Insurance

Although highly touted, the patient-centered medical home model failed to lower use of services or total costs and produced little quality improvement over three years, research has found.

Doctors and other health providers wrote about 11 million fewer prescriptions for narcotic painkillers in 2013 than in 2012, but some experts expected a bigger drop-off given the brighter spotlight on the nation's opioid epidemic.

Laura Beerman, director, customer segment analysis, Decision Resources Group, presented a discussion that highlighted the early results of accountable care organizations (ACOs). She said that while the Pioneer ACOs created a large initial buzz, their cost savings has varied widely.

Raulo S. Frear, PharmD, general manager, OmedaRx, says pharmacy benefit managers are aligning benefit designs for delivery system reform in a few ways. With respect to the delivery system reform, if you look at ACOs as a specific example, our experience has been that the ACOs are not really ready to talk about different benefit designs, Dr Frear says. They're still learning what it means to accept risk and that means risk across a lot more areas than just pharmaceuticals.

Session highlights from the Managed Markets Summit in Orlando, FL, February 25-27.

Neil Minkoff, MD, CEO, FountainHead HealthCare, discusses the impact that formulary has on both employer and consumer choice in the health insurance exchanges.

Laurie Wesolowicz, PharmD, director, pharmacy services clinical, Blue Cross Blue Shield of Michigan (BCBSM), says that clinical evidence and other factors can drive formulary decision-making. Evidence can influence the value and coverage recommendations for drugs covered under the pharmacy (formulary) and medical benefits.

A pharmacist-led Medicare Medication Therapy Management program can improve clinical outcomes in Medicare beneficiaries without an increase in medication costs.

CMS intends to implement a 1.9% rate reduction in payment rates for Medicare Advantage plans in 2015. Some payers fear that number may increase as fees associated with the Affordable Care Act (ACA), as well as other policy changes, also begin to impact physician reimbursement.

In a rare display of bipartisanship, key committees of both houses of Congress are backing legislation that would permanently erase the sustainable growth-rate formula, a poorly thought out payment reform measure that for more than a decade dictated sharp cuts in Medicare physician pay.

Medicare is proposing a small cut in Medicare Advantage rates for 2015, less than half of what private insurers were expecting from the federal agency. The final rule will be released April 7.

Decreased out-of-pocket spending on prescription drugs accounts for reduced financial burden of care to patients, and is consistent with improved access to care.

The CMS will offer end-to-end testing of Medicare claims using the ICD-10 diagnostic and procedure codes, an attempt to deliver much sought-after assurances that its contractors will be prepared for the Oct. 1 implementation date.

How Can Molecular Diagnostic Companies Show Value if Insurers Won't Pay?

To improve care, policy analysts and health leaders recommend there be fewer and narrower quality measures.

In response to a request for comment issued by the Centers for Medicare & Medicaid Services on its proposed Quality Strategy, the American Hospital Association is calling for more significant alignment of its quality measurement activities in order to reduce the burden on hospitals and providers.

Oncology clinical pathways have helped health plans deliver quality care while keeping an eye on costs. The lack of standardization in pathways can be cumbersome on a busy oncology practice. If Medicare adopts a pathways model, it could offer a framework for broader use.

Current reform efforts seek to tie providers' pay with performance, yet a recent finding suggests that less than 15% of internal medicine residency programs provide education that focuses on such training.

The American Medical Association pledged its full support for legislation repealing the Medicare sustainable growth-rate physician payment formula.

Susan Fox, director, business and product development, US Script, Inc, says the prescription benefit provides a unique opportunity to attract, attain, serve, and retain members in exchange insurance plans

Earning Too Little for Health-Law Subsidies but Ineligible for Benefits Under Existing Medicaid Programs

The CMS is extending the deadline for physicians and other eligible professionals to attest to meaningful use for the Medicare EHR incentive program for the 2013 reporting year and is offering some hospitals a second chance at receiving payment-as well as possible relief from the program's 2015 penalties for failing to comply in 2013.

With hospitals vehemently opposed to more Medicare cuts to fund the bipartisan legislation unveiled Thursday that would permanently end the annual charade around physician pay cuts, Congress may have to enact some form of payment or tax reform if it expects to get the job done this year.

A bipartisan agreement has been reached regarding the sustainable growth rate (SGR) and Medicare reimbursement model.