Business Strategy

The landmark Massachusetts healthcare reform plan requires all adults in the state to have purchased health insurance by July 1, and policy makers are scrutinizing whether the combination of "carrots" and "sticks" has spurred compliance. The legislation, adopted in April 2006, aims to establish universal coverage by subsidizing insurance for lower-income individuals and penalizing those with higher incomes who fail to sign up. Employers with more than 10 workers have to play or pay: provide coverage to employees or pay an annual fee.

Recently, there has been a slight decline in HMO enrollment, according to industry experts. PPOs are gaining share.

WASHINGTON, D.C.-As expected, the Centers for Medicare and Medicaid Services (CMS) has proposed a nearly 10% reduction in Medicare physician fees for 2008. The cut reflects the physician payment formula approved by Congress in 1998 that has long been the subject of criticism and debate.

As the concern about the long-term fiscal viability of Medicare continues to grow, so has the recognition that some of the services ordered by physicians-and subsequently billed to Medicare-might not be warranted.

If managed care executives can't get accurate information and honest opinions, they can't make the right decisions, according to Allan Baumgarten, author of annual state managed care reviews and an independent research consultant in policy, finance and local market strategies.

Healthcare organizations must begin leveraging the value of the products they deliver and infuse customer service into every interaction to remain competitive in this changing market.

Washington, D.C.-Despite earlier promises that consumer-directed healthcare (CDHC) programs would reduce healthcare spending by encouraging more efficient purchase of health services, consumer confusion and higher out-of-pocket costs seem to be slowing enthusiasm for these plans.

Washington, D.C.-Medicare pays private fee-for-service (PFFS) plans 19% more than prevailing fee-for-service spending, according to the June 2007 report of the Medicare Payment Advisory Commission (MedPAC). At the same time, beneficiaries are complaining of misleading promotional tactics by these plans.

More than half of all state Medicaid programs incorporate a financial incentive encouraging providers to deliver better quality care, according to a study by the Commonwealth Fund. In addition, the study finds that 70% of existing Medicaid P4P programs operate in managed care or primary care management environments. Nine Medicaid programs are joining with other payers, employers and providers in statewide or regional P4P efforts, which is an indicator that the Medicaid plans are keeping pace with HMOs-half of which are offering P4P programs of their own.

If managed care executives can't get accurate information and honest opinions, they can't make the right decisions, according to Allan Baumgarten, author of annual state managed care reviews and an independent research consultant in policy, finance and local market strategies.

The long-sought national interoperable health information system remains far from reality as standards prove difficult to establish, provider uptake goes slowly and privacy concerns continue. A year ago, there were high expectations that Congress would adopt legislation supporting the creation of standards for electronic health records (EHRs). That bill faltered over disagreements about anti-kickback language and new billing codes.

Typically not a big fan of movies, I was surprised by how much I enjoyed my DVD rental of "Man of the Year." The basic premise of the movie has a quirky, independent-party candidate winning the popular vote in a presidential race.

Experts say that 5% of all claims are fraudulent or abusive. If the total spent on U.S. healthcare annually is approaching $2 trillion, that 5% would add up to nearly $100 billion a year in fraudulent or abusive claims. And the percentage may be higher, perhaps as high as 10% of claims.

A number of cost-evaluation studies have emerged showing consumer-directed health plan (CDHP) members use less care. Meanwhile, others suggest that members are less satisfied with these plans and that they tend to choose unwise ways of saving money, such as skipping preventive care.

The mother of a child suffering from asthma calls Medical Mutual of Ohio's Nurse Line desperately needing advice. The nurse listens to the mother's concern and is poised to tell her everything she needs to know, but instead, the mother is told that she is not covered for this particular service.

A number of cost-evaluation studies have emerged showing consumer-directed health plan (CDHP) members use less care. Meanwhile, others suggest that members are less satisfied with these plans and that they tend to choose unwise ways of saving money, such as skipping preventive care.

When it comes to Medicare plans, managed care executives must find a way to increase value, say industry watchers.

Medicaid has to evolve into a delivery model that takes into account the uniqueness of each individual-both their specific health status, and issues outside of the traditional healthcare system, such as transportation, living conditions and substance abuse problems, according to insight from Newt Gingrich, founder of the Center for Health Transformation (CHT) and Rishabh Mehrotra, president and CEO of SHPS, a provider of health advocacy and health benefits solutions.

Hartford, conn.-In what industry watchers are calling the biggest example of marketing insurance products through an affinity group, Aetna and UnitedHealth Group will administer and deliver health insurance to AARP members.

National reports-In Idaho, the rate of uninsured is nearly 18%. National research shows that as the cost of health insurance premiums increases, so does the number of small businesses who drop coverage for their employees. And, in general, small businesses are least likely to offer health insurance to their employees.

Washington, D.C.-After months of speculation, the Bush administration named a veteran Health and Human Services (HHS) official to lead the Centers for Medicare and Medicaid Services (CMS) for the next two years.

Some industry behemoths such as the UnitedHealth Group and the Blue Cross Blue Shield Assn. (BCBSA) have decided to keep the member financial services in-house, creating their own banks. Other payers are developing relationships with multiple banks to offset the giants' economies of scale with flexibility and portability, allowing members to keep their money in the same bank even when they change health plans.

An assignment of benefits is a transfer of an insured's interest in policy benefits to another party. The policy generally requires a written assignment by the insured to the provider, allowing the provider to bill the health plan directly. Such an assignment results in the payment of medical benefits directly to the healthcare provider rather than to the insured.

Trumpeting the now-popular battle cry of transparency, many states are attempting to control the contractual arrangements between pharmacy benefit services providers and their clients. Because of the historical issues around hidden revenue streams and misaligned objectives, it is no wonder the public sector is taking note.

State regulation of pharmacy benefit managers (PBMs) would benefit states and consumers by providing a regulatory framework for the only entity involved in delivery of a healthcare benefit to the consumer that is largely unregulated.

Healthcare organizations are intimately familiar with intense prosecutorial scrutiny resulting from the government's battle against fraud and corruption. There are prominent examples of focused federal fraud investigations, resulting in hefty settlements. Congress has now enlisted the healthcare industry in their campaign against fraud.

There is growing recognition that teenagers have healthcare needs that are distinct to their own age group-needs that pediatricians and primary care physicians are not always equipped to handle.

ALTHOUGH THE NUMBER of North Americans and Europeans seeking care abroad is relatively small-about 150,000 Americans traveled abroad for care in 2005-it's expected to grow as more patients learn about the option and as overseas hospitals, healthcare travel firms and insurers lay the groundwork to accommodate them.

At present, most states have made HMOs subject to their insurance holding company acts. Insurance holding company acts are comprehensive bodies of law that govern the relationships and activities within insurance holding company structures. These laws indirectly regulate the activities of entities that are affiliated with insurance companies and HMOs, which would not otherwise be subject to regulation.

Despite a mounting clamor for reform from many health policy experts, Senate action to reduce payments to Medicare Advantage may be postponed this year. Influential senators oppose an across-the-board cut, which would reduce MA plan activity in rural and low-cost regions.