Category: The Business of Health Care

Nine States to Watch for ACA Implementation

Nov 9, 2012

By Josh Archambault

Healthcare reporters have been in a frenzy to report this week that the ACA is a done deal and states should get on with it. The election certainly changes the dynamic in the repeal effort, as Speaker John Boehner indicated in a recent interview with ABC News, yet the implementation battle is far from over.

The next interesting story line is developing out of an OK lawsuit pertaining to the legality of subsidies being made available in the federal exchange. To be more specific, it challenges an IRS rule that imposes an ACA employer mandate where the statute does not appear to authorize it. If this case were to prevail, it would undermine the “fallback” federal exchange that is going to be established for states that opt to forgo setting up their own state exchange.

Governors in SC, GA, FL, KS, VA, MO are on record that they will not set up a state exchange. Most believe, minus the Democratic Governor of MO since a ballot question prevents him from unilaterally setting up an exchange, that the subsidies will not be available in the federal exchange, and will put the federal government between a rock and a hard place.

The election results at the state level also play into this story.

What HHS Might Look Like Under President Romney

Oct 24, 2012• 4

By Dan Diamond

The world may not be ready for a Romney presidency.

Or more specifically: world leaders may not have done enough homework.

An interesting Washington Post story this week suggested that because the foreign polls have been so bullish on President Obama — 82% of Germans in one survey expected Obama to be re-elected — lawmakers around the world may be scrambling to adjust to a new team of U.S. diplomats and set of policies.

Is the health sector better prepared?

Given the close race — as of press time on Wednesday, most polls had the presidential race neck and neck — there’s been growing scrutiny of Republican health proposals. For example, the Kaiser Family Foundation and the Urban Institute on Tuesday released another report on the GOP House Budget Committee’s Medicaid plan.

But there’s been much less examination of the people who would steer Romney’s Department of Health and Human Services and the policies they’d carry out.

Possible, if Unlikely Contenders

A handful of names — all veterans of the George W. Bush administration — have been repeatedly floated as potential HHS secretaries under Romney. National Journal suggested that former HHS Secretary Michael Leavitt could return to the role. Meanwhile, ex-FDA and CMS head Mark McClellan is “the first name that comes to mind for many Republican health policy folks,” Politico’s Jennifer Haberkorn wrote earlier this year.

United Healthcare Expands to Brazil

Oct 13, 2012

By Bill Rusteberg

UnitedHealth Group is set to become the controlling owner of the largest healthcare company in Brazil, a country whose health market is rapidly growing, in one of the most high-priced overseas deals by a U.S. private insurance company.

The largest American insurer is spending $4.9 billion to acquire 90 percent of Brazil’s Amil Participacoes, which has about 5 million members, a provider network of 3,300 hospitals and 44,000 doctors, and also owns 22 hospitals and about 50 clinics, reported the Associated Press.

By entering the Brazilian healthcare market, UnitedHealth can better access the country’s 200 million population, only 25 percent of which has private insurance, at a time when Brazilian leaders increasingly are turning to private companies to insure its citizens, Reuters reported.

“Brazil has emerged as a consistently growing and evolving market for private sector health benefits and services. Its growing economy, emerging middle class and progressive policies toward managed care make it a high potential growth market,” UnitedHealth CEO Stephen Hemsley said Monday in a statement.

“Combining Amil, the clear market leader serving an under-penetrated market of nearly 200 million people, with UnitedHealth Group’s experiences and capabilities developed over the last three decades is the most compelling growth and value creation opportunity we have seen in years,” he said.

Amil’s founder Edson Bueno and his partner Dulce Pugliese will retain their 10 percent ownership of Amil for at least five years. Amil also will invest about $470 million in UnitedHealth Group shares, which it also will hold for five years, according to the Minneapolis Star-Tribune.

Care On the Continuum

Sep 20, 2012• 42

By ROB LAMBERTS, MD

My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point. Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid. The traditional way to be paid is for service rendered (either at an office visit or procedures done). This means that I am financially motivated to give the bulk of my attention to people when they are in the office. They are paying for my attention, so I try to give them their money’s worth. The corollary of this is that I tend to not think about people who are not in the office to be seen. The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters. Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits. My ability to help my patients depends on my ability to affect the continuum. If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful. I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then. People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know. Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit. Regardless of the reason, I get very limited interaction with my patients in this episodic care model.

My new practice model allows for, and even encourages interaction between face-to-face encounters. I intend on spending a significant part of my day systematically reviewing records to make sure they are up-to-date, and initiating contact if need be. I will also give them resources to be able to manage their care (or their wellness) without having to pay for each encounter. One reader (of another blog to be left unnamed) suggested that under this system he would get his “money’s worth” by using my service as much as possible. For him that meant coming to see me often, but in the model of care on the continuum it would involve going to the web site and updating records, sending me questions, or watching videos I’ve made on a particular subject. My hope is that all my patients would “get their money’s worth” between visits, and that perhaps this will reduce the need for actual face-to-face encounters. In fact, that is the whole point of what I am doing.Continue reading…

Refocusing Long-Term Care on People: The Three I’s

Sep 1, 2012

By Frank Spinelli

Both participants and caregivers in long-term care programs face a myriad of difficulties. Participants with long-term services and supports needs often have many health issues, meaning they are in constant transition between care environments and providers with their needs ever-evolving. As a result of visits to a number of doctors on a regular basis and the number of providers who support them, the participant’s information lives in multiple locations. This can lead to discrepancies between providers and the participant having to constantly provide the same information.

Caregivers, especially family members, are also facing great challenges. It’s a full-time job to care for someone in the home – it takes nearly 40 hours a week – and searching for a trusted service provider to take over can be another job in and of itself.

The root of the problem is that many long-term care programs are focused on the providers and not necessarily the people – those receiving the services and those providing them. Often, no one has the full picture of the participant’s health, which can lead to suboptimal care. An ideal situation is for everyone involved with the participant to be up-to-date and have a full-picture of their health and well-being at all times. When they are, services can be administered effectively with less risk for everyone involved.

How Do We Bend the Cost Curve? Reduce the Waste.

Aug 17, 2012• 1

By Wendy Everett, ScD

Health care had its own version of the LeBron James “Decision” last month with the Supreme Court upholding the critically important elements of the Affordable Care Act. Now that the uncertainty is behind us―at least until the November elections―health care leaders can continue preparing their organizations for the changes ahead.

Fixing the system requires reforms at the macro level. But it also takes a symphony of smaller actions happening in concert. As experience bears out, it is difficult to agree upon a collective action with so many competing interests in health care and the partisanship that has gripped politics. But there is a song that we can all agree upon, loud and in unison. Reduce the waste.

Nearly a third of our health care costs come from wasteful spending and inefficiencies that could be avoided. Left unchecked, this is a nail in the coffin of our system; but, if tackled, is a huge cost containing opportunity. By identifying waste in the delivery system and systematically reducing it, we could lower costs without resorting to budget cuts and fees that compromise the quality of care.

CMS Misses the Mark on Home Hemodialysis

Aug 12, 2012

By Joe Turk

We are disappointed that CMS’ recently proposed rules again miss a clear opportunity to address home hemodialysis access for Medicare patients.

Recent clinical research demonstrates the significant benefits of more frequent dialysis. Better clinical outcomes, lower mortality, and higher survival – the list goes on. Recognizing the strength of this data (and heeding the calls of numerous patient advocates), large national commercial insurers, including UnitedHealthcare and Aetna, recently clarified their policies, granting greater access to home, and more frequent, hemodialysis for commercial patients.

In recent weeks, CMS’ proposed rules for both Physician Fee Schedule and ESRD PPS Rule came out. In the proposed Physician Fee Schedule, physician payment will increase for in-center dialysis, but will remain essentially unchanged for home dialysis. Physicians are already paid generally 20% less to care for their home dialysis patients, and under the proposed rule for physician payment this disparity would grow. In the proposed ESRD PPS Rule, there were no mentions of home hemodialysis. None. In the rule, CMS proposes a 2.5% increase to the bundled payment rate, representing hundreds of millions dollars of additional money going to the Medicare dialysis program. None of this increase is going to address the known payment issues impacting access to more frequent home hemodialysis.

Latest CBO Report on Health Law Adds to Business Uncertainty

Aug 1, 2012• 2

By Matt Barry

The Congressional Budget Office’s new estimates of the budgetary impact of the Affordable Care Act, made in the wake of the Supreme Court’s ruling last month, glides right by one obvious fact: the budget analysts really have no idea how the court ruling will affect their previous estimates.

The CBO report says very clearly that “what states will be able to do and what they will decide to do are both highly uncertain.” Translation? They don’t know any more than anyone else right now about how states will act, now that the high court has determined that the federal government can’t force states to participate in the expansion of Medicaid by withholding the federal share for existing activities.

CBO isn’t to blame for this uncertainty. Rather, they should be commended for their candor in acknowledging the degree of uncertainty that remains. Most news reports and commentaries on the new CBO findings have downplayed or ignored this problem.

Why Nobody Believes the Numbers

Jul 22, 2012

MARKETPLACE

Did you know that the “official” industry guidelines for measuring care management outcomes are mathematically certain to overstate savings? And that about half the companies in the DM/wellness marketplace (including carriers) have invalidating mathematical mistakes right on their websites or in their brochures? And that others simply lie? And that the “gatekeepers” who are supposed to prevent these mistakes – leading benefits consulting and actuarial firms – routinely make up savings figures that are simply mathematically impossible and hope they don’t get caught?

This is the first book to treat outcomes as being math-based, not faith-based. It is aimed at the grown-up segment of the marketplace – people who really want to see how much they can save, rather than how much they can be told they can save. A dozen hilarious case studies—and we are naming names — will include:

·         Major carriers who simply make up numbers and dare you to catch them
·         Benefits consulting firms that specialize in “validating” mathematically impossible results
·         Vendors promising savings in excess of the mathematical limit of 100%
·         Carriers/vendors that are either totally clueless and/or think you are…and make up their own metrics like “reduction in undetected claims cost,” leading one to ask how they are able to detect undetected claims cost, and/or how an employee would otherwise have filed an undetected claim

Employers and Health Reform

Jul 21, 2012• 70

By MICHAEL TURPIN

“Change, before you have to…” Jack Welch

We live in a society that loathes uncertainty – particularly the unintended consequences that sometimes result from a catastrophic event or in the case of PPACA, landmark legislation. Wall Street and the private sector crave predictability and find it difficult in uncertain times to coax capital off the sidelines when the overhang of legislation or geopolitical unrest creates the potential for greater risk. Despite our best energies around forecasting and planning, some consequences, particularly unintended ones – only reveal themselves in time.

In the last decade, employers have endured an inflationary period of rising healthcare costs brought on by a host of social, political, economic and organizational failures. There was and remains great anticipation and trepidation as Congress continues to contour the new rules of the road for this next generation’s healthcare system. Optimists believe that reform is both a way forward and a way out of a mounting public debt crisis and a bypass for an economy whose arteries are clogged by the high cost of medical waste, fraud and abuse. Cynics argue reform is merely a Trojan Horse measure that offers an open invitation for employers to drop coverage and for commercial insurers to “hang themselves with their own rope” as costs continue to spiral out of control — leading to an inevitable government takeover of healthcare.

Meanwhile, leading economic indicators are flashing crimson warning signs as recent stop-gap stimulus wears off and long overdue private/public sector deleveraging results in reduced corporate hiring, lower consumer confidence and increased rates of savings. The symptoms of a prolonged economic malaise can be felt in unemployment stubbornly lingering around 9.2% and a stagnating US economy that is struggling to come to grips with the rising cost of entitlement programs. Across the Atlantic, the Euro-Zone is teetering as Italy and Spain (which represent more credit exposure than Greece, Portugal and Ireland combined) stumble toward default. Despite these substantial head winds, US healthcare reform is forging ahead – – right into the teeth of the storm.