Unbiased Analysis of Today's Healthcare Issues

Archive for the 'Managed Care' Category

Why providers love ACOs

“The good thing about the systems not being highly integrated and coordinated is that premiums are lower. Why are those hospitals and physicians [integrating]?  It wasn’t for increased coordination of care, disease management, blah, blah, blah—that was not the primary reason. They wanted more money and market share.” A Fresno, California medical group physician Using […]

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Do Medicaid Managed Care Organizations Save Money?

In the 1990s, State Medicaid programs turned to Managed Care Organizations (MCOs) to reduce costs.  States such as Florida, Indiana, Kentucky, Louisiana, Missouri, Ohio, South Carolina and Texas attempted to turn over their entire Medicaid programs to MCOs through waivers.  For instance, in 2007 MO HealthNet mandated managed care for all participants by 2013. Some of the larger […]

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Explaining Any-willing-provider and Freedom-of-choice laws

Hellinger (1995) defines any-willing-provider (AWP) and freedom-of-choice (FOC) laws.  These laws have been enacted by a number of states. “AWP laws require managed care plans to accept any qualified provider who is willing to accept the terms and conditions of a managed care plan. These laws do not require managed care plans to contract with […]

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California’s Current Health Insurance Market

The California Healthcare Foundation looks at the latest health insurance trends in the nation’s most populous state. In California, like in many states, there is a blurring line between what defines an HMO compared to other forms of health insurance.  Almost all insurance carriers now offer “a broad array of products, some of which do not […]

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How has episode-based P4P worked in California?

Episodes of care are defined as the bundle of medical treatments used to treat an illness over  a specified time period.  Because all treatments are bundled together, these episodes have been thought to provide a superior unit of analysis in pay-for-performance (P4P) systems.  In fact, Oxford Health Plan pioneered episode payment in the 1990s.  [Later, […]

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Do for-profit hospitals reduce safety net services?

Social safety net services are necessary, but often unprofitable for hospitals. Is the expansion of HMOs and for-profit hospitals jeopardizing these safety net servies? This is the question researcher Yu-Chu Shen investigates. To test this hypothesis, Shen examines how changes in the market share of HMOs and for-profit HMOs affects probability of shutting down following […]

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UnitedHealth Group Settlement

Marketplace reports that UnitedHealth Group has just reached a large settlement with the State of New York.  What did UnitedHealth Group do wrong? According to the State of New York, it was overcharging patients who went out of the network.  The N.Y. Times gives a good example:  “The patient might receive a doctor’s bill for $100, […]

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Did California’s Medicaid HMO contracts save the state money?

Throughout its history, Medicaid provided health insurance for the nation’s poor. It did this by reimbursing providers on a fee-for-service basis. In the 1990s, however, California and other states decided to let private insurance companies bid for the right to provide services for Medicaid patients. These HMOs would receive a fixed per patient per month […]

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Medicare Advantage funding to be cut

David Whelan chronicles the rise (and possibly future fall) of Medicare Advantage programs in his article “Unfilled Prescription” in Forbes. Earlier laws privatizing Medicare, starting with a pilot program in 1985, were written to give insurance companies only 95% of the money otherwise spent per Medicare member. The insurers were supposed to figure out how […]

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Consumer Channeling and Preferred Providers

Doctors often complain that health insurers are squeezing their profit margins. These insurers offer the physicians access to patients as part of their network in exchange for discounted fees. Physicians can decide not to join the network and charge higher prices, but may be left with fewer patients. The bargaining power of the health insurer […]

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