Kip Piper's Health Care Blog
Medicare, Medicaid, Health Reform

Health insurers, whether commercial health plans or public programs like Medicaid and Medicare, only wish to pay for care that is necessary. Every day they make decisions on what is and is not "medically necessary." Gov. Phil Bredesen has proposed a new definition of medical necessity for TennCare, Tennessee's long-troubled...
To help organizations planning to submit bids to serve beneficiaries under the new Medicare prescription drug benefit, the Centers for Medicare & Medicaid Services (CMS) has posted a wealth of valuable new information on it's website. Designed to help potential drug plan bidders better understand and estimate the Medicare population's...
Medicaid health plans are the Ginger Rogers of managed care. They have to do everything commercial and Medicare health plans do but have to do it backwards and in high heels. Despite dealing with more complex requirements and the toughest, most vulnerable patient populations, Medicaid health plans often provide...
Pharmacy benefit managers (PBMs) already administer Rx benefits for most employers and several Medicaid programs. Medicare's voluntary prescription drug benefit, set to begin in 2006, creates a huge new market opportunity for PBMs. However, the Medicare drug benefit will also create significant new challenges to PBMs and other organizations...
A new report examines the impact of state budget cuts on Medicaid managed care programs in four states: Florida, Massachusetts, Michigan, and Oregon. Developed by Bailit Health Purchasing LLC for the National Academy for State Health Policy, the study offers valuable insights. It's recommended reading for state Medicaid executives,...
Over nine million American children - 12.8 percent of kids - have special health care needs. They face a wide range of conditions, including congenital anomalies, severe physical disabilities, severe asthma, complex organ system diseases (e.g. cystic fibrosis, sickle cell anemia), major depression, and the devastating effects of physical...
Under the new Medicare prescription drug benefit, drug plans will have a fair amount of discretion in setting formularies. The idea is to encourage competition among drug plans and offer Medicare beneficiaries choice. The Centers for Medicare & Medicaid Services (CMS) will review the benefit designs of drug plan...
Prescription drug utilization varies dramatically among individuals. To make sure Medicare payments to Prescription Drug Plans (PDPs) reflect the health status of enrollees, the Centers for Medicare & Medicaid Services (CMS) is developing a risk adjustment methodology. Risk adjustment is a statistical process used to identify and adjust for...
Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress increased payments to Medicare Advantage plans. The objective is to increase participation by health plans and thereby create more choices for Medicare beneficiaries. While many pundits have criticized the payment increases as a
The pay-for-performance (P4P) movement continues to grow: 1. The Medicare Payment Assessment Commission (MedPAC) is calling on Congress to incorporate quality incentives in Medicare payments to hospitals, physicians, and home health agencies. In 2003, MedPAC released similar P4P recommendations for Medicare managed care plans and dialysis facilities. MedPAC says the...

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