners would be able to choose to document [Evaluation and Management ('E&M')] visits based on time spent with the patient or on their own medical decision-making.... Rather than having to re-document information from past visits, practitioners would have more options to simply review and update existing documentation. Physicians would further be allowed to simply review and verify certain medical records that staff members or the patient entered." (HealthLeaders Media)
Amazon, Berkshire Hathaway and JPMorgan Name C.E.O. for Health Initiative
"Amazon, Berkshire Hathaway and JPMorgan Chase, the powerful triumvirate that earlier announced its hope to overhaul the health care of its employees and set an example for the nation ... picked one of the country's most famous doctors to lead the new operation. Dr. Atul Gawande, a Harvard surgeon and staff writer for The New Yorker magazine, will become chief executive of the new company ... He said he was not stepping down from his current medical and other duties to take the job." (The New York Times; subscription may be required)
Behind the Numbers 2019: Healthcare and Medical Cost Trends (PDF)
38 pages. "[T]hree factors inflating medical cost trend in 2019: [1] Care anywhere and everywhere.... [2] Provider megamergers.... [3] Physician consolidation and employment.... Three factors are tempering the spending increases. [1] Flu impact.... [2] Care advocacy.... [3] High-performance networks.... HRI projects medical cost trend to be 6 percent in 2019 ... The net growth rate in 2019, after accounting for benefit design changes such as higher co-pays and narrow provider networks, is expected to be 5.5 percent." (PwC)
[Opinion] Can Low-Intensity Care Solve High Health Care Costs?
"[T]he cost of the same procedure on the same patient by the same physician can vary by thousands of dollars depending on whether it's performed in a hospital, a hospital's outpatient department, an ambulatory surgical center or a doctor's office. It can also vary by who's paying the bill -- which insurer or public program.... [A]ll other things equal, the shift toward lower-intensity, lower-cost settings is a worthy goal. But in some cases, outcomes may not be equal, and it seems we should make sure we're not cutting quality when we're cutting costs." (The New York Times; subscription may be required)
[Official Guidance] Text of HHS Request for Information: Facilitation of Public-Private Dialogue to Increase Innovation and Investment in Healthcare Sector
"This request for information solicits public comment ... on how to structure a workgroup, or other form of interaction between the Department and such participants in the healthcare industry, in order to best support communication and understanding between these parties that will spur investment, increase competition, accelerate innovation, and allow capital investment in the health care sector to have a more significant impact on the health and wellbeing of Americans. HHS also seeks comment more broadly on opportunities for increased engagement and dialogue between HHS and those focused on innovating and investing in the health care industry." (U.S. Department of Health and Human Services [HHS])
Department of Veterans Affairs Leads in Changing the Telehealth Landscape
"As a general rule, most telehealth practitioners are required to comply with various and state-specific licensing, registration, and certification requirements in order to render health care services via telehealth ... [T]he VA is exercising its authority as a federal agency to preempt conflicting state laws relating to the practice of medicine or other health care services via telehealth." (Epstein Becker Green)
Once a Vision for the Future, Virtual Health Is a Reality of the Present
"Virtual health led to a 15 percent reduction in length of patient stays, and improved the experience of chronically ill patients, and remote monitoring of patients once they leave the hospital can cut readmission rates. It is estimated that $7 billion a year (average of $126 per visit) would be saved if annual face-to-face doctor visits moved to virtual visits.... There are now about 200 telemedicine networks and 3,500 service sites in the U.S.... Virtual health can help improve medication adherence, health tracking, and patient accountability." (Deloitte)
How Have Healthcare Prices Grown in the U.S. Over Time?
"The average price paid by large employer plans for an inpatient admission for a laparoscopic appendectomy increased by 136% between 2003 and 2016, much faster than general price increases over the period (28%).... [T]he average price of a full knee replacement in the New York City area ($50 thousand) is more than twice the price of the same procedure in the Louisville, Kentucky area ($23 thousand). The national average was $34,063." (The Peterson-Kaiser Health System Tracker)
Network Adequacy Rules, Provider Consolidation Inhibit Insurer Entry Into New Markets
"As a newcomer to the Medicare Advantage market, Clover Health has sought to differentiate itself using big data and machine learning to improve beneficiary health management. But analytics can't save the insurer from well-established program requirements around network adequacy coupled with health system consolidation ... Instead, the insurer is asking the federal government to loosen requirements around the program to enhance competition." (FierceHealthcare)
[Opinion] Merging Insurers with the Health Care Delivery System
"The potential merger between Partners HealthCare and Harvard Pilgrim Health Care is not just another routine merger and acquisition activity, but it is one occurring at the heart of the U.S. health care system -- Massachusetts General Hospital being one of the oldest and most prestigious hospitals in the nation. It is distressing to see multiple hospitals and physicians merge to gain market advantage, but it is even more disturbing when an integrated health care delivery system is merging with one of the state's largest insurers." (Physicians for a National Health Program [PNHP])
[Opinion] Telemedicine Prescribing of Controlled Substances: The Dark Side of the New Congressional Bill
"Congress has taken another step forward to require the federal Drug Enforcement Administration (DEA) to activate a special registration allowing physicians and nurse practitioners to prescribe controlled substances via telemedicine without an in-person exam.... [T]his bill ... requires the DEA to issue 'interim final regulations.' ... Directing the DEA to issue interim final regulations, while expeditious, strips the public from the important need to review and comment on the DEA's approach to the special registration process." (Foley & Lardner LLP)
35-State Pediatric Group Claims Aetna Doesn't Review Medical Charts in Lawsuit Alleging Insurer Values Profits Over Care
"A national physician group is suing Aetna for 'improperly interfering with medical care,' alleging the insurer tried to claw back payments for necessary patient care, furthering accusations that the company fails to review patient charts.... The physician group, with employs 1,750 specialists across 35 states, also raised concerns that the insurer does not review medical charts when evaluating claims payments[.]" (FierceHealthcare)
CMS Paid Practitioners for Telehealth Services That Did Not Meet Medicare Requirements
"For 69 of the 100 claims in our sample, telehealth services met requirements. However, for the remaining 31 claims, services did not meet requirements.... 24 claims were unallowable because the beneficiaries received services at nonrural originating sites, 7 claims were billed by ineligible institutional providers, 3 claims were for services provided to beneficiaries at unauthorized originating sites ... Medicare could have saved approximately $3.7 million during our audit period if practitioners had provided telehealth services in accordance with Medicare requirements." (Office of Inspector General [OIG], U.S. Department of Health and Human Services [HHS])
Direct Primary Care Legislation Continues Its Roll Across the Country
"Direct primary care (DPC) is a style of clinical practice in which a healthcare provider ... offers primary care services to patients who pay a monthly membership fee for the provision of primary care services at no additional charge to the patient/member.... Florida Governor Rick Scott signed the 'Direct Primary Care Agreements' bill (HB 37) to amend the Florida Insurance Code and, in turn, made it clear that DPC agreements between physicians and patients do not constitute the making of insurance and therefore do not have to comply with the terms of the Florida Insurance Code." (Sheppard Mullin)
[Opinion] Impact of Prior Authorization on Patients and Physicians
"Our policymakers are still fixated on managed care, but their tool of prior authorization provides just one more demonstration on why the private insurers and their managed care excesses have to go.... 86 percent of physicians report that the prior authorization burden has increased over the past five years -- since the implementation of the [ACA]. That is a burden for both patients and their health care professionals that we need to dump." (Physicians for a National Health Program [PNHP])
[Opinion] ERIC Asks For Pay Parity Change in Connecticut Telehealth Legislation (PDF)
"[L]egislation that mandates that reimbursement for telemedicine be the same rate as that of in-person services is simply illogical and unnecessary.... [R]eimbursement rates should be negotiated between providers and insurers, not mandated by government." (The ERISA Industry Committee [ERIC])
Provider Networks: Actuarial Perspective on Performance, In and Out of Exchanges (PDF)
169 pages. "This report outlines the range of practice across the industry with respect to alternative networks for Exchanges. It starts with a basic overview and then moves through ways to drive higher performance based on the experiences of the authors of this report. This report is primarily focused on carriers and their efforts to develop networks. However, it also presents the financial perspectives of the individual buyers, hospitals and physicians and state management of Exchanges." (Society of Actuaries)
Why Does the U.S. Spend More on Health Care Than Other Countries?
"One reason could be that Americans are less healthy than people in other countries.... Another explanation could be that we use more medical goods and services. This turns out not to be the case.... A third option is for that the prices of the health care goods and services we use may be higher than those of other countries. This does indeed turn out to be the case ... One solution to this 'problem' would be to cut prices of pharmaceuticals as well as physician salaries. However, higher pharmaceutical prices have incentivized more innovation." (Healthcare Economist)
Health Care Spending in U.S., Other High-Income Countries
"In 2016, the U.S. spent 17.8 percent of its gross domestic product (GDP) on health care, while the average spending level among all high-income countries was 11.5 percent of GDP.... Except for diagnostic tests, the U.S. uses health care services at rates similar to those of other countries.... The average salary for a general practitioner in the U.S. is $218,173, nearly double the average salary across all high-income countries.... The U.S. spends $1,443 per person on pharmaceuticals, compared to the average of $749.... The U.S. spends 8 percent of total national health expenditures on activities related to planning, regulating, and managing health systems and services, compared to an average 3 percent spent among all high-income countries." (The Commonwealth Fund)
UnitedHealthcare Reports Positive Shift Towards Value-Based Care Plans
"UnitedHealthcare's annual report evaluated value-based programs that include 110,000 physicians and 1100 hospitals that treat patients in UnitedHealthcare employer-sponsored, individual, Medicare, and Medicaid products. The payer found that accountable care organizations (ACOs) had a greater effect on improving health and lowering costs than non-ACOs, with hospital admission rates being 17% lower for ACOs compared with non-ACOs." (American Journal of Managed Care)
[Opinion] A Few Suggestions to Simplify Healthcare
"The front door to healthcare delivery should be an easy-to-use smartphone application which is pre-populated with a healthcare calendar, set up with you and your doctor, to remind you of milestones including appropriate checkups for medical, dental and vision care.... Selecting your provider has to be easier.... [D]rug costs are too confusing.... Doctors' offices should be paperless." (Frenkel Benefits)
Oscar Health's Telemedicine Consultations Up 32% in 2017 as More Members Access Virtual Touchpoints
"Oscar Health saw a 32% increase in telemedicine consultations among its members last year amid an overall increase in virtual services. Telemedicine consults are less utilized than the other digital services offered by the company: 25% of members used the service in 2017, up from 17% in 2016. But those figures outpace other telemedicine leaders." (FierceHealthcare)
[Opinion] CVS-Aetna, a Few Weeks Later
"[CVS is] reserving cash for strategic acquisitions and building out their MinuteClinics.... CVS employees are required to use these clinics for their mandatory annual physicals, obviating the need for other more expensive primary care. Rumors are even circulating that following jettisoning tobacco, CVS is strongly weighing exiting the alcohol and grocery space and throwing all their resources into the health and wellness space." (Frenkel Benefits)
The Promise of Telehealth
"As with any emerging technology, telehealth presents challenges. These include reimbursement limitations, statutory and regulatory barriers, investment costs, broadband access considerations, and privacy and security issues ... Patients are increasingly willing to pay to receive health care at their own convenience and, more and more, payors are paying attention as providers begin to tap the potential." (Hodgson Russ LLP)
[Opinion] The Evidence-Based Medicine Problem: U.S. Doctors Cling to Procedures That Don't Work
"Despite concerns about the rising cost of health care, ... Medicare generally covers treatments deemed 'reasonable and necessary' -- a definition that doesn't include analysis of comparative effectiveness or cost in relation to other treatments. And what Medicare does influences the behavior of private insurers.... [This] approach promotes access to new medical products, yet it doesn't protect patients against the harms from receiving useless or low-value treatments. And it leaves less money to fund expensive therapies that have proven their worth." (Vox)
Maintaining Tissue Sample Quality Might Reduce Costly Medical Errors
"You might not suspect that the success of the emerging field of precision medicine depends heavily on the couriers who push carts down hospital halls. But samples taken during surgery may end up in poor shape by the time they get to the pathology lab -- and that has serious implications for patients as well as for scientists who want to use that material to develop personalized tests and treatments that are safer and more effective." (National Public Radio)
Study Identifies Unexpected Contributor to Rising Health Costs: Low-Cost Services
"One way to improve healthcare quality and efficiency and reduce the use of unnecessary care is to apply the principles of value-based insurance design (VBID), which aligns patients' out-of-pocket costs with the value of services." (American Journal of Managed Care)
Five Simple Charts Show That Risk-Based ACOs Are Working
"In 2016, ACOs in two-sided risk models accounted for only 10 percent of ACOs (48 of 458) but generated almost 30 percent of the total aggregate savings vs. benchmarks ... ACOs in one-sided models saved an aggregate of $541 million versus their benchmarks, but CMS paid out more than that -- $613 million -- in shared savings. In two-sided models, CMS fared better." (Health Affairs)
Mega-Deals Show How Insurers Are Taking Over Access to Care
"The nation's largest insurer, UnitedHealth Group, announced [Dec. 6] that it would buy a network of 300 primary care and specialist clinics from dialysis giant DaVita for $4.9 billion ... The deal ... comes days after CVS Health agreed to buy health insurer Aetna for $69 billion.... The two deals represent companies exploring new ways to rein in costs -- and the diversity in approaches shows that no one yet knows what will work." (
The Next Big Innovation in Health Benefits Design: 'Surgeons of Excellence'
"Self-insured employers, pursuing cost-efficiencies and streamlined care for employees, select certain hospitals to become provider-partners. They label these partners 'Centers of Excellence', and design their benefits packages around them.... Surgeon-level data....enables smarter selection of provider partners.... [and] uncovers variances that could have a tremendous impact on outcomes.... The scope of possible performance disparity can be very broad in any given facility." (mpirica)
Addiction and Mental Health vs. Physical Health: Analyzing Disparities in Network Use and Provider Reimbursement Rates (PDF)
48 pages. "As state and federal regulators increase their focus on enforcement of mental health and addiction parity laws, nonquantitative treatment limitations have emerged as a key trouble area for some health plans.... Based on an analysis of two large research databases of administrative claims data, [the authors] have identified significantly higher rates of out-of-network use for behavioral care compared to medical/surgical care, and have also found that medical/surgical providers are paid at higher rates than behavioral providers, often for providing the same services." (Milliman)
Massachusetts Bill Aims to Curb Health Care Costs by Regulating Hospital Reimbursement Rates
"One of the primary ways the bill proposes to moderate costs is by establishing a hospital alignment and review council which will set a 'target hospital rate distribution,' the minimum floor payment that an insurance carrier must reimburse a hospital for services." (Foley & Lardner LLP)
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