Blogs

Frank Diamond

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.

Contributing Voices
Paul Terry

Limiting access to any pleasures: tobacco, foods that are bad for you, the after-party of a Prince concert—you name it, you’re going to be unpopular with many people.  To quash what some see as their right and none of your business is to invite endless arguments that as often as not have little to do with the facts of the matter.  As someone who has weighed in on my share of health policy debates, I’ve long observed that the “greatest good for the greatest number” bromide calms my nerves, but it seldom holds sway with those who don’t see what good the policy is doing them.

I recently had the pleasure of teaming up with Dr. Laurie Whitsel, her colleagues at the American Heart Association, and top tobacco control and prevention experts in drafting “Guidance to Employers on Integrating E-Cigarettes/Electronic Nicotine Delivery Systems into Tobacco Worksite Policy.”  Developing the policy proved to be a tour de force review of the facts on the matter as well as a thorough immersion into discussions about private choices versus public policies.

The paper was recently published in the Journal of Occupational and Environmental Medicine. You can get a full-text PDF of it here (link is external).

Contributing Voices
Richard Mark Kirkner

In their decision to uphold tax subsidies for policies sold on the federal health insurance exchange established by the Affordable Care Act (ACA), the Supreme Court Justices showed a keen understanding of the history of various state health reform measures and how insurance markets operate in general, invoking terms like community rating, adverse selection and death spiral.

Contributing Voices
Frank Diamond

What many health plans like about the Affordable Care Act is that it’s going to expand the marketplace, handing insurers millions of new enrollees. The Supreme Court’s ruling today against King in King v. Burwell ensures that that should still be the case. Of course, the law is sometimes a “a river that don’t know where it’s flowing,” in the words of Bruce Springsteen. Today’s decision offers a bit of stability.

Contributing Voices
Peter Wehrwein

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.

Contributing Voices
Peter Wehrwein

It will take some time to fully digest the 592 pages of new rules for the Medicare Shared Savings Program (MSSP) ACOs.

You can get started and read them for yourself here (link is external).

But few items pop out even in an Evelyn Wood reading of the first 30 or so pages.

Contributing Voices
Frank Diamond

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.

Contributing Voices
Frank Diamond

Blame Hollywood. Or, at least, partly blame Hollywood. (We’ll take what we can get.)

Women ages 30 to 55 too often ignore the warning signs of an acute myocardial infarction (AMI), according to a study in Circulation: Cardiovascular Quality and Outcomes (link is external). They either don’t recognize more nuanced symptoms (dizziness, aching muscles, indigestion, fatigue), or they fear that their interpretation may be wrong. They often believe that a heart attack must always include an episode of intense chest pain, and while more than 80% of men and women in that age range with AMI do have chest pain, younger women are more likely to not have it

Contributing Voices
Peter Wehrwein

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.

Contributing Voices
Frank Diamond

New regulations for managed Medicaid promise to shake up an industry that, apparently, needs very much to be shaken up. The implications of last week’s Kaiser Family Foundation (KFF) report (http://files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-quality-star-ratings-nationally-and-by-state (link is external)) on the state of nursing homes (hint: not so good) builds even more anticipation about CMS’ plan to unveil the regulations any day now.

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