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Health plan costs - healthcare delivery

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Telemedicine Expanding Rapidly
"According to one recent survey, telemedicine services (i.e., remote delivery of healthcare services using telecommunications technology) among large employers (500 or more employees) grew from 18% in 2014 to 59% in 2016. Common selling points touted by telemedicine vendors include reduced health care costs and employee convenience. However, state licensure laws imposing restrictions on telemedicine practitioners can often limit the value (or even availability) of telemedicine services to employees. But that seems to be changing." (Benefits Bryan Cave)
The Company Behind Many Surprise Emergency Room Bills
"Early last year, executives at a small hospital ... started using a company called EmCare to staff and run their emergency room.... Although the hospital had negotiated rates for its fees with many major health insurers, the EmCare physicians were not part of those networks.... For a patient needing care with the highest-level billing code, the hospital's previous physicians had been charging $467; EmCare's charged $1,649.... Newport's experience with EmCare, now one of the nation's largest physician-staffing companies for emergency rooms, is part of a pattern." (The New York Times; subscription may be required)
Out-of-Network Billing for Emergency Care in the United States
"Because patients cannot avoid out-of-network physicians during an emergency, physicians have an incentive to remain out-of-network and receive higher payment rates. Hospitals incur costs when out-of-network billing occurs within their facilities.... [P]hysicians offer transfers to hospitals to offset the costs of out-of-network billing and allow the practice to continue.... [A] New York State law that introduced binding arbitration between physicians and insurers to settle surprise bills reduced out-of-network billing rates." (National Bureau of Economic Research [NBER])
[Guidance Overview] Telehealth Expansion Finally Comes to Texas
"For insurers, the bill clarifies that the Texas telemedicine parity law does not apply to services rendered only through audio interaction or by facsimile. In other words, insurers in Texas are prohibited from restricting coverage solely because it is provided through telemedicine, unless the services are only rendered through phone or fax. The bill also requires insurers to prominently post their telehealth coverage policies and payment practices on their websites so that consumers can easily determine whether and how coverage is available." (Morgan Lewis)
From Hotspot to Health Hub: How Communication and Data Can Help Solve the Growing Health Divide
"Just as law enforcement uses data to analyze and map out crime 'hotspots,' the health care community can do the same to hone in on the heaviest users of the health care system in communities across the country -- and that could help improve health outcomes and decrease spending." (Health Affairs)
Which Markets Are Most Likely to Be Disrupted by New Care Delivery Models
"To better evaluate the health markets poised for potential growth or disruption in care delivery models, Accenture examined market dynamics across payers, providers and consumers among more than 400 Core Based Statistical Areas (CBSAs) in the continental United States.... [A]pproximately 21 percent of CBSAs (86 CBSAs that comprise more than 37 million people) are well positioned for providers to disrupt local care delivery models.... These are the top 25 markets with a population base of more than 250,000[.]" (Accenture)
Why the Utilization Conversation in Telemedicine Is Bigger Than Dollars and Cents
"[A recent study] found that 88 percent of visits were additive, and only 12 percent replaced in-person visits. The result: telemedicine cost the payer $45 per patient more than a plan without telemedicine would have.... [T]he study doesn't consider the long-term impact of increased utilization of preventative care. If those extra visits keep patients out of the hospital because they catch a respiratory infection early and it prevents a more serious condition like pneumonia, those savings could make up for the cost of extra visits." (MobiHealthNews)
The Future is Now: Healthcare Delivery Systems
"[T]he next cost mitigation 'silver bullet' for employers who had already adopted high deductible plans [could be] provider-directed initiatives like bundled payments and value-based contracting.... [In one] exchange model ... instead of employees purchasing insurance networks, they are selecting from healthcare delivery systems.... [V]irtually every PBM is now hawking some version of limited retail networks with tougher clinical oversight." (Frenkel Benefits)
[Opinion] Healthcare is Complicated: Is it Fixable?
"[C]onsumers think healthcare is too complicated for them to understand. Thus, they depend on their caregivers to educate them and are predisposed to be dependent on what they're told. It hasn't changed. In this digital health age, only one in eight consider themselves well-informed and capable of navigating the system. It's too complicated for most Americans and perhaps even more for the GOP lawmakers seeking to transform it in an environment of intense media scrutiny and partisan rancor." (Paul Keckley)
[Opinion] Health Care Can Be Patient-Centered, Accessible and Affordable
"[A] new paradigm of innovative value-based payment and care delivery ... reconciles what many consider competing values: access, affordability and a patient focus.... Value-based care is patient-centered care.... Incentives and accountability create better outcomes for patients.... Realizing the benefits of value-based care requires commitment and investment.... Value-based care works when every stakeholder is engaged.... Value-based care doesn't just benefit patients; it's an economic engine that creates jobs." (Morning Consult)
A Factor in Higher Healthcare Costs: When Evidence Says No, but Doctors Say Yes
"For all the truly wondrous developments of modern medicine ... it is distressingly ordinary for patients to get treatments that research has shown are ineffective or even dangerous.... In 2014, two researchers ... found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. 'The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,' they wrote ... This perception, they continued ... 'may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.' " (The Atlantic)
Managing Hospital Employee Health Costs Can Help Prepare for Value-Based Care
"As employee health costs continue to rise they have a significant impact on hospital finances.... [H]ospitals already take full risk for the cost of their employees' health. By actively managing the employee health plan a hospital can achieve significant savings that can be used to fund the transformation to accepting risk (population health)." (BDO Center for Healthcare Excellence and Innovation)
CMS Announces 45 ACOs Are Now Participating in Next Generation Model
"For 2017, 28 new participants joined the Next Gen model, bringing the total number of participants to 45. CMS Innovation Center's Next Generation ACO Model was designed to test whether strong financial incentives for ACOs can improve health outcomes and reduce expenditures for Medicare fee-for-service beneficiaries. Provider groups in this model assume higher levels of financial risk and reward than are available under the shared savings program." (Healthcare Finance News)
UnitedHealth Group to Buy Outpatient Surgery Chain for $2.3 Billion
"While the acquisition is a relatively small one for UnitedHealth, whose annual revenues last year were around $180 billion, it marks the latest step in the company's evolution from a traditional insurer to a diversified health services company." (The New York Times; subscription may be required)
Specialty Pharmacies Say Benefit Managers Are Squeezing Them Out
"Three companies -- Express Scripts, CVS and Optum, owned by UnitedHealth -- now handle 75 percent of all prescription claims ... [I]ndependent pharmacies say that Express Scripts is unfairly wielding that market power to steer business to [its specialty pharmacy,] Accredo. Express Scripts patients typically cannot have their drugs covered by insurance if they use a pharmacy that is not in the network." (The New York Times; subscription may be required)
Why Are Hospital Prices Different? An Examination of New York Hospital Reimbursement (PDF)
151 pages. "Hospital reimbursement practices are complex and extremely varied ... There are significant differences in overall price levels ... among hospitals of similar size, services, and teaching designation... Hospitals with higher prices do not necessarily have higher quality.... Hospitals ... that serve more Medicare and Medicaid patients garner lower prices in the private commercial market.... Higher-priced hospitals may be higher-priced as a result of various forms of market leverage, which gives them more bargaining power to command higher prices when negotiating with insurers." (Gorman Actuarial, Inc., for NYS Health Foundation)
Catholic Health Initiatives Pulls Out of Insurance Business
"As more hospitals across the country consider launching their own health insurance plans, one big hospital operator is pulling out of the business. Catholic Health Initiatives (CHI), a large nonprofit health system based in Colorado, no longer plans to develop a 'wholly owned and nationally driven' insurance business ... The provider, which operates 103 hospitals in 18 states, lost nearly $110 million during the last fiscal year[.]" (FierceHealthcare)
Telehealth Alone Will Not Increase Health Care Access for the Underserved
"Providing high-quality care requires access to ancillary diagnostic services and in-person follow-up. Introducing telehealth into underserved communities generates new demand for services such as procedures or tests that can't be done through video conferencing.... Telehealth requires integration into a well-functioning health care system that has the capacity to address all the additional patient needs that telehealth generates." (Health Affairs)
Narrow Provider Networks for Employer Plans
"[In] 2016, only 7 percent of employers with health plans offered a narrow network. Also, in 2014, employers ranked narrow networks the least effective among several strategies to manage health insurance costs.... More than one-third of employers with health plans that have 5,000 or more workers now offer some type of alternative network, including tiered or 'high-performance' networks.... Where narrow networks are offered, their adoption could be increased by giving workers stronger financial incentives to consider them." (Employee Benefit Research Institute [EBRI])
Reference-Based Pricing: The New Frontier of Cost Control?
"The largest entity using [reference-based pricing (RBP)] is Medicare, which uses bottom-up pricing based on providers' costs of doing business ... Medicare determines a base rate for each service and then makes adjustments based on patient complications, geographic cost differences, and other factors. Employers who use RBP often pay providers the Medicare rate plus 20-50%. In contrast, PPOs provide a top-down discount off of billed charges for their in-network providers. With RBP, employers are shifting from discount-based to cost-based payments to providers." (Marsh Consulting Group)
Insurers' Flawed Directories Leave Patients Scrambling for In-Network Doctors
"As consumers review their coverage and shop for 2017 insurance through the federal health law's online marketplaces during the annual open enrollment period, many of the directories they are using are outdated and inaccurate. Some doctors in the directories are not accepting new patients and some are not participating in the network ... Still other physicians in the directories, who are listed as 'in-plan,' charge patients thousands of dollars extra per year in 'concierge fees' to join their practices." (Kaiser Health News)
National Health Spending: Faster Growth in 2015 as Coverage Expands and Utilization Increases (PDF)
"Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014." (Health Affairs)
Turbulent Times for Center for Medicare and Medicaid Innovation
"As lawmakers debate and discuss ways to repeal the [ACA], they will weigh the fate of the [Center for Medicare & Medicaid Innovation], funded through the health law with $10 billion for 2011 to 2019, and another $10 billion for each subsequent decade. [CBO] estimates the center would increase federal spending initially, but ultimately result in lower costs and save up to $34 billion over the next 10 years." (National Public Radio)
What Health Plans Need to Know About Millennial Customers
"Forty-five percent of doctors polled ... said the top difference between millennial patients and others is that millennials are more likely to challenge treatment recommendations than other patients. An additional 16% identified millennials' cost-consciousness as the biggest differentiator between them and other generations.... 28% said they expected millennials to drive the increased use of telemedicine. 27% said millennials would spur the proliferation of walk-in clinic settings. 24% said millennials would boost online scheduling and extended hours." (HealthLeaders Media)
The Sandbox Bully: Health Savings Accounts, Onsite Clinics, and Telemedicine
"Employers, particularly those employers that feel they are running out of room to further pare down medical plan design(s) or shift cost-sharing to employees, are increasingly looking toward alternatives like telemedicine and onsite clinics to help lower the cost of their group health plans.... For all of their advantages, health savings accounts (HSAs) do not easily co-exist with many other benefits. This article focuses on the HSA-compatibility issues employers face when implementing telemedicine and/or an onsite clinic in conjunction with a high deductible health plan (HDHP) with an HSA and potential solutions." (Haynes and Boone, LLP)
High Value Cancer Care: Guidance for Employers (PDF)
28 pages. "[H]ow can benefits professionals provide help when it comes to steering employees toward high-value care? How can they sort through the proliferation of cancer care benefits and programs available to hone in on those with the most value and/or can amplify the value of what they currently provide? And how can they move toward paying for value instead of volume?" (Northeast Business Group on Health [NEBGH])
Kaiser Now Interacts More with Patients Virtually Than In-Person
"52 percent of the integrated health system's 110 million physician-member interactions took place via smartphone, videoconferencing, kiosks, or other technology tools. [CEO Bernard Tyson] said that Kaiser is reversing the traditional health care delivery model that asks patients to come to providers and is instead bringing services to the patients." (The Advisory Board Company)
Report on the Proposed 2016 Cancer Claim Cost Valuation Table (PDF)
59 pages. "The purpose of this project was twofold: [1] To develop a new set of valuation tables for use with cancer insurance policies; [2] To aid actuaries pricing and reviewing product filings by providing information about the initial data provided by the industry in response to the data call. The current tables used to value reserves for cancer policies were developed in 1985 based on experience data from the late 1970s. Since that time there have been changes in the medical treatment of cancer and therefore the product design of cancer policies." (Joint American Academy of Actuaries and Society of Actuaries Cancer Claims Cost Tables Work Group)
Calculating Shared Savings: Administrative Formulas Versus Research-Based Evaluations
"Shared savings lie at the core of many recent health care payment and delivery reforms, most prominently those involving accountable care organizations (ACOs).... Although the main conclusions often overlap, there are times when administrative formulas and research-based evaluations can produce strikingly different results, provoking substantial confusion and consternation among stakeholders. This post looks at the advantages and disadvantages of the two approaches and discusses how they can be melded to best serve administrative, payment, and research needs." (Health Affairs)
Hospital Health Plans Growing as Providers Want More Control Over Care
"As health care delivery and payment models continue to evolve, some hospitals have decided to take more control over their private payment options and offer their own health plans. By cutting out the middleman of other insurers, these integrated hospital systems are able to oversee health care spending and ensure that patients receive the services they need." (Wolters Kluwer Law & Business)
[Opinion] The Time for Telehealth Is Now
"Today, almost all mobile and desktop computing devices are equipped with webcams capable of capturing high-definition video and sound quality. This innovation -- combined with broadband Internet connectivity that now extends across 80 percent of the United States, including the growing population who have online access only through their mobile device -- seems to be overcoming the technology obstacle previously associated to telehealth." (Jeffrey C. Bauer, for HFMA)
Medicare Accountable Care Organization Results for 2015: The Journey to Better Quality and Lower Costs Continues
"Overall, 31 percent of the MSSP and Pioneer ACOs received shared savings bonuses for their 2015 performance, an increase over the 27 percent that earned a bonus in 2014. While more ACOs are succeeding under the program, there continues to be substantial variation in financial performance and quality results." (Health Affairs)
Call Me Maybe? Telemedicine ROI
"Telehealth saves an average of $100 a visit, assuming an office visit costs $140 and a telehealth visit costs $40 ... Comparing a telemedicine visit for a minor ailment to an in-person visit, [one] vendor, reports it achieves an average savings of $673 per claim.... [One employer] saved about $192,000 since implementing telehealth, based on an average ER visit costing $1,233 average, urgent care visits at $150 and an e-visit average cost of $50." (International Foundation of Employee Benefit Plans [IFEBP])
Does Digital Health Need Reimbursement?
"[T]he reimbursement environment is changing for the better for telemedicine reimbursement ... But do digital health tools need direct reimbursement under third-party payment programs to thrive?.... With the push by the federal government and private payers for value-based purchasing, population health management and bundled and capitated payments (collectively, APMs), digital health tools can be valuable simply for the efficiencies improved quality they can bring to the delivery of health care services." (McDermott Will & Emery)
Should Big Insurance Become Like Walmart to Lower Health Costs?
"Now that hospitals have themselves combined, in many cases, into companies that dominate their communities, insurance executives argue the only way to fight bigness is bigness.... In metro areas with only a few big insurers, hospital and doctor bills tend to be lower than what economists would otherwise expect. If only one or two insurers are bidding to include providers in their networks, hospitals and doctors must submit to the offered deal or risk getting shut out of a huge piece of business." (Kaiser Health News)
[Opinion] Orszag and Emanuel Do Not Seem to Understand Bundled Payments
"The clinical course of a heart attack is highly variable and could involve only a few or a great many interventions. Under a bundled payment, the physicians and hospital are bearing the risk of the high costs of a potentially complicated, protracted course. Isn't it the role of the insurer, in this case Medicare, to pool risk? Shifting that risk to the health care delivery system creates the potential for either a reduction in important beneficial health care services, or exposing the delivery system to potential monetary losses and the risk of insolvency -- neither of which are desirable." (Physicians for a National Health Program [PNHP])
Telemedicine Arrangements: Beware of Inadvertently Dialing Up an Excise Tax
"The preventive services mandate is particularly problematic for telemedicine plans.... if a plan doesn't have an in-network provider that can provide such services, then the plan can't impose any cost sharing for the services to be performed out-of-network. It is difficult to see how any telemedicine arrangement can comply with this mandate on its own.... The fact that the employer is offering to its employees some other fully compliant major medical plan doesn't, in and of itself, negate the telemedicine plan's obligation to meet all the ACA's market reform requirements." (Bloomberg BNA)
Do You Know How Good Your Surgeon Is?
Infographic. "[W]hen healthcare consumers who need surgery start their research of potential hospitals or surgeons, they are bombarded with confusing amounts of ratings, 'best of' lists, and hoards of big data. When it comes to patient reviews, can you trust an anonymous Yelper to guide you to a quality surgeon? And when you come across websites with a ton of data like complication rates, volumes, mortality, or readmissions, how do you make appropriate conclusions about the risks you potentially face when you choose your healthcare provider?" (mpirica)
CMS Releases Medicare Current Beneficiary Survey (MCBS) Public Use File
"Beginning with data collected in the 2013 Medicare Current Beneficiary Survey (MCBS), a public use file (PUF) and accompanying documentation is available free for download ... The MCBS PUF is an easy to use data file with select data items that allow researchers to conduct analysis on health disparities, access to and satisfaction with healthcare, and medical conditions for community dwelling Medicare beneficiaries. The MCBS PUF ... provides a publically available alternative for those researchers interested in the health, health care use, access to and satisfaction with Medicare of beneficiaries, while providing the very highest degree of protection to the Medicare beneficiaries' protected health information meeting all necessary de-identification of the data and mitigating disclosure risk." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Paying for Value: Progress and Obstacles (PDF)
"For the most part, ... programs that combine quality measures and incentives for cost control and prudent resource use -- paying for value -- have not been in operation long enough to measure their effectiveness. Experimentation is increasing through approaches such as shared savings and bundled payment, but many questions remain about how best to define and measure value." (AcademyHealth)
House Committee Leaders Press Last Surviving Obamacare CO-OPs for Updates on Viability
"CMS has placed at least eight of the remaining 11 CO-OPs on 'Enhanced Oversight' or 'Corrective Action' Plans.... After reviewing these oversight plans, the Committee is concerned that CMS has not taken the appropriate steps to ensure that the remaining CO-OPs will be financially solvent for the remainder of the year. Federal taxpayers have invested over $1 billion into the remaining 11 CO-OPs. Especially considering this substantial taxpayer investment, the Committee wants to ensure CMS is taking the necessary and appropriate steps to keep these CO-OPs afloat." (Energy & Commerce Committee, U.S. House of Representatives)
50-State Survey on Telemental Health Laws in the United States
"[T]he survey details the rapid growth of telemental health -- mental health care delivered via interactive audio or video, computer programs, or mobile applications -- and the increasingly complex legal issues associated with this trend. Additionally, the survey provides one source for state-by-state coverage of legal issues related to telemental health, such as: Definitions of 'telehealth' or 'telemedicine'; Licensure requirements; Governing bodies; Reimbursement and coverage issues; The establishment of the provider-patient relationship; Provider prescribing authority; Accepted modalities for delivery (e.g., telephone, video) to meet standards of care." (Epstein Becker Green; free registration required to download survey report)
Telemedicine and the Long-Tail Problem in Healthcare
"Utilization of telemedicine is significantly higher for the Medicare population compared with commercial ... Telemedicine utilization rates appear to be higher in Alaska and in the Midwest and Southwest regions of the country ... Average charge levels for telemedicine services are approximately 9.4% lower than the equivalent services delivered on-site for Medicare, and 0.9% higher for commercial plans." (Milliman)
Healthcare Benefit Designs: How They Work
"All payment methods have strengths and weaknesses, and how they affect the behavior of health care providers depends on their operational design features and how they interact with benefit design.... This report analyzes the nuances of how seven different benefit designs work. These designs include narrow networks, tiered networks, reference pricing, high-deductible health plans, centers of excellence, value-based insurance design, and alternative sites of care." (Urban Institute)
Medicare Pays Bonuses to 231 Hospitals with Lower Quality Because of Cheaper Costs
"[For] the federal fiscal year that ended in September 2015 spending counted for 20 percent of a hospital's score in determining whether a hospital would get a bonus, penalty or regular payment. Under this formula, hospitals with Medicare spending below the median hospital were able to qualify for bonuses even though their quality measures were below the median.... CMS said it would consider revising the program for future years so that hospitals scoring below the national median for quality would not receive a bonus." (Kaiser Health News)
[Opinion] Confronting Consolidation (PDF)
"Aetna, Humana, Anthem, Cigna, they're all in merger/acquisition mode. Pharmaceutical manufacturers continue to merge ... Just two PBMs now control two thirds of the employer-sponsored prescription drug market.... So where does all this healthcare consolidation leave your corporate health plan? Probably not in a good place when it comes to patient access, provider choice, price competition and appropriateness of treatment.... [H]ow are plan sponsors going to protect themselves and their plan members from the increasing market power of the major healthcare players? ... Enter the U.S. Federal Trade Commission (FTC), whose role it is to protect consumers from anti-competitive practices." (Chelko Consulting Group)
Rewarding High Quality: Practical Models for Value-Based Physician Payment (PDF)
13 pages. "ACHP recommends these critical strategies for successful implementation of alternative payment models: [1] Introduce increasing levels of risk gradually, regularly assessing for provider and practice readiness and investing in care management capabilities. [2] Tailor measures to the performance improvement goals of physician practices. [3] Develop actionable performance data, to include patient satisfaction and clinical outcomes measures, and initiate frequent payer-provider engagement to drive improvement and share best practices. [4] Provide cost and quality information at the individual clinician level and, when possible, ensure that payment incentives go to both practices and individuals. This brief provides examples from ACHP plans for each of the four strategies." (Alliance of Community Health Plans [ACHP])
Is On-Site Health Care Right for Employers?
"These nine questions will help you determine whether an onsite health center is the right 'stretching' strategy to propose.... A high-quality onsite health provider can be much more than a vendor -- they can be a true partner in helping an organization improve the health of their workforce and the performance of their business." (
CMS Escalates Primary Care Reform
"CMS is looking for payers willing to align their payment structures, quality metrics, and data sharing with those of Medicare to meet the goals of its two-track successor to the Comprehensive Primary Care initiative." (HealthLeaders Media)
Health Plans Help Providers Convert to Quality, Value Model
"Health care providers need help moving to value-based reimbursement and adopting accountable care models, and insurers and health plans often provide the best support ... Drivers forcing providers to adapt to value based reimbursement include a retail environment accelerated by the [ACA], the drive toward consumer-driven health care and the MACRA legislation of 2015." (HR Daily Advisor)
CMS Introduces New Primary Care Payment Initiative for Healthcare Providers
"In a sharp departure from the current 'fee-for-service' system, which offers reimbursements per visit or procedure, providers who volunteer to participate will received fixed monthly fees for every patient and bonuses for meeting various quality goals. When their patients stay healthier and require less-expensive care, many primary care doctors will also share in the savings to Medicare, Medicaid or private insurers.... This summer, the administration will choose 20 states and regions that will be eligible for CPC-Plus, and will partner with private insurers so that the reforms will not just apply to government payments." (Politico)
The Power of the Patient-Centered Medical Home in Workplace Health and Wellness Centers
"By harnessing the power of the [patient-centered medical home (PCMH)] model in worksite or near-site health and wellness centers, forward-thinking employers are able to implement creative benefit structures that improve the health care delivered to employees. In the employer setting, the PCMH model can not only significantly reduce health care costs, but it can improve population health, and more importantly, sustain those improvements over time leading to long-term health care cost control and a healthier, more productive workforce." (QuadMed, via The Institute for HealthCare Consumerism [IHC])
Innovations in the Setting for Health Care Delivery: Will Expanding Care Options Increase or Decrease Costs?
"Historically, there were two options if you needed health care: your doctor or the emergency room. As demand for primary care increased and costs for emergency care soared, a third option appeared: urgent care. Recently, there has been an explosion of options to improve access to health care, including retail clinics at drug stores and telemedicine. In theory, these new options could reduce overall health care costs by treating conditions earlier and preventing more expensive care. The concern is, however, that people may increase their utilization of health care, thereby leading to higher overall costs." (Marsh Consulting Group)
Latest Battlefront for Closing Health Insurance CO-OPs? The Courts
"While many of the organizations met or exceeded their enrollment targets, most suffered massive losses because of what they claim were premium rates that were too low and claims volumes that were too high. In a pair of recently filed actions, the aftermath of these failures is starting to make its way into the federal courts. Health Republic Insurance, an association of three CO-OPs in New York, New Jersey and Oregon, is involved in both of the suits attempting to deal with the financial fallout of the closing CO-OPs." (Bloomberg BNA)
AHIP Tests 'One Stop' Provider Directory Model as Fines Threaten Insurer Inaccuracies
"Because more than 80 percent of consumers go to Google to find a doctor, and much of that information is inaccurate, America's Health Insurance Plans [AHIP] has initiated a first-of-its-kind provider directory ... A pilot program will start in April and run through September in three states: Indiana, California and Florida. Twelve health plans spanning the commercial, Medicaid, and Medicare Advantage markets are participating[.]" (Healthcare Payer News)
Maine Community Health Options, the Only Profitable CO-OP in 2014, Posts Major Losses
"The Maine Bureau of Insurance is closely monitoring Community Health Options, as the nation's only profitable co-op under the [ACA] in 2014 posted a net loss of $74 million for 2015 and 2016 this month ... In 2014, Maine Community Health Options, reported net income of $7.3 million[.]" (Healthcare Payer News)
Health Care Market Consolidations: Impacts on Costs, Quality and Access
"Health care markets are becoming more consolidated, causing price increases for purchasers of health services, and this trend will continue for the foreseeable future ... Government can still play an effective role in addressing higher prices that come from consolidation by pursuing policies that foster increased competition in health care markets. Many of these policies can be effective even in markets with high degrees of concentration, such as in Northern California." [Testimony before the California Senate Committee on Health on fostering competition in consolidated markets, Mar. 16, 2015] (The Brookings Institution)
Consumer Operated and Oriented Plan (CO-OP) Program: Frequently Asked Questions (PDF)
16 pages. "The fact that about half of the CO-OPs have ceased operations has generated a lot of interest in the program.... The report includes information about the structure of the CO-OP program, program requirements, the loan awards, and the current operating status of the CO-OPs." [Report R44414, Mar. 11, 2016] (Congressional Research Service [CRS])
No Evidence That Insurance Market Consolidation Leads to Greater Innovation
"Identifying the most effective and efficient providers, negotiating favorable terms with these providers, and providing financial incentives to patients to utilize these providers ... are tried and tested tactics in insurers' toolkits.... [T]here is no evidence of greater product innovation in more concentrated insurance markets.... Given the history of slow innovation in health insurance, one could argue that a change in insurance markets is necessary to stimulate more. To date, there is no evidence that consolidation will be that catalyst." (Health Affairs)
Texas Telemedicine 2015 Year in Review
"[A]mendments to the telemedicine rules ... [would have] required 'establishing a diagnosis through the use of acceptable medical practices, including documenting and performing patient history, mental status examination, and physical examination that must be performed as part of a face-to-face or in-person evaluation' ... Medicare, Medicaid and other payors continue to add aspects of telemedicine that qualify as reimbursable services ... Several other states, including Arizona, Colorado, Connecticut, Florida, Kentucky, Maine, Montana, Nebraska, New Hampshire, New Mexico, Oklahoma and Tennessee, have enacted legislation to regulate a variety of telemedicine activities." (Haynes and Boone, LLP)

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