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Medicare, Medicaid, Health Reform

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Monthly Archives: March 2013

Patient Engagement to Lower Health Costs and Improve Outcomes

It’s not uncommon for a patient to be confused or overwhelmed by a diagnosis or treatment plan.  Complicated medical procedures or decisions can overwhelm patients to the point that they feel that they cannot, or should not, ask questions of their providers.   However, this lack of patient involvement in decision making can lead to decreased patient compliance, higher costs,...

Chronic Care Management: Technologies to Better Manage Chronic Conditions

The nation's largest health care buyers - Medicare, state Medicaid programs, large employers, and health plans - are eager for ways to improve the quality and efficiency of chronic health conditions, which drive the bulk of health spending.  Payment reform and care delivery reforms are critically important.  Providers - particularly physicians, hospitals, and health systems - are under increasing...

Hospital Admissions: Trends in Hospital Utilization

Hospital admissions and readmissions are a hot topic in the healthcare community.  Reducing hospital utilization can result in a leaner, more efficient system with lower costs and greater health outcomes.  The opportunities to save money and improve care are extraordinary. Accordingly, Medicare, state Medicaid agencies, health plans, and patient organizations have joined the discussion to address preventable hospital utilization.  The...

Strategic Approach to Qualified Health Plans in Health Insurance Exchanges: Selecting and Managing QHPs

The qualified health plan contracting process in Health Insurance Exchanges present many opportunities and challenges for states and the Centers for Medicare and Medicaid Services (CMS).  Success in implementing the Exchanges - one of the Affordable Care Act's most complex and ambitious features - will require comprehensive, well-structured strategies, particularly for the selection and management of qualified health plans...

Physician Payment Reform: Preparing for Value-Based Reimbursement

Primary care is shifting to payment based on providing higher quality, lower cost health care. New payment models - such as patient-centered medical homes (PCMH) - replace or supplement traditional fee-for-service payments with per-member per-month payments, and emphasize coordinated care, quality measurement, and accountability. Some models offer cost-sharing, as with the Medicare Shared Savings Program for Accountable Care Organizations...

Four Payment Reform Models of Keen Interest to Large Employers

While the Affordable Care Act is expected to shift more of health coverage from the private employers to taxpayers, the most common source of health insurance for Americans is still though an employer or the employer of a spouse or parent.  According to the most recent census data, over half (55%) of all Americans receive employer sponsored health insurance. ...

Health Care Fraud: Using Health Services Research to Detect Fraud and Abuse

Fraud in the health care system is a significant and growing threat.  The FBI estimates that between 3% and 10% of all health care expenditures are lost to fraud each year - up to $280 billion annually.  Health care fraud not only raises costs for consumers and employers - through higher premiums, greater out of pocket expenses, and inefficiency...

Medicare-Medicaid Dual Eligibles: Measuring Quality of Special Needs Plans and State Demonstrations

Medicare-Medicaid dual eligibles are often held up as a prime case for the need for better care management to reduce health costs and spending while improving quality.  But doing so can be challenging.  Most dual eligibles have multiple health conditions, whether a chronic disease, severe cognitive or physical disabilities, or some other condition or impairment that requires long-term care. ...

Payment Reform Models: Coordinated Primary Care for Employees

Coordinated primary care models have shown great potential to reduce health care costs while improving care, a goal that will become even more important after the Affordable Care Act (ACA) coverage expansion provisions take full effect next year. The models typically involve communication among providers, a focus on patients with complex and expensive health needs, physician-patient communication, and a...

Payment Reform Models: Employers Explore Population-Based and Bundled Payment

For the past several years, major payers in U.S. health care have experimented with new payment models that create incentives to control unnecessary health care spending. The traditional fee-for-service model for health insurance does not give providers a reason to control health costs: The more services they provide, the more they get paid. Private and public health plans have sought...

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