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Health plan costs - healthcare delivery


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Adaption of Telemedicine Services in Healthcare Industry
"Telemedicine is revolutionizing the healthcare industry and is expected to grow from a $21.56 billion market in 2017 to a $93.45 billion market in 2026. This growth is highly attributable to the accessibility and convenience of telecommunication devices and the inevitability of government initiatives for reimbursement." (WithumSmith+Brown, PC)
DIY Mental Health: Survey Finds Employers Taking Action
"Among respondents with 5,000 or more employees, 69% said that workforce depression/anxiety was a concern in their organization, compared to just 28% of employers with fewer than 500 employees.... About half (48%) have enhanced the services offered by the EAP within the last two years, or changed EAP vendors to provide a more robust offering.... Just over a third (37%) have recently implemented a tele-therapy program through the medical offering's telemedicine vendor.... A small number of respondents -- 7% -- have contracted with a third-party vendor to supplement existing providers and broaden access options." (Mercer)
How Has the Quality of the U.S. Healthcare System Changed Over Time?
"This collection of charts explores trends in quality metrics in the United States over time. A related chart collection shows quality measures in the U.S. compared to peer countries." (The Peterson-Kaiser Health System Tracker)
Growth in Telehealth Outpaces Other Health Care Venues
"From 2016 to 2017, private insurance claim lines for services rendered via telehealth as a percentage of all medical claim lines grew 53% nationally ... From 2016 to 2017... national usage of urgent care centers increased 14%, of retail clinics 7% and of ASCs 6%, while that of EDs decreased 2%." (American Journal of Managed Care)
Highlights of 9th Annual Healthcare Industry Pulse Survey
"[F]ully one-third of healthcare executives surveyed ... believe non-healthcare market entrants could upend industry business models.... [N]early 40% of respondents said a market in which the majority of value-based relationships include both upside and downside shared-risk remains three to five years off -- a concerning finding that might indicate payers and providers continue to struggle in their efforts to scale complex, value-based care and reimbursement models from pilot to production." [Free registration required for download of full survey results.] (Change Healthcare)
Death by a Thousand Clicks: Where Electronic Health Records Went Wrong
"Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and yes, even save money.... Rather than an electronic ecosystem of information, the nation's thousands of EHRs largely remain a sprawling, disconnected patchwork. Moreover, the effort has handcuffed health providers to technology they mostly can't stand and has enriched and empowered the $13-billion-a-year industry that sells it." (Kaiser Health News and Fortune Magazine)
New York (Again) Seeks to Regulate Pharmacy Benefit Managers
"On January 15, 2019, Governor Cuomo released the 2019-2020 Executive Budget, which ... would require PBMs to be licensed and places limitations on how they can be compensated. This week, the State Senate released its own Budget that, while joining the Governor's efforts to regulate PBMs, purports to create additional safeguards around PBM business activities, including increased financial penalties on PBMs that violate the law." (Mintz)
Paying Patients to Switch: Impact of a Rewards Program on Choice of Providers, Prices, and Utilization
"For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewards program. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures." (Health Affairs; purchase required for full article)
Accelerating the Shift of Care to Lower Cost Settings
"The migration of care from inpatient (IP) to outpatient (OP) and ambulatory surgery center (ASC) settings ... is good news for consumers and employers as it promises to lower costs, improve access and convenience, and, if done right, deliver better outcomes. Payers who can accelerate this change can deliver better value and gain competitive advantage. But a strategic approach is needed to avoid antagonizing key stakeholders." (American Journal of Managed Care)
[Opinion] Administration Considers Groundbreaking Regulation Forcing Healthcare Providers to Disclose Secret Industry Pricing
"Insurers and providers alike will have a bullseye on the Trump Administration and the officials responsible for implementing this rulemaking. And that is no small lobby, with pockets as deep as one-fifth of the entire U.S. economy. The cash cow of obfuscation, secret discounts, unknown prices and third-party payment would begin a rather strict diet very soon if this information were permitted to flow into the light of day." (Benefit Revolution)
Telehealth: Connecting Consumers to Care Everywhere
"Telehealth has emerged as a new platform that improves access by removing traditional barriers to health care such as distance, mobility, and time constraints. For certain conditions, telehealth is as effective as in-person visits with potential for cost savings, and real benefits to provider efficiency, consumer convenience, and better management of chronic conditions." (America's Health Insurance Plans [AHIP])
Administration Weighs Publicizing Secret Rates Hospitals and Doctors Negotiate With Insurers
"Mandating public disclosure of the rates would upend a longstanding industry practice and put more decision-making power in the hands of patients. Hospitals and insurers typically treat specific prices for medical services as closely held secrets, with contracts between the insurers and hospital systems generally bound by confidentiality agreements." (The Wall Street Journal; subscription may be required)
74 Medicare ACOs Depart
"The departures of 13 percent of Medicare' ACOs left 487 in the program in 2019... [A] total of 59 MSSP ACOs dropped out of the program in 2016 and 2017... 26 percent of ACOs that reached the end of their three-year agreement opted to not renew their agreement at the end of 2018." (Healthcare Financial Management Association [HFMA])
What Is an Onsite Health and Wellness Clinic?
"When done right, an onsite clinic will help wrangle out-of-control healthcare costs and make them more predictable. And it does that not by cutting back on services, but by enhancing access to the kind of services that lead to better health outcomes ... Healthier people can be more productive, taking less time off for illness and medical care, and performing on the job with less distraction and anxiety." (Healthstat)
New CVS Health Hubs Are Key Part of Plan to Change How Americans Get Healthcare
"The stores have an increased focus on health services, including a wellness center and more chronic care management for diseases like diabetes, committing about 20% of the physical store space to health endeavors rather than snacks or other convenient store supplies." (Business Insider)
Why Aren't More Employers Implementing Reference-Based Pricing Benefit Design?
"The major barriers to [reference-based pricing (RBP)] adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices." (American Journal of Managed Care)
Senate Committee Hearing: How Primary Care Affects Health Care Costs and Outcomes
Feb. 5, 2019. Includes video and written testimony by: [1] Joshua J. Umbehr, M.D., Atlas MD; [2] Sapna Kripalani, M.D., Vanderbilt University Medical Center; [3] Katherine Bennett, M.D., University of Washington School of Medicine; [4] Tracy Watts, Mercer. (Committee on Health, Education, Labor and Pensions, U.S. Senate)
Transparent Hospital Pricing Exposes Wild Fluctuation, Even Within Miles
"Prices varied widely on some basic procedures, even for basic charges. For instance, the list price on a liter of basic saline solution for intravenous use ranged from $56 to $472.50, nearly seven times as much.... And they varied widely even when comparing nearby hospitals. The new rule mandates that the chargemasters be available on the hospital website in a machine-readable format, but not all hospitals make them easy to find, and understanding them is a bigger obstacle." (Kaiser Health News)
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)
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." (Healthcare Financial Management Association [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])
 
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