Next year is a big year for Medicare Advantage plans. In 2015, they will not receive bonuses unless they have a 4-star rating or above. Many health plans are feeling under pressure right now, and may even feel a little disgruntled, as their businesses could really take a hit next year if they fall even slightly below 4.
One way to view this challenge that may take the edge off the pain is that the CMS Five Star Quality Rating System for Medicare Advantage Plans is not just about being able to stay or earn a spot in the Medicare Advantage program. Taking steps to improve ratings can help Medicare Advantage plans and other health plans hoping to enter the program achieve the Triple Aim and move them even closer to getting the business results they really want. Read more about Improving Star Ratings Shouldn’t Be Just for Medicare
This is my third installment on the Choosing Wisely Campaign from the American Board of Internal Medicine Foundation and Consumer Reports that brings into sharp focus, and in plain English, the things patients and we physicians should question. The Choosing Wisely campaign now includes submissions by more than 60 medical professional societies and organizations. Examples include:
Why scheduling early delivery of your baby is not a good idea
Treating sinusitis: Don't rush to antibiotics
Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
Bone density tests: When you need them and when you don't
Treating migraine headaches: Some drugs should rarely be used
What prompted this update is a new video in the zeitgeist of today, with light music, happily dancing people from seniors to millennials, and scrolling text.
I am hoping to prompt readers of Managed Care to help to take viral this video for the important campaign to reduce unneeded and in some cases harmful medical testing, treatments, and services. A wise choice!
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.
The question facing health care organizations today is daunting: “How are we going to efficiently and effectively care for millions of new patients, many with chronic illnesses, and many who have never had access to routine health care in the past?”
At Franciscan Health System in Tacoma, Washington, we face the same problems as other health care systems. With 12,000 employees, including 1,200 physicians, and 46,000 hospital admissions plus 460,000 outpatient procedures, we fully understand the challenges of health care delivery today. However, we’ve found that the best approach to population management lies in a culture shift from treating lives at risk to a system where we front-load our attention to preventive medicine. Two things will allow us to be successful:
Team-based care which opens up access and enables physicians to extend their reach by adding certified physician assistants (PAs), nurse practitioners (NPs), care managers, health coaches, pharmacists, and others to the medical care team.
Electronic health records (EHR) technology connecting all providers with a complete and up-to-date medical record.
There’s a gap in the proverbial health care safety net that’s big enough for a whale to swim through.
People who are incarcerated, on probation, or on parole — what a recent study calls the “justice-involved population” — make up 22% of the 13 million newly eligible people.
“The justice-involved population has a higher disease burden than the general population, yet as many as 90% of justice-involved people lack health insurance at the time of their release from incarceration,” says the study, published in Health Affairs. “This disparity between disease burden and access can drive up the cost of health care, result in worse outcomes, and cause patients to seek care later than appropriate and in care settings that are often isolated and lack care coordination.” Read more about Ex-Prisoners In Need of Care
Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access.
To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers and providers. Payers must be agile enough to adjust network strategies on the fly, as they learn more about newly enrolled populations. They need the ability to administer more complex product designs, care delivery. and reimbursement initiatives quickly and efficiently.
Unfortunately, current network operations often struggle because of multiple sources of provider data, disconnected reimbursement systems, and manual loading between network management and contract management. As the need for administrative savings grows and networks and reimbursement arrangements increase in number and complexity, the problem with existing systems will increase.
One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers from “the tyranny of the office visit” to activities where success will be judged according to improvement in clinical metrics whether a patient visits the office or not. It’s the right vision from a health promotion advocate’s vantage point because it may serve as a preamble to an era where medical and public health practices and public policies truly intersect. Dartmouth’s Jack Wennberg famously observed predictable provider-centric small-area variation in the use of clinical procedures while the Centers for Disease Control and many other public health observers have long shown that ZIP codes have more to do with health than do medical codes. Can the next generation of health reforms reconcile the tension between these loosely related truths? Read more about Accountable Care Organizations and Cultural-Area Variation
Medicare plans are furiously working to develop an optimal 2015 bid to submit to the Centers for Medicare & Medicaid Services. The pressure is especially acute this year given the rapidly consolidating and fiercely competitive Part D environment. Missteps in the bid development process have always been costly — affecting member acquisition and retention and overall profitability for the plans. But in the current environment, bid errors paired with a poor star rating will severely reduce payments from CMS and likely put plans out of business.
The title of this post might also read "Don't Mess with Mother Nature"
We have seen remarkable improvements in human health as a direct result of the science that has brought us our antibiotic age with significant reductions in infant mortality, deaths due to bacterial pneumonia, and other serious infections that sometimes led to systemic infection and death.
Fast forward to today, when we may obtain with a prescription many of these powerful germ killers for $4 at WalMart and Target and drug and grocery store chains. Some retailers even give away a prescribed course of antibiotics as a loss leader to entice the customer to enter that store.
Three days of a severe headache that would not respond to the ibuprofen, naproxen, or acetaminophen. "I never get headaches" is what I said multiple times to my wife and to colleagues. The morning of day three, a rash started to appear on my forehead, in the left eyebrow, in the scalp, with swelling around the left eye and swollen lymph nodes at the angle of the jaw on the left. My wife mentioned "shingles". Poor early diagnosis on my part, and, I said "Oh !*#%! that is what I have". I was starting to feel as if I had been taken out by an NFL linebacker. Read more about Shingles is Hell!
Multiple news outlets are reporting that a letter signed by Representatives Henry Waxman, Frank Pallone Jr., and Diana DeGette was sent last week to the CEO of Gilead asking for justification for the high price set on its new Hepatitis C medication, Sovaldi. (See this story.) The lawmakers also stressed that they expect Gilead to explain how the drug will get to patients in government funded programs, like Medicaid and Medicare. Read more about Lawmakers Take Interest in Hep C Drug Pricing