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New Series Examines Serving High-Need, High-Cost Patients

The Commonwealth Fund is launching a new series of case studies describing “innovative programs designed to address the needs of the nation’s high-need, high-cost patients, a group that accounts for a disproportionate share of health care spending.” Among the types of programs it will profile are: home-based primary care enhanced primary care programs of all-inclusive care (PACE) accountable care for Medicaid populations guided care For a closer look at the new series and the programs it will profile go here, to the web site of the Commonwealth Fund.

Posted in Health care reform

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 … Read More

Posted in Health care reform

Safety Net Still Needed, Study Finds

Despite Affordable Care Act policies that have enabled millions of Americans to obtain health insurance, the health care safety net is still needed. Or so concludes a new report from the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms. For the report A Tale of Three Cities: How the Affordable Care Act is Changing the Consumer Coverage Experience in 3 Diverse Communities, researchers visited and examined conditions in Tampa, Columbus, and Richmond (Virginia), and among their conclusions was: We still need a safety net. Safety net programs in existence before the ACA were expected to become less necessary once the ACA coverage expansions took effect. And to some extent that has indeed been the case. But what was deemed affordable … Read More

Posted in Affordable Care Act, Health care reform

Hospitals Not Using Observation Status to Avoid Readmissions Penalties

Hospitals are not moving returning patients to observation status to avoid incurring financial penalties under Medicare’s hospital readmissions reduction program, according to new study published in the New England Journal of Medicine. Since that program’s inception, more than 3300 hospitals have reduced the rate at which they readmit Medicare patients within 30 days of their discharge from the hospital. A moderate increase in the classification of Medicare patients in observation status led some critics to suggest that observation status was being used to avoid penalties for readmissions. The study disagrees, concluding that …we found a change in the rate of readmissions coincident with the enactment of the ACA, which suggested that the Hospital Readmissions Reduction Program may have had a … Read More

Posted in Health care reform, Medicare, Uncategorized

Push From Volume to Value Continues

As the end of 2015 nears, CMS has used its blog to reflect on its continued efforts to move the U.S. health care system from one that pays for the volume of care provided to one that pays for the value of that care. The blog notes the replacement of the sustainable growth rate (SGR formula) with a new payment system that better supports patient-centered care; the creation of the Home Health Value-Based Purchasing model; and the introduction of Medicare reimbursement for advance care planning. The blog also describes the many programs launched by the Affordable Care Act-created Center for Medicare and Medicaid Innovation, including the Pioneer ACO Model, the Medicare Shared Savings Program, the Comprehensive Care for Joint Replacement … Read More

Posted in Affordable Care Act, Health care reform, Medicare

OIG Reveals 2016 Plans

The U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) has published its work plan for the 2016 fiscal year. In 2016, the OIG will continue to examine all aspects of HHS endeavor, including Medicare, Medicaid, hospital services, public health activities, and more. In the coming year it will continue a number of hospital-focused projects while also focusing more on health care delivery, health care reform, alternative payment methodologies, and value-based purchasing initiatives. Among the OIG’s planned Medicare projects in 2016 – some of them continued from the past and some of them new, quoted directly from the work plan – are: Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule. We will determine how … Read More

Posted in Affordable Care Act, Health care reform

Feds Approve Plan for PA to Establish Insurance Exchange

The U.S. Department of Health and Human Services (HHS) has approved a request by Pennsylvania Governor Tom Wolf for permission for his state to develop a state-based marketplace through which to offer health insurance to Pennsylvanians as provided for in the Affordable Care Act. Currently, Pennsylvanians seeking health insurance use the federal exchange.  The constitutionality of the use of that exchange is currently being weighed by the Supreme Court and the Wolf administration’s desire to create a state exchange is widely considered an attempt to avoid a crisis should the court rule against the federal government in the case of King v. Burwell.  A ruling in that case is expected in the very near future. Go here to see the … Read More

Posted in Affordable Care Act, Health care reform

PA Seeks to Establish Health Insurance Marketplace

In anticipation of a possible Supreme Court decision that could jeopardize the health insurance of an estimated 382,000 Pennsylvanians, the Wolf administration has applied to the federal government to establish a state-based health insurance marketplace. The Supreme Court is currently weighing a challenge to the use by some states of the federal health insurance marketplace and the contention of litigants that the Affordable Care Act specifies that insurance subsidies would only be available through state-based exchanges.  If the court rules against the federal government, the insurance of residents of states that did not establish their own exchanges and who instead obtained their insurance and federal subsidies through the federal exchange will be in jeopardy. The move by the Wolf administration … Read More

Posted in Affordable Care Act, Health care reform

PA Prepares to Establish Health Insurance Exchange (Just in Case)

Saying he wants to “protect 382,000 Pennsylvanians from potentially losing subsidies that help them afford health care coverage” if the Supreme Court rules that Affordable Care Act health insurance subsidies are available only to individuals who purchase insurance on state-operated insurance exchanges and not the federal exchange, Pennsylvania Governor Tom Wolf has informed the U.S. Department of Health and Human Services Secretary Sylvia Burwell that his state intends “implement a State-based Marketplace for Pennsylvanians to shop for health insurance coverage.” Governor Wolf notified the HHS Secretary of his decision in a May 1 letter.  The letter does not commit the state to developing its own exchange; it only declares the state’s intention to develop such an exchange if the Supreme … Read More

Posted in Health care reform

More That 400,000 Sign Up For Health Insurance in PA

Through early February, 430,000 Pennsylvanians have enrolled in health insurance plans through the federal health insurance marketplace. Of that number, 81 percent qualified for at least some financial assistance with their premiums.  Through December, more than two-thirds obtained insurance for no more than $100. To learn more about how Pennsylvanians are using the federal exchange to purchase health insurance, see this Central Penn Business Journal article.  

Posted in Affordable Care Act, Health care reform
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