Improving physician behavior probably ranks somewhat lower on hospital priority lists these days than getting ready to avoid penalties for early readmissions, which are mandated by the Affordable Care Act. A study by IMA Consulting says that many hospitals are still not prepared to deal with this. The study cites the Centers for Medicare & Medicaid Services in stating that “nearly half of all general acute care hospitals are at risk of payment reductions.” The penalties are slated to go into effect Oct. 1…. The Supreme Court’s upholding of health reform ensures, at least until November, that adults up to age 26 may stay on their parents’ policies. But UnitedHealthcare, Humana, and Aetna weren’t taking any chances. Before the ruling, they said that they would continue the policy no matter what happens with health reform… States’ Medicaid ACO efforts are at an early stage, as officials grapple with “relatively lengthy planning and implementation processes,” says an issue paper by the Kaiser Family Foundation. “While Medicaid ACOs are a strategy to more directly engage providers and provider communities in improving care, cost-containment is also a significant motivating factor for many states.”
Managed Care’s Top Ten Articles of 2016
There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.
They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?
A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.
More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.