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Contributing Voices
Norman S. Ryan, MD
Norman S. Ryan, MD

As if the worsening diabetes epidemic were not enough to worry about, this chronic condition also increases risk for complications like heart disease, stroke, and kidney failure. This is a major challenge for health plans managing the care of a growing population of Medicaid members, who tend to overutilize emergency rooms for routine or non-urgent care.

While preventive and disease management programs are helping improve outcomes for people with diabetes and other chronic conditions, more must be done beyond just phone outreach to adequately engage Medicaid members. For instance, the single mother with young children and no car doesn’t need a call to remind her of an A1C test; she needs help resolving socioeconomic barriers like lack of transportation or child care.

Contributing Voices
Peter Wehrwein

Three more organizations have exited CMS’s Pioneer accountable care organization (ACO) program, leaving just 19 of the original 32 participants in the fold for the elite program’s third year.

The Franciscan Alliance in Indianapolis, the Genesys Physician Hospital Organization in Flint, Mich., and the Renaissance Health Network in Wayne, Pa., in the southeastern part of the state, are leaving the Pioneer program, according to a list posted on the CMS website this afternoon.

Sharp Healthcare in San Diego had announced in August that it was dropping out.

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

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
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
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:

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