Here is a government compliance tool that will give you specific guidance on specific plan compliance issues for your employer groups plans.  Here is the link to the site:  http://www.dol.gov/elaws/ebsa/health/employer/.  I’ve pasted some of the features of the site below.  It is actually well done.  I’d recommend book-marking the site for future use.   Jeff

elaws – EMPLOYMENT LAWS ASSISTANCE FOR WORKERS AND SMALL BUSINESS---------                - Health Benefits Advisor for Employers

The Health Benefits Advisor for Employers provides an overview of certain federal laws that can affect health benefit coverage provided by group health plans. The requirements described in this Advisor generally apply to group health plans and group health insurance issuers (i.e., insurance companies and health maintenance organizations (HMOs)). However, for convenience, references here are generally limited to "group health plans" or "plans."

The laws discussed in this Advisor are included in Parts 6 and 7 of Title I of the Employee Retirement Income Security Act of 1974 (ERISA). These laws include:

    Consolidated Omnibus Budget Reconciliation Act (COBRA)

    Health Insurance Portability and Accountability Act (HIPAA)

    Mental Health Parity and Addiction Equity Act (MHPAEA) and Mental Health Parity Act (MHPA)

    Newborns' and Mothers' Health Protection Act (Newborns' Act)

    Women's Health and Cancer Rights Act (WHCRA)

    Genetic Information Nondiscrimination Act (GINA)

    Michelle's Law

This Advisor was developed by the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) and is designed to provide explanations of legislation, statutes and regulations. It provides general guidance only and should not be considered legal advice. If you have further questions not specifically addressed in the Advisor, please contact the Employee Benefits Security Administration regional office nearest you or call toll free 1-866-444-3272.

If you are an employer whose plan provides benefits through an insurance policy or HMO, you may also contact your state insurance department. For more information visit the National Association of Insurance Commissioners (NAIC) website. As discussed in the Advisor, state law regulating insurance companies and HMOs can change some of these federal rules if the state law is more protective of individuals.

The specific laws included in Parts 6 and 7 of ERISA are applicable to group health plans, and may or may not apply to your plan depending upon a number of factors, including the employees in your organization and the type of benefits offered under your health plan.

The Advisor contains sections on each law, provides a description of the employer obligations contained in the law and regulations, and links you to other materials to assist you in complying with that law.

Please note: The Patient Protection Affordable Care Act (ACA) provides additional health protections. This website does not reflect the passage of the ACA. For an overview of the Affordable Care Act, please visit the ACA Summary. For regulations, guidance and additional information, please visit the Department of Labor's ACA webpage.     

http://www.dol.gov/ebsa/healthreform

Lack of capacity is the operative phrase that best describes the results of healthcare reform in Massachusetts.  Once universal healthcare passed in Massachusetts the limited capacity of primary care physicians quickly got over-run.  Once individuals weren’t  given a choice…..they end up in expensive emergency rooms.  Proactive benefit consultants and brokers are heeding the lessons learned in Massachusetts and are proactively educating employer groups regarding the need to secure a PCP NOW!   This new study out of Colorado gives you grist for your mill.  Many local PCP groups are interested in helping you to educate your employer groups about the value of a PCP.  Coordinated care through PCP mitigates complex claims costs and serves as a prophylactic against the emergence of disease process and co-morbidities.  Take a look at this data and formulate a plan for your employers today.  We’re happy to help you to coordinate educational sessions between PCPs and your plan sponsors.  The study abstract is below.  Below that is a news story that covers the study.   Jeff

ONLINE FIRST
Health Insurance Status Change and Emergency Department Use Among US Adults

Adit A. Ginde, MD, MPH; Robert A. Lowe, MD, MPH; Jennifer L. Wiler, MD, MBA

Arch Intern Med. Published online March 26, 2012. doi:10.1001/archinternmed.2012.34

ABSTRACT

Background  Recent events have increased the instability of health insurance coverage. We compared emergency department (ED) use by newly insured vs continuously insured adults and by newly uninsured vs continuously uninsured adults.

Methods  We analyzed 159 934 adult respondents to the 2004 through 2009 National Health Interview Survey. Health insurance status was categorized as newly insured (currently insured but lacked health insurance at some point during the prior 12 months) vs continuously insured and as newly uninsured (currently uninsured but had health insurance at some point during the prior 12 months) vs continuously uninsured. We analyzed the number of ED visits during the prior 12 months using multivariable Poisson regression.

Results  Overall, 20.7% of insured adults and 20.0% of uninsured adults had at least 1 ED visit. However, 29.5% of newly insured adults compared with 20.2% of continuously insured adults had at least 1 ED visit. Similarly, 25.7% of newly uninsured adults compared with 18.6% of continuously uninsured adults had at least 1 ED visit. After adjusting for demographics, socioeconomic status, and health status, recent health insurance status change was independently associated with greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% CI, 1.22-1.42 vs continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). Among newly insured adults, this association was strongest for Medicaid beneficiaries (IRR, 1.45) but was attenuated for those with private insurance (IRR, 1.24) (P < .001 for interaction).

Conclusions  Recent changes in health insurance status for newly insured adults and for newly uninsured adults were associated with greater ED use. As policy and economic forces create disruptions in health insurance status, new surges in ED use should be anticipated.

INTRODUCTION

Jump to Section  ∙ Top  ∙ Introduction  ∙ Methods  ∙ Results  ∙ Comment  ∙ Author information  ∙ References

The United States is facing increased instability in health insurance coverage.¹ Government efforts to expand health insurance coverage, including the 2010 Patient Protection and Affordable Care Act,² seek to enhance access to primary care and to reduce potentially preventable emergency department (ED) visits and hospitalizations. However, providing insurance to previously uninsured individuals may effect a paradoxical increase in health care use by creation of a "moral hazard" or by increased use of services that had been previously deferred.^3-4 In addition, economic recession, with higher rates of unemployment and transient employment, along with entitlement program cutbacks, create a population of newly uninsured individuals who have abruptly reduced access to acute and primary care.⁵

This type of health insurance "churning" results in populations of newly insured and newly uninsured individuals, who for different reasons can struggle with access to outpatient care and may turn to EDs for medical services.^6-7 The ED is an important bellwether for access to care, the most common venue for acute care, and the most frequent source of inpatient admissions⁸; changes in ED use are an important indicator of health care system performance. Prior studies^9-13 have demonstrated that ED use was higher among uninsured or underinsured populations facing barriers to outpatient care, including financial and geographic ones, and limited access to primary care services. In addition, newly insured individuals may no longer face a financial disincentive to seek care. If barriers reduce access to traditional sources of primary care, these individuals may be more likely to use ED services than when they were uninsured. Recent legislation and economic recession are likely to increase health insurance instability. To our knowledge, the potential effect of such changes in health insurance status on the use of EDs, many of which are already crowded, has not been previously studied.

The objective of this study was to compare ED use patterns among newly insured vs continuously insured adults and among newly uninsured vs continuously uninsured adults. Based on findings of prior investigations that suggest a change in overall health care use with gain⁴ or loss⁵ of insurance, we hypothesized that changes in health insurance status (recent gain or loss of coverage) would be associated with increased ED use.

METHODS

Jump to Section  ∙ Top  ∙ Introduction  ∙ Methods  ∙ Results  ∙ Comment  ∙ Author information  ∙ References

STUDY DESIGN

The National Center for Health Statistics conducts the National Health Interview Survey (NHIS), a cross-sectional household interview survey of a sample of respondents that approximates the noninstitutionalized US civilian population. The NHIS has been conducted annually since 1957, with the most recently available data being from 2009. We received a waiver from our institutional review board to analyze publicly available NHIS data from 2004 through 2009.

DATA COLLECTION

Details of NHIS survey methods are described elsewhere.^14-15 Briefly, the sample is obtained using a stratified multistage probability study design with oversampling of certain subgroups, including racial/ethnic minorities and older adults. The NHIS uses a 2-stage sampling strategy covering geographic primary sampling units, with a primary sampling unit defined as a county, a small group of contiguous counties, or a metropolitan statistical area. For each primary sampling unit, second-stage units are used, composed of area and permit segments expected to contain 8 to 16 addresses.

From 2004 through 2009, the NHIS collected household interview data, including demographics, health status, and health care use, for 159 934 adults (

18 years), who represent an annualized US population of 222 million. The annual response rate of the NHIS is approximately 90% of the eligible households in the sample. Strategies for sampling, methods for data collection, and survey questions were similar throughout the selected NHIS years to maintain consistency and to facilitate comparisons.

VARIABLES

The primary predictor variables were health insurance type and recent changes in health insurance status. We considered adults who reported private insurance with or without any other health insurance type as having private insurance and those reporting Medicaid with or without Medicare as having Medicaid. We considered adults who reported having only Medicare coverage, without private insurance or Medicaid, as having Medicare only. We considered adults who did not report private, Medicaid, or Medicare coverage but reported another health insurance type (eg, other public or military) as having other insurance. We considered adults who reported no current health insurance coverage as being uninsured.

We categorized adults with some current form of health insurance as newly insured if they reported a lack of health insurance coverage at some point during the prior 12 months. Conversely, continuously insured adults had health insurance without disruption during the prior 12 months. We categorized adults without current insurance as newly uninsured if they reported having some form of health insurance coverage during the prior 12 months. Conversely, continuously uninsured adults did not have health insurance at any point during the prior 12 months. In a secondary analysis, we also evaluated the "dose response" for intervals up to 3 years since last having insurance. The relationships and population prevalences of these 4 primary comparison groups are shown in the Figure. We compared these groups to measure the association with the primary outcome of ED use, assessed by the question, "During the past 12 months, how many times have you gone to a hospital emergency room about your own health (this includes emergency room visits that resulted in a hospital admission)?" Possible answers were none, 1, 2 to 3, 4 to 5, 6 to 7, 8 to 9, 10 to 12, 13 to 15, or 16 or more; refused to answer; or "don't know."

View larger version (10K): [in this window] [in a new window] [as a PowerPoint slide]   Figure. The relationships and prevalences of 4 primary comparison health insurance status groups among the US population. Percentages are population weighted.

The primary associations were adjusted by potential confounding variables, including demographics (age, sex, race/ethnicity, and US Census region), socioeconomic status (poverty income ratio and education), and health status, as listed in Table 1. The poverty income ratio is the ratio of the observed family income category to the family's appropriate poverty threshold set by the US Census Bureau. Self-reported health status was measured by the question, "Would you say your health in general is excellent, very good, good, fair, or poor?" We also included body mass index, alcohol use, cigarette use, and chronic health conditions (hypertension, diabetes mellitus, coronary artery disease, stroke, asthma, and cancer), selected based on their high prevalence and potential for increased ED use.

View this table: [in t

Many of you and your plan sponsors often ask about what constitutes preventive services under the new PPACA mandates.  Here is a good article  to help you with that.  As you know, we firmly advocate for having employers incentivize the use of annual preventive services as a prophylactic against catastrophic claims in a group plan.  Further, we’ve found that the use of these services gets employees into the system with a primary care physician to ensure continuity of care.  This purposeful activity allows the PCP to get baseline information on a member and to recognize changes from year to year which can signify an emerging disease process or co-morbidities.  Tactically, savvy agents and brokers are doing whatever they can to associate members with a PCP NOW since there will be a likely scarcity of PCPs once PPACA is fully enacted.  Use this information to your advantage as you teach your plan sponsors how to efficiently finance their health plans.    Jeff

Stay Healthy, Save Money with Preventive Services Covered at 100% Under Health Care Reform

Preventive health care–including annual physical exams, screenings, and immunizations–is essential to good health. Yet many Americans don’t receive the regular preventive care they need, despite the fact that chronic diseases, which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the country’s health care spending–are often preventable.

Why do so few Americans get the preventive care they need? Often, the reason is cost.

The Affordable Care Act (health care reform) attempts to address this problem by requiring all new group and individual health insurance plans as of September 23, 2010 to pay 100% of the costs for preventive care services ranked A and B by the U.S. Preventive Services Task Force (USPSTF).

If your health plan qualifies, you can take advantage of a wide range of preventive care services to help you avoid illness and improve your health–at no cost to you, so long as you receive these services from a health care provider within your health plan’s network of doctors and hospitals.

You won’t have to pay a copayment at the office visit, and not a penny toward coinsurance or your deductible. Doctors and health care facilities continue to charge for these services. But now it’s the health insurance companies that pay the costs. Essentially, preventive care becomes ‘free’ for the policyholder, greatly increasing the incentive to take advantage of these services.

The following lists outline the preventive care services covered by these rules for adults, women, and children.

Adults
Covered preventive services for adults include:

• Abdominal aortic aneurysm: A one–time screening for men of specified ages who have ever smoked
• Alcohol misuse screening and counseling
• Aspirin use for men and women of certain ages
• Blood pressure screening for all adults
• Cholesterol screening for adults of certain ages or at higher risk
• Colorectal cancer screening for adults over 50
• Depression screening for adults
• Type 2 diabetes screening for adults with high blood pressure
• Diet counseling for adults at higher risk for chronic disease
• HIV screening for all adults at higher risk
• Immunization vaccines for adults (recommendations vary):

• Hepatitis A
• Hepatitis B
• Herpes zoster
• Human papillomavirus
• Influenza (flu shot)
• Measles, mumps, rubella
• Meningococcal
• Pneumococcal
• Tetanus, diphtheria, pertussis
• Varicella

Obesity screening and counseling for all adults

Sexually transmitted infection (STI) prevention counseling for adults at higher risk

Tobacco use screening for all adults and cessation interventions for tobacco users

Syphilis screening for all adults at higher risk

Women
Covered preventive care services for women, including pregnant women, include:

• Anemia screening on a routine basis for pregnant women
• Bacteriuria urinary tract or other infection screening for pregnant women
• BRCA (breast cancer gene) counseling about genetic testing for women at higher risk
• Breast cancer mammography screenings every one to two years for women over 40
• Breast cancer chemoprevention counseling for women at higher risk
• Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
• Cervical cancer screening for sexually active women
• Chlamydia infection screening for younger women and other women at higher risk
• Contraception: Food and Drug Administration–approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
• Domestic and interpersonal violence screening and counseling for all women*
• Folic acid supplements for women who may become pregnant
• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
• Gonorrhea screening for all women at higher risk
• Hepatitis B screening for pregnant women at their first prenatal visit
• Human immunodeficiency virus (HIV) screening and counseling for sexually active women*
• Human papillomavirus (HPV) DNA test: High–risk HPV DNA testing every three years for women age 30 or older* with normal cytology results
• Osteoporosis screening for women over 60, depending on risk factors
• Rh blood incompatibility screening for all pregnant women and follow–up testing for women at higher risk
• Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users
• Sexually transmitted infections (STI) counseling for sexually active women*
• Syphilis screening for all pregnant women or other women at increased risk
• Well–woman visits to obtain recommended preventive services for women under 65*

Note: Services marked with an asterisk (*) must be covered with no cost–sharing in plan years starting on or after August 1, 2012.

Children
Covered preventive care services for children include:

• Alcohol and drug use assessments for adolescents
• Autism screening for children at 18 and 24 months
• Behavioral assessments for children of all ages
• Blood pressure screening for children
• Cervical dysplasia screening for sexually active females
• Congenital hypothyroidism screening for newborns
• Depression screening for adolescents
• Developmental screening for children under age 3, and surveillance throughout childhood
• Dyslipidemia screening for children at higher risk of lipid disorders
• Fluoride chemoprevention supplements for children without fluoride in their water source
• Gonorrhea preventive medication for the eyes of all newborns
• Hearing screening for all newborns
• Height, weight, and body mass index measurements for children
• Hematocrit or hemoglobin screening for children
• Hemoglobinopathies or sickle cell screening for newborns
• HIV screening for adolescents at higher risk
• Immunization vaccines for children from birth to age 18 (recommendations vary):

• Diphtheria, tetanus, pertussis
• Haemophilus influenzae type B
• Hepatitis A
• Hepatitis B
• Human papillomavirus
• Inactivated poliovirus
• Influenza (flu shot)
• Measles, mumps, rubella
• Meningococcal
• Pneumococcal
• Rotavirus
• Varicella

Iron supplements for children ages 6 to 12 months at risk for anemia

Lead screening for children at risk of exposure

Medical history for all children throughout development

Obesity screening and counseling

Oral health risk assessment for young children

Phenylketonuria (PKU) screening for this genetic disorder in newborns

Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk

Tuberculin testing for children at higher risk of tuberculosis

Vision screening for all children

It’s important to keep in mind that while the health plan cannot charge you a copayment, deductible, or coinsurance when the primary purpose of the office visit is the recommended preventive care service and the service is NOT billed separately from the office visit, you may be required to share some of the costs if the preventive service is not the primary purpose of the office visit. And remember, preventive services are covered at 100% only when received from health care providers within the health plan’s network.

For the most up–to–date list of covered preventive care services, please visit http://www.uspreventiveservicestaskforce.org.

Source: Healthcare.gov

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We saw a lot this week in the press about Anthem and Aetna’s initiatives in this region around ACOs.  I’m posting some detailed information below about ACOs, what they mean and how they are likely to change the way that healthcare is financed.  It is important that brokers and consultants know and understand these changes.  The first post is from this month’s New England Journal of Medicine.  Both posts describe the incredible challenges facing this approach and conclude that rapid change and cost reduction isn’t likely.    Jeff

Keeping Score under a Global Payment System

Bruce E. Landon, M.D., M.B.A.

N Engl J Med 2012; 366:393-395February 2, 2012

Comments open through February 8, 2012

Article

References

Comments (2)

It is widely acknowledged that continued growth in health care spending is threatening the viability of the U.S. health care system. Although there are no clear comprehensive solutions to this problem, most observers see payment reform as the next best hope for reining in out-of-control costs. Our current fee-for-service payment system provides incentives to physicians to increase the delivery of services, which results in excessive utilization. Moreover, neither individual physicians nor the patients receiving the services bear the brunt of these utilization decisions. Rather, they're reflected in ever-rising health insurance premiums or tax-financed government expenditures shared by all. Many observers are therefore calling for fundamental redesign of the ways in which physicians and hospitals are compensated for the care they provide. Most options call for bundling payments to physicians; specific approaches range from prospective payments for discrete episodes of care (e.g., coronary-artery bypass surgery) to global payment or risk-based models of care.

Global prospective payments became prevalent during the heyday of managed care in the 1990s. Such so-called capitation payments were common in many markets, whereas in others physician organizations were actively preparing themselves for a coming tide of capitation that never materialized. In a fast-growing economy, both patients and physicians bridled at the restrictions of choice and access associated with such payment arrangements, and capitation quickly fell out of favor. In addition, the information systems and infrastructure necessary to successfully manage risk under global payments were underdeveloped during that period. After a lull of more than a decade, however, global payment is again seen as the potential savior of the health care system.

Among the most important anticipated experiments in global payments are accountable care organizations (ACOs), which were included as part of the Affordable Care Act and are also being developed under the auspices of the Center for Medicare and Medicaid Innovation. ACOs represent a hybrid of our fee-for-service system and true capitation. The ACO regulations, proposed by the Obama administration last March and finalized in October, call for two models of shared savings. In the first model, health care organizations would be eligible to share in savings but would bear no risk for losses for the first 2 years. Under this program, ACOs would be eligible for approximately 50% of the savings accrued by the Medicare program after they surpassed a fixed savings threshold. In the second model, there is both upside and downside risk sharing for participating health care organizations from the start. Because these organizations are taking on risk for losses, they would also be eligible for a larger percentage of shared savings. This latter version of ACOs most closely approximates true capitation. These proposed ACOs are similar to arrangements already present in the commercial sector, such as the Alternative Quality Contract rolled out by Blue Cross Blue Shield of Massachusetts in 2009.1,2

Conceptually, global payment represents an important opportunity for changing the perverse incentives inherent in our current fee-for-service system. To be successful, however, ACOs must pass these incentives along to their member physicians, who continue to be responsible for most utilization decisions. Although organizations can implement various managerial strategies to influence physicians' decision making (e.g., radiology decision support and prior authorization), ACOs are unlikely to reduce the rate of increase in health care spending without some essential changes in the behavior of member physicians — and therein lies the rub. The fundamental questions become how ACOs will choose to divide their global budgets and how their physicians and other service providers will be reimbursed. Thus, this system for determining who has earned what portion of payments — keeping score — is likely to be crucially important to the success of these new models of care.

Under ACOs and many commercial global payment products, providers will continue to receive traditional fee-for-service payments, and hospitals will receive their usual contracted payments, through either the diagnosis-related-group (DRG) system or per diem payments. All spending for each patient that is attributed to the ACO will then be tracked and compared with the calculated budget retrospectively at the end of the performance year in order to calculate savings or losses. Thus, standard fee-for-service payments remain the de facto method for keeping score, which works against the very design of the program. The inequities of the fee-for-service system, which reward proceduralists and specialists at the expense of cognitive specialties and primary care, remain embedded in the payment system. Although organizations can receive surplus payments, additional revenue from any surpluses will not flow into organizations until at least 18 months after the program begins.

As global payment systems are currently designed, primary care physicians stand to be among the big winners. However, to earn rewards, they will also have to shoulder the largest burden of the work needed to succeed under risk-sharing arrangements.3 In a well-functioning health care system, primary care physicians are the point of access, are responsible for care coordination and management, have perspective on the whole patient, and have the ability to manage the care of a patient population. Moreover, most quality incentives being incorporated into the payment systems for ACOs and other new global payment contracts also fall under the purview of primary care. To accomplish the care-management and quality goals, however, primary care physicians will need substantially more resources — for hiring care managers and other personnel to pursue population health management, for coordinating and managing care, and for implementing processes to ensure adherence with quality measures.

Although many ACOs will direct future surpluses to primary care, infrastructure payments to facilitate the development of the care-management functions noted above have not been built into the design of the ACO program or many new versions of capitation. Since most of these organizations will continue to rely on fee-for-service payments for the purpose of keeping score, making funds available to invest in this infrastructure would require a transfer of funds from specialists or hospitals to primary care, and it may be difficult for organizations to unilaterally alter the flow of funds to accomplish these aims. Moreover, although organizations may face strong incentives to control costs, specialist physicians who continue to be paid through the fee-for-service system and hospitals, which continue to receive DRG-based payments, face no such inherent incentives — and in fact will continue to benefit from practicing in much the same way as they do now.

Over time, if global payments become the norm, there is likely to be a resurgence of subcapitation and budgets for particular specialties, and systems will be designed to provide similar incentives to specialists while also enhancing funding for primary care. In addition, ACOs and their aligned hospitals must share incentives to control hospital costs. This transition, however, is likely to be painful and prolonged under the current design of the programs. Certainly, adjustments to the fee schedule that limit specialist pay and divert funds to primary care will be helpful, but even more helpful would be up-front payments that organizations can use to invest in their care-management and primary care infrastructure to facilitate this transition without taking funds from specialists or hospitals, at least until they achieve surpluses that ensure the continuation of this funding stream. Tightly managed multispecialty or primary care groups without strong alignment with a hospital may be well positioned to manage this transition.

The health care system is placing tremendous hope in changing incentives to control the ever-increasing costs of care. Hybrid approaches such as ACOs that incorporate global incentives but continue to keep score using fee-for-service payments will face serious challenges as they attempt to place increasing burdens on the already-stressed primary care system without providing additional resources for achieving the aims of global payments — slowed growth in costs and higher-quality care.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

And this is from a blog called “On Running a Hospital” by Paul Levy:

Thursday, February 02, 2012

Landon lands on the major issues about capitation

Bruce Landon offers an excellent summary in today's New England Journal of Medicine about the necessary conditions for a capitated, or global, payment regime to be successful.  He notes:

The fundamental questions become how ACOs will choose to divide their global budgets and how their physicians and other service providers will be reimbursed. Thus, this system for determining who has earned what portion of payments — keeping score — is likely to be crucially important to the success of these new models of care.

Under ACOs and many commercial global payment products, providers will continue to receive traditional fee-for-service payments, and hospitals will receive their usual contracted payments, through either the diagnosis-related-group (DRG) system or per diem payments. All spending for each patient that is attributed to the ACO will then be tracked and compared with the calculated budget retrospectively at the end of the performance year in order to calculate savings or losses. Thus, standard fee-for-service payments remain the de facto method for keeping score, which works against the very design of the program. The inequities of the fee-for-service system, which reward proceduralists and specialists at the expense of cognitive specialties and primary care, remain embedded in the payment system. Although organizations can receive surplus payments, additional revenue from any surpluses will not flow into organizations until at least 18 months after the program begins.

My regular readers may recall that I raised a similar point last year, when I noted:

Now, though, let me let you in on a little secret with regard to capitated care. Underneath the global budget, there is still a fee-for-service arrangement establishing the transfer prices among the providers in a network. That GI specialist will still get paid for each colonoscopy. The big thing to work out in this system is the allocation of any surplus or deficit in the annual budget among the various specialists.

Unless that allocation is skewed heavily towards primary care doctors, decisions about the level of care given will not change. But, if the allocation is skewed too heavily towards the PCPs, there is no real income signal for the specialists, leading to a danger that they will not feel invested in the end result. Unless the system is accompanied by intensive, real-time reporting, along with clear penalties for excessive care, it will not work.  

Bruce appears to concur, further explaining some necessary conditions for success:

As global payment systems are currently designed, primary care physicians stand to be among the big winners. However, to earn rewards, they will also have to shoulder the largest burden of the work needed to succeed under risk-sharing arrangements. . . . To accomplish the care-management and quality goals, however, primary care physicians will need substantially more resources — for hiring care managers and other personnel to pursue population health management, for coordinating and managing care, and for implementing processes to ensure adherence with quality measures. 

He concludes: 

The health care system is placing tremendous hope in changing incentives to control the ever-increasing costs of care. Hybrid approaches such as ACOs that incorporate global incentives but continue to keep score using fee-for-service payments will face serious challenges as they attempt to place increasing burdens on the already-stressed primary care system without providing additional resources for achieving the aims of global payments — slowed growth in costs and higher-quality care.

Posted by Paul Levy at 2/02/2012 08:47:00 AM

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   For the last few weeks I’ve sent out various postings that feature carrier initiatives and partnerships with mobile technology vendors.  Remote monitoring is a big thing this year.  We’ve also been posting about advances in telemedicine.  Savvy agents and brokers are paying attention to these initiatives.  Health care reform is creating a scarcity of primary care physicians.  PCP capacity will become a big problem for most plan sponsors.  Consumer initiatives and education promise to create more activist health plan membership.  Educated consumers seem to engage the system more responsibly and often advocate for themselves.  Best practice brokers are activating plan sponsors and their members with these leading edge technologies while teaching members about the importance of securing a PCP now.  Members will come to appreciate cost and quality if they have a relationship with a PCP and other tools to monitor their personal health on a daily basis.  This is a powerful combination!

   We are most interested in working with  brokers who are trying to get employers to incentivize membership usage of preventive benefits.  We’re finding that brokers who are doing this are getting positive feedback and are setting themselves up to talk about the next level of engagement with members.   Members who are activated, i.e. have a reason to suddenly be involved in the maintenance of their health, need ways to track their progress and failures.  These new devices are effective and inexpensive and often give members a reason to stay engaged.  Multiyear strategies that first incentivize and then engage members seemingly are producing long term ROI. 

   Last week I posted about Aetna’s new relationship with Best Buy stores to sell monitoring devices.  This piece speaks to United’s new program.  Agents and brokers are being given new opportunities to affect change within groups.  These are exciting times to engage.     Jeff

UnitedHealth Group Announces New Strategic Partnerships with Mobile Health Technology Firms

·         CareSpeak Communications, Lose It! and Fitbit offer mobile technologies designed to help improve and enhance consumers’ health and well-being

·         CEOs of these three companies to present at UnitedHealth Group’s exhibitor booth at the 2012 International Consumer Electronics Show in Las Vegas

Press Release: UnitedHealth Group – Mon, Jan 9, 2012 12:08 PM EST

MINNETONKA, Minn.--(BUSINESS WIRE)-- UnitedHealth Group has announced strategic partnerships with three health technology companies that offer mobile products and services designed to help improve consumers’ health and well-being.

UnitedHealth Group’s new business partners – CareSpeak Communications, Lose It! and Fitbit – help simplify the consumer health care experience by making relevant, practical information easier to access by using consumer-friendly technology devices such as smartphones and other mobile devices.

“Technology is playing an increasingly important role in the way that people take control of their health. UnitedHealth Group is committed to developing innovative solutions, and we look forward to working with such creative partners as CareSpeak Communications, Lose It! and Fitbit to help people live healthier lives,” said Rick Jelinek, executive vice president and CEO of Emerging Business Group at UnitedHealth Group.

CareSpeak Communications has developed a medication and disease management application that helps patients manage their health using two-way text messaging on their mobile phones. The CareSpeak system can be used by individual patients to self-manage their therapies, by a pharmaceutical company or pharmacy to provide alerts as a value-added service to their customers, by a health benefits provider to help plan participants manage their health, and by clinicians to manage their patients’ health. The technology enables patients to report, via text message, their medication intakes and biometric data (blood glucose levels, blood pressure, weight, etc.) to their clinician and/or care providers, and receive educational and motivational messages, incentives and rewards for meeting their health goals.

“We are thrilled to work with UnitedHealth Group – one of the largest and most sophisticated health care companies in the world,” said Serge Loncar, founder and CEO, CareSpeak Communications. “Finding innovative ways to improve clinical outcomes is of great significance, and we share UnitedHealth Group’s commitment in doing just that.”

Lose It!, created by FitNow Inc., is a mobile app and website that helps consumers manage their weight and improve their health by tracking their progress, offering peer support, and providing important caloric and nutritional information on what they eat. The mobile app is available for iPhones and Android devices.

“Healthy weight and nutrition management are key to helping people be happier and healthier, but are also critical to managing health care costs,” said Charles Teague, CEO, FitNow Inc. “Millions of people have used our tools to help them lose weight – more than 7 million pounds to date. We look forward to working with UnitedHealth Group to further leverage our technology and reach even more people.”

Fitbit offers a sleek, wireless tracker that includes an accelerometer to more accurately count how many steps a user takes, and an altimeter to track stairs climbed. The device also calculates how many calories are burned. The mobile device is also a sleep monitor that tracks both how long and how well the user sleeps. The information can be uploaded wirelessly to Fitbit.com where consumers can analyze their physical activity.

Fitbit will be integrated with the OptumizeMe® mobile health app developed by UnitedHealth Group’s health services company, Optum. OptumizeMe engages and empowers consumers to achieve health goals and encourages healthy behaviors. With coaching, relevant and personalized content, and connection to social networks, OptumizeMe also lets people create health challenges – with friends, co-workers and others – to help achieve health and fitness goals.

“Physical activity is paramount in helping people improve their health and well-being. Fitbit is dedicated to developing innovative and simple ways to motivate and empower consumers to achieve the results they want for their health and fitness,” said James Park, co-founder and CEO, Fitbit.

Loncar, Teague and Park will be featured speakers this week at UnitedHealth Group’s exhibitor booth at the 2012 International Consumer Electronics Show (CES) in Las Vegas. UnitedHealth Group is participating in CES to showcase the health and well-being company’s innovative technology products and services to help consumers live healthier lives and help improve and enhance the health care system.

The 3,500-square-foot booth will feature Microsoft Xbox with Kinect fitness challenges, real-time biometric screenings, presentations by leading health experts, innovative product and service demonstrations, and more. UnitedHealth Group will also provide a cyber café with Internet-enabled workstations and a coffee lounge area for CES attendees. UnitedHealth Group’s own experts will present as part of the CES Digital Health Summit and the Silvers Summit.

For more on UnitedHealth Group’s presence at CES as well as the company’s booth, fitness challenges and speaking engagements, please visit www.ceshealth.com or follow @CESHealth on Twitter.

About CareSpeak Communications
CareSpeak Communications provides mobile communications technology solutions to health care professionals, patients, and caregivers for better medication and clinical compliance, resulting in improved outcomes. The company offers its services to clinical organizations, insurers, payers, benefit managers, and the pharmaceutical industry. CareSpeak Communications is a privately held company, headquartered in New Jersey. Visit www.carespeak.com for more information.

About Fitbit
Founded in 2007 in San Francisco, CA, Fitbit is dedicated to delivering simple, innovative health and fitness products and services that help people lead healthier, more active lives by giving them the tools to become more aware, more motivated and more fit every day. Fitbit’s Ultra Wireless Activity + Sleep Tracker is the leading wireless fitness tracker on the market, with distribution at leading national retailers such as Amazon.com, Best Buy, Brookstone, Radio Shack, REI and Target. Fitbit is funded by the Foundry Group, True Ventures and SoftTech VC. For more information please visit www.fitbit.com or connect with us on Facebook or Twitter.

About Lose It!
Lose It! is a mobile application and website that uses proven principles of weight loss tracking and peer support to help users manage their weight. Lose It! is available directly to consumers, but can also be incorporated into corporate wellness or professionally administered weight loss programs, as a tool to help manage populations. More than 10 million people have used Lose It! on their mobile device or on the web since 2008. FitNow, Inc., the creator of Lose It!, is a privately held company headquartered in Boston, Massachusetts. Learn more at www.loseit.com or download Lose It! from your mobile device's app store.

About UnitedHealth Group
UnitedHealth Group (NYSE: UNH - News) is a diversified health and well-being company dedicated to helping people live healthier lives and making health care work better. With headquarters in Minnetonka, Minn., UnitedHealth Group offers a broad spectrum of products and services through two distinct platforms: UnitedHealthcare, which provides health care coverage and benefits services; and Optum, which provides information and technology-enabled health services. Through its businesses, UnitedHealth Group serves more than 75 million people worldwide. For more information, visit UnitedHealth Group at www.unitedhealthgroup.com.

Wellness initiatives and other snap on programs seemingly aren’t affecting the big claimants in most plans since these populations are already disease processed.  So, while we can prevent big claims in the future…….how do we get to the big $$$$ NOW??  Here’s a great piece.  More and more carriers are talking about ACOs and tiered networks as the best way to treat the most complex medical cases.  Are you familiar with these organizations in your area?  If you’re not….you should be.  As a benefit professional in your area are you meeting with the BEST doctor’s groups to hear their value proposition so that you can bring it to your customers??  Our co morbid populations are killing our plans. This piece talks about working with benefit administrators and executives to pick networks that coordinate care and deliver the best care.  Plenty of opportunity here.  Great piece that touches on many of the health care policy issues that we’ll address this year.   Take a look.  Jeff

It’s 2012. Let’s Recap

Posted on January 4, 2012 by Brian Klepper

Tom Emerick

Posted 1/02/11 on Cracking Health Costs

Let’s hit a few highlights of 2011.  In Cracking Health Costs we described certain…um…scary trends in health care in the US:

• US spending on health care is lapping our peer countries while our life expectancy is declining comparatively.  This is a major drain on our economy and is costing us jobs.
• We have a huge amount of unnecessary surgery and testing.  It’s getting worse, not better.  (Read The Treatment Trap by Rosemary Gibson and Janardan Prasad Singh for real life examples.)
• In health plans today, a small number of members are spending most of the money.  I’ve seen very large plans in which 10% of members are spending 80% of plan dollars.   These “outliers” are usually in the middle of serious acute health crises and are way beyond wellness, preventive, value-based purchasing, HSA incentives, consumer driven health care, public/private partnerships, etc.  “Outliers” often need specialized tertiary or quaternary care.
• There is huge variation between tertiary and quaternary referral centers in terms of getting the diagnoses right, having the best outcomes, and saving lives.  The best referral centers are the most cost effective too.
• Most specialists in the US don’t coordinate care or diagnoses.  As a consequence, a large number of “outliers” are misdiagnosed and/or have bad treatment and surgical plans.  This is a huge opportunity for benefit plans.
• Alas. We know that true reform can never and will never come from Washington. Members of Congress will see to it that clinics and hospitals in their districts are protected.
• Health insurers understand this but are often not supported by corporate benefit executives when they delete poor performing doctors and hospitals from their networks.
• Most benefit executives are looking for the deepest discounts when selecting a network, not the lowest net cost, a big difference.  Lowest net cost comes from getting diagnoses right, avoiding bad surgery, and coordinating care.  Those traits trump deepest discount every time.  A small but growing number of large corporations are getting this one right.
• If the system is to be reformed it will be done by corporate benefit executives.  Congress can’t.  Insurers can’t.
• Most of the clinicians who over-test and do a poor job of getting diagnoses and treatment plans right aren’t going to improve until someone takes their patients away.  Period.

The question is, how to take their patients away.  There’s a way.

If you are a benefit executive:

• Ask your TPA, carrier, or PPO to start figuring out who the “A players” are and load your networks with them.  Ask them to identify the “C clinicians” and begin the process of deleting them from your network.  The savings potential from this is huge. Plus, you will be protecting your employees and improving the quality of their care.
• Educate your employees about this.
• For your outlier population, implement centers of excellence for their specialized needs.
• If your company has more than 5,000 covered lives or so, you should develop and implement direct contracts with the best of the best centers of excellence, ones like Mayo Clinic and Cleveland Clinic.  Great companies like Pepsi, Walmart, and Lowes have done just this, plus many others. You can do it too.

Tom Emerick is a former VP of US Benefits for Walmart. He now consults, and writes at Cracking Health Costs.