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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
CMS Unveils New Medicaid Managed Care Regulation
For the first time in more than 20 years, the federal government is introducing major changes in how it regulates Medicaid managed care.
The Centers for Medicare & Medicaid Services describes the 1425-page rule as aligning Medicaid managed care with other health insurance programs, updating how states purchase managed care services, and improving beneficiaries’ experience with Medicaid managed care.
To learn more about what CMS has proposed, go here to see the rule itself.
Go here to see CMS’s news release accompanying the new regulation.
Go here to (under the link “final rule”) to find nine fact sheets summarizing key aspects of the new regulation.
And go here for a commentary on the new rule and the context in which it was released by CMS acting administrator Andy Slavitt.
SNAP has prepared a memo describing the new rule. Representatives of such hospitals may request a copy of this memo by using the “contact us” link in the upper right-hand portion of this screen.
PHC4 Reports on Hip and Knee Replacement Surgery
The Pennsylvania Health Care Cost Containment Council has released a report on complications from hip and knee replacement procedures performed at Pennsylvania hospitals.
The analysis looks at more than 56,000 procedures performed in 2013, quantifying complications, lengthy hospital stays, readmissions, and more.
Find the PHC4 report here.
Could Housing Support Help Medicaid Behavioral Health Patients?
Amid indications that assisting with permanent supportive housing can be a cost-effective, evidence-based way of helping to address the behavioral health needs of some Medicaid recipients, housing and behavioral health groups are beginning to take a closer look at how Medicaid resources might be used to help support such housing.
In a new report, the National Council for Behavioral Health examines the possibility of using Medicaid resources to finance the delivery of services in supportive housing for Medicaid beneficiaries facing behavioral health challenges.
The report examines the policy context for developing integrated permanent supportive housing options in state Medicaid programs; opportunities for Medicaid to finance and deliver housing-related services; and the implications for behavioral health authorities and providers.
For a closer look at the issue, its implications, and the means through which such resources might be brought to bear, go here to see the National Council for Behavioral Health report Using Medicaid to Finance and Deliver Services in Supportive Housing: Challenges and Opportunities for Community Behavioral Health Organizations and Behavioral Health Authorities.