Focus On Data in Era of Value-Based Models of Reimbursement

“Despite the continued prevalence of the traditional fee for service reimbursement models as the primary method of payment, over time healthcare’s reimbursement will give way to value-based models of reimbursement.”

That prediction made by longtime friend and consultant Russell Foster surrounding the need for accurate data as value-based models of reimbursement continue to emerge has come true.

You know that valued-based reimbursement today is a significant focus. Payer reimbursement strategies are tipping in favor of providers who can deliver the clinical and financial goods. In the mix are bundled payments, shared savings, pay for performance and bonuses.

Payment Bundling, PHO Shared Savings, and Pay for Performance are all in the mix of emerging models of episode-based payments, physician-hospital organizations and physician bonus structures.

One major health payer’s 6,300 enrolled primary care physicians can earn bonus payments across six measure sets — a broad spectrum of measures from clinical and quality measures to prescribing Continue reading

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Managed Care Organization ACO Initiatives; Provider Reimbursement Shift

Managed care organizations’ adoption of accountable care goes well beyond the accountable care organization (ACO) initiatives of caring for the Medicare population.

Health plans see the potential of ACOs in terms of the quality of care and reimbursement models.

Among the managed care organizations partnering with providers to launch ACOs are UnitedHealth Group, Aetna, Humana, Cigna, Highmark and others.

For instance, Cigna is involved in 86 collaborative accountable care initiatives in 27 states. These programs encompass more than 880,000 commercial customers and more than 35,000 doctors, including more than 16,000 primary care physicians and more than 19,000 specialists, Cigna said.

The health plan’s goal is to have 100 accountable care relationships reaching one million customers in 2014.

UnitedHealth Group has ACO initiatives underway in eight states.  And, $28 billion of the Continue reading

Key Trends Facing Private Practice Physicians in the New Year Identified

Physicians in private practice have their non-clinical work cut out for them in the year ahead. Results of the ACA changes, the launch of the federal and state health insurance market places, demanding paperwork burdens, and coming changes in coding requirements and health IT are all issues facing the physicians in 2014.

Among the key trends that seen to be bearing down on practicing physicians are:

 –  Rapidly increasing medical consolidation seen across health care systems and insurance companies alike.

–   The difficulty physicians experience while trying to negotiate favorable terms with payers because  the total number of health insurers has been decreasing for some time as a result of industry consolidation.

–   Physicians are continuing to struggle with a growing regulatory paper work burden.

In addition the recent launch of the health insurance exchanges is already driving high levels of confusion among patients, physicians and employers.

Coping with minimal education and support on the new health insurance exchanges from the government, many private practice physicians are unsure of how these new insurance policies will affect their practices. Continue reading

Three Additional MCOs Signed For State Medicaid Health Services in KY

Anthem, Humana and Passport have signed agreements with the Cabinet for Health and Family Services to provide healthcare services to state residents who will be newly eligible for coverage under the expansion of Medicaid, a provision of the Affordable Care Act.

The three new MCOs are in addition to Coventry and WellCare, which are currently serving this area, officials said.

Beginning October 1 residents in 104 Kentucky counties who are determined to be newly eligible for Medicaid will be able to choose the health plans as their healthcare provider for coverage effective Jan. 1, 2014.

“Under the terms of the contract, the three MCOs will initially serve exclusively the more than 300,000 who will be newly eligible for Medicaid,” officials said. Continue reading

Tax Credits Estimated to Average $2,700 Per Family Next Year for People Who Now Buy Their Own Insurance

Americans who currently buy their own insurance through the individual market would receive tax credits averaging nearly $2,700 next year for coverage purchased through new insurance marketplaces, found a new study.

The tax credits or subsidies would cover 32 percent of the premiums on average for this group of enrollees in a so-called “silver” plan, according to the Kaiser Family Foundation analysis. .

Foundation researchers released the analysis as some states are releasing information on what premiums will be in 2014 when the Affordable Care Act’s market reforms and newly created health insurance marketplaces take effect.

The rate announcements illustrate “sticker prices” that do not reflect federal subsidies that will offset the cost of insurance for many current individual market policy holders, said the foundation based in Menlo Park, California.

“Tax subsidies are an essential part of the equation for many people who buy insurance through the new marketplaces next year,” Foundation President and CEO Drew Altman said. “They will help make coverage more affordable for low- and middle-income people.”

Under the ACA tax credits will be available to subsidize premiums for people who buy their insurance in the new marketplaces, do not have access to other affordable coverage, and have incomes between 100 percent and 400 percent of the federal poverty level (between about $11,500 and $46,000 for a single person, and $24,000 and $94,000 for a family of four).

An estimated 48 percent of people who currently have individual market coverage will be eligible for tax credits, researchers found. Tax credits among those eligible will average $5,548 per family, and subsidies will average $2,672 across all families now purchasing their own insurance, the researchers said.

Many people who are now uninsured will also be eligible for subsidies in the new marketplaces, and their tax credits will likely be higher on average since they have lower incomes than those who now buy their own coverage, the researchers said.

Using data from the Congressional Budget Office (CBO) and the federal government’s Survey of Income and Program Participation, study authors said the analysis estimates the average impact of the ACA on the individual market by quantifying how current enrollees will fare once relevant provisions of the health law are implemented.

Premium data released by states thus far suggest that the CBO premium projection is reliable, the researchers said. While subsidies and premiums will vary widely depending on each enrollee’s personal characteristics, the analysis focuses on averages to provide an indication of how much overall assistance the law will provide to people buying their own coverage today, the study authors added.

Take Your Corners – Hospital Health Plan Negotiation Strategies

Hospital managed care teams need to understand their markets are much more expansive than other hospital competition, advises, a senior exec with a company that provides a range of services to providers.

“Essentially, there are three basic ways of dealing with negotiation differences: Continue reading

Accountable Care Organizations Getting More Scrutiny

A number of independent practice associations (IPAs) and other physician organizations – PHOs, multi-specialty medical groups and hospitals have created new accountable care organizations.

Because we produce the National Directory of Physician Organizations, we naturally are following ACO developments.

ACOs are very much top-of-mind as ACO numbers grow. And with that awareness comes increased attention. Continue reading