General competitor
Competition frame
General competitor
General supplier

General competitor details

Summary

The competitive elements of the health care value delivery system are discussed.  These include:

Typical provider problems are discussed: These include:


Introduction

The health care industry has a complex value delivery system including cooperating and competing providers. 

Individual agents from each aspect of the value delivery system are described within their class. 



Employers as insurers

Employers obtain government subsidies when they act as health insurance reduces volatility in standard of living by compensating for losses of income during periods of unemployment, for catastrophic losses from disaster, or death of a family income earner as described by Gordon.  Insurance companies must set aside reserves to handle such claims.  Britain initially required that insurance buyers also have an insurable interest.  That is required in insurance markets to ensure buyers of insurance don't destroy their asset just to obtain the insurance.  Health insurance is treated separately being unusual, since the subscriber is likely to know more about their state of health than the insurer is and the subscriber is more likely to purchase the health insurance when aware of their increased risk.  This behavior collapses the risk pool by: forcing the insurer to increase the premiums, and encouraging healthy individuals to opt out of health insurance coverage. 
payers is a hospital's specific mixture of the four different types of payer:
  • From the 1930s the insurers Blue Cross and Blue Shield catalyzed health care activity by paying a daily per diem to hospitals for the diagnoses and treatments the hospital's dispensed.  At their inception in 1966 Medicare and Medicaid followed this reimbursement model. 
  • From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.  This forced alignment of the supplier, diagnosis, treatment, billing and reimbursement processes.  The health care network is still structurally aligned around PPS.  Under scrutiny of ProPAC and its successor MedPAC,  as well as pressure of the BBA after 1997, the payments per DRG have been steadily reduced until it was below the cost of care, forcing hospitals to seek margin from their other payers.  Medicare outlier payments benefited hospitals that inflated charges and thus became eligible. 
  • Employers as they experienced cost shifting from the hospital's increased product charges moved their employees over to managed care based payment. 
  • Private payers pay hospitals directly for their diagnosis and treatment.  Typically this group has little power.  There are default rates for private payers - typically 40% of billed charges that are not covered by a fixed payment or a fee schedule.  For the uninsured poor until 2004 they obtained little discount on the hospital's chargemaster list price, because insurers and CMS required to be charged the lowest value offered to any patients.  Medicare has now relaxed this constraint. 
.  But they have been threatened by the increasing cost of health care delivery.  By 2016 they are reducing this risk, is an assessment of the likelihood of an independent problem occurring.  It can be assigned an accurate probability since it is independent of other variables in the system.  As such it is different from uncertainty. 
by cost-shifting is the practice of:
  • States to shift dual eligibles from Medicaid to Medicare federal funded services. 
  • Hospitals to maintain margins, when under pressure from reduced reimbursement, by increasing charges for services provided to non-contractually protected patients. 
to their employees (Sep 2016). 
Key employers:

An expected dis-intermediation of general hospitals is showing signs of expanding.  Wal-Mart's contracting with centers of health care excellence is seen as a leading indicator of a shift from use of costly local general hospitals to help control costs.  Companies are motivated by the need to rein in health care costs, which continue to rise faster than overall  inflation, but the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
  • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
    • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
    • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
    • Children, allowed to, stay on their parents insurance until 26 years of age. 
  • Medicare solvency improvements. 
  • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
  • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
  • Medical home models.  
  • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
  • Qualifications for ACOs.  Organizations must:
    • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
    • Participate in the MSSP for three or more years. 
    • Have a management structure. 
    • Have clinical and administrative systems. 
    • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
    • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
    • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
    • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
  • CMMI Medicare payment experimentation.  
  • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
  • A requirement that chain restaurants must report calorie counts on their menus. 
is also changing how some view their obligations to their employees. 

Some firms like Walgreens, are giving those who qualify money to buy insurance on a private health exchange.  Aon Hewitt, a benefit consultant that will oversee health plans on Walgreens's behalf, said 18 large employers had signed up so far, including Sears and Darden Restaurants.  General Electric is taking the opposite approach.  And it is not seen as unique. 



CalPERS - California Public Employees Retirement System


CalPERS is one of the nation's largest buyers of health care benefits.  It is viewed as an indicator of what other large employers will do. 
2015 CEO and chief investment officer Ted Eliopoulis
2015 Vice President Henry Jones
2016 Chairman of the CalPERS investment committee Michael Flaherman
2016 CalPERS chief of public affairs Wayne Davis
  • CalPers, Blue Shield of California, Hill Physicians Medical Group, and Dignity Health formed an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
     (2010)



    • CalPERS bills California cities once a year for their share of the cost of paying pensioners assuming that its investments will return 7.5% in the future.   But the assumed rate of return is dropping increasing the state and city's share of the costs (Dec 2016).  And the cost of pensions has been rising -- especially for the police. 
    CalPERS supports state governments by using actuarial evaluations of pension commitments.  But this is shifting:


    Calpers interim reports had been based on its actuarial books (which are typically used to help employers plan stable annual budgets).  But it also has books that reflect the "market value" of the pension funds (reflecting the current values of assets and liabilities of the fund) that have been earned.  The market value must reflect the full cost today of providing a steady, guaranteed income for life.  Even the actuarial valuations of costs owed by governments to pensioners have been growing as US populations are aging and public workers retire. 

    In California, some local governments now doubt they can afford their pension plans and have asked to exit from CalPERS.  But when they leave CalPERS calculates the market value at that point and bills for any gap in funding.  CalPERS must do that since it has no way of going back to the employers later and asking for any additional funds.  CalPERS then keeps the money in a separate "termination pool". 

    The hidden underfunding is typical of US public pensions.  Retired public workers, local taxpayers and municipal bond buyers are currently exposed to risk they are not aware of. 

    CalPERS Amy Morgan noted "CalPERS does not exist to make money.  CalPERS exists to fully pay out benefits that are promised to its members."  Morgan noted the law required CalPERS to perform a complete evaluation after the termination date has passed, and to recover all the money needed to ensure retirees would be paid in full. 


    But they are also pursuing municipalities which fail to fund their commitments:
    • CalPERS is pursuing Layalton, a small city that has failed to fully fund their pension liabilities.  And it is also considering cutting pension payments if such cities fail to make good on their commitments (Oct 2016). 
    • CalPERS puts pressure on other pension funds and state finances as it lowers projected return on investment (Dec 2016). 


    The California state government does not backstop the pensions of small towns.  CalPERS Wayne Davis explains "The State of California is not responsible for a public agency's unfunded liabilities."   And CalPERS can't forgive Layalton, since other towns would demand similar treatment.  

    CalPERS has $290 billion in pension assets to protect, but they are committed to pensioners from other cities which are contracted with CalPERS and funding their actuarial pension commitments. 

    Already Stockton's bankruptcy is a legal status for an entity that cannot repay its creditor's loans.  It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations.  It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised. 
    resulted in the Judge Christopher Klien, concluding that the city had the right to break with CalPERS -- but it could not switch to a cheaper pension plan without abrogating its labor contracts.  Stockton stayed with CalPERS.  





    Jun 2013 CalPERS has instituted a program to cap prices of commodity hospital treatments

    CalPERS has agreed pricing caps with a number of hospitals in California for commodity operations.  The NYT reports that under the program, some employees are being given the choice of going to one of 54 hospitals, including well known medical centers including Cedars-Sinai and Stanford University Hospital, that have agreed to charge no more than $30,000 for a hip or knee replacement.  Prices for the operation vary between $15,000 and $110,000 within the state. 

    CalPERS worked with insurer Anthem Blue Cross to introduce the program. 

    Overall costs of operations under the program fell 19 percent in 2011, the programs first year, with the average amount it paid hospitals for a joint replacement falling to $28,695 from  $35,408, according to an analysis by WellPoint's researchers that was released Jun 2013 at a health policy conference.  The study found no impact on the quality of care. 


    CalPERS started using reference pricing constrains a policy holder to a reimbursement for the reference price of a treatment rather than the specific hospitals billed price.  Patients have to pay the difference.  It can allow subscribers broader access to different health care providers than narrow networks.  It is only applicable for elective procedures where the patient can shop around (Aug 2016). 
    - paying hospitals a maximum contribution for 450,000 of its members for: knee/hip replacement, colonoscopies, cataract removal and several other elective procedures; in 2011.  The patients foot any excess in the price. 

    At the initiation of the approach 41 of California's several hundred hospitals could provide knee and hip replacement procedures for $30,000 with acceptable quality.  Some hospitals were charging more than $100,000. 

    CalPERS reduced patient cost-sharing if patients chose a free-standing, outpatient surgical center as opposed to a general hospital. 

    UC Berkeley health economists is the study of trade between humans.  Traditional Economics is based on an equilibrium model of the economic system.  Traditional Economics includes: microeconomics, and macroeconomics.  Marx developed an alternative static approach.  Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics.  Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. 
    ' James Robinson and Timothy Brown reported patients with reference pricing constrains a policy holder to a reimbursement for the reference price of a treatment rather than the specific hospitals billed price.  Patients have to pay the difference.  It can allow subscribers broader access to different health care providers than narrow networks.  It is only applicable for elective procedures where the patient can shop around (Aug 2016). 
    flocked to lower-priced hospitals and out-patient surgical centers.  Prices and total spending for the procedures plummeted:
    • Knee/hip replacement market share for lower-priced hospitals increased by 28%.  Higher-price hospitals responded to loss of share by reducing prices.  Prices on average fell 20% saving CalPERS $6 million over two years. 
    • Cataract removal surgery average price dropped nearly 20%
    • Colonoscopy prices fell 28%
    • Knee and shoulder arthroscopy prices fell 17%
    Quality was not found to be affected in the study. 

    Prices of reference-priced services for CalPERS declined 20% during a period when health care prices paid by employer-sponsored plans rose by 5.5%. 

    Reference pricing can affect the 40% of health care spending which is elective.  But it requires patients to get access to and understand procedure prices and quality details and there to be enough providers to develop a competitive local market.  There is an administrative cost in calculating effective reference prices.  So additionally some large employers are contracting with centers of excellence such as the Cleveland Clinic to add choice outside of the local market. 



    Subsiquently (Sep 2014) the activity generated the ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
     style joint venture Vivity. 


    2014 CalPERS has $300 billion in assets it is managing.  It liquidated $4 billion in hedge fund investments.  This was a catalyst to investors subsequently shifting out of hedge funds (Sep 2016).  But CalPERS intends to continue investing in private equity.  Even as their performance fails to justify such faith (Jul 2016). 


    Nov 2015 NYT CalPERS Paid $3.4 Billion To Private Equity Firms

    Alexandra Stevenson reports for years, state pension funds have invested money earned by teachers, firefighters and other government employees with private equity firms without having a full picture of how much they were earning and what they were paying in expenses. 

    The pension industry is under public scrutiny, it has had disappointing performance and is faced with ballooning deficits. 
    In 2015 CalPERS will for the first time, pay more to its retirees than it makes from its investments and contributions (Dec 2015). 

    Henry Jones, chairman of the investment committee said "Private equity is a complicated asset class and the board and investment office staff will now have even more insight into our program." 
    CalPERS disclosed it had paid $3.4 billion since 1990 to: Carlyle, Blackstone, Apollo; on carried interest is a fund manager's share of the earnings from a profitable investment.  It is a performance fee, charged by venture capital firms and private equity firms in addition to the smaller management fee.  There is a congressionally granted tax loophole which keeps the tax rate on carried interest low - 15% in 2016.  This loophole on capital gains was setup to encourage people investing their own capital to take more risk.  But general partners at venture and private equity firms do not have the associated risk.  The loophole reduces US tax receipts by $2 billion each year. 
    profits of $24.2 billion.  Private equity has the highest net returns in the CalPERS portfolio yielding 11.1% since 1990.  Not so since then (Jul 2016). 
    J.J Jelincic, a member of the CalPERS board said a break down of the transaction fees charged by the private equity firms was missing from the released breakdown.  "We certainly know more than we did before, but it's not the complete story yet." Transparency push being undermined (Jul 2016). 

    CalPERS bench mark for investment is an amalgamation of domestic and foreign stock market indexes with 3% added. 

    CalPERS and California proposition 61
    CalPERS is ambivalent about California proposition 61 which aims to constrain the rise in drug prices (Jul 2016). 


    G.E. - General Electric


    Sep 2013 NYT reports GE provided health care plans are connected directly to doctors and hospitals 
    General Electric, one of the largest employers in the USA spends more than $2 billion a year offering coverage to 500,000 employees and retirees and their families.  It is using its considerable clout in Cincinnati where it has a giant aviation business to work directly with doctors and hospitals to improve care and reduce costs. 

    Over the last few years, G.E. has pushed for the creation of medical homes are primary care architectures which deliver: patient-centered, accessible, coordinated, comprehensive care of high quality and safety (Dec 2015).  The models have been made more significant due to Affordable Care Act payment reform requirements.  The goal is to reduce treatment costs and improve population health by reengineering of the traditional silo'd provider network.  See PCMH. 
    with access to all of the patient's medical records,

    In Cincinnati, about 118 doctors' practices have converted to medical homes is patient centered medical homes:
    • Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems.   The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes.  The PCMH
    • Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students.  HCI3 argues this use of PCMH is flawed.  PCMH is driven by the medical home models of the ACA.  In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care.  It is focused on treating the whole person.  It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications.  It must ensure extended access and availability of its services and patients preferences about access.  It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA).  Many argue that to be effective it must be connected to a 'medical neighborhood'.  The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination. 
      •  
    , and all five of the major health systems are making their primary care practices move in that direction.  G.E. has also pushed for greater transparency of results. 

    "If we don't take accountability ourselves for figuring this out, we're part of the problem," said Sue Siegel, a senior executive at G.E., who sees transformation of health care both as a business opportunity and a business necessity. 

    "We have to be involved in the solution," she said.  "We can't just wait for someone to tell us that it is going to be fixed." 

    What distinguishes the effort by G.E. is its direct focus on hospitals and doctors.  Companies looking to the private exchanges are largely hoping to save money and want to be freed from the headache of administering health benefits. 


    In Cincinnati, G.E. took both a cheerleading and coordinating role.  In early 2010, Jeffrey R. Immelt addressed local business leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
    and urged them to think strategically and align their efforts to make more of a difference.  There were already significant efforts under way to foster medical homes (PCMH) The Patient-centered medical home
    • Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems.   The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes.  The PCMH
    • Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students.  HCI3 argues this use of PCMH is flawed.  PCMH is driven by the medical home models of the ACA.  In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care.  It is focused on treating the whole person.  It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications.  It must ensure extended access and availability of its services and patients preferences about access.  It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA).  Many argue that to be effective it must be connected to a 'medical neighborhood'.  The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination. 
    , for example, and G.E. pushed to find more financing to expand the concept to more medical practices and keep the focus on that initiative. 

    "The ever-present vigilance of the employers help nudge things along," said Craig Brammer, chief executive of three area health care coalitions, including the Greater Cincinnati Health Council, which is made up of the area's hospitals, health plans and employers. 

    The city's health systems say they recognize that insurers and employers are increasingly going to reward them for better tracking their patients in and out of the hospital.  "We are clearly gearing up to change directions from FFS is fee-for-service payment.  For health care providers the high profits were made in hospitalizations, imaging and surgery.  Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment.   to what I'll call payment for value," said Will Groneman, an executive vice president for TriHealth, one of the systems. 

    The medical home (PCMH) The Patient-centered medical home
    • Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems.   The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes.  The PCMH
    • Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students.  HCI3 argues this use of PCMH is flawed.  PCMH is driven by the medical home models of the ACA.  In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care.  It is focused on treating the whole person.  It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications.  It must ensure extended access and availability of its services and patients preferences about access.  It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA).  Many argue that to be effective it must be connected to a 'medical neighborhood'.  The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination. 
    also appears to resonate with employees.  When Mary Farris, a 44-year-old marketing executive for G.E, found herself going to a local urgent care center is an efficient and less costly 'alternative' to the ER.  There is no accepted standard.  Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls.  Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones.  Unlike an ER they can not admit patients to a hospital.  Some also offer services like pre-employment drug screening and summer camp physicals. 
    because she could never get an appointment with her physician, she switched to a practice that had become a medical home. 

    What strikes Ms. Farris was how much time the doctor and medical assistant spent gathering her medical history and making sure there weren't additional medical issues.  While she came in for a spider bite, the focus was her well-being as a working mother whose father was seriously ill at the time.  "The picture was more on all of me as opposed to one isolated incident," she said.  "Somebody was trying to connect the dots." 

    In Cincinnati, there are beginning to be grudging signs of success.  Early results are promissing: patients enrolled in medical homes had 3.5 percent fewer visits to the emergency room (ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    ) and 14 percent fewer hospital admissions over the four years from 2008 through 2012.  G.E. plans to ask an outside firm to do a more detailed analysis. 



    But employers looking to adopt a similar strategy will find "it's hard to do," said David Lansky, the chief executive of the Pacific Business Group on Health, which represents West Coast employers.  While "the opportunity is significant," he said, companies may not have the time or resources to work in too many of their locations, with different hospitals and health plans in each market. 

    G.E. recently signed an agreement with Hospital for Special Surgery in New York, a high-volume orthopedic hospital, to oversee the care of some employees getting hip and knee replacements.  That doesn't sit well with Cincinnati's UC Health System. 
    G.E. is unapologetic.  The company says it will continue to try a variety of appraoches until it finds a way to tame health care costs even more than the annual growth rate achieved so far of under 3 percent.  "You'll see many, many experiments across the board," Ms. Seigel said. 

    G.E. and prediabetes management
    G.E. has sponsored pre-diabetic is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes.  Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two.  Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it.  Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years.  The YMCA developed a pre-diabetes treatment program.  People can use a test devised by the CDC to assess their risk of pre-diabetes.   workers to help avoid type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure.  Insulin and glucose levels are regulated by the pancreas, liver, muscle, brain and fat.  Diabetes occurs when the insulin level is insufficient to regulate the glucose in the system.  Increased fat levels in obesity demand more insulin overloading the pancreas.  Persistent high glucose levels are also toxic to the pancreas beta cells.  High glucocorticoid levels have been associated with type 2 diabetes.  There are genetic risk factors since siblings of someone with the disease have three times the baseline risk (about 50% of the risk of getting type 2 diabetes is genetic).  The inheritance is polygenic.  More than 20 genes have been identified as risk factors, but that is too few to account for the 50% weighting so many more will be identified.  Of those identified so far many are associated with the beta cells.  The one with the strongest relative risk is TCF7L2.  The disease can be effectively controlled through a diligent application of treatments and regular checkups.  Doctors are monitored for how under control their patients' diabetes is (Sep 2015).  Treatments include:
    • Metformin - does not change the course of pre-diabetes - if you stop taking it, it is as if it hasn't been taken. 
    • Diet
    • Exercise
     (Mar 2016). 


    G.E. International
    G.E. vice chairman for international operations
    • 2016 John Rice. 
    G.E. and post TPP trade moves with China
    John Rice sees China's moves to replace the TPP is the Trans Pacific Partnership, a twelve country, Pacific regional, trade deal between: Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, United States, Vietnam;  The U.S. aims to use the agreement to constrain competition from China.  The initial 12 countries account for more than a quarter of global seafood trade and a quarter of the World's timber and pulp production.  Five of the nations are among the World's most biologically diverse.  The TPP includes:
    • Patents and copyrights chapters. 
    • State-owned businesses chapter. 
    • Investor-state dispute settlement chapter which enforces extrajudicial tribunals for arbitrating disputes.  The tribunals give investors legal recourse if a government changes policies in ways that hurt the value of their investments. 
    • An environmental chapter that covers illegal wildlife trafficking, forestry management, overfishing and marine protection.  Environmentally destructive subsidies, such as cheap fuel for illegal fishing boats and subsidies for boat building in overfished waters are banned.  The chapter enforces Cites with economic sanctions and disallows trade in wildlife taken illegally from a country. 
    • Requirements that member countries strengthen port inspections and document checks. 
    • Requirements that a country in the agreement take action if they discover contraband that has been harvested illegally, even if the product is not illegal in that country. 
    as important for G.E.:

    American business leaders aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group.  John Adair developed a leadership methodology based on the three-circles model. 
    are looking to join the R.C.E.P. is the regional comprehensive economic partnership, a Chinese driven trade agreement, that is likely to replace the T.P.P. 
    discussions too:
    • GE International's John G. RIce commented "Two-thirds of what we do there ends up in another country.  So if they're going to lower tariffs and trade barriers within that region, we'll find ways to do more there." 


    GE Capital
    GE Capital's Healthcare financial services business was sold to Capital One for $9 billion. 
    GE kept the aspect that lends financing to GE HealthCare customers.  

    GE asks to have its "systemically important is a Dodd-Frank financial reform act designation for the largest companies which would have a catastrophic impact on the global financial system and can not be allowed to fail. 
    " designation removed (Mar 2016). 


    Alphabet

    Alphabet is the corporate parent of Google and the other unrelated businesses. 
    2015 CEO Sundar Pichai


    Sundar Pichai was born in Tamil Nadu, South India.  His father was an electrical engineer in Chennai working for GEC.  The family did not get a rotary phone until he was 12 years old.  He saw how the phone helped improve productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs.  It is a complex capability of agents.  It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. 
    :
    • Prior to having the phone, finding out the results of a blood test meant catching a bus to the hospital, waiting in line, and often being told to return the next day because it wasn't ready.  It was a three hour round trip. 
    • With the phone it was a quick call to find out the status and or results. 
    Pichai saw the value of technology and read all the material about computers and semiconductors he could obtain.  His aspirational goal was to attend Stanford University.  That led to his working as a process engineer at Santa Clara's Applied Materials.  But he could see that Google was becoming a key player on the Internet.  He was impressed by the growth potential, simplicity and accessibility of Deskbar. 

    In 2004 he joined Google as a product manager, just as the Internet was deploying Web 2.0 and AJAX is asynchronous JavaScript and XML.  It is an architecture and techniques for using Web technologies to provide client server communications without reloading a web page or refreshing the browser. 
    .  He worked on Google Toolbar, which could be added to any browser to provide access to Google Search.  That required the building of a client engineering team at Google. 

    By 2006 Google was looking at ways to run applications effectively on the web.  The team proposed development of Chrome so that:
    • A multiprocess architecture would protect one application from any others running on the client. 
    • A high speed implementation of JavaScript to make the applications respond like desktop clients.  
    Chrome was deployed in 2008, aligned with a top-level annual objective "develop the next-generation client platform for web applications.  The main key result was "Chrome reaches 20 million seven-day active users." 

    Pichai saw the Chromebook as an additional step allowing a laptop to directly integrate with the cloud applications. 



    2017 Senior VP for cloud business - Diane Greene.  Greene argues that "you can turn [machine learning] technology to whatever field you want, from manufacturing to medicine." 
    2017 Cloud business Artificial Intelligence chief scientist Dr. Fei-Fei Li, on sabatical from directing Stanford University's Artificial Intelligence Laboratory.  Dr Li notes that big-data is the digital gold. 



    Google Wellness
    Director of global food services Michael Bakker. 
    Google has promoted healthy eating for years.  It has been using Zipongo since 2011.  About half of Google's employees have signed up and used the application for at least a month.  Zipongo takes their preferences and biometric inputs and provides customized menus resulting in these employees eating more fruit, nuts, calcium, fish, and fibre rich foods.  Bakker argues "We do think we can help employees make food choices that are better for them as an individual."



    Amazon

    Amazon is based in Seattle, Washington. 
    Amazon has extended into physical retail with the purchase of Whole Foods.  Its expanding access to the wholesale and retail pharmacy: PillPack; and medical device markets may be disruptive (Oct 2017, Jun 2018). 


    Apple Computer

    Apple is based in Cupertino, California

    Comcast Corporation

    Comcast is based in Philadelphia. 
    Comcast is in 2018, the largest cable company in the US.  It has 225,000 employees. 


    Comcast spends $1.3 billion a year on health care.  It reports over the last 5 years its health care costs have increased at 1% a year, compared to 3% average for other large employers. 


    Comcast has rejected:
    Instead, Comcast's Shawn Levitt explains "Our model is based on providing employees support and assistance in making the right decisions for themselves and their families.  Employees should not feel alone, confused and overwhelmed when it comes to understanding and selecting their benefits." 

    Comcast has replaced insurance companies in its health benefits innovation search.  It is leveraging startups instead:
    NBGH agrees "We see the start-up community as where the real disruption is taking place." 

    Reed Abelson asserts that Comcast's success in controlling health costs comes from directly confronting the problems, rather than depending on middlemen.  It allows Comcast to use multiple strategies which together limit the number of large claims.  Workers with company health benefits are told to go to Accolade first.  And Grand Rounds helps in handling overtreatment is the application of unnecessary health care.  It is a complex problem:
    • Overtreatment needs to be adaptive.  As people age their medicine levels typically need to be changed.  Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).  
    • Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings.  And again these vary with age. 
    • Patients who have learned a regime, and been told it was successful, may resist instructions to change it.  Some worry that they will impact their health care provider's treatment performance measures. 
    .  Grand Rounds are able to get access to the EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    and insurance details.  Insurers can be protective of their data, but large employers, such as Fidelity, successfully push back. 




    Honeywell

    Morris Plains, NJ
    Honeywell is a conglomerate that invents and manufactures solutions including: Thermostats, Home systems, Mobile productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs.  It is a complex capability of agents.  It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. 
    ;
    CEO David Cote

    Honeywell health plan with sticks and carrots
    Employees were sent a health enrolement email from Honeywell requesting their: Weight, Cholesterol levels and other medical information.  If it wasn't provided the employee would pay upto $2,250 in health insurance penalties, or $4000 if they were married. 
    Honeywell started to levy the charges in 2013.  This year the charges are capped at $1,500. 

    Federal regulations make wellness programs voluntary.  But it may not feel that way for the workers. 

    IBM 

    IBM is building a globally optimized business with 'industry platforms' based on AI and cloud infrastructure:

    IBM Wellness programs
    IBM's chief health officer Dr. Kyu Rhee said "We strongly believe eating healthy is a social endevor, both at work and at home.  It makes no sense if you eat healthy at the office and then eat badly at home." 

    IBM has tried to influence the wellness is a health care oriented employer based strategy for reducing health care costs and encouraging wellbeing.  Wellbeing has traditionally been a focus of public health.   of its employees for many years.  It has a traffic light system to indicate the assumed healthiness of each choice. 
    In 2007 it offered a $150 cash rebate for IBM families recording their healthier eating habits in a confidential online system for eight weeks. 

    IBM has adopted Zipongo, offering its service to 10,000 employees in Jan 2016. 


    IBM Customer Experience Analytics
    IBM provides digital analytics to model customer behavior and cross-channel details

    Jun 2010 IBM Purchase Coremetrics
    Coremetrics provides digital marketing optimization software and web analytics. 


    Trader Joe's

    Trader Joe's decided to send at least some employees to the new public exchanges.  Trader Joe's has left coverage for three quarters of its workforce untouchedbut is giving part-time workers a contribution of $500 to buy policies in the newly created state marketplaces.  Because of the employees' low incomes, the company says it believes many will be eligible for federal subsidies to help them afford coverage. 

    UPS - United Parcel Services


    Aug 2013 NYT reports United Parcel Services told its white-collar workers that, in an effort to reduce its health care costs, it will no longer cover some 15,000 spouses who can obtain coverage through their own employers.  The company said its move was prompted primarily by projected increases in the amount it would have to pay for employees' medical care and secondarily by various costs associated with the health care reform law is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    . 

    U.P.S. is joining a small but growing number of companies that decline to cover working spouses who can obtain coverage at their own workplace.  The costs and complications of two separate policies may vary from family to family.  In some cases, the plans may have different networks of doctors and offer different benefits.  U.P.S. says that eliminating a spouse from a family plan could reduce the premium paid by many of its employees by enough to cover some or all of the premium the spouse will have to pay for a separate policy at another company. 

    Although U.P.S. is taking other steps, such as a tobacco cessation program, to improve employee health and reduce medical spending, the spousal policy will simply shift the insurance burden from U.P.S. to the other company.

    Walgreens


    Walgreens, the retail drugstore, doesn't plan to lower its share of its workers' health care costs but hopes to foster more competition among insurers, leading to better prices and more choice for employees. 


    Wal-Mart


    CEO is Douglas McMillon since February 2014.  He worked his way up from fishing tackle sales at the company in Bentonville. 

    Wal-Mart (Walmart) has:
    • 2014 revenue $485 Billion. 
    • 5000 stores and clubs
    • 1.4 million Employees. 


    2015 strategy issues:
    • Wal-Mart has spent heavily on increased salaries ($1.5 Billion) and Internet sales infrastructure (several billion) without a strategic benefit.  Sales have not surged.  Wal-Mart has lost price dominance.  Its immense network of distribution centers and stores should help it in on-line commerce but its system is optimised to deliver goods on pallets to stores. 
    • Under siege from Costco and Aldi.  Sam's clubs are low margin worrying analysts. 
    • Life style speed up is encouraging shoppers to go to convenient local stores and online (Amazon which has online sales of $80 billion).  Price, selection and convenience all help Amazon and local shops.  Wal-Mart is being disrupted. 
    • Wal-Mart web strategy has been operational since 1999 but to little effect ($12.2 billion sales or 2.5% of total sales).  Now it aims to optimize multi-channel but that is proving very expensive.  Amazon has gone through an agressive investment cycle over the past 5 years allowing them to improve fullfilment and focus it on the individual.  Its quick and cost-efficient.  It is also focused on the Intenet only where sales are growing.  Amazon can deliver its 10-100 fold larger selection of goods much cheaper and faster than Wal-Mart's online operations.  Wal-Mart is building an internal technology team, vast new fulfillment centers and cloud data centers, to improve its online offerings.  Columbia's Bruce Greenwald argues they would be better teaming with a technology company with the analytics and cloud computing capacity. 
    • Wal-Mart's customers are relatively poor. 

    Feb 2016 Wal-Mart under increasing pressure from poor sales outside of USA: China, Brazil, Britain
    Competition from Amazon and other e-commerce sites has continued to impact sales.  Earnings per share were down year on year. 

    Jan 2016 Wal-Mart to close 269 Stores Worldwide
    Wal-Mart is responding to pressure from Amazon by:
    • Closing a record 269 stores worldwide - 154 in the US.  The bulk of the rest in Brazil. These will be offset by the opening of 300 new stores.  Four Sam's Club and 12 Supercenters will close. 
    • Abandoning Wal-Mart Express (102 stores) - its small format for urban areas a strategy started in 2011.  They were undermined by Dollar stores etc. 
    • 10,000 U.S. is the United States of America.   job losses and 6,000 in the rest of the world. 
    Web retailers are undermining brick retail sales.  There huge online catalogs are very attractive.  Amazon accounted for a quarter of all retail sales in 2015.  So Sears, Macy's and J.C. Penney are also closing stores.  Retail sales are flat to falling.  Price is a poor competitive strategy.  Wal-Mart's stock is at its lowest value in five years.  A possible emerging market initiated recession would add to Wal-Mart's problems. 

    Wal-Mart's has spent heavily on e-commerce but its online sales growth is slowing. 


    Jan 2016 Wal-Mart responds to increased hiring with pay rises. 

    1.2 million Wal-Mart stores employees will be paid $13.38 per hour as of Feb 2016.  Part time workers will also get an increase from $10 to $10.58 an hour.  These wages are still less than the government average wage of $14.95. 

    2012 Wal-Mart contracts with centers of excellence

    Wal-Mart contracted with health systems like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need transplants, heart and spine care.  The company says it will soon expand the program to other centers of excellence. 

    Wal-Mart markets itself as PCP with the opening of clinics with broader offerings. 

    New Entrants



    8th August 2014 Wal-Mart opens 5 primary care locations with more to follow
    Wal-Mart has been trying to turn some of its customers into patients for years.  It has accelerated that strategy opening five primary care locations in South Carolina and Texas, plans a 6th in Palestine Texas, within a week and will have opened six more by the end of 2014. 

    Wal-Mart is partnering with QuadMed which will staff and run the clinics.  Still the doctors will not see patients directly.  They oversee compliance and prescription ordering similarly to the process at Wal-Mart's acute care clinics. 

    Wal-Mart explains that the new clinics offer a broader range of services, including chronic disease management, than the 100 or so Wal-mart acute care clinics already deployed across the country.  Unlike CVS, Walgreens and Costco, Wal-Mart is marketing itself as a PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
    .  Most of the $1.7B spent on health care in the US is targeted at chronic care.  Wal-Mart accepts Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    , is enrolling some of its stores with Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    , but currently does not accept third party insurance.  However, the clinics can help drive traffic to Wal-Mart's pharmacy which does accept third party coverage. 

    Wal-Mart, CVS and Walgreens are all aiming to benefit from the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    driven shift in health care delivery.  Wal-Mart has a vast rural footprint and is placing its new clinics where PCPs are scarce and medical care is often prohibitively expensive.  It aims to become an entrypoint into a continuum of care delivery. 

    Some critics warn that chronic care patients need complex care that will be difficult for Wal-Mart to provide due to the problems of managing typical complications of diseases like type 2 diabetes is diabetes mellitus or disease management in health care. 
    . 

    Dozens of Wal-Mart's acute care clinics have closed as its initial efforts at delivery stumbled.  But in part that is due to the limited offering which is used by customers in the winter but has little to offer for the rest of the year.  To make it profitable you need to have more than a clinical encounter.  You need to sell them prescriptions, a bag of chips etc. while they are waiting.  The new focus on chronic conditions could improve attendence all year round. 

    Wal-mart like other big retailers are losing sales to online providers. 


    5th Feb 2014 CVS announce stopping sales of cigarettes as part of strategy to enter health care provider market
    CVS announced cigarette products are inconsistant with its health care focus (NYT). 

    Pharmacy Benefit Management

    PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    s negotiate with drug companies on behalf of insurers (employer plans, Medicare part D is a federal program to subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as part of the MMA and delivered entirely by private companies.  It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad group of elderly voters and a small but influential group of payers: UnitedHealth, Humana, CVS Health; while pharmaceutical companies also benefited from increased sales of reimbursed drugs.  It includes:
    • E-prescribing regulations.  Health care providers that electronically prescribe Part D drugs for Part D eligible individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP SCRIPT standard to transmit prescriptions & related information internally but must use NCPDP SCRIPT (or other adopted standard) to transmit information to another legal entity.  
    • Premium subsidy set by a market average.  Medicare collects bids from all plans that reflect their costs of providing the minimum required level of drug coverage. It then sets the subsidy at 74.5% of the average bid.  
    • Premium coverage gap (doughnut hole) between the 74.5% premium subsidy and the catastrophic-coverage threshold.  The BBA of 2018 required Part D insurers cover 5% of the beneficiaries coverage gap and drug companies provide discounts that reduce federal spending by a total of $7.7 billion through 2027. 
    , Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    ).  They include:

    The largest three: Express scripts, CVS Caremark and OptumRX cover 180 million people, control 80% of the PBM market and bring in more than $200 million a year in revenue. 

    In theory PBMs can bargain for lower drug prices, using the power of their formularies are lists of drugs that a health plan will cover.  The health plans control where and if the drug is listed in the plan.  A less expensive drug can be assigned a lower copayment to encourage patients to use it.  To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs.  Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether.  That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure.  , but the system incentivizes them to select the drug with the largest rebate to them. 

    PBM rebates

    PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    s get "rebates" from drug manufacturers -- they are payed based on sales and other criteria. 
    The rebates are not publicly disclosed.  Analysts suggest they may amount to as much as 50 percent of the list price of drugs like insulin regulates the metabolism of carbohydrates, fats and protein by signalling the absorption of glucose by fat, liver and skeletal muscle cells.  It is a peptide hormone generated in the islets of Langerhans beta cells of the pancreas.  Peter Medawar explains it was an early drug therapy success.  As manufacturers have shifted from products developed by extraction to biologics: Humulin, Lantus, Levemir; safety has improved.  But the US list price has risen steeply (Feb 2016, Jan 2017)
    .  The rebates could be passed along to consumers, but there is evidence of situations where the rebates are kept as profits.  In Jan 2016 Anthem complained that Express scripts which was acting as its PBM, was not sharing enough of its savings. 


    Health management organizations (HMO is a health maintenance organization.  Originally HMOs were fashioned after Dr. Paul Ellwood's admiration for group practices such as: Kaiser Permanente, Mayo Clinic; which employed salaried physicians and charged fixed fees rather than FFS.  Ellwood argued that this architecture helped keep subscribers healthy which he termed a health maintenance organization.  President Nixon was convinced by Ellwood signing the HMO Act.  But the legislated HMO did not have to conform to Ellwood's group practice architecture.  Instead by 1997 for-profit commercial insurance companies operated two-thirds of the HMO business.  The legislated HMO:
    • Provides or arranges managed care for:
      • Health insurance
      • Self-funded health care benefit plans
      • Individuals
    • Acts as a liaison with health care providers
    • Covers care rendered by those doctors and others who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in return for access to patients.  Treatment choices were often driven by insurance company rules.  Financial incentives often based the contracted physician income on success in reducing expenses rather than health outcomes.  There are a variety of contracts with physicians:
      • Closed panel plan
      • Open panel plan
      • Network model plan
    • Covers emergency care regardless of the providers contracted status. 
    ):


    Represented by the AHIP. 


    2014 Health insurance product offer

    The health insurance product offering is currently a yearly subscription.  This discourages the payers include four types:
    • From the 1930s the insurers Blue Cross and Blue Shield catalyzed health care activity by paying a daily per diem to hospitals for the diagnoses and treatments the hospital's dispensed.  At their inception in 1966 Medicare and Medicaid followed this reimbursement model. 
    • From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.  This forced alignment of the supplier, diagnosis, treatment, billing and reimbursement processes.  The health care network is still structurally aligned around PPS.  Under scrutiny of ProPAC and its successor MedPAC,  as well as pressure of the BBA after 1997, the payments per DRG have been steadily reduced until it was below the cost of care, forcing hospitals to seek margin from their other payers.  Medicare outlier payments benefited hospitals that inflated charges and thus became eligible. 
    • Employers as they experienced cost shifting from the hospital's increased product charges moved their employees over to managed care based payment. 
    • Private payers pay hospitals directly for their diagnosis and treatment.  Typically this group has little power.  There are default rates for private payers - typically 40% of billed charges that are not covered by a fixed payment or a fee schedule.  For the uninsured poor until 2004 they obtained little discount on the hospital's chargemaster list price, because insurers and CMS required to be charged the lowest value offered to any patients.  Medicare has now relaxed this constraint. 
    from focusing on the long term health of their members since some other insurer may obtain the benefits.   And people tend to change insurers whenever they change jobs, lose Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    coverage, or gain access to Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
    .  Similarly the yearly nature of the product is misaligned with costs that occur in one year but provide benefits over a longer period.  For example Sovaldi (sofosbuvir) is Gilead Sciences hepatitis-C drug.  It is the first effective cure with acceptable side effects.  Sofosbuvir was originally developed by Pharmasset which sold the rights to Gilead for $11 billion.  In 2014 Sovaldi costs $84,000 for a typical course of treatment. 
    cures hepatitis-C is a virus which destroys the liver during infection.  In 2016 it affects 185 million people worldwide.  Once the virus genome was sequenced in 1989 Dr. Bartenschlager and Dr. Rice worked to replicate the virus in the laboratory.  Rice realized the genome sequence was missing details that stopped the lab replication.  Bartenschlager was then successful at replicating the virus in cells in his laboratory.  The replication technique allowed Pharmasset's Dr. Sofia to develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat that allowed the drug to enter the liver, where the coat was destroyed and the polymerase inhibitor was activated.  With high concentrations of the drug, sofosbuvir, in the liver it could eradicate the hepatitis C virus.   Sovaldi was the first sofosbuvir approved by the F.D.A. 
    in a few weeks.  This should reduce the long term cost of liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions.  It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein.  It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels.  The embryonic endoderm cells invade the mesoderm to form the liver bud.  Subsequently the liver bud vascularizes and is colonized by hematopoietic cells.  The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances.  In a healthy adult liver cells do not divide significantly.  But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver.  There are over 100 disorders of the liver.  Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide. 
    failure in the current patient base.  However, insurers are loath to pay the high cost per pill since they are unlikely to benefit long term from the improved health of the insured who can switch insurers each year.  Medicaid based HMO is a Health Maintenance organization managed care plan as opposed to a PPO plan.  It uses the allocated PCP as a gatekeeper who must refer a patient to any health specialist for the patient to gain access. 
    products are particularly sensitive to annual cost increases.    Intermountain has developed a novel approach that encourages long term contracting with its health plan SelectHealth (share). 

    Health insurers would benefit from forcing more transparency in estimating the value of drugs and hence correlations to drug pricing.  They are encouraging transparency legislation in Congress.  They view drug companies  as using R&D costs for justifying price increases.  But they say these are sunk costs and have little to do with pricing.  If people are being cured how is that affecting costs? 

    Entering a health insurance market such as a new state is difficult primarily because of financial and network effect based barriers: 
    Startups: Oscar and Zoom+ have entered the insurance market. 

    Some health care providers have started to enter the health insurance market.  Some Medicaid plans have line extended into other health insurance.  Network effects provide the incumbents with significant competitive advantage.  Additionally they typically have built up large capital cushions. 
    Health Insurance Co-operatives
    23 health insurance nonprofit startups entered the health insurance market based on the support provided by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    .  These companies were designed to provide affordable insurance coverage to individuals and small businesses.  The ACA goal was to generate competition to the plans sold by large insurance companies.  But the co-ops have been losing money (Aug 2015). 

    The original ACA architects plan was for a public option to compete with the big insurance plans.  But that would have resulted in the ACA failing.  Senator Kent Conrad proposed the co-ops as a fallback.  But they have to fight network effects of the big Blues and commercial insurers to become profitable. 

    The ACA provided some support to insurers entering new markets, where there was no data to help them effectively price the policies they offered.  The assistance included:

    Some co-ops started to fail just a year into the new system implementation: Coopertunity health, Louisiana health and now the latest Nevada Health Co-op where ceo Pam Egan told customers that the co-op would stop selling policies next year, pointing to high medical costs and limited opportunities for new investment.  Even if the co-ops gain new customers they have to find more capital to cover state requirements to cover potential medical costs.  The federal government had promised to consider ways to support their initial growth but insurance experts doubt that the government changes are enough to prevent failure.  One aspect was to require insurers with lots of healthy patients to cross fund insurers with less healthy patient bases.  But startups are not guaranteed to endup with the unhealthy patient bases.  A small startup in Alabama with just 1,100 members is having to pay the dominant Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    $1.5 million! The ACA loans were not large enough to sustain the Co-ops through their first years of investments and policy payouts.  At the same time consolidation among the big insurers is pressuring the co-ops further. 

    Oct 2015 Eight Co-ops have now failed in: Colorado, Iowa, Kentucky, Louisiana, New York - Health Republic, Nevada, Tennessee and Oregon - Health Repubic. 
    Nov 2015 Over half have failed: Michigan - Consumers Mutual. 


    ACA health exchange integration

    Dec 2013 NYT Health Insurers extend premium deadline
    To minimize the chance of chaos as people signup for ACA health coverage, insurers have extended the first month premium deadline by ten days.  If a customer goes to the ED is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
    or PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
    office after Jan 1st 2014 they will be retroactively covered if they send their payment by Jan 10th.  Wellpoint offered additional help.  The ten day extended coverage generates little risk for the insurers due to the large deductables that must be reached before any payouts are required. 

    Insurers are worried that since the health insurance markets are lagging in verifying the policies that are issued invalid applications will cause instability.  People are likely to be scrambling to find coverage if their plans lapse and they have trouble figguring out their benefits, and which doctors and hospitals are included. 

    Some insurers, such as Florida Blue, have encouraged insurance applicants to sign with them directly so the contract is recorded accurately. 

    Aetna

    Offers virtual visits as an option for certain employers.  Uses Teladoc. 

    Aug 2016 After the merger with Humana was blocked by the federal government, Aetna announced they would pull out of the personal insurance marketplaces (Aug 2016). 

    2015 Under market pressure Aetna is seeking to merge with Humana for $37 Billion.  The transaction should close in 2016, subject to regulatory and shareholder approval. 
    The combined company would have an estimated revenue of $115 billion and serve 33 million people.  The board will expand to 16 members with 4 from Humana. 
    The consolidation was assisted by the Supreme Court decision upholding the part of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    allowing individuals to receive subsidies when they buy policies through HealthCare.gov. 

    The merger was subsequently blocked by the courts (Feb 2017). 

    CEO Mark Bertolini argued the combination would promote greater operational efficiencies that enable us to lower costs and create value for our customers and provider partners.  Bertolini emphasized the need to be large enough to invest the capital and resources necessary to be competitive in a rapidly changing environment.  Key reasons are:
    Kaiser Family Foundation estimates that the merged companies will cover 26% of all Medicare Advantage enrollees nationwide making it the leading provider. 

    Mr. Bertolini has a golden parachute and so stands to make $131.3 million in a takeover if he is pushed out. 

    Aetna pushes back against surgery assistant charges. 
    Aetna has litigated against excessive use and fees for out-of-network assistants in surgery. 
    J. Edward Neugebauer, chief litigation officer of Aetna said the company sued an in-network neurosugeon on Long Island who always calls in an out-of-network partner to assist, resulting in huge charges.  The surgeons shared a business address. 

    Aetna CarePass
    Aetna had developed and offered a personalized health data platform for patients called CarePass.  It was discontinued because it did not deliver on the anticipated results. 

    Aetna has purchased HCIT companies:

    Aetna ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    Healthagen 
    Aetna has an ACO pilot with Carillion Clinic.  Aetna has branded its accountable care and other technology solutions as Healthagen.  It seems a similar business structure to UHC's Optum. 

    Aetna says they have policies in place to support people who are in the middle of medical treatments. 


    AmeriHealth Caritas


    AmeriHealth Caritas provides managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses.  It was based on the group practice organizations: Kaiser, Mayo Clinic; operations.  The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care.  Original capitation based implementations were problematic with only Kaiser succeeding.  Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts. 
    solutions for Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     and Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    . 

    Anthem Inc.  (Wellpoint until 2014)


    Anthem is a provider of health plans offered on the public insurance marketplaces. 
    CEO Joseph Swedish. 

    Pressure to merge health insurers Anthem & Cigna
    Anthem has agreed to merge with Cigna for $48.3 billion + taking on Cigna's debt.  Anthem will pay $103.40 a share in cash and 0.5152 of a share in Anthem stock ($188 per share).  It is a transaction that will be subject to antitrust scrutiny.  They argue the merger will result in greater scale and major cost cutting ($2 billion).  Given the pending merger of Aetna and Humana, there will only be three major health insurers.  Fewer competitors tends to increase insurance premiums which may be an issue to the Federal government.  Merger is catalyzed by:
    As the companies merge their competitors will also adapt.  Centene argues they will use the opportunity to compete more in Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     plans. Centene, WellCare and Molina Healthcare all specialize in public Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    programs and are likely targets for merging. 

    The merger effects will likely differ by region across the country depending on the local market share.  And large employers will find they can offer employees less options. 

    Sep 2015 Mr Swedish told a senate committee reviewing the merger that the merger would "uniquely benefit consumers" by expanding access to care through a more extensive network of doctors and hospitals.  He noted that the combined company would face robust competition in many geographic markets and product lines.  The consumers union was skeptical suggesting a dominant insurer could force doctors and hospitals to cut costs so much that the quality of care might suffer.  They doubt the merger will pass the requirements of the Clayton act of 1914.  It aimed to prevent anticompetitive practices.  It specifies particular prohibitied conduct, a three-level enforcement scheme, exemptions (labor union and agricultural organization safe harbor, and major league baseball exemption) and remedial measures.  It has four sections which modify the Sherman Act:
    • Section 2 controls price discrimination between purchasers if it lessons competition.  
    • Section 3 controls exclusive dealings where purchasers are required to buy a tied product. 
    • Section 7 control mergers and acquisitions where the effect substantially lessens competition.  It allows the government to regulate all mergers and gives the government discretion whether to approve a merger or not.  Section 7 was later strengthened to cover asset acquisitions by the 1950 Celler-Kefauver amendments.  Section 7a requires companies considering a merger to inform the FTC and DOJ. 
    • Section 8 limits people from being directors of two or more competing corporations if those two corporations would violate the anti-trust criteria by merging.  
    . 

    According to Professor Leemore Dafny, a health economist is the study of trade between humans.  Traditional Economics is based on an equilibrium model of the economic system.  Traditional Economics includes: microeconomics, and macroeconomics.  Marx developed an alternative static approach.  Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics.  Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. 
    at Northwestern University, past history does not indicate that insurance consolidation leads to savings for consumers or that the large insurers are likely to be more innovative. 

    Smaller insurers do not have the resources of big insurers. 


    The AMA is the American Medical Association. 
    is unhappy with the possibility of the Anthem/Cigna and Aetna/Humana mergers.  The mergers increase the power of the payers include four types:
    • From the 1930s the insurers Blue Cross and Blue Shield catalyzed health care activity by paying a daily per diem to hospitals for the diagnoses and treatments the hospital's dispensed.  At their inception in 1966 Medicare and Medicaid followed this reimbursement model. 
    • From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.  This forced alignment of the supplier, diagnosis, treatment, billing and reimbursement processes.  The health care network is still structurally aligned around PPS.  Under scrutiny of ProPAC and its successor MedPAC,  as well as pressure of the BBA after 1997, the payments per DRG have been steadily reduced until it was below the cost of care, forcing hospitals to seek margin from their other payers.  Medicare outlier payments benefited hospitals that inflated charges and thus became eligible. 
    • Employers as they experienced cost shifting from the hospital's increased product charges moved their employees over to managed care based payment. 
    • Private payers pay hospitals directly for their diagnosis and treatment.  Typically this group has little power.  There are default rates for private payers - typically 40% of billed charges that are not covered by a fixed payment or a fee schedule.  For the uninsured poor until 2004 they obtained little discount on the hospital's chargemaster list price, because insurers and CMS required to be charged the lowest value offered to any patients.  Medicare has now relaxed this constraint. 
    relative to the hospital groups and doctors.  Likely they will respond by combining as well. 

    If both hospitals and Insurers consolidate patients may be less powerful if there is less market competition.  Similarly the increase in power may keep out startups and reduce the motivation to innovate.  Still Express scripts merger with Medco Health did not significantly undermine competition. 

    Increased power is likely to reduce the motivation for the big insurers to innovate and partner with hospitals and doctors in innovative ways.  They will focus on lowering prices of the providers and doctors. 

    The merger was subsequently blocked by the courts (Feb 2017). 

    Anthem is a board member of the U.S. Chamber of Commerce. 

    Anthem's IngenioRx
    Anthem partners with CVS to form PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    (Oct 2017)


    Anthem tele-health
    Anthem will cover virtual urgent care visits for its 16 million members in 11 states by the end of 2015. 


    Anthem Blue Cross

    Anthem Blue Cross is part of WellPoint -> Anthem inc post 2014.  It covers 14 states. 

    It is the for-profit version of the Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    Blue Shield non-profit plans. 

    Nov 2015 California fined Anthem Blue Cross for inaccurate provider directories for Anthem health plans. 


    Anthem and vivity. 
    It has worked with CalPERS to provide a program capping prices of commodity operations at a list of hospitals.  It has generated (Sep 2014) the joint venture Vivity.  Pam Kehaly of Anthem said the venture was expected to produce significant savings and profit by reducing unnecessary tests and uneeded hospital and emergency room admissions.  She argued "What motivates the hospitals to collaborate is that they will all benefit if the care is better and less costly.  That is a discussion that would never occur if you didn't have a shared P & L." 
    Anthem ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    Anthem has an ACO pilot with Sharp HealthCare medical groups


    Arches Health Plan

    Arches is a Utah plan operating through the federal exchange. 

    Nathan Johns the CFO commented "Our enrollees generated 24% more claims than we thought they would when we set our 2014 rates".  This resulted in collected premums of $39.7 million and claims of $56.3 million in 2014. 

    Arches has requested increases of 45% for 2016. 


    Blue Cross Blue Shield




    In more than 30 states nonprofit Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    sells the most policies to large employers, with almost a dozen capturing three-quarters of the market according to Kaiser family foundation data.  It is the key presence in Massachusetts, Minnesota, Oregon and Washington.  Anthem Blue Cross is the for profit BCBS. 

    During the great depression the AHA is the American_hospital association. 
    encouraged the development of Blue Cross, and other medical societies supported the development of Blue Shield to help catalyze use of medical services.  Both payers include four types:
    • From the 1930s the insurers Blue Cross and Blue Shield catalyzed health care activity by paying a daily per diem to hospitals for the diagnoses and treatments the hospital's dispensed.  At their inception in 1966 Medicare and Medicaid followed this reimbursement model. 
    • From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.  This forced alignment of the supplier, diagnosis, treatment, billing and reimbursement processes.  The health care network is still structurally aligned around PPS.  Under scrutiny of ProPAC and its successor MedPAC,  as well as pressure of the BBA after 1997, the payments per DRG have been steadily reduced until it was below the cost of care, forcing hospitals to seek margin from their other payers.  Medicare outlier payments benefited hospitals that inflated charges and thus became eligible. 
    • Employers as they experienced cost shifting from the hospital's increased product charges moved their employees over to managed care based payment. 
    • Private payers pay hospitals directly for their diagnosis and treatment.  Typically this group has little power.  There are default rates for private payers - typically 40% of billed charges that are not covered by a fixed payment or a fee schedule.  For the uninsured poor until 2004 they obtained little discount on the hospital's chargemaster list price, because insurers and CMS required to be charged the lowest value offered to any patients.  Medicare has now relaxed this constraint. 
    reimbursed is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
     the hospitals with a per patient daily per diem and some additional margin. 


    The BCBS association has been accused of cartel practices. 

    They must offer a competitive alternative to a combined Aetna-Humana or Anthem-Cigna.  They are faced with decreasing revenues and more competition from new entrants, such as co-op plans enabled by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    and Ascension, Catholic system and North Shore-LIJ in New York which can leverage their local standing. 



    Prime Therapeutics is Blue Crosss Blue Shields PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    . 
    David Lassen of Prime is seeing an increased request for narrower formularies are lists of drugs that a health plan will cover.  The health plans control where and if the drug is listed in the plan.  A less expensive drug can be assigned a lower copayment to encourage patients to use it.  To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs.  Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether.  That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure.   and excluded drugs.  However, Prime was worried about the disruptions for patients forced to switch drugs. 
    Blue Health Intelligence
    Blue Health Intelligence manages integrated medical and pharmacy claims for 110 million individuals. 
    2013 It has purchased Intelmedix its analytic solution provider. 

    BlueCross of Alabama
    Blue Cross of Alabama includes a division that is a Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     ZPIC is Zone Program Integrity Contractor.  A CMS Medicare benefit integrity MIP contractor for one of the seven national CMS designated zones.  It has a benefit Integrity unit with the primary goal of identifying and acting upon benefit fraud.  
    . 

    Blue Cross Blue Shield of North Carolina
    Seeking a 2016 rate increase of 25% for its 397,000 consumers. 
    Justified by:

    Blue Cross Blue Shield of South Carolina
    BCBS South Carolina is working with Zipongo. 


    Blue Cross Blue Shield of Georgia

    Dec 2017 Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    Blue Shield initially developed in the early 1930s to provide health insurance for physician visits.   of Georgia is exiting from the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    individual markets in 74 of the 159 counties in Georgia (Dec 2017). 



    Blue Cross of Idaho

    BlueCross BlueShield of Illinois
    Seeking a 2016 rate increase of 23%




    BCBS Illinois ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    BCBS Illinois has a shared savings contact with Advocate Health Care. 


    Blue Cross Blue Shield of Kansas

    Seeking a 2016 rate increase of 37% for 28,600 consumers

    They justified the increase noting "Kansans who purchased these individual plans since 2014 were older, in general, than expected and required more medical services than anticipated". 



    BCBS Massachusetts

    2017 Dana Gelb Safran BCBSMA chief performance measurement & improvement officer

    Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    Blue Shield of Massachusetts has developed the Alternative Quality Contract (AQC) is:
    • A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts.  It was developed to support change.  It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction.  Its key components are:
      • Integration across the care continuum
      • Accountability for performance measures for ambulatory and inpatient care.  Includes a 10% incentive for performing. 
        • Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome. 
      • Global payment for all medical services with health status adjustment and with margin retention. 
      • Five year contract to create a sustained partnership 
     (AQC).  Ezekiel Emanuel notes an executive from BCBS concluded:
    • More than half the AQC savings were associated with shifting to lower-cost settings. 
      • Initially switched settings in areas where no relationship was threatened: lab tests, imaging & colonoscopies. 
      • Later hospitals and specialists with lower prices were selected. 
    • There was no change in the amount of care provided. 

    Dana Safran believes:

    BCBS Massachusetts ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    BCBS Massachusetts has an alternative quality contract (AQC) is:
    • A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts.  It was developed to support change.  It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction.  Its key components are:
      • Integration across the care continuum
      • Accountability for performance measures for ambulatory and inpatient care.  Includes a 10% incentive for performing. 
        • Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome. 
      • Global payment for all medical services with health status adjustment and with margin retention. 
      • Five year contract to create a sustained partnership 
     with annual global budget, and quality incentives for participating providers. 

    Blue Cross BlueShield of Michigan

    Is running a Provider Delivered Care Management is transitioning to mean an aggregate of utilization management, case management, disease management, and independent review for populations.  But it sometimes refers to geriatric care management which is the process of planning and coordinating long term care of the elderly.  Such care managers have typically been trained in nursing, social work, and gerontology.  They integrate health care and psychological care with other services such as housing, home care, nutrition, socialization, financial and legal planning. 
    Pilot operated by IHP and using Care Team Connect's integration infrastructure. 

    BlueCross BlueShield of MN

    Blue Cross Blue Shield of Minnesota American Well for Tele-health is the use of remote health care.  It includes telepharmacy and clinical telehealth for stroke and psychiatry.  It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors. 
    . 

    Blue Cross BlueShield of MN request 50 percent rate increases for 2016
    Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    and Blue Shield of MN requested rate increases of 50% for 2016 for plans of the health exchanges.  They argue their claims have not slowed at all over 2015.  The trend has gotten a little worse.  They reported a surge in prescription drug expenses.  Two high-cost specialty drugs cost tens or hundreds of thousands of dollars a year when used to treat complex or rare diseases: cancer, rheumatoid arthritis, hemophilia, HIV.  By 2015 they account for one-third of all spending on drugs in the United States and should reach 50% by 2025.  With the MMA constraining Medicare drug price negotiations many old generic drugs appear to be being rebranded with controlled distribution as specialty drugs and re-priced with vast margins (Sep 2015). 
    for rheumatoid arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart.  It can be treated with: Enbrel, Humira, Ilaris, Xeljanz;
    , Enbrel and Humira, account for one-fourth of prescription drug costs in the company's individual health plans. 

    The ratio of claims paid to premium revenue was more than 115%.  The company said it lost more than $135million on its individual insurance business in 2014.  They argue 2015 deficit will be higher. 
    BCBS MN ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
     BCBS MN has a shared savings contract with five providers. 

    Blue Cross Blue Shield of Mississippi



    Blue Cross Blue Shield of New Mexico


    Seeking a 2016 rate increase of 51%



    Blue Cross Blue Shield of Nebraska

    CEO Steve Martin

    BCBS Nebraska's Steve Martin 2015 health evolution summit
    Steve Martin talked at the 2015 health evolution summit:


    Blue Cross Blue Shield of Oklahoma


    Seeking a 2016 rate increase of 31%

    Blue Cross Blue Shield of Texas


    Offers narrow network - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans.  This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans.  By limiting the number of providers/doctors offered in the plans the few that are included should get more business.  Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers).  In large cities narrow networks are even more common.  Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills.  There are problems induced by narrow network constraints:
    • Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts.  Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running.  If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.  
    • Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016). 
    plans on the exchange.  HCA has effectively gained access to most of these plans in Apr 2014. 

    Asked for 60% increases for 2017 ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    insurance exchange policies.


    Blue cross Blue Shield of Tennessee


    Seeking a 2016 rate increase of 36%

    Lost $141 million because they were not very accurate in predicting the utilization of health care in 2014. 

    Tennessee insurance commissioner JUlie Mix McPeak said she would ask "hard questions of the companies we regulate, to protect consumers." 


    BlueShield of California


    Blue Shield of California uses Teladoc. 

    BlueShield describes 2014 California health exchange rates
    Its premiums for individual customers would increase about 13 percent on average next year over current premiums; about 8 percent of that increase would cover rising hospital and medical costs, which would have happened anyway.  The other 5 percent pays for better benefits, guaranteed coverage for pre-existing conditions, and taxes and fees imposed on insurers by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    . 

    Nov 2015 California fined Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    of California for inaccurate provider directories for its health plans. 

    Blue Shield of California ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    s
    2012 Blue Shield of California has two ACOs in Northern California: 


    Cambia Health Solutions

    Cambia Health Solutions is a nonprofit health insurance corporation in Portland, Oregon.  It sells insurance through subsidiaries including Regence BCBS. 

    CEO Mark Ganz

    Cambia health's Mark Ganz 2015 Health evolution summit
    Mark Ganz talked at the 2015 health evolution summit on end-of-life and palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  : Cambia based on four pillars of how to transform health care experience from worst areas - Palliative care issue is that physicians are not trained in palliative care with death as a failure.  For most people caring at end-of-life is frustrating.  Cambia want to add palliative care to support these situations.  Curative care is very impacting.  Need to cure the culture is how we do and think about things, transmitted by non-genetic means as defined by Frans de Waal.  CAS theory views cultures as operating via memetic schemata evolved by memetic operators to support a cultural superorganism.  Evolutionary psychology asserts that human culture reflects adaptations generated while hunting and gathering.  Dehaene views culture as essentially human, shaped by exaptations and reading, transmitted with support of the neuronal workspace and stabilized by neuronal recycling.  Sapolsky argues that parents must show children how to transform their genetically derived capabilities into a culturally effective toolset.  He is interested in the broad differences across cultures of: Life expectancy, GDP, Death in childbirth, Violence, Chronic bullying, Gender equality, Happiness, Response to cheating, Individualist or collectivist, Enforcing honor, Approach to hierarchy; illustrating how different a person's life will be depending on the culture where they are raised.  Culture:
    • Is deployed during pregnancy & childhood, with parental mediation.  Nutrients, immune messages and hormones all affect the prenatal brain.  Hormones: Testosterone with anti-Mullerian hormone masculinizes the brain by entering target cells and after conversion to estrogen binding to intracellular estrogen receptors; have organizational effects producing lifelong changes.  Parenting style typically produces adults who adopt the same approach.  And mothering style can alter gene regulation in the fetus in ways that transfer epigenetically to future generations!  PMS symptoms vary by culture. 
    • Is also significantly transmitted to children by their peers during play.  So parents try to control their children's peer group.  
    • Is transmitted to children by their neighborhoods, tribes, nations etc. 
    • Influences the parenting style that is considered appropriate. 
    • Can transform dominance into honor.  There are ecological correlates of adopting honor cultures.  Parents in honor cultures are typically authoritarian. 
    • Is strongly adapted across a meta-ethnic frontier according to Turchin.  
    • Across Europe was shaped by the Carolingian empire. 
    • Can provide varying levels of support for innovation.  
    • Produces consciousness according to Dennet. 
    of control.  


    Capital BlueCross

    Capital BC is a Harrisburg, Pennsylvania BlueCross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    health insurer. 



    Capital District Physicians' Health Plan (CDPHP)

    CDPHP offers New York health insurance and Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     Plans.
    It is offering employers a plan that caps any rate increases at under 10% in the first and third years. 


    CareConnect

    CareConnect is the insurance plan for North Shore-Long Island Jewish Health System.  It has enrolled 28,000 customers but is not yet profitable (Sep 2015). 
    CEO Alan Murray. 

    By June 2016 CareConnect has 100,000 subscribers which are insured through either large or small employers.  That is a 'well understood' population which allowed CareConnect to plan and operate effectively.  Alan Murray noted "If we only had the individual market, we would have taken undue risk because we would not have understood that market."  He said Careconnect is close to turning a profit. 


    Northwell Health's Michael Dowling is closing its CareConnect Insurance division because it has been generating large losses. 

    13% of CareConnect's customers use the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    personal exchanges. 
    Most of CareConnect's customers use small business plans. 



    Dowling notes "It has become increasingly clear that continuing the CareConnect health plan is financially unsustainable, given the failure of the federal government and Congress to correct regulatory flaws that have destabilized insurance markets and their refusal to honor promises of additional funding." 


    The regulatory problems are:




    CareFirst Blue Cross of Maryland


    Rates were initially set low for the state marketplace but have been rising allowing Evergreen a foothold. 


    CareMore Health Plan

    CareMore is a health plan (Medicare Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits.  It was originally enacted as part of BBA Medicare + Choice or Part C plans.  The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS.  When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month.  The participant pays the Medicare part B premium and if required a part C premium each month.  The MA plans offer a PCP who coordinates care.  And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer.  About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019.  The ACA introduced quality outcome and patient satisfaction based differential payments into MA.  To measure the performance it added a five-star quality rating scheme.  MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars.  The highest rated plans are provided with large additional payments.  It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA.  And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage.  However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding.  It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. 
    ) that is structured as an integrated health system focused on pro-active health care for its members to limit hot spot is a highly connected agent with an outsize influence.  In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande.  Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients.  Robert Pearl argues the strategy has limited applicability in the current health care network.  He asserts a revolution can/must happen that will help this strategy to become broadly applicable.  Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community.   costs and improve overall outcomes and welfare. 

    CEO 2017 Sachin H. Jain
    Leeba Lessin is a non-physician leader. 
     
    CareMore is part of Anthem. 


    CareMore is a Medicare Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits.  It was originally enacted as part of BBA Medicare + Choice or Part C plans.  The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS.  When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month.  The participant pays the Medicare part B premium and if required a part C premium each month.  The MA plans offer a PCP who coordinates care.  And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer.  About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019.  The ACA introduced quality outcome and patient satisfaction based differential payments into MA.  To measure the performance it added a five-star quality rating scheme.  MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars.  The highest rated plans are provided with large additional payments.  It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA.  And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage.  However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding.  It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. 
    health plan and health system in California which specializes in caring for chronically ill patients.  Medicare provides CareMore with an overall payment for the expected costs of each beneficiary and benchmarks its quality of service and coverage levels.  CareMore provides its own care which is highly effective:
    CareMore's Sachin Jain comments "In hospitals, we're great at customizing care.  We have different intensities for patients with different needs: an observation unit, a general medical ward, an intensive care unit.  But on the outpatient side, we haven't done that.  In your average clinic, all patients get scheduled for 15 or 30 minutes, regardless of whether their problem list is empty or 10 pages long.  Our model tries to fix that." 



    CareMore patient care standardization
    CareMore adopts standardized protocols from government and professional societies; which they apply to the major illnesses they treat. 
    Ezekiel Emanuel notes that CareMore has to be careful that they can afford to adopt the protocols, since many of their Medicare Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits.  It was originally enacted as part of BBA Medicare + Choice or Part C plans.  The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS.  When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month.  The participant pays the Medicare part B premium and if required a part C premium each month.  The MA plans offer a PCP who coordinates care.  And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer.  About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019.  The ACA introduced quality outcome and patient satisfaction based differential payments into MA.  To measure the performance it added a five-star quality rating scheme.  MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars.  The highest rated plans are provided with large additional payments.  It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA.  And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage.  However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding.  It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. 
    plan subscribers have fixed incomes.  Caremore apply an affordability constraint, to ensure that patients can adhere to their treatment plans.  CareMore explicitly selects medications, treatments etc., to minimize costs to patients. 


    CareMore chronic care coordination

    Caremore see their chronic care strategy as different:
    As the management of chronic illness became more standardized and efficient, CareMore has viewed behavioral health as increasingly significant. 
    CareMore behavioral health integration
    When a subscriber has their Healthy Start exam with a CareMore nurse practitioner, it includes screening tests for depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Treatments include: CBT, UMHS depression management.  As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards.  Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women.  Michael Pollan concludes anxiety is fear of the future.  , cognitive deficits etc.  And CareMore include an annual depression screen in its diabetic includes type 1 and type 2.  Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. 
    treatment pathways and EHR refers to electronic health records which are a synonym of EMR.  EHR analysis suggests strengths and weaknesses:
    • The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
    • The EHR does not necessarily reflect the patient's situation accurately. 
    • The EHR often acts as a catch-all.  There is often little time for a doctor, newly attending the patient, to review and validate the historic details. 
    • The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting. 
    • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes.  With the EHR 12 minutes may be required to update the record!
    .  Then CareMore careteams assess the contribution of behavioral health and psychosicial issues in shifts in care plan results. 

    CareMore setup a behavioral health SWAT team: psychiatrist, psychologist, social worker[, addiction specialist to assist seniors addicted to prescription medications]; to rapidly see: within 2 to 3 days; patients who test positively in their screening tests and provide medications or CBT is cognitive behavioral therapy.  It was originally designed to treat depression.  CBT leverages cognitive and behavioral principles to cope with behaviors, induced by prior conditioning, which cannot be managed directly with rational thoughts.  Instead it assumes that one's relationship with maladaptive thinking and emotional bindings can be changed through antecedent strategies.  CBT is problem focused and action oriented.  Errors in thinking like: overgeneralizing, magnifying negatives, minimizing positives and catastrophizing are replaced with more realistic and effective thoughts.  . 

    CareMore de-institutionalization
    CareMore extensivists can manage across the care continuum.  So they can constrain over-testing & -treatment in all settings.  CareMore standardizes techniques across settings.  But they work in a 'high touch' care team that builds a relationship with the patient, overcoming the fear that early discharge is a profit driven strategy.  And because CareMore's financial agreement with the institutions is per diem based rather than a DRG is a diagnosis-related group.  It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits.  The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides.  It assumes patients within a grouping are clinically similar.  Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities.  For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed.  , the financial incentives align too. 

    Upon admission the care team: extensivist, case manager is defined by American Case Management Association as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost effective outcomes.  Case management productivity, discharge planning, utilization, coding and documentation, denials (RAC), Patient satisfaction (HCAHPS) and performance improvements are often measured to constrain overheads.  Patient flows can be assessed via numbers of: admissions, observation days, patient days, outpatient visits, discharges, E.D. volumes, occupancy, and denial rates.  , nurse practitioner; start planning for discharge - have costly handoff problems reviewed by project BOOST.  When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue.  Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs.  Discharge information can include:
    • Patient info
    • Behavioral summary
    • Treatment history
    • Medical history
    • Treatment objectives
    • Insurance policy
    • Discharge plans
     and how to transition over to home care. 

    SNF is skilled nursing facility. 
    s are preferred to hospitals, whenever ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
    support is not needed, since they charge less, giving CareMore a higher SNF bed day rate than the Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     average.  With the CareMore team practicing on site, patients typically get discharged before the last day of Medicare reimbursement is the payment process for much of US health care.  Reimbursement is the centralizing mechanism in the US Health care network.  It associates reward flows with central planning requirements such as HITECH.  Different payment methods apportion risk differently between the payer and the provider.  The payment methods include:
    • Fee-for-service,
    • Per Diem,
    • Episode of Care Payment, 
    • Multi-provider bundled EPC,
    • Condition-specific capitation,
    • Full capitation.  
    . 

    Prior to discharge to home, CareMore coordinates with DME - Durable Medical Equipment describes any medical equipment using in the home to aid in a better quality of living. 
    providers and HHA is home health agency. 
    s to ensure all necessary equipment has been delivered and installed.  The care team will see the patient after discharge, at home or a CareMore center. 
    CareMore geographic expansion
    CareMore is working to expand, from Southern California, into Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    markets in Atlanta with Emory, Memphis and Des Moines by replicating its most successful Southern California practices.  They use their chronic care coordination strategy to shift patients out of hospital to lower cost facilities is a Post-Acute Care provider.  A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services.  Acute care hospitals become portals to the PAC business.  Referrals are key.  PAC includes different types of facility focused on different severity of illness (high to low):
    • Long term care Hospital (LTCH),
    • Inpatient rehabilitation facility (IRF),
    • Skilled nursing facility (SNF),
    • Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
    • Outpatient rehabilitation.  SNF and HHA represent 80% of discharges and expenditures.  Assisted living is not part of federal Medicaid, but states often include it through a waiver. 
    and their homes.  This requires trained extensivists and care-managers is transitioning to mean an aggregate of utilization management, case management, disease management, and independent review for populations.  But it sometimes refers to geriatric care management which is the process of planning and coordinating long term care of the elderly.  Such care managers have typically been trained in nursing, social work, and gerontology.  They integrate health care and psychological care with other services such as housing, home care, nutrition, socialization, financial and legal planning. 
    to ensure home care and DME - Durable Medical Equipment describes any medical equipment using in the home to aid in a better quality of living. 
    providers are integrated and coordinated. 

    In Memphis, CareMore needed to:
    Sachin Jain explains "We have done things like extend hours, so now our offices are open 7 a.m. to 7 p.m. Ii is a nurse-practitioner-based primary care consists of providing accessible, comprehensive, longitudinal, and coordinated care in the context of families and community.  Interpreting the meaning of many streams of information and working together with the patient to make decisions based on the fullest understanding of this information relative to the patient's values and preferences is key to PCP providing value. 
    system with long visits.  We have also implemented an ER avoidance program to try to get them to use CareMore offices before going to the E.R. 


    Catamaran

    Is a PBM is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    . 
    Chief medical officer Dr. Sumit Dutta. 

    Mar 2015 purchased for $13 Billion by UHC.  The deal combines Catamaran's BriovaRx with UHC's pharmacy services businesses. 

    They are excluding 54 drugs from an optional formulary in 2014. 

    They also became alarmed when their spending on compounded pharmaceuticals make unique prescription drugs to order when doctors conclude that standard formulations are not effective treatments. 
    quitupled in two years.  This included:

    Centene Corporation

    Centene is a major supplier of Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program.  Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem.  The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states.  As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year.  In 2017 it pays for 40% of new US births. 
    plans. 
    2017 Centene CEO Michael Neidorff

    With the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care).  In part it is designed to make the health care system costs grow slower.  It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s.  It funds these changes with increased taxes on the wealthy.  It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew.  The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO).  The ACA did not include a Medicare buy in (May 2016).  The law includes:
    • Alterations, in title I, to how health care is paid for and who is covered.  This has been altered to ensure
      • Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
      • That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).  
      • Children, allowed to, stay on their parents insurance until 26 years of age. 
    • Medicare solvency improvements. 
    • Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision. 
    • Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.  
    • Medical home models.  
    • Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health. 
    • Qualifications for ACOs.  Organizations must:
      • Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers. 
      • Participate in the MSSP for three or more years. 
      • Have a management structure. 
      • Have clinical and administrative systems. 
      • Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO. 
      • Be accountable for the quality and cost of care provided to the Medicare FFS patient population. 
      • Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care; 
      • Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.  
    • CMMI Medicare payment experimentation.  
    • Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act). 
    • A requirement that chain restaurants must report calorie counts on their menus. 
    catalyzed 2015 mergers of Aetna/Humana & Anthem/Cigna and major hospital groups, Centene says it might move more into Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
    • Benefits
      • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
      • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
      • Part C: Medicare Advantage 
      • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    • Eligibility
      • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
      • Persons under 65 with disabilities who receive SSDI. 
      • Persons with specific medical conditions:
        • Have end stage renal disease or need a kidney transplant. 
        • They have ALS. 
      • Some beneficiaries are dual eligible. 
      • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    • Sign-up
      • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
      • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    • Premiums
      • Part A premium
      • Part B insurance premium
      • Part C & D premiums are set by the commercial insurer.  
     insurance buying some of the plans that could be divested if some of its competitors merge.  It announced it would buy Health Net. 

    Centene is entering additional individual markets as others exit (Jun 2017)


    Centene's Neidorff commented "It's a good business for us.  Centene has done well.  Centene recognizes there is uncertainty" in the new health care legislation (May 2017).  

    Centene has experience being the only insurer in a market: Maricopa County, Arizona; and it had found this market no worse than its others. 

    Centene provides coverage to 1.2 million people through state marketplaces. 




    CIGNA

    Cigma CEO David Cordani planned to become president and COO of merged Anthem/Cigna.  The merger was subsequently blocked by the courts (Feb 2017). 
    Cordani said the merger cost improvements would go back to the employer, the governmental entity an/or the individual and the merger would receive the necessary regulatory approval.  Initially Cigna rejected Anthem's offer of $47 billion citing risk of antitrust suits that have ensnared Anthem as the largest member of the Blue Cross Blue Shield association.  BCBS association has been accused of cartel practices.  The rejection was viewed as a way to increase Anthem's offer price. 

    Mr. Cordani has a golden parachute and so stands to make $58.7 million in a takeover if he is pushed out. 

    Cigna offers:
     
    CIGNA ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems.  Advocate health illustrates the idea.  Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize.  But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business.  The ACA regulates qualification to be a Medicare ACO.  Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS.  But the ACO is eligible for shared savings.  Within the shared savings program the CMS innovation center has setup advanced payment ACOs.  As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment.  CMS has established quality measures for ACOs for Medicare.  The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. 
    • CMS initiated its Physician Group Practice Demonstration in 2005.  By 2008 the congressional budget office reported on Bonus-eligible organizations. 
    • CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
    • CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing. 
    • CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.  
    • Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.  
    CIGNA has a Medical home contract with Piedmont Physicians Group


    Community Health Options

    Community of Maine has captured more than half of its market and achieved a surplus of $5.9 million. 


    Consumers' Choice Health Plan

    Consumers' Choice is South Carolina's health insurance co-op. 
    Its enrollment was 70,000 in 2015 up from 46,000 in 2014.  Consumers' is still losing money in 2015.  They plan to break even in 2016. 

    It paid its top two executives $458,000 and $351,710 in 2013

    President Jerry Burgess commented "I am not overpaid.  My compensation is similar to that at nonprofit health care enterprises of similar size."  Burgess is also president of the Tennessee coop which pays half his salary. 


    Consumers' Mutual Insurance of Michigan

    Co-operative startup. 
    Posted a notice on its website saying it will not sell health plans in 2016 on the insurance market place. 


    CoOportunity Health

    CoOportunity is a federal insurance cooperative in Iowa.  It was given $145 million in federal loans to get started. 

    Its lack of subscribers and profits came to the attention of the Iowa insurance commissioner and it was declared insolvent by a state court. 


    Coventry Health Care

    Coventry is a unit of Aetna (acquired in 2013).  It is based in Bethesda, Maryland.  It is a national insurer. 

    Coventry is seeking rate increases of 19% for 2016 in Missouri.  They explained the rates reflected the cost of care.  For 2016 we expect medical costs will grow by 8 - 10 % in the individual market.  They also noted that the federal government is scaling back a transitional program that helped insurers pay certain very large claims. 


    Dean Health Plan

    Dean Health Plan is an HMO plan is a Health Maintenance organization managed care plan as opposed to a PPO plan.  It uses the allocated PCP as a gatekeeper who must refer a patient to any health specialist for the patient to gain access. 
    in Madison Wisconsin.  It started as a response to the Wisconsin state legislatures mandate that all state workers be offered a HMO option to build competition to the Blue Cross Blue Shield Plan.  It was formed and owned by physicians at the Dean Clinic. 

    Dean is a very highly ranked HMO.  It is a 5-star Medicare Advantage Plan.  J.D. Power ranked it the highest health plan in Minnesota-Wisconsin.  It offers the lowest cost silver plan on the Wisconcin individual exchanges. 


    Evergreen Health

    Evergreen Health is a co-op in Maryland.  It competes with a large Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments.  Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures.  The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment.  Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. 
    plan CareFirst.  It has 22,500 customers with plans to double in a year. 

    CEO Dr. Peter Beilenson

    As CareFirst has raised its rates Evergreen's plans have become more competitive. 


    Express Scripts

    Express Scripts is the largest pharmacy benefits manager is pharmacy benefit manager.  These companies, such as Caremark, were often originally PPMs.  PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers.  PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. 
    .