The Pennsylvania Patient Safety Authority has issued its 2015 annual report.Affordability a Challenge for Many Newly Insured
Many Americans who have obtained private health insurance through the Affordable Care Act continue to have problems affording health care.
According to a Kaiser Family Foundation report based on focus groups six states, low-income individuals with new private insurance report continued problems with:
medical debt- affording care that is not covered by their insurance plans
- handling out-of-pocket expenses, including deductibles
- unexpected bills for treatment they thought was covered
Such patients pose a challenge for many Pennsylvania safety-net hospitals because of their inability to afford their co-pays and deductibles, leaving these hospitals with unexpected uncompensated care and bad debt. Because they care for more low-income patients than the average hospital, this is a bigger problem for the state’s safety-net hospitals.
For a closer look at how the study and focus groups were conducted and what they found, go here for the Kaiser Family Foundation report Is ACA Coverage Affordable for Low-Income People? Perspectives from Individuals in Six Cities.
New Tools for Addressing Old Medicaid Problems
The new federal Medicaid managed care regulation gives state Medicaid programs new tools with which to address longstanding Medicaid challenges.
In an article titled “The Medicaid Managed Care Rule: The Major Challenges States Face,” the Commonwealth Fund describes the tools the rule does and does not offer for addressing five major Medicaid challenges:
reaching medically underserved communities- unstable eligibility and enrollment
- organizing coverage an care and developing effective payment incentives
- aligning managed care with health, education, nutrition, and social services
- information technology
Find the article here, on the Commonwealth Fund’s web site.
Hello world!
Welcome to WordPress. This is your first post. Edit or delete it, then start writing!
Background Information on Payment Methodologies and Benefit Design
The Urban Institute has issued two new papers with background information on health care payment methodologies and the design of health care benefits packages.
The first paper, Payment Methods: How They Work, describes nine payment methodologies:
- fee schedules
- primary care capitation
- per diem payments to hospitals for inpatient visits
- DRG-based payments to hospitals for inpatient visits
- global budgeting for hospitals
- bundled payments
- global capitation for organizations
- shared savings
- pay for performance
The second paper, Benefit Designs: How They Work, explains seven different types of benefit designs:
- value-based design
- high-deductible health plans
- tiered networks
- narrow networks
- reference pricing
- centers of excellence
- benefit design for alternative sites of care
A third paper, Matching Payment Methods with Benefit Designs to Support Delivery Reforms, describes how to match benefit designs with payment methods.
Go here to find Payment Methods: How They Work.
Go here to find Benefit Designs: How They Work.
And go here to find Matching Payment Methods with Benefit Designs to Support Delivery Reforms.
Pennsylvania Health Law Project Releases Monthly Newsletter
The Pennsylvania Health Law Project has published the April 2016 edition of Health Law News, its monthly newsletter.
Included in this edition are articles about a new, faster process the state has introduced for people to enroll in Medicaid; the awarding of contracts to managed care organizations to participate in the state’s HealthChoices program; an update on the Community HealthChoices program that will help nursing home-eligible seniors remain independent in the community; new funding for the state’s “Money Follows the Person” demonstration program; and more.
Find the latest edition of Health Law News here.
PA Awards HealthChoices Managed Care Contracts
Last week Pennsylvania’s Department of Human Services awarded new contracts to managed care organizations to provide physical health services under the state’s HealthChoices Medicaid managed care program.
Eight different organizations were awarded 23 separate three-year contracts, to take effect on January 1, 2017, to serve more than two million Medicaid beneficiaries in five state HealthChoices regions.
All of the managed care organizations will be operating under a contractual mandate to increase how much care they provide on a value-based purchasing basis through accountable care organizations, bundled payment models, patient-centered medical homes, and other integrated care delivery approaches. They also will be required to coordinate their efforts more effectively with the behavioral health care organizations that serve their members.
Learn more about who won the contracts and how the winners will be expected to perform differently than HealthChoices managed care organizations have in the past in this state news release.
PA Medicaid: One Year, 625,000 New Beneficiaries
Last week marked the one-year anniversary of Pennsylvania’s Affordable Care Act-authorized expansion of its Medicaid program.
In that year, nearly 625,000 Pennsylvanians enrolled in the program.
Among them,
- 46 percent are under the age of 35
- 109,000 are parents
- 300,000 are employed
If past Medicaid utilization patterns hold true, most of these new Medicaid beneficiaries will receive most of their health care benefits from the state’s private safety-net hospitals.
Learn more about Pennsylvania’s Medicaid expansion, who has taken advantage of it, and how the program has changed in the past three years in this state news release.
Data-Sharing Could Help Address “High-Fliers”
A new study suggests that hospitals might better serve frequent emergency room patients if they share data with one another.
According to a new report in the journal JAMA Internal Medicine, nearly 70 percent of “high-fliers” – patients known to make repeated visits to hospital ERs – visited more than one hospital ER in a study of patients who had more than five ER visits in Maryland in 2014. As a result, individual hospitals may not have a complete picture of such patients’ medical issues and the frequency with which they are turning to hospitals for care – a problem that could detract from individual hospitals’ attempts to find better ways to serve such patients.
A possible solution, the study suggests, is better information-sharing among hospitals.
Pennsylvania’s safety-net hospitals serve more such patients than the typical hospital because their communities have more low-income and uninsured residents with limited access to medical care.
To learn more about the study and its implications for efforts to reduce overuse of hospital ERs, go here to find the JAMA Internal Medicine study “The Adequacy of Individual Hospital Data to Identify High Utilizers and Assess Community Health.”
Medicare Proposes New Way to Pay Docs
Clinicians would be paid based more on the quality of care they provide than on the quantity of services they deliver under a new Medicare quality reporting and payment proposal released last week by the Centers for Medicare & Medicaid Services.
The proposal, required by Congress last year as part of the Medicare Access and CHIP Reauthorization Act that constituted the final “Medicare doc fix” and spelled the end of the sustainable growth rate formula that constrained Medicare payments to physicians for more than a decade, would be phased in over a period of years, would end so-called meaningful use requirements for physicians, and would compensate most clinicians based on their performance on quality measures, some of them of their own choosing, in four categories – quality, advancing care information, clinical practice management, and cost – that would be part of a new Merit-Based Incentive Payment System.
Clinicians who assume financial risk as part of what CMS is calling Advanced Alternative Payment Models – programs such as the Next Generation ACO model, the Comprehensive Primary Care Plus program, and tracks 2 and 3 of the Medicare Shared Savings Program – would participate in a separate quality reporting and payment program that would respond to the greater financial risks such providers shoulder with greater potential financial rewards.
Learn more about the latest Medicare proposal from the following resources:
- a CMS fact sheet
- a CMS video
- an FAQ from Kaiser Health News
- the 962-page proposed regulation itself