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This Week in Managed Care: July 2, 2016


This week, the top stories in managed care include the largest healthcare fraud takedown, one successful accountable care organization imparted its secrets, and a report identifies pharmacy trends in the public health exchanges.

Hello, I’m Justin Gallagher, associate publisher of The American Journal of Managed Care. Welcome to This Week in Managed Care, from the Managed Markets News Network.

Healthcare Fraud Takedown

Last week, a nationwide sweep by the Department of Justice and HHS netted 301 arrests for healthcare fraud, involving $900 million in suspected false billings. The crackdown is the latest effort by the federal government to root out billing for services that never took place—or worse, for unnecessary treatments performed on unsuspecting patients.

As AJMC reported this week, the fight against healthcare fraud goes back nearly a decade, but it gained strength when the Justice Department and HHS were given $350 million under the Affordable Care Act. Key elements of the success in fighting fraud include:

  • The creation of the Healthcare Fraud Prevention & Enforcement Action Team, known as HEAT.
  • A shift from a “pay and chase” model to the use of predictive modeling to spot suspicious billing.
  • A focus on 9 known Medicare fraud “hot spots,” especially in Florida, Texas, Brooklyn, and Chicago.

Secret to ACO Success

Accountable Care Organizations, or ACOs, have been touted as the best way to deliver good care and produce savings. But how can ACOs know going in that their model will work?

In the current issue of The American Journal of Accountable Care, authors from the Hackensack Physician Hospital Alliance write that accreditation is a key to success. The Hackensack group featured a key entry requirement: all its physician practices had to be certified by the National Committee on Quality Assurance as Patient-Centered Medical Homes. The Hackensack ACO saved money for 2 successive years.

The authors wrote: “As a whole, the ACO had fewer hospital admissions, readmissions, and emergency department visits compared with a group of ACOs—these were major factors that reduced our expenses, as we focused on maintaining a high level of quality.”

Read the full article.

Stephen Nuckolls, CEO of Coastal Carolina Quality Care, spoke with AJMC recently about the importance of getting physicians to buy into the ACO mission. Watch the interview.

Pharmacy Trends on ACA Exchanges

The recent Exchange Pulse report from Express Scripts reports 3 trends, based on the pharmacy benefits manager’s experience handling claims for 9 million patients on the nation’s insurance exchanges under the Affordable Care Act. The report looks at events that are having the biggest impact on year-over-year spending and prescription use. The 3 key trends are:

  • Increased utilization, not rising unit costs, was the bigger driver in overall spending on drugs by health plans.
  • HIV and hepatitis C drugs are the most expensive categories, but costs are starting to level off.
  • The fastest-growing prescription plan over the past 2 years has been the silver plan. Platinum and gold plans had higher overall spending, but silver plans saw more rapid growth.

Nominate Emerging Leaders

This is the final week to nominate a rising star for the Seema S. Sonnad Emerging Leader in Managed Care Research Award. The prize was created in 2015 to recognize scholars at the beginning of their career who have the potential to make a lasting impact in the field.

Nominations are due July 11th. You can learn more here.

For all of us at the Managed Markets News Network, I’m Justin Gallagher. Thanks for joining us.

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