Blogs

For a method that transcends distance, there are a lot of dustups over turf when it comes to telemedicine, as Managed Care made clear in our June issue. Managed Care’s July issue (coming soon!) gives telemedicine the cover story treatment, and with good reason. Videoconferencing, text messaging, email (and now, even Facebook—but more on that below) means that a treatment option that’s been called “the next big thing” since at least the Clinton administration (Bill, that is; no jumping the gun) may have finally passed the audition. Well, maybe.

As Kaiser Health News pointed out recently, significant roadblocks remain (link is external). The population that’s most homebound and physically impaired—the demographic that could really benefit from this technology—lacks access. Fewer than 1% of Medicare beneficiaries get care remotely. That, for a lot of reasons, as Kaiser points out, the primary one being that Congress said “no,” concerned that telemedicine could lead to overutilization and more costs.

3: Nevada, New Mexico, and Oregon have authorized state-run exchanges but are using the federal exchange for many enrollment functions. If King prevails, it’s not clear how the court decision will affect these three states.

3: As Lyle Denniston (link is external) and others have written, the premium subsidies at issue in King v. Burwell are one of the legs of the ACA’s three-legged stool. The other two are the individual mandate and the rules against denying or pricing insurance because of pre-existing conditions.

ACA supporters say that if court rules in favor of King, the premiums will become unaffordable and the insurance markets that the ACA has created will go into a death spiral of fewer and fewer participants and higher and higher premiums.

The law’s critics note, though, that the effect of the ruling against the insurance subsidies will depend on how Congress responds and, moreover, it’s in the interest of ACA supporters to paint a scary picture of the consequences of a ruling against the premium subsidies.

4: “….established by the State.” King v. Burwell hinges on those four words in the ACA.

A 653-page rule (link is external) handed down yesterday by CMS definitely represents one giant step for Medicaid managed care, and a step taken (for the most part) in the right direction, according to one industry insider.

Jeff Myers, president and CEO of the Medicaid Health Plans of America (MHPA), told us last week to expect something big, and big is what CMS provided for the most substantial change in Medicaid in over a decade.

The rule includes a medical loss ratio (MLR), something commercial health plans know all too well. Under the ACA, health insurers must spend at least 80% to 85% of premium dollars on medical care, or refund the difference to consumers. The new rule says that Medicaid plans will also have to meet the 85% MLR goal, but the penalty would be definitely delayed or even, possibly, discarded, depending on how states react.

Our April 2015 cover story was about the growing clout of PBMs. Reason number one for the power surge is simply that the companies are getting bigger, and size means added leverage with manufacturers and insurers.

Bigger fish are buying smaller fish and then getting acquired by fish bigger than themselves.