P&T
Our
Other
Journal
MediMedia Managed Markets

 

Blogs

Contributing Voices
Jessica Cherian, PharmD, RPh
Jessica Cherian, PharmD, RPh

Nowadays, every turn of a newspaper page, click of a media page on the Internet, or flip to a news channel brings us to an update, or more likely a criticism, of the public exchanges. With all of the attention on this side of the exchanges, we might be forgetting about the private exchange.   The private exchange serves as a channel for individuals and employers to purchase health insurance that is separate from the newly opened public exchanges developed under the Patient Protection and Affordable Care Act.

 The biggest difference between the two stems from the fact that government subsidies aren’t available to those choosing to purchase health insurance from the private exchange. This explains why much of the news regarding private exchanges focuses on the group market, as employers that choose to participate in a private exchange provide employees with an subsidy to be used toward the purchase of health insurance, a method also known as defined contribution.

Contributing Voices
Craig Keyes, MD, MBA

It seems many of us have some preconceived ideas of what new Medicaid members will look like: They’ll be older, sicker, higher utilizers of services and, more challenging to care for.

But when we take a closer look at populations that will qualify for Medicaid over the next several years, a different picture appears. Chances are the new Medicaid member is going to be that part-time waiter at your favorite local restaurant or the young woman with a toddler and another on the way who decided to go back to school.

Contributing Voices
Tom Ewers and Munzoor Shaikh

Tom Ewers and Munzoor Shaikh of West Monroe Partners discuss the ins and outs of pre-close integration planning for health care payer mergers and acquisitions.

The M&A process should begin by clearly defining both the acquisition strategy, type of acquisition (Leverage Business Model (LBM) or Re-invent Business Model (RBM)) and the overall approach to integrating the two companies. Acquirers should then hone in on which consolidation and collaboration opportunities need to be pursued to generate the expected benefits. Then, they should define a clear investment thesis and operating model to help formulate the integration approach, thus completing their pre-close homework.

Next, payers should transition to the operational and IT diligence steps within the integration lifecycle. These efforts begin by building a diligence and integration team with expertise in a number of different disciplines that cover the target organization’s key capabilities and represent stakeholders from the potential acquirer.

As the strategy and pre-close phases come to an end, initiating pre-close integration planning is the next step to reach a successful transaction outcome. This is especially important for payers because not only do they tend to have specialized claims processing, but also there are various new requirements and forces at play today given the advent of the Health Insurance Exchanges (HIX). Plan early to provide clear “Day-1” direction and to set stakeholder expectations.

Contributing Voices
Paul Terry

The recent Health and Productivity Conference sponsored by the National Business Group on Health (NBGH) signaled the arrival of what social scientists have long held as vital to the success of wellness: a balance between personal and organizational engagement in health.

Contributing Voices
Randy Vogenberg, PhD, RPh

Although the results overall are not too surprising, after two rounds of end-to-end ICD-10 testing, the results at the North Carolina Healthcare Information and Communications Alliance are “scary,” executive director Holt Anderson told the Medical Group Management Association annual conference last week.

Contributing Voices
Jessica Cherian, PharmD, RPh

The Pioneer Accountable Care Organization (ACO) was an additional ACO model offered by Medicare, designed for groups that were already experienced in coordinating patient care across the care continuum. The shared-savings payment policy in this case is aligned with higher levels of both sharing and risk than that of the basic Shared Savings Program. Many had high hopes for the Pioneer groups and anticipated positive results when it came time for reporting in 2013.

Contributing Voices
Tom Ewers and Munzoor Shaikh

In several posts, Tom Ewers and Munzoor Shaikh of West Monroe Partners discuss the dynamics of health care payer mergers. Here, they describe the need for comprehensive operational and IT diligence.

Ewers-Shaikh.jpg

Success in health care mergers and acquisitions begins with getting the right people on the right teams.

If coordinating M&A transactions is not a common occurrence, then the chances of successfully completing a profitable transaction are slim. Studies show that most M&A transactions fail exactly for this reason.

Contributing Voices
Steven Peskin, MD

In doing research for a Grand Rounds needs assessment on humanism in medicine, I re-acquainted myself with a classic lecture by Dr. Francis Peabody, "The Care of the Patient" published in the Journal of the American Medical Association. (Peabody, FW: The Care of the Patient. JAMA 1927; 88:877–882.)

The words that Peabody spoke to his students in 1927, as Peabody himself faced his own mortality, having been diagnosed with cancer at age 45, are resonant and worthy of daily reminder for any of us involved in caring for patients, designing care models, influencing benefit plans, organizing systems of care, integrating technology into patient care, or serving in adminstrative leadership.

“Medicine is not a trade to be learned, but a profession to be entered,” he told his students. “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.... the secret of the care of the patient is in caring for the patient.”

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

Princeton’s Uwe Reinhardt, PhD, renowned health care economist, sits down with Managing Editor Frank Diamond to discuss the economic effects of the Affordable Care Act, wellness programs, and the state of health care in the United States in general.

Contributing Voices
Craig Keyes, MD, MBA

I saw my doctor last month for an annual physical. I cannot imagine a better primary care physician; he’s so thorough, so kind. After an exhaustive review, he said all seemed pretty much “ship shape,” but he had to add one dig: “Hey, I was glad to hear you finally went for your screening colonoscopy. Thing is … I can’t find any evidence that it actually happened. No claim, no entry into the electronic medical record, nothing. Did you end up having the procedure?” 

Pages