GE Healthcare Camden Group Insights Blog

Top 10 Trends for 2017: Twists and Turns Ahead!

Posted by Matthew Smith on Jan 19, 2017 1:31:54 PM

By Laura P. Jacobs, MPH, President, GE Healthcare Camden Group

No one can say that the healthcare landscape is boring – and 2017 may be an especially interesting ride. Repeal/Replace? New transactions? Impact of digital? How will consumers behave? Who will the new disrupters be? How will population health models evolve? Who will merge with whom? The year will bring incremental changes in a variety of arenas, and it could deliver monumental shifts in other ways. Here’s how we size up the top trends and the related management imperatives to succeed:

1. Repeal, Replace, or Revise

The fate of the Affordable Care Act (ACA) is still uncertain, but regardless there will be changes to which healthcare organizations must respond. Major changes to Medicare, Medicaid, and individual coverage may not take effect in 2017, but financial planning will take heightened importance to identify potential scenarios for ensuing years. High deductible health plans and HSAs, price transparency, and continued focus on affordability will put pressure on providers to deliver value in order to win.

2. The March to Value Continues

Regardless of the specific changes that may come with changes to the ACA, payers (Medicare, Medicaid, employers, and commercial insurance carriers) will continue to seek ways to lower costs and improve the experience for patients. The Centers for Medicare & Medicaid Services (CMS) will continue to link payments to performance on a variety of outcomes (e.g. hospital-acquired conditions, readmits, value-based measures). The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) will have significant impact on physician reimbursement, and as a result will galvanize integrated delivery systems, physician networks, and medical groups to implement efficient ways to demonstrate quality, patient experience, effective use of electronic medical records, and overall efficient resource utilization. Medicaid is moving to managed care in many markets, and commercial carriers and employers will continue to emulate many of the CMS payment models: ACOs, bundled payment, pay-for-performance.

The lines between payer and provider will continue to blur, as payers acquire or provide services to providers (note Optum’s [United Health Group] recent announcement of its purchase of Surgical Care Affiliates [SCA], a leading ambulatory surgery center and surgical hospital provider). With the expected growth of the Medicare Advantage market, providers will evaluate their role as partners or competitors with payers in this space. We expect to see more joint venture or partnership arrangements between payers and providers to launch new health plan products or delivery models. We will also likely see more large, self-insured employers reaching out to providers seeking performance-based payment models to drive lower overall health costs and better outcomes.

Harmonizing your population health strategies with your market’s pace of movement to value-based payment may be one of the most important strategies for your organization: moving too fast or too slowly could challenge both market position and financial performance.

3. The Cost Imperative

While value-based payment models require healthcare organizations to demonstrate quality and patient experience outcomes, the predominant focus is still on cost. With governmental budget pressure, employer pressure on commercial premiums, and in some markets highly consolidated payer dynamics, providers will continue to be challenged to reduce costs and find new efficiencies in the delivery of care. The focus for providers will be to redesign patient throughput, reduce variation through defined work flows and clinical protocols, and optimize use of existing facilities. Capital preservation will be as important as operating expense management to sustain or improve financial performance. Some leading hospitals are developing capacity command centers that combine systems engineering principles, commonly seen in industries such as aviation and power, with predictive analytics to manage and optimize patient flow, safety, and experience – and avoid costly outlays for new bed towers or surgery centers. Bottom line for healthcare leaders is that traditional ways of reducing costs (across the board spending cuts or layoffs) will not create the sustainable cost or quality advantages that will be necessary to succeed either in the short- or long-term. This means re-engineering the process of care across the continuum, engaging clinicians in every aspect of redesign, and imbedding a culture that supports effective change management become increasingly critical.

4. Let’s Make a Deal

Consolidation will continue across the industry. Payers will continue to consolidate as a result of continued premium pressures and the need to defray infrastructure costs. Provider transactions in every form will continue to be active in the year ahead: hospitals, surgery centers, physician groups, post-acute providers, population health “enablement” companies, technology companies , and others will come together in a variety of combinations. Organizations will seek partnerships to serve larger populations, acquire business expertise in a new area, and find efficiencies. With some organizations at a peak in their expansion or acquisition activity, 2017 will also be a critical time to focus on integrating the components that have been acquired or merged. Unless a concerted effort is put in place to identify, structure, and activate an integration plan that is designed to realize the intended goals, many organizations may find they have over-reached or cannot achieve the expected benefits of the expansion.

5. Consumerism Continues to Strengthen

Healthcare has traditionally not been very consumer-friendly (arcane billing practices and charges, hard to make appointments, fragmented care, access on the provider’s terms and so forth). But with deductibles that will increase again in 2017, as well as new disrupters in both the digital and care delivery space, providers must pay closer attention to the consumer experience – whether or not they have actually been a “patient” yet. This means price transparency, access where, when, and how the patient desires, quality reporting, a social media strategy, and digital outreach to create consumer awareness and loyalty will be increasingly important. Determining the definition and attributes (not just the logo) of the health system’s “brand” must carry through all venues of care, whether the consumer uses an app, a website, a phone, or an in-person visit to interact with the organization.

6. Care Everywhere

Care models will continue to evolve in 2017 thanks to the explosion of mobile technology, applications for home and self-monitoring, and the expansion of urgent care facilities and retail care centers. Private equity-backed as well as employer-backed new models for primary care, complex care, and digital tools will continue to proliferate. Telemedicine and “video-visits” will become more widely used – to improve access to complex care for remote areas as well as to provide greater convenience for consumers who would prefer not to leave their home or office for care. As an example, more than half of Kaiser Permanente’s patient visits are done virtually. Competitors will not be limited to those physically located near or in your service area; the new competitive dynamic will include those that can reach your population by cell phone or the internet. It will be imperative that management establish its access strategy and consider all of the tools available as care is being redesigned.

7. Capitalizing on Digital

After making significant investments in electronic medical records and a plethora of other information technology tools – financial systems, data warehousing, care management, predictive analytics, disease management, scheduling, and reporting among them – there’s a rallying cry to convert this mass of data points into actionable information. The call to action now is not necessarily what the next IT purchase will be, but how will the systems that have been purchased co-exist and even work with one another to optimize decision-making and forward-looking actions. The hospital, filled with “smart” equipment and systems, can be characterized now as a complex data “organism.” True transformation will come when organizations utilize artificial intelligence (AI) and the “internet of things” (digital systems “talking” to each other) to optimize patient flow, productivity, clinical decision-making, and the role of clinicians and other care team members.

8. “Outside the Box” Healthcare Cost Drivers

While inpatient and physician care still account for the majority of healthcare costs, pharmacy costs have been increasing at a faster pace, and will likely to continue to do so into 2017 and beyond. There is a rising focus on behavioral health, as individuals with mental health disorders often generate higher medical costs and greater use of emergency departments. With reimbursement for behavioral health still lagging, providers in this space will see increased demand, but will likely struggle financially unless avenues for reducing costs through care redesign or changes in reimbursement are effected. Population health programs will increase their focus on impacting the social determinants of health, as the impact that areas outside of healthcare (housing, nutrition, transportation) have on health status gains greater awareness. This will require health systems to determine how to optimize relationships with community service organizations to drive better outcomes and better health for at-risk individuals.

9. Clinical Advances Continue

Health systems such as Geisinger Health System are making headlines with their use of DNA sequencing on patients to help refine care protocols and interventions. We will see other examples of the expansion of precision medicine, using an individual’s genetic profile, although it will remain fairly limited in the near term. The Cancer Moonshot and other initiatives funded by the 21st Century Cures Act will provide an impetus for speeding up clinical advances and the introduction of new drugs in the years ahead. Watch for the use of robotics in situations both inside the operating room and at the bedside: lifting, moving, and even interacting with patients. Watch for 3D printing to augment the availability of organs for organ replacement. Academic medical centers and research institutes will have opportunities to partner with technology companies as well as community providers to explore and evaluate medical advances. Venture funding for monetizing intellectual property will continue to flow to those initiatives that make healthcare more cost effective and produce reliable outcomes.

10. Managing the Most Precious Resource

Human capital needs are changing. Workforce management is and will remain of paramount importance as the healthcare world evolves. With labor costs comprising the lion’s share of expenses, it makes sense from a purely financial perspective. But with today’s lower unemployment rate, and demand for many key roles in healthcare outstripping supply, healthcare organizations must prioritize workforce management as a cornerstone to change management and operational excellence. Generational differences demand different approaches and even policies in human resource management. Healthcare workers, including clinicians, non-clinicians, as well as the management team are increasingly facing burn-out due to constant change and ever-rising expectations. New approaches for recruitment, talent development and training, leadership coaching, and workforce management must be embraced as roles, responsibilities, and expectations evolve.

Managing an organization through these changes will not be any easier in 2017 than it was in the past years. Keeping an eye on the horizon, while staying attentive to the buffeting winds on all sides will allow healthcare leaders to maintain perspective and stay focused on making the tough decisions necessary to remain aloft. 

Strategic Planning in Uncertain Times

Jacobs.jpgMs. Jacobs is president at GE Healthcare Camden Group and has been with the firm since 1990. She has more than 30 years of experience in the areas of integrated delivery system development, payer strategy, population health management, healthcare strategic and financial planning, transactions, and governance/ management systems. She is a noted speaker and industry resource on the impact of healthcare trends, most notably the requirements for success in value-based payment models, clinical integration, and creating successful integrated delivery systems. She may be reached at


Topics: Affordable Care Act, Obamacare, Trends, Mergers & Acquisitions, Laura Jacobs, Healthcare Data Analytics, Healthcare Consumerism

A View into a World without the Affordable Care Act

Posted by Matthew Smith on Nov 11, 2016 7:45:10 AM

By James Smith, MBA, FACHE, Executive Vice President, and David DiLoreto, M.D., MBA, Senior Vice President, GE Healthcare Camden Group

Healthcare changes are on the way….AGAIN. Just as providers, health plans, and consumers thought they had begun to understand the “new” rules and had developed and activated the strategies required for success in an outcomes-based world; we find ourselves facing changes once again. With a new presidency launching in January, it appears certain that The Affordable Care Act (“ACA”) (also known as “Obamacare”) will be modified, repealed, and/or replaced.

With myriad questions floating around the television networks and on social media, it’s important to not get too far out over our skis before decisions are made. But we can address some of the larger questions Americans are asking. First, let’s assume the ACA is completely repealed--and ask and propose answers to 10 of the burning questions that are top of mind.

1. What are the big changes? 

A new administration may want the mandates, taxes, and regulations to go away, and individuals to be able to go to insurers and shop based on highly transparent information about providers, physicians, networks, and health plans on quality of care, service levels, and cost. Transparency, costs, and access will become the focus both for individual and group insurance premiums and healthcare provider charges. Balancing the budget will take precedence over access to insurance and healthcare services.

2. What goes away? 

The health insurance industry and providers would be released (immediately or within a short, prescribed time period) from numerous regulations, taxes, and rules connected with the ACA. The healthcare exchanges would be dismantled, or be continued as a non-subsidized option for States to administer at their discretion. Loss of minimum medical loss ratios (“MLR”) and rate oversight could lead to even larger premium increases as insurers would seek to return to profitability from the losses in their exchange business and stranded development costs.

3. What would be the most striking game changer of the economic impacts? 

According to a report with estimates from Kaiser Health Foundation, 20 million-plus people could lose their federal subsidies and tax credits that allowed them to purchase insurance, or lose eligibility as the rules change from ACA’s expansion of Medicaid eligibility. States would instead likely be provided block grants by the federal government, ending the federal-state funding partnership. The loss of the public subsidies for private insurance and reduction in Medicaid eligibility will likely increase bad debt, slow or stop cash flow, which will stretch reserves and change decision options for providers.  

4. What is NOT likely to change?

Payment reform within Medicare designed to reduce costs and promote quality (i.e. the shift from fee-for-service to fee-for-value) is not likely to change significantly. MACRA and other regulatory changes shifting the payment models have been largely bi-partisan supported, so are not likely to be significantly impacted. What would be uncertain is the continuation of initiatives sponsored by CMMI, the CMS Innovation Center, which was funded by the ACA. CMMI has launched bundled payments, and many other pilots such as CPC+ to foster faster movement to value-based care.

5. What does this do to providers? 

It could mean credit downgrades for many since recent capital investments in new service lines were made based upon volumes and service mix far different than what may occur. More high-deductible plans with low or underfunded HSAs and a return to more uninsured could lead to sicker patients, more intensive care, and hospitalizations and service line requirements and capacity needs different than planned for under ACA. The market may see a greater use of narrow networks or high-performing networks by health plans to reduce plan cost. Picture the payer mix (lower Medicaid and higher uninsured) and volumes (generally lower) you may have had in 2013, but with payers (including Medicare) putting dollars at risk for efficiency and quality.

6. Will we see more consolidation of providers and physicians? 

Yes, on both counts. The mere uncertainty of the environment if funding for the uninsured remains in flux could exacerbate a trend toward consolidation. Providers must seek every avenue of cost reductions and access to cash as they make new investment decisions in capital, equipment, buildings, service mix, management talent, and other resources. Just as today, efficiency will be the priority, but even more so. Layoffs to reduce staffing costs and strategic focus on services to increase market share and use of resources will be one of the few ways for providers to react.

7. Where would people go? 

As we have seen in the past, emergency departments will be the first site of care for many without insurance. Continued focus of providers on enabling access points to the most clinically appropriate and lowest cost site of care will continue to be a priority so consumers have viable alternatives to manage their healthcare needs with convenience.

8. What will insurers do? 

As insurers lose members, they too will react by attempting to grow market share and cut costs. Consequently, insurers would have to reallocate costs throughout their company—forcing layoffs, consolidations, and ultimately bankruptcy for those who cannot change fast enough. This cascade could accelerate consolidation with greater concentration of both health plans and providers as they respond to a necessity to grow even larger and to do it faster to absorb decreasing membership across a set of fixed costs. Remember too, that insurers will remain heavily regulated as the regulatory controls flow back to the state insurance and health departments. They may be able to return to state rules which allow experience rating and denial of coverage. The possibility of easing the sale of health plan products across state lines, a concept that candidate Trump proposed, could make managing health plan payment models and policies from the provider perspective even more complex than before--but it could provide more competition for health plans with sizable market share in certain states. Health plans may have a greater ability to increase premiums and to do these things with less oversight. Many have invested in new products, and there would no longer be controls over benefits, nor would there be limits on administrative costs and caps on profits which, in turn, could send premiums as well as out-of-pocket expenses even higher.

9. Sometimes campaign rhetoric is tempered by the political and economic realities of governing. Is there a middle ground that might be reached?

Speaker Paul Ryan released the GOP’s healthcare reform plan, “A Better Way,” in June 2016. The plan contains key initiatives that, if implemented, incrementally could increase the role of the private health insurance sector while reducing costs without wholescale withdrawal of coverage. For instance, expanding the use of consumer-directed healthcare options and removing the limits that ACA placed on HSAs, FSAs and HRAs provides more insurance options without eliminating coverage. Eliminating the taxes and fees on self-insured plans, eliminating excise taxes on medical device manufacturers as well repealing the “Cadillac” tax on high-cost plans would be consistent with campaign promises. Increasing support for portability, enabling purchasing across state lines, expanding opportunities for pooling, and advocating for meaningful medical liability reform are all contained within this plan.

10. What about Medicaid expansion? 

The most popular aspect of Obamacare was the expansion of health insurance coverage and, at least politically, it may prove hard to reverse. Over 98 million Americans are now covered by Medicaid at any point in each year. One in four dollars in the average state budget is spent on Medicaid coverage, and the total state and federal support for the program exceeds $545 billion. By 2025 the GAO projects that 108 million Americans will be covered by Medicaid, the federal share exceeding $600 billion and the combined state and federal spending in program approaching $1 trillion. Limited access to physicians and inconsistent quality remain significant obstacles to improving health outcomes for Medicaid beneficiaries. The GOP may look to expand block grants to states while relaxing the federal waiver process. This would create incentives for state governments to search for solutions to the cost and consequences of the recent expansion. Fueled by the shift toward more value-based reimbursement, considerable attention and increased scrutiny and changes in supplemental payments may be opportunities for cost reduction. As the largest payer of long-term services and support, and with continued increasing demand, states will also look to rebalance or reduce costs by shifting to home and community based services.

Changes are most definitely on their way, but as we’ve done in the past, we’ll adapt and adopt these new changes together. 2017 will be a year in which the legislative changes could be made, and in some cases Trump could use an Executive Order to defund certain provisions of the ACA. 2018 will likely be the soonest any substantive changes would be effective, given the fact that open enrollment is already underway and plans are in effect for 2017. We’ll continue to provide timely updates as we learn more in the coming weeks and months.

Jim Smith.jpgMr. Smith is an executive vice president with GE Healthcare Camden Group. He is a nationally recognized strategy and business healthcare consultant, author, and speaker. Mr. Smith has more than 30 years of experience as a leader of provider-owned, for-profit, and not-for-profit health plans, hospital, and health systems, as well as a large physician group. He has extensive experience in managed care and provider network development/operations, health system planning and development, medical group formation and operations, and direct contracting. He may be reached at



DiLoreto.pngDr. DiLoreto, senior vice president at GE Healthcare Camden Group, is a physician-executive who is highly experienced in executive management, strategy and operations of healthcare delivery systems, and managed care companies. He has deep management expertise in community-based and academic health systems, large group medical practices, hospitals, and managed care organizations. His areas of specialty include clinical transformation, population health, business process improvement, leadership development, medical informatics, quality improvement and patient safety, and data management and analytics. He may be reached at

Topics: ACA, Affordable Care Act, Obamacare, David DiLoreto, James Smith

CMS Releases New Proposal to Improve Accountable Care Organizations

Posted by Matthew Smith on Dec 1, 2014 5:42:00 PM

Courtesy of The Centers for Medicare & Medicaid Services (CMS) 

ACO, CMS, Accountable Care OrganizationThe Centers for Medicare & Medicaid Services (CMS) today released a proposal to strengthen the Shared Savings Program for Accountable Care Organizations (ACOs) through a greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. The proposed rule reflects input from program participants, experts, consumer groups, and the stakeholder community at large. CMS is seeking to continue this important dialogue to ensure that the Medicare Shared Savings Program ACOs are successful in providing seniors and people with disabilities with better care at lower costs.

CMS Administrator Marilyn Tavenner said, “This proposed rule is part of our continued commitment to rewarding value and care coordination – rather than volume and care duplication. We look forward to partnering with providers and stakeholders to continuously refine and improve the Medicare Shared Savings program.”

Through the Affordable Care Act, ACOs encourage doctors, hospitals and other health care providers to work together to better coordinate care when people are sick and keep people healthy, which helps to reduce growth in health care costs and improve outcomes. ACOs become eligible to share savings with Medicare when they deliver that care more efficiently while meeting or exceeding performance benchmarks for quality of care. 

The Shared Savings Program now includes more than 330 ACOs in 47 states, providing care to more than 4.9 million beneficiaries in Medicare fee for service. Recently, CMS announced first year Shared Savings Program (SSP) results:

  • 58 SSP ACOs held spending below their benchmarks by a total of $705 million and earned shared savings payments of more than $315 million. 
  • Another 60 ACOs had expenditures below their benchmark, but not by a sufficient amount to earn shared savings.

Other Affordable Care Act initiatives to improve care and reduce costs have helped reduce hospital readmissions in Medicare by nearly 10 percent between 2007 and 2013 – translating into 150,000 fewer readmissions – and quality improvements have resulted in saving 15,000 lives and $4 billion in health spending during 2011 and 2012.

CMS is seeking comment on a number of adjustments to improve the Medicare Shared Savings Program, including:

Providing more flexibility for ACOs seeking to renew their participation in the Program.

Many ACOs elect to enter the Program under a one-sided risk model, where the organization participates in shared savings with the Medicare program, but does not take on additional performance-based risk. More experienced ACOs that are ready to share in financial losses in return for the opportunity for a higher share of savings may elect to enter a two-sided model. CMS is proposing to give ACOs the option of a longer lead time to transition to a two-sided performance risk model after their first agreement period. ACOs would have the opportunity to renew under the one-sided model for one additional agreement period. ACOs that enter the Shared Savings Program under the two-sided performance risk model would see no change.

Encouraging ACOs to take on greater performance-based risk and reward.

CMS is proposing to create a new two-sided risk model, called “track 3,” which integrates some elements from the Pioneer ACO model, such as higher rates of shared savings and prospective attribution of beneficiaries - a list of assigned beneficiaries provided at the start of the performance year, and no further beneficiaries will be added to the list during the performance year.

CMS is seeking comments on a number of care coordination tools that would make two-sided performance risk models more attractive to ACOs such as expanded use of telehealth, beneficiary attestation, and more flexibility around post-acute care referrals to help ACOs better coordinate care for beneficiaries using these services. These tools could all help encourage participating providers to improve quality and care coordination for Medicare beneficiaries, which in turn would result in better patient experiences and greater shared savings for both the ACO and the Medicare program.

Emphasis on primary care.

CMS proposes to refine the way Medicare beneficiaries are assigned to an ACO to place greater emphasis on primary care services delivered by nurse practitioners, physician assistants and clinical nurse specialists and to allow certain specialists not associated with primary care to participate in multiple ACOs.  

Alternative methodologies for benchmarks.

CMS seeks comment on alternative methodologies that would make ACO benchmarks for determining shared savings and losses gradually more independent of the ACO’s past performance and more dependent on the ACO’s success in being more cost efficient relative to its local market. For example, CMS is considering whether shared savings received by an ACO should be added back to the benchmark in future performance periods.

Streamlining data sharing and reducing administrative burden.

CMS proposes to streamline the process for ACOs to access beneficiary claims data necessary for health care operations such as quality improvement activities and care coordination while retaining the opportunity for beneficiaries to decline to have their claims data shared with the ACO.

A fact sheet with more information about the proposed rule is available at:

The proposed rule will be open to a 60-day comment period.

The proposed rule is available for viewing at:

Comments may be submitted at:  

This rule is scheduled to be published in the Federal Register on 12/08/2014 and available online at

Topics: ACO, Accountable Care Organization, CMS, Affordable Care Act

Medicaid Reform: Are You Ready?

Posted by Matthew Smith on Nov 19, 2014 1:11:00 PM
By Gregory Shufelt, Adam Medlin, Patricia A. Hines
The Camden Group

The Camden Group, ACA, Affordable Care Act, Medicaid, Healthcare Reform, In an article for HFMA's HFM Magazine, our colleagues at The Camden Group urge health system leaders to view any steps they take to prepare for their state's Medicaid reform initiatives as integral to their organization's evolution toward value-based care and population health.

Hospitals and health systems should follow a four-step process to evaluate their state’s Medicaid initiatives and to develop new care models to better manage the Medicaid patient populations they serve:

  • Perform an initial assessment
  • Identify opportunities and risks
  • Develop a business plan
  • Implement the plan

More than 72 million Americans receive healthcare coverage from Medicaid, including children, nondisabled adults, pregnant women, individuals with disabilities, and seniors with both Medicare and Medicaid coverage (known as dual eligibles). This number is expected to grow to 93 million by 2024.a New reports are showing that even in states where Medicaid expansion under the Affordable Care Act (ACA) was rejected or put on hold, Medicaid enrollment is still expanding due to the “woodwork effect,” whereby people previously eligible for Medicaid are just now signing up, due in large part to the outreach and educational efforts associated with the ACA. Regardless of their state’s decision to expand Medicaid, healthcare leaders should prepare for potentially drastic changes in how states manage their Medicaid programs.

To read the full version of this article, please click the button, below:

Medicaid Reform, Affordable Care Act, ACA, Population Health

Topics: Medicare, ACA, Affordable Care Act

Infographic: State of Emergency--Overcrowding in the ER

Posted by Matthew Smith on Aug 20, 2014 1:51:00 PM

Infographic, Health Directions, HD Insights Blog, When the ACA was enacted, ER visits were expected to decrease. Instead, the inverse is happening. What happens when an ER is faced with more patients than it can accommodate? Between 1995 and 2010, annual ER visits in the U.S. grew by 34%, while the number of hospitals with ERs declined by 11%. From long wait times to sky-high medical costs, overcrowding puts undue pressure on patients, providers and administrators when efficient, high-quality care matters most.

The Miken Institute School of Public Health at George Washington University created this infographic to show the impact of overcrowding on U.S. emergency rooms. The graphic looks at some of the major causes of congested ERs, examines the impact on care delivery and explores proposed solutions to the problem of overcrowding. 

The infographic highlights crucial areas for administrators, communicators, and physicians, nurses, and other ER staff:

  • The increase (national averages) in wait times for ER patients, broken down by urban/rural locations and other factors.

  • Boarding and ambulance diversion statistics.

  • Case urgency percentages.

  • Risks and costs of overcrowding, including uncompensated care figures.


George Washington University, ER, Emergency Room, Infographic


Brought to you by MHA@GW: MHA degree

Topics: Infographic, ACA, Affordable Care Act, Obamacare, ER, Emergency Room

Hospitals Seek To Help Consumers With Obamacare Premiums

Posted by Matthew Smith on Aug 15, 2014 12:02:00 PM
Article courtesy of Kaiser Health News.
Obamacare, Affordable Care Act, Finance

Low-income consumers struggling to pay their premiums may soon be able to get help from their local hospital or United Way. Some hospitals in New York, Florida and Wisconsin are exploring ways to help individuals and families pay their share of the costs of government-subsidized policies purchased though the health law’s marketplaces – at least partly to guarantee the hospitals get paid when the consumers seek care.

But the hospitals’ efforts have set up a conflict with insurers, who worry that premium assistance programs will skew their enrollee pools by expanding the number of sicker people who need more services.

“Entities acting in their [own] financial interest” could drive up costs for everyone and discourage healthier people from buying coverage, insurers wrote recently to the Obama administration.

Insurers are asking the federal government, which regulates the health insurance marketplaces, to restrict the practice.  

To date, regulators have sent mixed messages about whether they will permit such programs—even as providers across the country are moving to set them up.

“We saw the need in our community,” said Sarah Listug, spokeswoman for United Way of Dane County, a Wisconsin group that is using $2 million donated by a local hospital system to help more than 650 near-poverty-level policyholders pay their premiums. “We have had calls from all over the U.S. asking how to set up partnerships like this.”

The South Florida Hospital and Healthcare Association is seeking at least $5 million in donations from its 45 member hospitals toward premiums for first-time insurance buyers next year.

And members of the Healthcare Association of New York State, which represents 500 hospitals and nursing homes, are considering expanding existing consumer assistance programs to help people pay their premiums “to the extent that is legal and proper,” said Jeffrey Gold, senior vice president and special counsel.

Providers Have Financial Incentive

Hospitals or their foundations have long paid premiums for some patients— often those who fell behind after leaving their jobs and taking on the entire cost of coverage under a 1986 law known as COBRA.

But the issue of “third-party payments” has taken on new urgency because of a provision in the federal health law that could leave providers on the hook for unpaid bills.  Under the law, insurers must give subsidy-eligible enrollees who fall behind on payments a 90-day “grace period” before cancelling their policies. 

While insurers must cover bills for the first 30 days, they may hold off paying those bills for the next 60 -- and ultimately, deny payment if the patient doesn't catch up on premiums. That means doctors and hospitals face the prospect of not getting paid for their services, or having to seek payment directly from their patients.

That’s a big incentive for providers to help pay those premiums.

“It’s a situation where patients will be better off and the providers are better off as well if patients are able to maintain coverage,” said Mark Rukavina, a Massachusetts-based expert on medical debt who consults for the hospital industry. “But it does raise questions.”

Insurers argue that if federal regulators permit such programs, they should bar hospitals from selecting participants based on their health, or from directly paying the premiums.

"If third parties provide incentives to gain coverage only once someone is sick, that will -- as the administration has warned -- clearly lead to a less healthy risk pool and put upward pressure on premiums for everyone,” said Brendan Buck, a spokesman for the trade group, America’s Health Insurance Plans (AHIP).

But Gold of the New York hospital group thinks insurers’ concerns are overblown. He says insurers have already calculated into their rates that a certain percentage of policyholders will be sicker than average.

“If a couple of people who show up at hospitals or other providers have a premium lapse, I don’t understand why someone making them whole [by paying their premiums] would skew the risk pool,” he said.

Hospitals Try To Allay Fears

To avoid problems, hospitals are drafting selection criteria tied to income level -- and are paying consumers’ premiums for an entire year, rather than simply when they lapse.

In the Wisconsin program, for example, eligible residents must live in Dane County, earn between 100 percent and 150 percent of the federal poverty level – about $11,490 to $17,235 for an individual— and enroll in a subsidized silver plan.

The program, called HealthConnect, pays the difference between the subsidy and the cost of the plan for the entire year, which could be as little as $20 to $50 a month for individuals, although it runs higher for families. Money for the program comes from the University of Wisconsin-Madison health system.

In South Florida, meanwhile, “we’re not talking about making premium payments for those who enrolled, then fell behind, but only [for] first-time buyers,” said Linda Quick of hospital group, which has not yet finalized its plans.  

The association plans to enlist several local United Way chapters to help find and enroll eligible residents.

Still, Quick acknowledges that getting the program off the ground may be difficult because of the cost to hospitals.

“I have a couple of systems where we’re talking about half a million dollars” in contributions, she said.

And the enrollees who are helped may never need hospital care, in which case those facilities would see no return on their investment.

Regulators Send Mixed Messages

To date, the administration has said insurers must accept payments toward premiums and other costs from government programs such as the Ryan White HIV/AIDS Program, which helps provide medical services and defrays costs for people living with HIV/AIDS.

But it has been less clear about the role hospitals and other health care providers might play.

Last October, a letter from the administration to Rep. Jim McDermott, D-Wash., indicated that hospitals and drugmakers could help subsidized policyholders pay their premiums.

But that was quickly followed by a Nov. 4 online FAQ discouraging such “third party payments” by hospitals and others because they could “skew the risk pool.”

After protests by patient groups, another advisory said insurers could also accept premium payments from not-for-profit foundations which set financial eligibility criteria and do not consider enrollees’ health status.

An interim final rule in March left out any mention of payments by charitable foundations, although it reiterated concern about payments made directly by hospitals.

Both the insurance industry and hospital groups are seeking clarification.

AHIP, the insurers’ trade lobby, has asked the government not to allow hospital-affiliated foundations to run aid programs. The funds “must be donated to a legally independent foundation that is separate from the organization with a potential financial interest,” AHIP said.

The hospital industry, meanwhile, wants insurers to be required to accept premium payments made by health systems as well as by their foundations.

“Any effort to limit the ability of hospitals or hospital-affiliated foundations to help individuals in need to obtain access to health insurance coverage is bad public policy,” wrote Rich Umbdenstock, president and CEO of the American Hospital Association. 

Topics: ACA, Affordable Care Act, Obamacare

New Infographic Examines Physicians’ Salaries in 2014

Posted by Matthew Smith on Aug 13, 2014 3:37:00 PM

Physician Salary, Affordable Care ActThere are a lot of great take-aways in Medscape's 2014 Physician Salary Report and resulting infographic, including data related to:

  • Ways doctors are managing their income
  • The impact of the Affordable Care Act
  • Income gender disparity
  • Career satisfaction

Many physicians are becoming more proactive in managing their incomes by being more selective about insurers and patients and providing ancillary services. In addition, a small but growing number of physicians are moving toward cash-only practices.

To view a larger version of this image, please click here.

Physician Compensation, Medscape

Topics: Infographic, Affordable Care Act, Salaries, Salary, Medscape, Career Satisfaction, Physicians

Visualizing Health Policy: Public Opinion At The End of the First Affordable Care Act Open Enrollment Period

Posted by Matthew Smith on May 21, 2014 10:56:00 AM

ACA, Affordable Care Act, This Visualizing Health Policy infographic takes a look at public opinion of the Affordable Care Act at the end of the first enrollment period, including the persistent deep partisan divisions, the sources of people’s impressions, and the favorable views towards many of the ACA’s least well-known provisions. Further, more people want Congress to improve the ACA than to repeal it.


Affordable Care Act, ACA, Kaiser Family Foundation

Source: Kaiser Family Foundation analysis. Original data and detailed source information are available here .

Topics: ACA, Affordable Care Act, Kaiser Family Foundation

Population Health Management Market to Reach $40.6 Billion by 2018

Posted by Matthew Smith on May 1, 2014 7:58:00 AM

population healthA new report published by MarketsandMarkets studies the global population health management market over the forecast period of 2013 to 2018. Population health management solutions are increasingly being adopted by healthcare providers, payers, employer groups, and government bodies across the globe, particularly in the U.S. This report studies the global market over the forecast period of 2013 to 2018. This market is estimated to grow at a CAGR of 26% to reach $40.6 billion by 2018 from $12.8 billion in 2013.

The adoption of population health management solutions enables the healthcare industry to reduce costs while improving the quality of healthcare. The solutions also provide positive returns on investment. Furthermore, legislative reforms of the Affordable Care Act (ACA) in the U.S., federal funding, rise in aging population, and incentives by the government for the adoption of PHM programs have stimulated the adoption of population health management solutions in the healthcare industry. 

Population Health Barriers

However, in spite of the numerous benefits of population health management certain barriers exist including:

  • huge investments
  • lack of skilled analysts
  • fragmented end-user market
  • security of patient data are restraining the growth of this market

The North American market commands the largest share of the global PHM in 2013. Europe represents the second largest market, but is growing at a lower rate, while the Asian market is relatively new to population health management; however, the increasing health IT adoption, proficiency of IT skills, and outsourcing trend will drive the growth of this market.

Top Population Health Players

The global Population Health Management Market is a highly fragmented market with some major players such as:

  • Phytel Inc.
  • McKesson Corporation
  • Verisk Health Inc.
  • Health Catalyst, LLC
  • Allscripts, Inc.
  • i2i Systems Inc.
  • Wellcentive, Inc.
  • Conifer Health Solutions, LLC
  • Explorys, Inc.
  • Healthagen, LLC

End-User Market

The end-user market is divided into providers, payers, employer groups, and government bodies. The providers market accounted for the largest share of 65% of the global market. This market was valued at $8.3 billion in 2013 and is expected to grow at a CAGR of 26% from 2013 to 2018, to reach $26.4 billion by 2018. However, the employer groups segment is expected to have the highest CAGR of 27.2% from 2013 to 2018. Based on geography, the market is divided into North America, Europe, Asia, and Rest of the World (RoW: Pacific countries, Africa, Middle East, and Latin America).

Clinical Integration, Health Directions, Population Health

Topics: Accountable Care, Population Health, ACA, Affordable Care Act

New & Updated FAQs for the EHR Incentive Programs

Posted by Matthew Smith on Apr 4, 2014 10:45:00 AM

EHR, Meaningful Use, CMSTo keep you updated with information on the Medicare and Medicaid EHR Incentive Programs, CMS has recently added three new FAQs and five updated FAQs to the CMS FAQ system.

CMS encourages you to stay informed by taking a few minutes to review the new information below.


New FAQs:

  1. For Eligible Professionals (EP) in the Medicaid EHR Incentive Program using the group proxy method of calculating patient volume, how should the EPs calculate patient volume using the “12 months preceding the EP’s attestation” approach, as not all of the EPs in the group practice may use the same 90-day period. Read the answer.
  2. Can a hospital count a patient toward the measures of the “Patient Electronic Access” objective in the Medicare and Medicaid EHR Incentive Programs if the patient accessed his/her information before they were discharged? Read the answer.
  3. When demonstrating Stage 2 meaningful use in the EHR Incentive programs, would an eligible professional (EP) be required to report on the “Electronic Notes” objective even if he or she did not see patients during their reporting period? Read the answer.

Updated FAQ:

  1. Do States need to verify the "installation" or "a signed contract" for adopt, implement, or upgrade (AIU) in the Medicaid EHR Incentive Program? Read the answer.
  2. For Stage 1 and 2 meaningful use objectives of the Medicare and Medicaid EHR Incentive Programs that require submission of data to public health agencies, if multiple eligible professionals (EPs) are using the same certified EHR technology across several physical locations, can a single test or onboarding effort serve to meet the measures of these objectives? Read the answer.
  3. For the Stage 2 meaningful use objective of the Medicare and Medicaid EHR Incentive Programs that requires the successful electronic exchange of a summary of care document with either a different EHR technology or the CMS designated test EHR, if multiple eligible professionals (EPs) are using the same certified EHR technology across several physical locations, can a single test meet the measure? Read the answer.
  4. In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made available by their eligible professional (EP), can the other EPs in the practice get credit for the patient’s action in meeting the objectives? Read the answer.
  5. When reporting on the Summary of Care objective in the EHR Incentive Program, which transitions would count toward the numerator of the measures? Read the answer.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Meaningful Use, Stage 1, Stage 2, EHR, EMR

Topics: EHR, EMR, ONC, Electronic Health Record, Electronic Medical Record, Affordable Care Act

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