Democratic Rep. Pete Stark of California will introduce legislation to remedy a defect in last year's Balanced Budget Act that could cost the government $1 billion this year. The miscue, discovered by HCFA, is overpayments to HMOs resulting primarily from inaccurate projections of Medicare inflation. HMOs are likely to balk.... In an unrelated matter, an existing law bearing Stark's name — known informally in Washington as Stark II--has aroused the ire of the Medical Group Management Association. Stark II expands the scope of Stark I, which outlawed physician referrals to clinical lab services in which the physician had a financial stake. In January, HCFA issued rules for implementation of Stark II, which prohibits referrals to myriad health services, including physical therapy, radiology and home-health services, if the referring doctor has a financial relationship with that entity. MGMA sent a letter to HCFA passionately arguing that Stark II distorts the intent of the original law and that it would affect virtually all physician referrals.
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.