What’s New in Health Care Reform: Dec. 23


What's New in Health Care Reform provides an overview of the past week’s news, updates, and commentary in health care reform and utilization management.

Value in Medical Care

We applaud expanding reimbursement analysis beyond Medicare data to include commercial insurance. Development of value-based payment models will require transparency and a comprehensive view of health care spending. Both clinical input and insurance claims data must be included. The era of big data has made this a possibility. One example is OptumLabs, where providers, payers, life sciences companies, and policy makers are collaborating to understand value in health care. It is essential to differentiate locally provided care from complex specialty care best provided by destination medical centers. Future payment models should recognize making an accurate diagnosis, providing appropriate treatment and achieving the best results. It will be through a commitment to work collaboratively that payers, providers and policy makers build a sustainable, value-based health care delivery system in our country. JOHN H. NOSEWORTHY, President and Chief Executive, Mayo Clinic, Rochester, Minn. Via NY Times.

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Medicare Slow to Adopt Telemedicine Due to Cost Concerns

For Medicare patients, it’s also incredibly rare. Nearly 20 years after such videoconferencing technology has been available for health services, fewer than 1 percent of Medicare beneficiaries use it. Anthem and a University of Pittsburgh Medical Center health plan in western Pennsylvania are the only two Medicare Advantage insurers offering the virtual visits, and the traditional Medicare program has tightly limited telemedicine payments to certain rural areas. And even there, the beneficiary must already be at a clinic, a rule that often defeats the goal of making care more convenient. Congress has maintained such restrictions out of concern that the service might increase Medicare expenses. Via Kaiser Health News. 

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ER Doctors Say Federal Rules Could Raise Patients Out-Of-Network Bills

Two professional organizations representing emergency doctors warn that a new federal rule could lead to higher out-of-pocket costs for consumers when they need emergency care outside their health plan’s network of providers. But consumer advocates and health policy experts say the groups’ proposed solution doesn’t adequately protect consumers. Via Kaiser Health News.

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HealthCare.Gov Enrollment Surges to Nearly 6 Million so Far

Nearly 6 million Americans so far have enrolled in insurance for 2016 through HealthCare.gov, President Obama announced, touting a big increase over last year that he said shows the Affordable Care Act is succeeding. The number who have already signed up on the federal insurance exchange compares with 3.4 million at the same stage a year ago and comes at a significant moment in the ACA’s enrollment cycle: the deadline for people who want health plans in place starting on New Year’s Day. The figures also show that 2.4 million of the current total are new customers, about a third more than at this point last year. Via Washington Post.

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State Insurance Regulators Press for Reforms to ACA’s Risk Adjustment Program

The plan would install a so-called circuit breaker to prevent companies from paying more than 2% of their premium revenue into the program each year. That boundary would make insurers' financial obligations more predictable and avoid the kinds of surprise payouts that contributed to the destabilization of several health plans in 2015. Via SNL.

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Surge in Prescription Costs Hit Medicare in 2014

Hefty price increases for a number of prescription drugs contributed to higher spending by the U.S. Medicare program in 2014, according to new government data. The Centers for Medicare and Medicaid Services identified at least five drugs that were covered under Medicare’s Part D drug benefit and had increases of 100% or more in cost per unit from 2013 to 2014. At the top of the list was Vimovo, a pain reliever whose cost-per-unit rose more than 500% after Horizon Pharma PLC purchased rights to the drug from AstraZeneca. Via Wall Street Journal.

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Could the Cadillac Tax Be the New Doc Fix?

There’s plenty of speculation that this won’t be the last time the Cadillac tax is delayed. For lawmakers and industry participants, it brings back memories of the Sustainable Growth Rate — also referred to as SGR or the “doc fix” — a now defunct annual adjustment to the Medicare doctor payment formula that was on the congressional agenda for almost two decades. The Cadillac tax may evoke the same type of problem. Via Morning Consult.

Health Plans’ Coverage of Some Drugs Can Be a Source of Consumer Confusion

Despite advice to shop around before selecting a plan, consumers may find that getting answers about drug coverage can be an exercise in frustration, despite a federal health law requirement that insurers provide lists of the prescription medications included in their plans. That’s because many treatments — particularly intravenous treatments like those used in cancer, hemophilia, or multiple sclerosis — are covered under a separate part of an insurance plan, not the pharmacy benefit. Via Kaiser Health News.

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Lax Auditing Encouraged Overcharging by Medicare Advantage Plans

Despite facing mounting evidence federal officials were overpaying some Medicare health plans by tens of millions of dollars a year, the government dialed back efforts to recover as much of the money as possible, newly released records show. The privately run Medicare Advantage plans offer seniors an alternative to traditional Medicare and in recent years have signed up more than 17 million members, about a third of people eligible for Medicare. Centers for Medicare and Medicaid Services records reveal that officials there as early as 2008 identified a group of privately run Medicare Advantage health plans they suspected of ripping off the government, even calling them highfliers. But CMS officials chose to do just 30 in-depth financial audits to recover overpayments each year, even though the records make clear they could complete many more. Via NPR.

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In Budget Deal, Health Law Foes Took a Different Path

Republican foes of President Barack Obama's health care law may be able to get more by chipping away at it than trying to take the whole thing down at once. That's one lesson of the budget deal passed by Congress and signed by the president last week. Via AP.



Kelley Luedke

Kelley Luedke is a Marketing Channel Manager at Mayo Clinic Laboratories. She is the principle editor and writer of Insights and leads social media and direct marketing strategy. Kelley has worked at Mayo Clinic since 2013. Outside of work, you can find Kelley running, traveling, playing with her kitty, and exploring new foods.

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