Unbiased Analysis of Today's Healthcare Issues

ACA and narrow networks

One way for insurers to reduce health care costs is to restrict patient access to only lower cost providers.  This phenomenon is known as narrow networks.  On the one hand, narrow networks can promote efficiency by driving down provider price and directing patients to the highest value physicians.  Alternatively, if insurers use narrow networks to direct patients […]

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Obamacare’s slow repeal?

While we are waiting for the King v. Burwell verdict, which could repeal large sections of Obamacare, the house of representatives has already approved rolling back some ACA provisions. Modern Healthcare reports: Lawmakers postponed final passage of the proposed Protecting Seniors’ Access to Medicare Act despite a majority voting in favor of the bill. The […]

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Covered California and Adverse Selection

The Affordable Care Act requires all individuals to be offered the same premium regardless of health status. Although there are some ratings bands based on age and smoking status, most people who purchase insurance on health insurance exchanges receive the same premium for any given insurance product from any given insurance company. The insurance products […]

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Medicare starts using prior authorization

Included within the many changes to physician payment in HR2, is one provision that may surprise people; a subset of Medicare physicians will be required to receive prior authorization to conduct imaging services. Beginning with 2017, and in consultation with stakeholders, the Secretary will identify ordering professionals with low adherence to applicable [appropriate use criteria] […]

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What is MIPS?

Yesterday I posted about MIPS, the new Medicare physician reimbursement program set to begin in 2019.  The Health Affairs blog provides a nice summary of some of the changes. First and probably most importantly, the formulaic approach to setting base payment rates is gone, replaced with automatic increases for all doctors from 2015 through 2019. For […]

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Medicaid Expansion and States’ bottom line

A recent RWJF Issue Brief notes that states that expanded Medicaid received more revenue from the federal government and had less state-level spending on programs that support the uninsured. In examining Medicaid expansion across eight states—Arkansas, Colorado, Kentucky, Michigan, New Mexico, Oregon, Washington and West Virginia—it is clear that states are realizing savings and revenue […]

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Transitioning to Alternative Payment Models

CMS has stated that they want 30% of all fee-for-service payments to be transitioned to alternative payment models–such as pay for performance–in the upcoming years.  A future where all providers are paid capitation or based on some measure of value is not here yet.  And in the interim, providers are dealing with a complex system […]

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5 Trends 5 years after by ACA

From a PwC report on “Five trends to watch as the Affordable Care Act turns five“: Risk Shift: Raising the stakes for all healthcare players. The ACA added force to new payment models that reward outcomes and penalize poor performance such as high rates of readmission and hospital-acquired conditions. Primary care: Back to basics. Experimentation […]

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Medicaid Expansion States

Which states have decided to receive additional federal funds to expand the share of people they cover under Medicaid?  The Kaiser Family Foundation has the answer. Alabama Not Moving Forward at this Time Alaska  Not Moving Forward at this Time Arizona Implementing the Medicaid Expansion  Arkansas Implementing the Medicaid Expansion California  Implementing the Medicaid Expansion Colorado Implementing the Medicaid Expansion […]

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Who will pay the Cadillac tax?

Beginning in 2018, many individuals will face the “Cadillac” tax. What is the Cadillac tax? The Cadillac tax is a tax on high-cost health insurance plans. According to a Truven report, it is calculated as “40 percent of the excess of total per employee per year (PEPY) healthcare costs above statutory threshold limits of $10,200 […]

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