Tag Archives: ACA

Cleveland Clinic details hits to operating margin

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http://www.healthcaredive.com/news/cleveland-clinic-details-hits-to-operating-margin/425703/

  • The Cleveland Clinic’s latest financials show the hospital system ended the first half of 2016 with a significantly lower operating margin than at the same time in 2015, landing at 1.2% after the six-month period that ended June 30, 2016 vs. 5.6% in June 2015.
  • Although the system’s revenue went up 17% during this period compared to last year, reaching $3.93 billion, that revenue failed to keep pace with a 23% increase in expenses.
  • The system had anticipated a smaller margin this year, Cleveland Clinic chief financial officer Steve Glasstold Modern Healthcare, partly as a result of increased investments in new care-delivery models and consultants to manage those projects, as well as providing raises to medical and other employees to retain in-demand clinicians.

States that resisted the ACA face the biggest hurdles in 2017

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http://www.fiercehealthcare.com/payer/states-resisted-aca-face-biggest-hurdles-2017?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWmpJMlpEZzFZbVV3WXpSaSIsInQiOiI0dCs1NW9kd0ord0VnTUpDWkgzcUp6VmpOV09JNUpldnBqcTh3eUJNTithQUs5QWc0N1JBbjJRYWZmRVJRN216MjNHQ2tFNGhrQWNON2NwR0dLSkdiVTZTSGxDVEZkNVwvejNoRitlVFpGblU9In0%3D

Document titled "Patient Protection and Affordable Care Act"Document titled "Patient Protection and Affordable Care Act"

States that are set to experience reduced competition in their health insurance exchanges also appear to be the ones that were unwilling to lay the groundwork to create a robust marketplace.

The issues that many states are now facing regarding consumer choice and premium pricingwere predicated by resistance from Republican politicians, who failed to expand Medicaid or conduct the necessary outreach to enroll healthy individuals into marketplace plans, according to the Los Angeles Times. In fact, eight of the nine states that have the fewest plan options next year refused to expand Medicaid and failed to engage in outreach.

“It’s the same basic lesson I tell my kids,” Joel Ario, a former insurance commissioner in Oregon and Pennsylvania, told the newspaper. “If you put the work into something, you will get results. If you just sit on the sidelines and complain, you shouldn’t be surprised if things don’t work out.”

Uncovered California: Why Millions Have Fallen Into Health Care Gaps

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Uncovered California: Why Millions Have Fallen Into Health Care Gaps

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“Right now, I have a medicine sitting at Wal-Mart pharmacy that I can’t purchase till payday,” Jacqueline, a 55-year-old San Diegan told me during a telephone interview in mid-April. She asked that her last name not be used for this story. “I’ll go without, eight or nine days till payday. It’s for my high cholesterol.”

Five years after the Affordable Care Act became law, and more than three years after California began moving aggressively to implement its provisions, upwards of three million Californians remain without health care coverage; and millions more, like Jacqueline, have basic coverage but continue to be grievously under-insured.This is the story of how so many Californians continue to fall through the ACA’s cracks.

“Uncovered California” is a three-part series of stories and videos examining how the Golden State is trying to fill holes in its health care coverage. Sasha Abramsky’s articles look at working people who are falling through coverage cracks, and at what’s being done to help community college students gain access to mental health services. Debra Varnado reports on efforts to expand the role of nurse practitioners to increase medical services for low-income Californians.

As Healthcare Changes, So Must its CEOs, CFOs, COOs…

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http://www.healthleadersmedia.com/leadership/healthcare-changes-so-must-its-ceos-cfos-coos%E2%80%A6

Image result for CEO, COO, CFO

To keep up with big changes in how healthcare is administered, financed, and organized, top leaders are finding a need for new talents and organizational structures.

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

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http://www.commonwealthfund.org/publications/issue-briefs/2016/aug/high-need-high-cost-patients-meps1

A Population-Based Comparison of Demographics, Health Care Use, and Expenditures

Abstract

Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics.

Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks.

Methods:Analysis of data from the 2009–2011 Medical Expenditure Panel Survey.

Key findings: High-need adults differed notably from adults with multiple chronic diseases but no functional limitations. They had annual health care expenditures that were nearly three times higher—and which were more likely to remain high over two years of observation—and out-of-pocket expenses that were more than a third higher, despite their lower incomes. On average, rates of hospital use for high-need adults were more than twice those for adults with multiple chronic conditions only; high-need adults also visited the doctor more frequently and used more home health care.

Conclusion: Wide variation in costs and use of services within the high-need group suggests that interventions should be targeted and tailored to those individuals most likely to benefit.

The Promise and Pitfalls of Bundled Payments

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http://www.commonwealthfund.org/publications/blog/2016/sep/bundled-payments?omnicid=EALERT1095386&mid=henrykotula@yahoo.com

Why Bundled Payments?

Under bundled payments, a single payment is made for all of the services associated with an episode of care, such as a hip or knee replacement or cardiac surgery. Services might include all inpatient, outpatient, and rehabilitation care associated with the procedure.

There are a number of potential advantages to this payment approach. Bundled payments give providers strong incentives to keep their costs down, including by preventing avoidable complications. Bundled payments also can encourage collaboration across diverse providers and institutions, as well as the development and implementation of care pathways that follow evidence-based guidelines. In addition, bundles target the work of specialists, who have been less likely up to now than primary care physicians to participate in value-based payment arrangements.

More conceptually, health care economists are drawn to bundled payments because a bundle of care constitutes a clinically and intuitively meaningful “product” — in this case, the clinical episode. Defining clear products in health care helps create markets in which providers directly compete on quality and price. One barrier to effective health care markets has been that prices, when available, tend to relate to inputs into clinical care — such as pills, bandages, bed days, or X-rays — that are not meaningful to consumers of care and that don’t necessarily predict the total costs of care. For example, a health system that charges a lot for X-rays may still be more efficient because it uses fewer of them or saves money on other inputs. Bundles bring all these inputs together into a single price for a single basket of services.

Without Medicaid expansion, Texas hospitals left holding the bag

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http://www.fiercehealthcare.com/finance/without-medicaid-expansion-texas-hospitals-left-holding-bag

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Should Texas ever decide to expand Medicaid eligibility under the Affordable Care Act, its hospitals would be spared about $358 million a year in costs tied to uncompensated care, a new study has found.

The research was conducted by the Florida-based consulting firm Health Management Associates on behalf of the Texas Health and Human Services Commission, The Dallas Morning News has reported. The report was not immediately available online.

If Medicaid were expanded, about 9 percent of the approximately $4 billion a year Texas’ hospitals spend on uncompensated care could be saved, the newspaper reported. Health Management Associates (HMA) predicted about 668,000 Texans out of the 1.1 million eligible for Medicaid coverage would enroll if eligibility were expanded.

But, quoting the report, the newspaper said that Texas lawmakers are not inclined to expand Medicaid anytime soon.

A “Volatile Marketplace”: Second Quarter Earnings Calls Offer Glimpse of How Insurers Are Faring on ACA Marketplaces—and What 2017 Might Bring

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http://www.commonwealthfund.org/publications/blog/2016/sep/volatile-marketplace?omnicid=EALERT1094761&mid=henrykotula@yahoo.com

This has been a turbulent year for the Affordable Care Act (ACA) marketplaces. As part of our ongoing efforts to better understand how the post-ACA insurance markets are evolving, we reviewed the 2016 second-quarter (Q2) earnings calls and financial filings of several large, publicly traded insurers that participate on the marketplaces: Aetna, Anthem, Centene, Cigna, Humana, Molina, and United.1  While the picture provided by these calls and financial reports is limited – dozens of other participating insurers are not required to report to investors because of their nonprofit or private status – they can help us better understand some of the trends affecting the marketplaces’ stability, including insurer exits from some health insurance marketplaces and increases in 2017 premiums.

 

High-Risk Pools For Uninsurable Individuals

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High-Risk Pools For Uninsurable Individuals

Figure 1: Concentration of Health Care Spending in U.S. Population, 2011

In the debate over the future of the Affordable Care Act (ACA), proposals have emerged that would repeal or weaken rules prohibiting health insurance discrimination based on health status, instead offering high-risk pools as a source of coverage for people who would be uninsurable due to pre-existing conditions.

In Congress, HR 2653 was introduced by members of the House Republican Study Committee to repeal the ACA and replace it with other changes, including state high-risk pools.  This bill would authorize $50 million for seed grants to help states establish high-risk pools, and $2.5 billion annually for 10 years to help states fund high-risk pools.  Recently, House Republicans released their proposal to replace the ACA, entitled A Better Way.  This plan would significantly modify ACA insurance market rules to provide a one-time open enrollment opportunity; thereafter, only individuals who maintain continuous coverage would be guaranteed access to insurance without regard to their health status.  This plan also would provide $25 billion over 10 years in state grants to help fund high-risk pools.  Pools would be required to cap premiums (at unspecified levels) and would be prohibited from imposing waiting lists.

For more than 35 years, many states operated high-risk pool programs to offer non-group health coverage to uninsurable residents.  The federal government also operated a temporary high-risk pool program established under the ACA to provide coverage to people with pre-existing conditions in advance of when broader insurance market changes took effect in 2014.  This issue brief reviews the history of these programs to provide context for some of the potential benefits and challenges of a high-risk pool.

Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors

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Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors

Figure 1: Risk Adjustment Under the Affordable Care Act

As of January 1, 2014, insurers are no longer able to deny coverage or charge higher premiums based on preexisting conditions (under rules referred to as guaranteed issue and modified community rating, respectively). These aspects of the Affordable Care Act (ACA) – along with tax credits for low and middle income people buying insurance on their own in new health insurance marketplaces – make it easier for people with preexisting conditions to gain insurance coverage. However, if not accompanied by other regulatory measures, these provisions could have unintended consequences for the insurance market. Namely, insurers may try to compete by avoiding sicker enrollees rather than by providing the best value to consumers. In addition, in the early years of market reform insurers faced uncertainty as to how to price coverage as new people (including those previously considered “uninsurable”) gained coverage, potentially leading to premium volatility. This brief explains three provisions of the ACA – risk adjustment, reinsurance, and risk corridors – that were intended to promote insurer competition on the basis of quality and value and promote insurance market stability, particularly in the early years of reform.

CONCLUSION

The Affordable Care Act’s risk adjustment, reinsurance, and risk corridors programs were designed to work together to mitigate the potential effects of adverse selection and risk selection. All three programs aimed to provide stability in the early years of a reformed health insurance market, with risk adjustment continuing over the long-term. Many health insurance plans are subject to more than one premium stabilization program, and while the programs have similar goals, they are designed to be complementary. Specifically, risk adjustment is designed to mitigate any incentives for plans to attract healthier individuals and compensate those that enroll a disproportionately sick population. Risk corridors were intended to reduce overall financial uncertainty for insurers, though they largely did not fulfill that goal following congressional changes to the program. Reinsurance compensated plans for their high-cost enrollees, and by the nature of its financing provided a subsidy for individual market premiums generally over a three-year period. Premium increases are expected to be higher in 2017 in part due to the end of the reinsurance program.