Archive for the ‘Health Insurance Exchanges’ Category

Infographic: Insurers Respond to Rise of Private Exchanges

June 25th, 2014 by Jackie Lyons

Health insurers are adopting single-insurer exchanges over multi-insurer private exchanges, at 56 percent and 32 percent respectively, according to a new infographic from Array Health.

This infographic also identifies future health insurance trends, target populations, requirements for a successful exchange and what has changed from 2013 to 2014.

Narrow Network Strategies and Trends for Health Plans and PBMs outlines the tactics health plans are using to restrict medical and pharmacy networks while still maintaining adequate access to care and positive relationships with providers. It also summarizes case studies of health plans and PBMs that have formed narrow networks and the results they’ve seen.

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5 Ideas to Improve ACO Performance Results

June 19th, 2014 by Cheryl Miller

One step John C. Lincoln network took to improve performance results at the end of its first year as a Medicare Shared Savings Program accountable care organization (MSSP ACO) was to focus on a relatively small number of patients, the top 5 percent of beneficiaries by claims volume who actually account for about 60 percent of medical spend, explains Heather Jelonek, CEO for ACOs at John C. Lincoln Network, who shares additional strategies here.

First, we decided to institute wellness visits across our health system. We’ve worked with several large third party payors here in the valley where they’re now recognizing the Medicare G-codes for wellness visits. We bring those patients in and get a full survey of what’s been going on with them.

Second, we’re engaging in regular population management. We now have our physicians talking about how often they want to see their patients with diabetes or hypertension or cancer.

Third, we’re also starting to focus on those individuals who are ‘aging in;’ those patients who are about 62½. We’re trying to get them in and get them into a routine, making sure they’ve got A1C scores every quarter and every six months, and have had their flu shots and colonoscopies. We’re hoping a healthier generation of individuals coming into the Medicare program improves the quality outcomes that we’ll see long-term.

Fourth, we’ve developed a standardization for our quality reporting. We’ve looked at the top 5 percent of our beneficiaries by claims volume, who actually account for about 60 percent of our medical spend. We’re hoping that by focusing on a relatively small number of patients, we’ll have a drastic impact on outcomes.

Next, we’re also leveraging our electronic medical record (EMR) to the fullest extent; we’re participating in a number of conversations and baseline studies with EPIC®. They are very interested in seeing what we’ve done with the tool and how we’re making it usable for our ACO reporting.

But the one thing that we will continue to struggle with and continue to dive deeply into is integration opportunities: talking to other communities, looking at health information exchanges (HIE’s) as we’re acquiring a new practice or signing a new community physician onto our ACO — bringing everybody to the table so that we’re all speaking the same language.

Excerpted from Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care.

Narrow Networks Top Payor Product Innovations List for 2014

June 17th, 2014 by Patricia Donovan

If recent market data is any indication, employers are gravitating toward narrow networks in greater numbers. For instance, a March 2014 Wells Fargo Insurance survey of more than 70 insurance companies placed narrow networks among the top three employer product innovations in 2014, along with are accountable care organizations (ACOs) and increased wellness programs.

In just one example, Harvard Pilgrim HealthCare this week introduced ElevateHealth℠, a partnership with Dartmouth-Hitchcock and Elliot Health System that is a non-profit, high-performance, defined-network product offering access to premier hospitals and providers in New Hampshire.

With its emphasis on care coordination within the network, ElevateHealth insurance premiums on average offer 10 percent savings compared with Harvard Pilgrim’s similar full-network plans, the insurer said.

And last month, UnitedHealthcare announced it would cut 2 to 4 percent of the physicians in its Medicare Advantage network in some Virginia service areas.

In theory, narrow networks—and their close cousins, tiered, tailored and high performance networks—sound like a good thing: health insurance products that group providers into tiers based on their cost or efficiency of care, then steer patients to choose these providers through lower premiums or cost sharing.

In practice, however, some consumers served by narrow networks are balking at the difficulty of obtaining appointments with network providers. Earlier this month, the Wall Street Journal reported that insurers in several states are expanding hospital and physician networks for plans sold through the Affordable Care Act’s health insurance exchanges amid gripes from patients and state officials about limited provider choices.

Anthem Blue Cross, Blue Shield of California, Health Net and WellPoint are among insurers that have substantially expanded provider networks in its exchanges, the article stated. And more providers are slated to join Harvard Pilgrim HealthCare’s ElevateHealth’s network beginning in July.

Earlier this year, industry thought leaders analyzed what the proliferation of narrow networks means for healthcare. Steven Valentine, president of The Camden Group, talked about the impact on both providers and consumers.

“First of all, we anticipate an increase in the number of covered lives,” Valentine said during HIN’s annual healthcare trends forecast. “Providers are going to see an increase in patient volumes, especially primary care providers. And especially providers in states that have opted to stay in Medicaid.”

However,” he continued, “Many of the qualified health plans have narrow networks, so patients are probably going to be confused about which doctors are in their networks and probably will shift around until they can find the right place for them.”

Providers in networks with bronze plans will probably have much higher increases in patient volumes, he predicted. “And other providers will probably see some shifting until patients can figure out where they need to go.”

Regardless of the confusion, Valentine expects the trend of narrow networks to continue. “We clearly see narrow networks operating in conjunction with tiered benefit plans; that is, a lower premium, a more narrow network. We’ve clearly seen that in some of the exchanges as we look at the various medal options that are available. Narrow networks are here to stay; they are not going to go away.”

Catherine Sreckovich, managing director in the healthcare practice at Navigant, concurs. “I agree 100 percent. We’re going to see [narrow networks] more and more. And to the extent there continues to be competition in the exchanges and more health plans trying to get involved, this trend will continue.”

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Can Healthcare Embrace Data Aggregation to Support Value-Based Reimbursement?

May 13th, 2014 by Patricia Donovan

In order for value-based payment models to succeed, the system must support sophisticated data exchange between payors, providers, pharma and care management. Is healthcare ready for this challenge? Julie Schilz, director of care delivery transformation for WellPoint, responds from the payor’s point of view.

I can answer this in several ways. One is that right now, payors have clinical claims information. We can do wonderful things with that information. But how powerful it would be to be able to add clinical data from providers to enrich that claims data. And also to add information related to social determinants of health to truly create a picture of a member.

One of the reasons we were excited to participate in Comprehensive Primary Care initiatives is the component in which as a multi-payor structure we come together and define data aggregation. We bring our data forth to the practices who are selected to participate in the primary care initiative as payors, and are able to report in a consistent manner out to the practices.

This isn’t easy. There is hard work ahead of us; it is incredibly important work ahead of us. One of the discoveries we are making in this process, which we call ‘barrier busting,’ is to assure that everyone is in agreement in terms of the use of the data. Then we need to come together and decide: do we all have the same definitions around data use in our reporting structure? Is an attributed member for this payor the same as an attributed member for another payor? We must consider security of data; we have to assure privacy and security in the process.

We also know that it’s technically possible to exchange this data. For example, with the Continuity of Care Record (CCR), there are structures that exist in terms of how to share this data back and forth. But it still doesn’t always make it easy. There’s been some great work done by the Office of the National Coordinator for Health Information Technology. I was part of a program associated with that. There are many health information exchanges that are doing this work. There are all-payor claims databases that are forging ahead with this work.

It’s the right work to be doing, but it is not as easy as flipping a switch; there are governance structures, there are conversations, there are security structures that need to be in place in order for this to be successful.

Excerpted from: Driving Value-Based Reimbursement with Integrated Care Models

Infographic: Private Exchanges and Employer Implementation

May 9th, 2014 by Jackie Lyons

As the ACA employer mandates continues to take effect, more employers are reporting an interest in offering employee health benefits through an exchange, according to a new infographic from the Healthcare Trends Institute.

This infographic also provides an outlook of private exchange implementation among employers, as well as what employers look for in a private exchange.

You may also be interested in AIS’s Health Insurance Exchange Directory and Factbook, the definitive health industry guide to health insurance exchange implementation and stakeholder strategies, with in-depth coverage of every big-dollar business issue related to the new marketplaces — including technological infrastructure, consumer support tools, benefit design, marketing, FFEs and much more.

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Infographic: In-Network Vs. Out-of-Network Provider Healthcare Costs

April 21st, 2014 by Jackie Lyons

Consumers typically pay significantly less for in-network providers and more for out-of-network providers. Furthermore, approximately one in 10 Americans goes out of network for care, according to a new infographic from Excellus BCBS.

This infographic also provides comparative examples of the different costs for in-network and out-of-network procedures, as well as how choosing a health plan and provider can affect these costs.

Learn more about health plans and coverage in AIS’s Health Insurance Exchange Directory and Factbook. The new health insurance exchange marketplaces, public and private, will have a profound impact on the under- and uninsured, and will permanently alter the way health insurance is bought and sold. This resource is the definitive health industry guide to insurance exchange implementation and stakeholder strategies.

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Infographic: Paying More Under PPACA

February 7th, 2014 by Jackie Lyons

Forty-eight percent of Americans surveyed in a recent study reported they would repeal the Patient Protection and Affordable Care Act (PPACA) if they could, while 38 percent would keep it in place.

However, experts claim there have not been large premium increases, according to a new infographic from LifeHealthPro. This infographic shows the effects of the PPACA on part-time and full-time workers, the American response to the PPACA, as well as changes experienced in the past year including higher costs, fewer doctors and more.

12 Questions to Measure Population Health Management

 title= The most encouraging post-ACA metrics have been achieved by healthcare organizations that customize a model or intervention to better serve their population’s needs. Healthcare Innovation in Action: 19 Transformative Trends examines a set of pioneering efforts supporting the industry’s seismic shift from a volume-based culture to one rewarding value and patient-centeredness.

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Infographic: The Impact of U.S. Healthcare Spending

January 24th, 2014 by Jackie Lyons

Medical bills cause more than 60 percent of bankruptcies in the United States, where healthcare is the most expensive in the world, according to an infographic from CauseWish.

This infographic also identifies reasons why individuals are uninsured, shows average prescription spending per person and hospital spending per discharge, and shows the states with the highest uninsured populations.

Statistics and Trends of Healthcare in the U.S.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

You may also be interested in this related resource: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Healthcare Business Week in Review: Home Visits; Patient Portals; Health Insurance Marketplaces; Hospital Pricing

January 17th, 2014 by Cheryl Miller

There is no place like home visits to address safety issues, and patient care concerns. Despite the explosion of mobile and telehealth technologies, there is no substitute for person-to-person contact — at least when it comes to populations at high risk of hospital admission or readmission, the results of the Healthcare Intelligence Network’s inaugural Home Visits study indicate. Three-fourths of healthcare organizations visit some percentage of their patients or health plan members in their homes in order to keep patients safer and healthier and to keep readmissions and costly utilizers at bay.

But there is a time and place for telehealth technology, and new research in the journal Medical Care shows that diabetics who used an online patient portal to refill medications and schedule their appointments, among other tasks, increased their medication adherence and improved their cholesterol levels by 6 percent, compared to occasional users or non-users. Researchers say the current study provides new evidence that patient portals may help patients adhere to their medications and achieve improved health outcomes.

About one-quarter of Americans potentially eligible for health coverage visited insurance marketplaces by December, up from 17 percent in October, according to a new Commonwealth Fund survey. Forty percent of these visitors were young adults; three-quarters said they were in good health; and more than half said they are likely to try to enroll by the March 2014 deadline. The survey, conducted between December 11 and 29, 2013, is the second in a series aimed at tracking Americans’ experiences with the marketplaces in the ACA’s first open enrollment period. The first Commonwealth Fund survey, conducted in October, found that 17 percent of people potentially eligible for coverage had visited the marketplaces during the first month.

Despite increasing scrutiny on hospital pricing practices, some U.S. hospitals are charging more than 10 times their cost, or nearly $1200 for every $100 of their total costs, according to new data released by National Nurses United (NNU) and the Institute for Health and Socio-Economic Policy (IHSP).

The 100 most expensive hospitals listed charge 765 percent and higher, more than double the national average of 331 percent, the report says. Fourteen U.S. hospitals charge more than $1,000 for every $100 of their total costs (a charge to cost ratio of 1,000 percent) topped by Meadowlands Hospital Medical Center in Secaucus, NJ, which has a charge-to-cost ratio of 1,192 percent. California, with a statewide average of 451 percent charge to cost ratio, ranks third overall in the United States. The detailed report includes the most expensive hospitals, the top 10 for each state, and the 50 most expensive hospital systems.

Discussions about end-of-life care for adults are never easy; they are even more difficult when they concern children. The National Institute of Nursing Research (NINR) has launched a new campaign, Palliative Care: Conversations Matter, that is designed to help children and families navigate a serious illness, and better inform them of supportive resources. A component of the National Institutes of Health (NIH), it brings together parents and palliative care clinicians, scientists, and professionals, who give their input and expertise on what they feel is needed in the field. Don’t miss the video which tells one mother’s story about her daughter’s bout with neuroblastoma and how palliative care helped them through it.

You can share your organization’s work in palliative care in our current e-survey: 10 Questions on Palliative Care. With more organizations focusing on palliative care as a means to enhance the patient experience during advanced or terminal illness, many are strategizing new ways to assess and address patients’ needs at this time, from consultations in the ED to face-to-face evaluations in outpatient clinics. Describe your organization’s efforts in palliative care by February 7, 2014 and you will receive a free summary of survey results once it is compiled.

Our congratulations to one of our survey participants, Timothy Price, a market research analyst with Caresource, who was randomly selected as the winner of our training DVD from our 10th annual Healthcare Trends & Forecasts webinar.

Healthcare Business Week in Review: Children’s Health Coverage, ACOs, Reducing ED Visits

January 10th, 2014 by Cheryl Miller

Some good news to welcome in the new year: nearly two-thirds of the nation’s leading healthcare executives believe the healthcare system will be somewhat or significantly better by 2020 than it is today as a result of national healthcare reform, according to a study published in the Health Affairs blog.

Additionally, 93 percent believe that the quality of care provided by their own hospital or health system will improve during that time period. The findings, based on research by the University of Pennsylvania and the Children’s Hospital of Philadelphia, includes responses from 74 senior executives from large hospitals and health systems across the United States.

More good news: doctors, hospitals and other healthcare providers have formed 123 new Medicare ACOs, providing approximately 1.5 million more Medicare beneficiaries with access to high-quality coordinated care across the United States.

According to a CMS announcement, the new ACOs include a diverse cross-section of healthcare providers across the country, including providers delivering care in underserved areas. More than half of ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately one in five ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities, CMS said.

Good news extends to low-income children as well, with our report that 23 states received over $307 million in bonuses for improving access to children’s health coverage and successfully enrolling eligible children in Medicaid, according to CMS.

States that met at least five out of eight specific features to streamline enrollment, including using data-matching to reduce paperwork and eliminating face-to-face interview requirements, received performance bonuses, designed to offset the costs of insuring this demographic, and initiated by The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

Some news to ponder: contrary to the idea that convenience prompts many privately insured people to seek care in emergency departments (EDs), those most likely to use EDs believe they urgently need medical attention, according to a new study by the Center for Studying Health System Change (HSC).

Only rarely did respondents cite convenience as a reason for choosing ED care. About one in four people (24.8 percent) reported their doctor’s office was closed when they needed help, and close to a quarter (24.1 percent) indicated their physician instructed them to go to an ED.

Wondering what healthcare industry areas are ripest for expansion in 2014? Check out our latest HINfographic: 7 Value-Based Priorities for Healthcare’s Smart Money, based on the latest HIN market research.