Managed Care

 

Blogs

Contributing Voices
Peter Wehrwein

Maybe, just maybe, accountable care organizations (ACOs) are the best bet for hitting the health care exacta of controlling costs and improving the quality of care.

Figures released by CMS on September 16 showed that the 23 organizations in the elite Pioneer program and 220 in the Shared Savings program produced over $372 million in savings while earning $445 million in shared savings payments.

Contributing Voices
Paul Terry

Though hospitals were the slow adopters of EHRs, most are now fully engaged in trying to satisfy the federal requirement for “meaningful use” of an EHR thanks to CMS financial incentives. Still, as much as acceptance of the complex requirements needed to earn incentives is now a given with three fourths of health systems achieving stage 1 requirements, my discussions with providers from around the country leaves me observing that the intense focus on the details behind satisfying requirements has obscured the greater health policy picture.

Contributing Voices
Edie Castello

The United States spends considerable money on health care. Unfortunately, the clinical return on investment has been coming up short for years, according to Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, an oft-cited Commonwealth Fund study.

Contributing Voices
Krishna R. Patel, PharmD, RPh
Formulary Restrictions Blow Medication Adherence

If you haven’t already heard about the negative impact of formulary restrictions on adherence, well here it is. With mixed messages regarding formulary restrictions’ impact on patients, a recently published systematic literature review, published by Happe, et al., sought to get to the bottom this.

Contributing Voices
Paul E. Terry, PhD and David Anderson, PhD, LP

Paul E. Terry, PhD

David Anderson

David Anderson, PhD, LP

We’ve known Michael O’Donnell, the publisher and editor in chief of the American Journal of Health Promotion, for 30 years. He is not prone to hyperbole. So he got our attention when he recently wrote that he had just published “the most extensive and well-conceived review conducted to date” on the financial impact of workplace health promotion.

He calls the paper “one of the best reviews ever conducted on any topic in workplace health promotion.” The study by Siyan Baxter and colleagues shows how the quality of the research methodologies used in the 51 interventions examined in their final analysis affected the magnitudes of the ROI’s reported. An archived webinar that summarizes the study findings is available free on this page at the  American Journal of Health Promotion.

Studies vary

There is a time-honored belief among health services researchers that the more rigorous the methodology, the smaller the size of the differences between groups will be. This is precisely what Baxter and colleagues found with respect to return on investment, which they calculated as ROI = (benefits – program costs) / program costs rather than the more typical approach of reporting ROI as the ratio of benefits to costs, i.e., ROI = benefits : costs. Nevertheless, Baxter, who is a PhD candidate in medical research at Australia’s University of Tasmania, found ROIs averaging 0.26 ($1.26 per dollar invested) in the 18 high-quality studies and –0.22 ($0.78 per dollar invested) in 12 studies using the most rigorous methodology, namely, the randomized controlled trial (RCT). For the 43 less rigorous studies of moderate or low quality, Baxter found ROIs averaging 1.79 (i.e., benefits of $2.79 per dollar invested), which is consistent with the oft cited ROI of 3:1 reported in a recent review by Harvard Economist Katherine Baicker and her colleagues.

Contributing Voices
Norman S. Ryan, MD

Next year is a big year for Medicare Advantage plans. In 2015, they will not receive bonuses unless they have a 4-star rating or above. Many health plans are feeling under pressure right now, and may even feel a little disgruntled, as their businesses could really take a hit next year if they fall even slightly below 4.

One way to view this challenge that may take the edge off the pain is that the CMS Five Star Quality Rating System for Medicare Advantage Plans is not just about being able to stay or earn a spot in the Medicare Advantage program. Taking steps to improve ratings can help Medicare Advantage plans and other health plans hoping to enter the program achieve the Triple Aim and move them even closer to getting the business results they really want.

Contributing Voices
Steven Peskin, MD

This is my third installment on the Choosing Wisely Campaign from the American Board of Internal Medicine Foundation and Consumer Reports that brings into sharp focus, and in plain English, the things patients and we physicians should question. The Choosing Wisely campaign now includes submissions by more than 60 medical professional societies and organizations. Examples include:

  • Why scheduling early delivery of your baby is not a good idea
  • Treating sinusitis: Don't rush to antibiotics
  • Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
  • Bone density tests: When you need them and when you don't
  • Treating migraine headaches: Some drugs should rarely be used

What prompted this update is a new video in the zeitgeist of today, with light music, happily dancing people from seniors to millennials, and scrolling text.

I am hoping to prompt readers of Managed Care to help to take viral this video for the important campaign to reduce unneeded and in some cases harmful medical testing, treatments, and services. A wise choice!

http://www.youtube.com/watch?v=FqQ-JuRDkl8

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and is governor of the American College of Physicians, New Jersey South.

Contributing Voices
Dean Field, MD

The question facing health care organizations today is daunting: “How are we going to efficiently and effectively care for millions of new patients, many with chronic illnesses, and many who have never had access to routine health care in the past?”

At Franciscan Health System in Tacoma, Washington, we face the same problems as other health care systems. With 12,000 employees, including 1,200 physicians, and 46,000 hospital admissions plus 460,000 outpatient procedures, we fully understand the challenges of health care delivery today. However, we’ve found that the best approach to population management lies in a culture shift from treating lives at risk to a system where we front-load our attention to preventive medicine. Two things will allow us to be successful:

  • Team-based care which opens up access and enables physicians to extend their reach by adding certified physician assistants (PAs), nurse practitioners (NPs), care managers, health coaches, pharmacists, and others to the medical care team.
  • Electronic health records (EHR) technology connecting all providers with a complete and up-to-date medical record.
Contributing Voices
Frank Diamond

There’s a gap in the proverbial health care safety net that’s big enough for a whale to swim through.

People who are incarcerated, on probation, or on parole — what a recent study calls the “justice-involved population” — make up 22% of the 13 million newly eligible people.

“The justice-involved population has a higher disease burden than the general population, yet as many as 90% of justice-involved people lack health insurance at the time of their release from incarceration,” says the study, published in Health Affairs. “This disparity between disease burden and access can drive up the cost of health care, result in worse outcomes, and cause patients to seek care later than appropriate and in care settings that are often isolated and lack care coordination.”

Contributing Voices
Michael Flanagan
Michael Flanagan

Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access.

To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers and providers. Payers must be agile enough to adjust network strategies on the fly, as they learn more about newly enrolled populations. They need the ability to administer more complex product designs, care delivery. and reimbursement initiatives quickly and efficiently.

Unfortunately, current network operations often struggle because of multiple sources of provider data, disconnected reimbursement systems, and manual loading between network management and contract management. As the need for administrative savings grows and networks and reimbursement arrangements increase in number and complexity, the problem with existing systems will increase.

The road ahead requires preparation and challenges to current assumptions. Here is a template for health plans to drive their activity on the health insurance exchange:

Pages

Meetings

Pharmaceutical Pricing and Contracting Conference Philadelphia, PA September 22–23, 2014
Private Health Insurance Exchanges Conference Washington, D.C. October 7–8, 2014
National Healthcare Facility Management Summit Palm Beach, FL October 16–17, 2014
National Healthcare CFO Summit Las Vegas, NV October 19–21, 2014
National Healthcare CXO Summit Las Vegas, NV October 19–21, 2014
Innovative Member Engagement Operations For Health Plans Las Vegas, NV October 20–21, 2014
4th Partnering With ACOs Summit Los Angeles, CA October 27–28, 2014
2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014