General competitor

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. 
  • Health care is provided to patients by a complex value delivery system.  In this contents list we reference: key situations; new participants aiming to disrupt or compete with incumbents; Indirect payers including employers and insurers; process managers including PBMS; Providers of acute, ambulatory, homecare/hospice care; Pharmacies; Ambulances. 



Employers as insurers

Employers obtain government subsidies when they act as health insurers.  But they have been threatened by the increasing cost of health care delivery.  By 2016 they are reducing this risk by cost-shifting 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 SCOTUS 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 patent-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. 
  • 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

In 2010 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 Kaiser 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.  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 programs 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.  



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' 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 Kaiser 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.  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 programs 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. 
, 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.  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.  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. 
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 nascent access to the pharmacy and medical device markets may be disruptive (Oct 2017). 



Honeywell

Morris Plains, NJ
Honeywell is a conglomerate that invents and manufactures solutions including: Thermostats, Home systems, Mobile productivity;
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

  • UPS drives employees spouses to their own employer (Aug 2013)

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 SCOTUS 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 patent-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. 
  • 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 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 Walmart 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 low FFS leverage of the PCP compared to specialists. 
.  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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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.  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 SCOTUS 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 patent-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. 
  • 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. 

Walmart like other big retailers are losing sales to online providers. 


Whole Foods Market

Whole Foods business model has been threatened by major food retailers market extending into organic produce.  This has resulted in pressure from hedge funds is an investment fund that accepts investments from a limited number of accredited individual or institutional investors.  Hedge funds are able to use investment methods that are not allowed for other types of fund. 
: Jana Partners; which resulted in Amazon's acquisition of Whole Foods. 


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. 
s negotiate with drug companies on behalf of insurers (employer plans, Medicare part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries enacted as part of the MMA.  It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies flow to a broad group of elderly voters and a small but influential group of payers 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. 
, Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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 Health 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 but the system incentivises 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. 
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 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.  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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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 is Gilead Sciences hepatitis-C drug.  It is the first effective cure with acceptable side effects.  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 allowing it time to recover from the stress of processing toxic substances.  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 SCOTUS 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 patent-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. 
  • 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 low FFS leverage of the PCP compared to specialists. 
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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
allowing individuals to receive subsidies when they buy policies through HealthCare.gov

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 Kaiser 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.  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 programs 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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.  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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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 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 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 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. 

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. 
(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 Kaiser 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.  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 programs 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 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 SCOTUS 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 patent-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. 
  • 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. 
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
BlueCross 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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

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 Kaiser 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.  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 programs 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 


Dana Safran believes:

BCBS Massachusetts ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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

BlueCross BlueShield 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, 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 Kaiser 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.  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 programs 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 SCOTUS 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 patent-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. 
  • 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


BlueShield 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 SCOTUS 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 patent-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. 
  • 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 Kaiser 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.  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 programs 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 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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 SCOTUS 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 patent-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. 
  • 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 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.  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.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  About 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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.   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 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.  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.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  About 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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 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.  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.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  About 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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. 


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. 

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.  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 SCOTUS 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 patent-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. 
  • 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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 will become president and COO of merged Anthem/Cigna
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 Kaiser 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.  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 programs 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 serving Missouri. 

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. 

President Tim Wentworth

Express Scripts says specialty drug prices rising over ten percent per year
Express Scripts says that spending on 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). 
has risen 14.1 percent in 2013 and by even greater amounts in each of the previous few years.  Express scripts owns Accredo specialty pharmacy dispense specialty medications.  They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste.  These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained.  Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. 


Most of that increased spending comes from price increases in already marketed drugs where yearly increases often exceed 10 percent year after year.  In part that is because other countries control the price payed for drugs and so the US is used to sustain global increases in price. 

Express Scripts halt payment for some specialty drugs
To discourage further price increases Express Scripts recently stopped paying for Advair is GlaxoSmithKline's big selling respiratory medicine. 
and Victoza is Novo Nordisk's big-selling diabetes drug. 
for many of their patients resulting in precipitous declines in the drugs' market shares.  It also excluded Xeljanz is a Pfizer pill for rheumatoid arthritis. 
.  Advair sales in the United States fell 30 percent in the first quarter.  Symbicort from AstraZeneca which remained on the list grew 20%. 

Express Scripts will exclude 54 drugs from its 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.   in 2014.  And in 2015 they plan to offer an optional formulary with 200 exclusions. 

Express scripts in 2014 noted that it was spending $171 million in Q1 on compounded drugs in comparison to $28 million in q1 2012.  In consequence It is stopping paying for more than 1,000 ingredients used in compounding.  This will cut spending on such medicines make unique prescription drugs to order when doctors conclude that standard formulations are not effective treatments. 
by 95%. 

Express scripts added both Repatha and Praluent to their 2016 formulary (Oct 2015). 

Oct 2015 Express scripts constrain Valeant. 
Express scripts say they will stop paying for drugs dispensed by Philidor Rx Services, a specialty pharmacy dispense specialty medications.  They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste.  These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained.  Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. 
tied to Valeant's catalytic sales strategy

Express scripts president Tim Wentworth talks at the 2015 health evolution summit
Tim Wentworth talked about drug pricing economics at the 2015 health evolution summit:

Dec 2015 Express scripts replace Turing's Daraprim on formulary
Express scripts Dr. Steve Miller announced they would promote a $1 compounded medicine from Imprimis to replace Turing's $750 Daraprim on their formulary 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.  
Express scripts will have to manage prescriptions for Daraprim.  They propose to help doctors migrate prescriptions to the compounded medicine.  They will work with the Infectious Diseases Society of America and the HIV Medicine Association to inform doctors about the process. 

Express Scripts puts pressure on high cost anti-inflammatory medications: Humira, Enbrel; (Sep 2016). 

Express Scripts's InsideRx
The program includes:


Extended Home Care

CEO Vincent Achilarre - donated $10,000 to the Senate Republican Campaign committee in 2012. 

Jun 24th 2013 NYT 'Albany, Reinventing Long-Term Care, Endorses Firms It Accused of Fraud' 

Owners formerly included Joseph Zappala a long standing Republican fund-raiser in New York. 

It was recommended for 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. 
status by Dean G. Skelos, the Republican leader 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. 
in the New York State Senate.  Under state law, the leaders of the Legislature can each nominate four agencies for HMO status or equivalent.  In his nominating letter Mr Skelos cited Extended's "unique experience in working with a diverse home care population." 

Extended was seeking a coveted role as a managed long-term care plan and in March 2013 the health commissioner awarded that HMO status to the company after a year long review.  Extended paid $150,000 to the lobbying form of former Senator Alfonse D'Amato last year. 

Previously Extended had been fined $9.5 million in a settlement of false-claims suits.  In 2010 New York's incoming Governor Andrew Cuomo had a $2 billion budget deficit.  In looking for areas to cut from the budget it was found that HHA is home health agency. 
were not saving money, as was their design goal.  Instead they were costing more than the prior health care provider structure!  The cost of caring for frail elderly and disabled people at home had more than doubled from 2003 to 2010, to $1.3 billion, even though fewer people were being treated.  Further investigation highlighted high costs at Excellent Home Care and Extended Home Care.  The agency admitted no wrong doing. 

Home care was originally promoted as a cheaper alternative to hospitals and nursing homes, but as agencies proliferated in the 1990s their billings soared, and government auditors were overwhelmed. Governor  Mario M. Cuomo imposed a moratorium on licensing new agencies in 1994, as President Bill Clinton did nationwide in 1997. 

The administration of Gov. George E. Pataki soon opened a loophole: limited licenses for the care of groups with special needs.  Extended and excellent each secured one. It was conditional on them limiting service to people with developmental is a phase during the operation of a CAS agent.  It allows for schematic strategies to be iteratively blended with environmental signals to solve the logistical issues of migrating newly built and transformed sub-agents.  That is needed to achieve the adult configuration of the agent and optimize it for the proximate environment.  Smiley includes examples of the developmental phase agents required in an emergent CAS.  In situations where parents invest in the growth and memetic learning of their offspring the schematic grab bag can support optimizations to develop models, structures and actions to construct an adept adult.  In humans, adolescence leverages neural plasticity, elder sibling advice and adult coaching to help prepare the deploying neuronal network and body to successfully compete. 
disabilities.  This was meant to be a small patient population.  However, when Extended was audited there were thousands of patients, only 5% of which had developmental disabilities.  It was collecting $93 million from Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
.  

As part of Medicaid redesign the moratorium was lifted in 2012. 

State officials and companies that were found to be gaming FFS argue that with the new payment structure the history was almost irrelevant. 

As attorney general Andrew Cuomo's inquiry found rampant fraud linked to schools that sold bogus credentials to untrained aides.  In the case that resulted in the biggest settlement, federal and state authorities contended that Extended and Excellent Home Care had knowingly bulled the government for services by such aides, and also knowingly billed for work that the aides, employed by a subcontractor, never performed.  A whistle-blower, who said she had been fired by Excellent when she reported the problem, received $1.6 million in the settlement. 

Both Extended and Excellent said they were unknowing victims that had done nothing wrong.  They claimed others falsified records. 

By 2010, billings per recipient at Extended had risen by 94% in seven years, to $31,305 and only 25 percent of its patients were developmentally disabled.  But the cost per patient dropped to $30,253 in 2011, after state payment procedures changed.  Today 88% of the patients are developmentally disabled. 

Jason Helgerson, the New York State Medicaid Director, minimized the importance of the bad HHAs.  In the new system, he said, built-in incentives for cost-efficiency change the nature of the beast.  "If a plan attempts to game us, it will catch up with them," he said. 



Advocates for the frail elderly say a rush to cut costs has already hurt some patients.  The New York Legal Assistance Group sued five agencies in 2011 including Excellent, but not Extended -- saying they had illegally tried to dump disabled patients who suddenly became unprofitable when the 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.   system was replaced.  The agencies paid $50,000 each in a settlement and promised to do better, without admitting wrong doing.  Mr Levy, Excellent's lawyer, said the shedding of high-needs clients was an industry wide issue in 2011, caused by the cutbacks in state payments, which also led to problems paying the subcontractors who sent the aides into homes. 



During the public discussion of Excellent, one state planning council member, Howard Fensterman, waited outside.  He had declared a conflict of interest, since he is one of Excellent's lawyers and his wife has applied for partial ownership. 
Mr. Fensterman is past chairman of fund-raising for Mr. Cuomo on Long Island, and his Lake Success law firm has donated more than a half-million dollars to candidates of both parties over the past decade records show, including more than $17,700 to Mr. Cuomo and $43,291.25 to Senator Skelos, the Senate Republican leader 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. 
.  Excellent and the Fenstermans' separate contributions include another $13,500 to Governor Cuomo. 

Excellent is seeking an expanded license, and has applied to be a 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. 
plan under the name Olympia. 
Excellent is run by Joseph Goldberger who helped raise $500,000 from his Hasidic community in Brooklyn for Mr. Pataki's 1994 campaign. 
Benjamin Landa, a nursing home magnate, has raised money for both parties, and his own contributions include $12,500 to the Republican National Committee, $10,000 to the Democratic Senatorial Campaign Committee, $6,500 to US Senator Charles E. Schumer and $10,000 in 2012 to State Senator John Sampson, a powerful Democrat who was charged with embezzlement and other crimes. 


Fallon Health Plan


Payer who sponsored MA-SHARE RHIO grid supplies the clinical exchange network. 

Fallon has provided most of the funding for the implementation of the SAFE Health Info program.  Funding from Fallon health plan and some grants have funded development of community-led EHR refers to electronic health records which are a synonym of EMR.  EHRs have 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-patent setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
and HIE a Health Information Exchange is responsible for the transmission of healthcare-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
  • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
  • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
project to exchange health information among Fallon Clinic, St. Vincent's Hospital and University of Massachusetts Memorial Health Care.  It is intended long term to transform the project into an RHIO is regional health information Organization facilitates the HIE transfer of health information electronically across organizations.  There are four components to an RHIO: convenor, transactor, grid, and last mile.  RHIOs are viewed as key components of the NHIN.  Two technological architectures are used to implement the HIEs: (1) Data warehouses and (2) federated database systems.  This results in two RHIO architectures:
  1. Centralized - where local nodes data is extracted, transformed and then loaded into the central warehouse.  Technically this suffers from central data being out of date by the time between batch updates generated by the distributed extract and transform processes. 
  2. Federated - where record locators are stored in data bases at each RHIO node linking to the actual data.  There were no protocols defined and standardized initially for supporting the operation of the federation.  INPC and IHIE are examples of operational federated RHIOs.  
, the Central Massachusetts Health Information Organization. 


FirstWest Benefit Solutions

FirstWest Benefit Solutions is an insurance agency in Orem Utar.  It is focused on employer group benefit plans. 
Managing Partner Dave Jackson reviewed the Intermountain Healthcare SelectHealth Share strategy.  He comments that Intermountain's plan is "the first innovative thing we've seen in a long time.  Share has got everybody at the table -- everybody's got accountability and got things to do." 


Florida Blue

Florida Blue is providing ten days of extended coverage and encourages direct application to them.  For people who do signup with the federal site it suggests they keep a record of all transactions. 


Grand Valley Health Plan

Grand Valley of West Michigan, is an integrated health system.  It employs a full team of medical staff (staff-model 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. 
) to promote wellness and prevent catastrophic illnesses.  All new patients are accepted.  There are no claim forms, no excessive out-of-pocket expenses, and no mix-ups between practitioners and health insurers.  Staff privileges are maintained at most area hospitals. 

Operates the fully accredited Grand Valley Surgical Center for ambulatory and outpatient surgical procedures.  It does not own hospitals

Group Health 

Group Health is a Washington state and North Idaho health plan provider. 

It is organized as an integrated health system which does not own hospitals


Harvard Community Health Plan (HCHP)

HCHP was a integrated delivery 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. 
.  It:


Harvard Pilgrim Health Care


Payer who sponsored NEHEN RHIO transactor provides community-wide exchange of healthcare administrative data. 

Harvard Pilgrim limits payments to compounding pharmacies make unique prescription drugs to order when doctors conclude that standard formulations are not effective treatments. 
in 2014. 


Health Care Services Corporation

Insurer based in Chicago. 

An executive is on the board of the U.S. Chamber of Commerce
However, it has stated "We are convinced that ending smoking may help people live longer, enjoy a better quality of life and reduce costs in our health system.  This is a point of view we have advocated for decades and made clear to organizations that we support." 

It suffered large losses $282 million in the first year of 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
coverage. 



HealthFirst 


HealthFirst is a New York State 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. 


NYT Aug 2013 price gouging for saline supplies and healthfirst
Supplied Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
HMO Plan to Chinese family who were taken ill with food poisoning and treated at St. Lukes Cornwall 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). 

HealthFirst paid $119 to settle the grandmother's $2,168 bill without specifying how much of the payment was for the Saline.  It paid $66.50 to the doctor, who had billed $606. 

Health Net

Health Net is one of the largest publicly traded managed health care companies. 
Based in Woodland Hills, Los Angeles, CA

CEO Jay Gellert

It was originally a non-profit but was allowed to convert to for-profit in 1992 although it left much of the ownership in the hands of the California 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.   Foundation.  It has since merged with Qualmed and Foundation health. 

It requested 9% premium rate increases for Oregon in 2016.  The Oregon insurance commisioner approved a 34.8% increase. 

It provides health benefits to more than 6.6 million Americans through 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
, Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
, TRICARE is the DOD civilian health care program for military personnel, retirees and their dependents.  It is the civilian component of the Military Health System managed by the DHA.  Congress goal was to allow military personnel increased access to health care resources available in the civilian economy. 
, and VA - Department of Veterans Affairs.  Includes the Veterans Health Administration.   programs.  
It provides behavioral health, substance abuse and EAP is an employee assistance program. 
programs to more than 7.3 million Americans. 
It 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. 
products for prescription drugs. 

Health Net Insurance offers insurance plans in Arizona, California (includes Medi-Cal is the California Medical Assistance Program the state Medicaid welfare.  It includes SSP.  ), Oregon and Washington. 
Health Net Dental is based in Irvine CA. 
Managed Health Network, Inc. offers EAP is an employee assistance program. 
s. 
Health Net Federal Services, inc. offers TRICARE. 
It includes subsidiaries that provide: 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. 
, POS is a point of service plan which uses a managed care foundation to trade reduced choices for lower costs.  It combines aspects of an HMO and a PPO plan. 
, insured PPO preferred provider organization health plan allows direct access to any health specialist although there is typically a network of contracted specialists as opposed to a HMO health plan.  
and government health contracts.  It has subsidiaries in Oregon and Arizona. 

It has over 9000 employees. 

Health net's Gellert 2015 health evolution summit
Jay Gellert talked at the 2015 health evolution summit about a benchmark for disruption:



Health Republic Insurance of Oregon

President and CEO Dawn Bonder
Health Republic of Oregon annouced in October 2015 that it would close its doors having learned that it would receive only $995,000 of the $7.9 million it had expected from the Government. 
Bonder argues "Risk corridors are a federal program established in 2010 to protect health insurers against the uncertainties they faced in setting the level of insurance premiums when they did not know who would sign up for coverage under the ACA.  HHS collects funds from plans with lower than expected claims and transfers them to plans with higher than expected claims.  The ACA was designed to capture back excess insurance profits while supporting initial losses with the goal of making the corridors tax payer neutral.  They phase out in 2016 (Dec 2015). 
have become a political football.  We were stable, had a growing membershipand could have been successful if we had received those payments.  We relied on the payments in pricing our plans, but the government reneged on its promise.  I was disgusted is a universal human emotion.  Pinker notes it has its own facial expression and is codified in food taboos.  The mind must be associated with the proximate environment and parents minimize the risk for their omnivorous children by teaching them what foods to eat and what to avoid.  The children's minds are initially receptive to trying all foods but their brains subsequently lock in on the foods they have experienced.  These parental choices are affected by schematic influence on what has been beneficial.  Adolescent's brain developments undermine these constraints enabling intergroup transfers.  Disgust is modulated by the insula cortex which projects signals to the amygdala. 
."  Marco Rubio's provision has limited the Administration's payments to 13% of required funds (Dec 2015). 



Health Republic Insurance of New York

Health Republic is a New York Co-op. 
It lost $77.5 million on premium revenue of $521 million in 2014 but signed up 155,400 people - five times its projected enrollment. 
They argue they never intended to be profitable in the first three years. 


HighMark

Uses Teladoc.

Humana


Humana is based in Louisville, Ky. 
CEO Bruce D. Broussard. 

Mr. Broussard has a golden parachute and so stands to make $26.1 million in a takeover if he is pushed out. 

Humana has been struggling to meet analysts' profit expectations (2014 - 2015).  Revenue and membership rolls are up. 

Humana gets most of its revenue from Medicare Advantage 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.  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.  When they obtain treatment they will have to pay a copayment which may be quite high for some specialists.  About 25% of Medicare beneficiaries are enrolled with Medicare Advantage.  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. 
which is a growing market (one of the few organic growth areas in health insurance) with baby boomers choosing Advantage plans.  UHC is the largest provider of these plans with Humana a close second. 

Humana includes the Concentra Urgent Care clinics. 

Humana and UHC command 50% of the individual insurance market in 2015. 

Aetna & Humana (valued at $27 billion before any merger talks) plan to merge 2015. 

Humana ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
Humana have an ACO pilot with Norton Healthcare. 


Independence blue cross

Health plans for southeastern Pennsylvania (Philadelphia)
CEO: Daniel Hilferty
Independence Dan Hilferty 2015 interview
Hilferty talked at the 2015 healthevolutionsummit:



International Federation of Health Plans

Is a global network of health insurers. 

CEO Tom Sackville - former UK health minister. 

It compiled a list of drug, scan and procedure prices.  For 2013 it found that the US came out the most costly in all 21 categories:

  • Americans pay on average four times more for a hip replacement as patients in Switzerland or France. 
  • Americans pay three times more for a Caesarean section than in New Zealand or Britain. 
  • Average price for Nasonex (nasal allergy spray) is $108 in US and $21 in Spain. 
Hospital costs are about 3* those in other developed countries, but they last no longer. 

Japan Post Insurance

Japan Post Insurance and Watson
Japan Post Insurance is working with IBM's Watson to help inexperienced employees perform claim examinations as accurately as experts (Oct 2016). 


Kentucky Health Cooperative

In 2015 it has 52,000 people enrolled, down from 56,680 in 2014.  That is still more than half the people that obtained coverage through the Kentucky insurance exchange. 
It lost $50 million last year as it paid out $1.25 in claims for every dollar of premiums. 

They attracted many consumers with serious illnesses.  One of their most popular plans had low premiums, low out-of-pocket costs and  a large provider network. 

Kentucky's insurance commissioner recently approved rate increases averaging 25% for the Kentucky co-op in 2016. 

Like many co-ops Kentucky Health will stop providing insurance in Jan 2016. 


Land of Lincoln Health Cooperative

Land of Lincoln Health is a cooperative based in Chicago Illinois. 


LifeWise

LifeWise is the second largest health plan in Oregon. 
The Oregon insurance commissioner, Lauri Cali, approved a 2016 rate increase of 33%


Louisiana Health Cooperative

Louisiana Co-op started with $65 million in federal loans, said it would voluntarily halt operations at the end of 2015. 
Greg Cromer, a Louisiana state legislator (R) and CEO of the plan said it was "not growing fast enough to maintain a healthy future." 


Magnolia Health Plan

Mississippi provider of cheap Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
health plans. 

Mississippi health insurance commissioner suggested some of the insurance plan attrition in Mississippi (Oct 2015) may be due to disenchantment with the low cost Magnolia Health policies.  He is trying to ensure that Magnolia respond to calls for help and that their provider networks are sufficient. 


Main Health Management Coalition

Main Health Management ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
Main Health Management Coalition has a multi-stakeholder group supporting ACO pilots. 

Oakwood Accountable Care Organization (ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
), L.L.C. 

Oakwood's mission is to provide services, tools and knowledge management to position Oakwood ACO members to maximize clinical value, payer contracts and incentive opportunities. 
Oakwood's vision is to be the preferred means of alignment between the physicians the healthcare system and other community partners to become the leader in clinical integration, 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. 
and payer/purchaser contracting in southeast Michigan. 

Oakwood uses Wellcentive and Care Team Connect for its IT infrastructure. 

Wellcentive is integrated with EHR and claims data and empowers clinical staff to optimize visit volume, improve care effectiveness, reduce costs and increase patient involvement.  WellCentive is the core quality tool that reaches across all practices in the ACO. 

Oakwood ACO will use Care Team Connect to improve care coordination aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family.  Successful care coordination requires face-to-face interactions.  It also requires aligned incentives (ACO, Bundled payments).  AHRQ defines quality measures for care coordination.  The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation.  The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care.  It is argued that care coordination must include six specific activities:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
  2. Creation and updating of proactive plan of care
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  
through the MIPCT program and reduce hospital readmissions have become a source of increased revenue for hospitals.  But with government interested in reducing the US health care cost curve ACA's HRRP (pay-for-performance), BPCI and CTI and Interact discharge initiative have all increased the focus on unnecessary readmissions.  Now the end-to-end process is under scrutiny with hospitals reengineering discharge (RED) and PAC providers using RAI and TCN. 
related to chronic heart failure is congestive heart failure which occurs when the heart is unable to generate enough blood flow to meet the body's demands.  There are two main types: failure due to left ventricular dysfunction and abnormal diastolic function increasing the stiffness of the left ventricle and decreasing its relaxation.  Treatments include: digoxin;


MedImpact

Medimpact based in San Diego
Founded in 1989
Medimpact provides 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. 
services to commercial MCO is a managed care organization contractually allowed by state governments to contract with IPAs to provide state care with risk based reimbursement.  An MCO typically includes:
  • Traditional health maintenance organizations certified with respect to public health law;
  • Special purpose prepaid health service plans;
  • HIV special needs plans;
  • Managed long term care plans. 
, 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
, etc. 
Solutions include: Claims processing, Manufacturer contract management, Retail/mail network management, Specialty, Cost Quality and outcomes management;
Medimpact has 60,0000 pharmacies. 

Partnering with Blink Health pricing site; 


Meritus Health Partners

Meritus is based in Arizona. 
CEO Tom Zumtobel
Meritus is a health insurance co-op.  It lost $7.2 million in 2014 and projects a loss of $6.7 million for 2015.  It will operate in the black in 2016. 

Moda Health Plan

Moda is an Oregon Health Plan.  It also has plans for Alaska and Washington. 
Moda has the largest enrollment in Oregon. 

The Oregon insurrance commisioner, Laura Cali approved a 2016 rate increase of 25%  In her review she found the cost of providing coverage across Oregon insurers to individuals and families in 2014 was $830 million while premiums were only $703 million. 


Nevada Health co-op

The Nevada co-op paid its CEO $340,000. 
It announced it would close down in August 2015.  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. 


National Alliance of State Health Coops

Chairman Dr. Martin Hickey is also CEO of New Mexico co-op.  He presumed a handful of co-ops would fail.  But suggested red ink would start to disappear in 2016. 


Neighborhood Health Plan


Payer who sponsored MA-SHARE RHIO grid supplies the clinical exchange network. 


New Mexico Cooperative

CEO Dr.Martin Hickey argued these co-ops are an inherently risky venture. 


Oregon Health Co-op


Requested a 5.3 percent increase for 2016.  State gave them a 19.9% increase. 


Oscar

Oscar is a for profit health insurance startup based in New York.  It plans to enter California and Texas in 2016. 
Joshua Kushner is the 30 year (2014):
  • Co-founder of Oscar (2014). 
  • Co-founder of Thrive Capital. 
CEO Mario Schlosser, was a Harvard classmate of Joshua Kushner.  He
  • Previously cofounded Vostu, a Video game company which by 2017 was struggling and laid off most of its staff, with Kushner and another Harvard classmate. 
Pharmacist benefits manager Mihir Patel. 

By 2017 Oscar generated hundreds of millions of dollars in losses, and many executives have departed.  It has declared it will exit the personal insurance market in Dallas and New Jersey.  It aims to refocus on selling health insurance to corporations. 

By 2016 Oscar has become a case study in how brutally tough it is to become profitable in the state individual health insurance market places.  Oscar has now attracted 135,000 customers, about half of them in New York State.  But for every dollar of premium it obtains in New York the company loses 15 cents.  It lost $92 million in New York State in 2015 and has lost $39 million in the first three months of 2016.  It has $750 million in investor injected capital. 

Companies have been:
The market turned out to be smaller than Oscar hoped.  Fewer employers have dropped health insurance than expected which keeps wealthy is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.  
, healthy adults out of the individual exchanges. 

Oscar recently requested to raise rates by a weighted average of 20% for 2017.  Regulators will decide on the acceptable premium in August 2016. 
It is also proposing to offer plans to small business. 
Oscare has used another insurer's network in New York, but it is focused on partnerships with systems to create narrow networks that specialize in 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. 
.  It has experimented with these networks in California and Texas. 

Oscar's freindly branding is also causing some issues.  People are disappointed when Oscar is like other insurers, disputing coverage. 

Oscar is expected to lose money ($27.5 million in 2014). 
Oscar has raised $350 million including a high profile $32.5 million from Google Capital.  Other investors include: Kushner's Thrive, Li Ka-shing of Hong Kong, Ping An Insurance (Wen Jiabao's relatives). 

Oscar has attracted 40,000 customers in Nw York and New Jersey.  By 2016 it also operates in California and Texas.  The customers have unlimited access to nurses and doctors by telephone.  And they can use the web site to:
  • Look up medical records
  • Book appointments


Physician Organization of Michigan (POM) ACO

Formed by University of Michigan and eight other physician organizations in Michigan.  It has 1,800 physicians and cares for more than 81,000 Medicare beneficiaries. 

University of Michigan argued that this partnership helps develop relationships for coordination of care aims to transfer information between the patient and each care participant as required and establish accountability by defining who is responsible for each care delivery activity, the extent of that responsibility and when that responsibility will be transferred to other care participants or the patient and family.  Successful care coordination requires face-to-face interactions.  It also requires aligned incentives (ACO, Bundled payments).  AHRQ defines quality measures for care coordination.  The situation is usually complex and adaptive due to the interactions of all the providers, settings, the patients' preferences, and the number of physical health problems, treatments, and the patients' social situation.  The potentially exponential increase in complexity as the number of these factors present increases leads to patient hot spots requiring explicit proactive coordination of care.  It is argued that care coordination must include six specific activities:
  1. Determination and updating of care coordination needs: Needs assessment should identify preferences and goals, current situation and past history.  It needs to be updated periodically and after new diagnosis and other changes in health or functional status. 
  2. Creation and updating of proactive plan of care
  3. Communication
  4. Facilitation of transitions: typical transition problems are detailed by Project Boost.  A challenging issue with transitions is what to do when there is no resource to take over the coordination role in the handoff. 
  5. Connection to community resources: Community resources are any service or program outside the health care system that may support a patient's health and wellness. 
  6. Alignment of resources with population needs: need to see the system-level, assess the needs of populations to identify and address gaps in services.  


Pittsburgh Health Plan

This is the UPMC health plan with 2.4 million members. 
It has developed predictive health analytics aims to improve patients' healthcare outcomes and contain costs by using modeling technology integrating lifestyle information with patient data and modeling healthcare outcomes.  At the population level the hope is to create a total view by combining and structuring big data.  Then by segmenting the data at the cohort and patient level by risk, interventions and programs tailored to each person can be designed, supported by integrated care coordination.  A Shewhart cycle is then used to iteratively learn and optimize the process. 
models that analyze data including patient claims, prescriptions and cencus records to determine which members are likely to use the most emergency and urgent care. 
Data sets of past health care consumption are fairly standard tools for predicting future use of health services.  Pittsburgh recently enhanced its forcasting models with details on members' household income, education levels, marital status, race or ethnicity, number of children at home, number of cars etc.  One of its data sources is Acxiom



It has identified a few unexpected correlations:



Dr. Pamela Peele, chief analytics officer for UPMC insurance services division, sees this as another layer of vision, that helps her figure out better predictive models and improve allocation of medical resources. 

The health plan has not yet acted on the correlations it found in the household data.  But it already segments its members into different "market baskets," based on analysis of more traditional data sources.  Then it assigns care coordination to certain members flagged as high risk because they have chronic conditions that aren't being properly treated. 

The goal is to steer those patients to 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 low FFS leverage of the PCP compared to specialists. 
or specialists who can provide care that is more coordinated, more consistent and less costly than sporadic 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). 
visits. 

PHP Chief Medical Officer Dr. William Shrank
Dr. Shrank commented on the subscriber's medication adherence is focused on improving how effectively patients take their medicines.  In the US in 2017 the problem is huge and costly (Apr 2017).  Chronic diseases such as Malaria illustrate the complexity of the task.  A coherent medical network with shared access to EHR should help.  So do blister packs with the days of the week marked.  M-health glow caps with a wireless transmitter that lights up if medication has not been taken as expected.  An improved prescription label is less open to confusion.  Codes on drugs can be scanned by smartphones to initiate download of an informational video.  Smart pillboxes control when pills are dispensed.  Measuring the contents of a medication bottle can alert for intervention if too much or too little is in the bottle.  Drug manufacturers see ways to get closer to the patient: Sanofi Toujeo deployment; Pharmacies are implementing VDS to support medication adherence: Connected Care;
problems (Apr 2017)



University of Pittsburgh health plan's Dr. William Shrank agreed the problem is complex:
  • Prescriptions may be too complicated
  • Patients may be confused
  • Patients don't have symptoms
  • Patients don't like the drugs side effects
  • Patients can't afford the drugs
  • Patients think it's a sign of weakness to take the drugs
Dr. Shrank notes that using a measure that does not fix all aspects that are impacting a patient will be a problem.  





Premera blue cross

Premera is a major insurance plan serving Alaska, Oregon and Washington.  Its parent is 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 association

It is a nonprofit blue cross blue shield licensed health insurance company based in Mountlake Terrace, Washington founded in 2000. 

Providence Health & Services

Is a large provider in Washington and Oregon which includes health plans and hospitals (Providence Hospital). 

Providence ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
$30M two year contract with public employee benefits board


QualChoice Health Plan/Insurance Company

QualChoice is University Hospital's Health Plan. 
Former CEO J.B. Silvers outlines cascade of problems if 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
insurance markets are allowed to fail (Jan 2017)


Regence blue cross blue shield

Regence is part of Cambia Health.  It operates in Oregon, Washington state, Idaho. 


Rocky Mountain Health Plan

Rocky Mountain is a Colorado health insurer. 
Rocky Mountain works closely with the Grand Junction Health System to support an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
template system with 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.  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.   based primary care (Dec 2015). 

Rocky Mountain opens its books to doctors, showing them which practices were efficient, what promoted the best care and what simply drained money from the system.  Doctors can see how difficult it is to balance a budget when they order unnecessary treatments, such as extended hospital stays. 

The Rocky Mountain Health Plans was formed in response to the HMO act is the Health Maintenance Organization Act of 1973 which amended the PHSA to provide assistance for the creation of HMOs including:
  • Money for development
  • An override of specific restrictive state laws
  • A mandate offered to specific employers to offer an optional HMO plan as part of their employee benefits package. 
of 1973.  Physicians formed the nonprofit HMO which was turned over to a community board as a non profit venture.  It now serves 40% of the local population.  It has contracts with nearly every doctor in Grand Junction.  So it is powerful in:
  • Keeping costs low
  • Reducing unnecessary care. 
  • Driving best practices into the health care network. 
Doctors also formed an independent physicians association to work with Rocky Mountain.  They agreed to set aside about 20% of their compensation.  In return Rocky Mountain provides a funding mechanism that allows doctors' reimbursements for Medicare and Medicaid patients to be the same as what they receive for private patients, so it is not difficult for people on the government plans to find a doctor. 

Being a non-profit money remaining in the fund is allocated back to the doctors encouraging them to work efficiently. 


Scott & White Health Plan

Scott & White is a Texas Health Plan

Scott & White is seeking a 32% rate increase for 2016. 

Marinan R. WIlliams, CEO said the high cost of health care claims in 2015 in Texas indicated there was a real need for 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
.  "People are getting services they needed for a very long time.  There was a pent-up demand.  Over the next three years, I hope, rates will start to stabilize," Mr Williams said. 

SelectHealth

Intermountain Healthcare's health insurance unit. 
2016 CEO Patricia Richards

SelectHealth Share
Intermountain Healthcare's innovative health plan is part of a strategy to provide employers with a predictable health care offer (Feb 2016). 
For 2016 it has only enrolled 11,000 subscribers. 


Tufts Health Plan


Payer who sponsored NEHEN RHIO transactor provides community-wide exchange of healthcare administrative data. 

In 2000 Tufts refused to pay Partners HealthCare what it considered unjustifiably high prices.  Partners promptly announced it would no longer accept Tufts insurance and created an uproar among members of the Tufts plan who wanted to retain access to the two prestigious hospitals.  Faced with defections that could undermine its business Tufts gave in. 


United Concordia

United Concordia is a dental insurance company insuring 8 million people. 
United Concordia is based in Harrisburg Pennsylvania. 


United HealthCare

UnitedHealth Group (UHC)
2015 CEO Stephen Hemsley


UHC had 2016 revenues of $180 billion. 


Nov 2015 UnitedHealth Group lowered profits estimates after health exchange losses
UnitedHealth Group lowered profit estimates having generated $600 millions in losses selling individual policies on 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
exchanges from 2015 - 2016.  UHC consequently warned that it is considering discontinuing selling policies through the exchanges. 

UHC had stayed on the sidelines of the public health exchanges during 2014.  They have a limited number of enrollees. 
UHC cited low growth in signups for 2016 and high health care costs for exchange subscribers in 2015. 

Stephen Hemsley commented "In recent weeks, growth expectations for individual exchange participation have tempered industrywide, cooperatives have failed, and market data has signaled higher risks and more difficulties while our own claims experience has deteriorated." 

UHC offers plans in 34 state exchanges and has enrolled 550,000 customers as of Nov 2015.  That is significantly less than its rivals. 

It may drop out of the exchanges altogether in 2017.  UnitedHealth's market share in private Medicare plans and Optum services mean their exchange business is of little significance to the company. 

UHC Strategy


Abelson sees UHC migrating from a health insurer to a diversified health services company.  The strategic extension of its Optum group is in line with this. 




United Healthcare (UHC) offers virtual visits as an option for certain employers. 

Participating in consumer electronic show. 

UHC merged in 2007 with Sierra Health Services. 
Academics looked at the effects of the merger on consumers in Nevada.  They noted in a report in Health Management, Policy and Innovation:
  • "If there were any benefits to consumers realized from the merger, we could not observe them, and we infer that they did not come in the form of lower premiums." 
  • "On the contrary, the evidence suggests that large health insurer mergers are anticompetitive and cause injury to consumers through an increase in the price of health insurance services." 
  • "Premiums in Nevada markets increased by 13.7 percent after the merger relative to the control group." 
  • "Our findings suggest that the merging parties exploited the market power gained from the merger." 

United Healthcare has spent over $2B on HCIT since 1992 integrated under its brand OptumInsight.  This includes:
  • 2007 LighthouseMD (EHR) for $10M
  • 2009 AIM Healthcare services (RCM) for $440M
  • 2009 CareMedic (ASP revenue cycle)
  • 2010 Picis (OR) for $400M
  • 2010 Executive Health Resources (coding) for $1.3B
  • 2010 Axolotl (HIE) for $100M
  • 2013 Humedica (analytics)

United Health buys Humedica an analytics solution company.  This should allow UHC to mine any information that flows through their infrastructure.  HIE a Health Information Exchange is responsible for the transmission of healthcare-related data among facilities, health information organizations and government agencies according to national standards.  They are designed to address legal, organizational and technical challenges that would otherwise impede the sustainability of health information interchange.  An HIE is a component of the HIT.  It must enable reliable and secure transfer of data among diverse systems and facilitate access and retrieval.  The two main types are private and public exchanges.  Private exchanges may be able to leverage homogeneous IT infrastructure to facilitate data sharing.  Public exchanges are likely to be heterogeneous.  RHIO provide the regional organizations to support such HIE.  They are there to ensure that infrastructure amplification initiates.  The government will ensure that low healthcare density areas are served by public HIE infrastructure.  Both centralized and federated technical solutions were initially considered for implementation by the RHIOs for deploying HIE as specified in the Markle Foundation's NHIN common framework.  Common framework clients such as appropriately architected HIE use SOAP messaging to interact with their local SNO's ISB and RLS.  The HIE SOAP query transactions follow the HL7 Query Model.  Alternatively some HIE's are now using direct messaging to support interoperation.  HIE deployment goals have been phased (1 - supporting care transitions, 2 - Quality and care management, 3 - Population health).  Some HIEs will support "EHR-lite" as part of their functionality.  HIE does not yet solve some difficult challenges:
  • Safeguarding the security of health information.  Currently HIEs conforming to the common framework only provide locations of clinical data held remotely.  
  • Providing effective life cycle management.  The HIE is dependent on the local set of entities to provide updates that match the current state of the entity data. 
technology is another key point of access to the flows. 

March 2015 United Health buys 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. 
Catamaran Corp for $13 billion in cash. 

UHC and Humana control 50% of the individual insurance market in 2015. 

UHC is publishing a drug value and cost framework (Jun 2015) and will require oncologists to check with UHC prior to administering a drug to a patient. 


UHC tele-health
UHC announced in April 2015 that it would cover virtual visits for most of its 26 million commercial members by next year. 
UHC argues that lack of PCP and $50 price justify the coverage. 


UHC ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
UHC has an ACO with Tucson Medical Center. 


UHC Optum Strategy
UHC builds out its Optum Strategy acquiring outpatient surgery network Surgical Care Affiliates to extend OptumCare (Jan 2017)


UHC's Optum unit offers a broad range of health care services to hospitals, doctors and other insurers.  It also offers medical care directly to patients via OptumCare:
  • Optum primary care practices
  • Optum urgent care centers 
  • 20,000 affiliated physicians
Surgical Care Affiliates will broaden this direct offering.  Larry Renfro explained "Combining SCA and OptumCare will enable us to continue the transition to high-quality, high value ambulatory surgical care, partnering with the full range of health systems, medical groups and health plans." 


OptumRx is UHC's 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. 
Chief medical officer - Brian Solow
They are not excluding drugs from their formularies as of June 2014.  Patients with Gaucher disease protested when UnitedHealthCare required virtually all patients to use just one of the three similar and very expensive therapies. 

Oct 2015 OptumRx constrain Valeant. 
OptumRx say they will stop paying for drugs dispensed by Philidor Rx Services, a specialty pharmacy dispense specialty medications.  They aim to save health plans money by: teaching patients how to apply their medicines and deal with side effects, ensure they take the full course and limit waste.  These specialized channels can be used by drug companies to limit competition to their drugs since access in constrained.  Generic drugs rebranded as specialty medications may escape competition, remove copayment and formulary exclusion sales inhibitors and obtain considerable pricing power. 
tied to Valeant's catalytic sales strategy


VNSNY-Choice managed long-term care plan

New york's largest managed long-term care plan. 

It was suspended for several months in 2013 over the cherry-picking of able-bodied seniors, lured into the system by new adult day care centers offering free takeout food, casino trips and games of table tennis.   NYT documented hundreds of enrollees who were not impaied enough to be eligible, but who cost Medicaid $3,800 a month each. 


WellCare Health Plans


WellCare is based in Tampa, Florida. 
Wellcare specializes in offering coverage in the public Medicaid programs. 


Wellmark blue cross blue shield

Wellmark services Iowa and South Dakota. 


WellPoint is Anthem INC post 2014


Wellpoint is a for-profit company formed from the consolidation of 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. 
plans in different states to become one of the nation's largest insurers. 

Wellpoint had the largest presence in the individual and small business markets that 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
sought to overhaul.  The company had been thriving under rules that allowed it to avoid covering people with expensive medical conditions and charge much higher prices to people who were old or sick.  It covers nearly 36 million people. 

It consiquently was quite threatened by the changes proposed by the ACA.  It was for years the most antagonistic to health reform.  It outraged is a doomsday machine emotion of uncontrollable righteous anger.   customers and regulators by proposing an increase of nearly 40% in some annual premiums in 2010 (at Anthem Blue Cross) under former CEO Angela Braley.  And for 2014 it has proposed a double digit increase in California.  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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • 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.  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 are likely to be lower profit than its traditional plans. 

It was considered to be lacking in innovation in its traditional strategy for paying doctors and hospitals.  It used its size to sqeeze out the lowest prices. 

Feb 2014 NYT Onetime Critic of Health Law Anthem May yet Profit From It
But under new CEO Joseph Swedish, a former health care provider executive, Wellpoint has captured a large portion of the government money being spent on Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
, and can gamble on the new insurance exchanges because of protections offered by the federal government in the early days 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
's introduction. 

It has now undertaken a flurry of initiatives:

Swedish's strategy was driven by the recognition that it must protect its existing businesses while acting on its vision of the future that required it to remake its relationships with doctors and hospitals to change the way health care is delivered.  It also recognised that the government was going to be a major customer through such programs as 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
and Medicaid.  The company spent $300 million in preparation and expects to invest more.  "We're not old Blue," said Mr. Swedish.  "If we position ourselves simply as an insurance company, we are going to fail."  Unlike UnitedHealth and Cigna, Wellpoint could not afford to ignore the health exchanges where its former customers would then sign up with other insurers. 

The company reported net income of $2.5 billion on revenue of $71 billion for 2013.  Its quarterly profits were lower.  Wellpoint told shareholders that it was comfortable with the mix of customers it was enrolling and the premiums it was charging.  Analysts see Wellpoint emerging as a leader in Medicaid and the health exchanges as well as commercial insurance. 

It has emerged in the early months of the rollout as the largest presence in the newly created state marketplaces.  The company has signed up half a million people in the 14 states where it has 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. 
plans.  It has captured a leading share of the market in at least six states: California, Connecticut, Indiana, New Hampshire, New York and Virginia.  It lags in Maine and Kentucky where new entrants have emerged as formidable competitors. 
Amerigroup
Wellpoint is also increasing the number of people it insures through Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
, as states rely more heavily on on private companies to manage the program (including managed long-term care).  Wellpoint bought Amerigroup, a large Medicaid 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. 
company for $4.9 billion. 

Government focused coverage is now 45% of Wellpoint's overall business up from 10% two years ago. 

WellPoint worked with Kroger Company to start a price capping program for commodity operations with hospitals following its Anthem Blue Cross units experience with a similar program with CalPERS (Anthem and Vivity) initiated in 2011.  Kroger selected a price that still allowed employees significant choice of hospitals.  This has generated (Sep 2014) the joint venture VivitySweedish argued the JV is a result of the demand by employers that insurers and providers work more closely  on finding better ways of delivering care.  "This integrated approach I would call game-changing in the Los Angeles marketplace" he said. 

In part the price capping is enabled by the Federal government's decision to release Medicare data on hospital charges.  WellPoint also uses Castlight Health which offers companies Web-based tools that help employees compare hospitals and doctors. 

WellPoint plans to allow video consults with physicians' on-demand via webcams or smartphones. 

WellPoint are participating in the consumer electronics show. 

Wellpoint integration with the government health insurance exchanges includes staffing call centers throughout the Christmas holidays and teams of employees will be working to process applications for the compressed time remaining afer the web sites initially failed. 
Wellpoint say that they have policies in place that help people who are in the middle of medical treatments.  "These established policies, which in certain instances such as pregnancy, chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned.  It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%). 
or postsurgical care, allow the member to continue recieving care from an out-of-network provider for a specified period of time.  These policies vary by state and will continue to apply to current members,"  Wellpoint said in a statement.  

WellPoint is involved with IBM's Watson health care strategy.
 
WellPoint includes the company HealthLink.

HealthLink  

WellPoint's HealthLink builds regional provider networks is the owned health system and its extended network of partners.   and makes them available by contract to more than 90 payers of health benefits.  HealthLink's 600,000 members access approximately 90,000 participating physicians, hospitals and other health care professionals. 


Vivity

Vivity is a 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. 
/ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
constructed as a joint venture between Wellpoint's Anthem Blue Cross and independent hospitals covering greater Los Angeles and Orange county: UCLA Health, Cedars-Sinai, Good Samaritan, Huntington Memorial, MemorialCare Health, PIH Health and Torrance Memorial Health

For employers (CALPERS), the venture offers a welcome alternative to the power oriented creation of bigger and bigger provider networks. 

The hospitals in the joint venture have committed to working with Anthem and each other to find ways to make health care more affordable while keeping quality high.  The hospitals have agreed to provide care at or below their cost and will share in all of the financial results.  They will have a shared P&L. 

The hospitals must meet certain quality standards to ensure that they are not stinting on care. 

It offers an alternative to Kaiser's HMO architecture. 

While members will select 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 low FFS leverage of the PCP compared to specialists. 
they will have access to the different hospitals and specialists within the network.  The hospitals hope to share EMR refers to electronic medical records which are a synonym of EHR.  EMRs have 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-patent setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
records and collaborate on treatment. 

Zoom+

Zoom+ is a for-profit health plan in Oregon.  It claims to be "Kaiser 4.0".  It started as a collection of urgent care centers 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. 

Founded by Dr. David Sanders and Dr Albert ?

It aims to provide a health plan, access technology, web consumer appeal, and integrated delivery at its 26 clinics covering Portland and Vancouver Washington. 


Behavioral health insurance

Behavioral health has become an area of primary coverage under the ACA.  However, it is still treated as a low priority by insurers because 80% of the ACA payment must be used for patient reimbursements.  So most insurers pass through the operation of behavioral health to two low cost operators: Behavioral health systems, Magellan Health;


Behavioral health systems

Behavioral health systems

Magellan Health

Magellan Health




Admissions process:



Categories of admission include:



Urgent care clinics

Urgent care clinics 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. 
such as FastER and ASAP Urgent Care provide an efficient, lower cost alternative 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). 
.  They should not be used for true emergencies: chest pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Pain is the main reason people visit the ED in the US.   or compound fractures should be treated at the ED.  They aim to provide an accessible location, extended hours compared to the 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 low FFS leverage of the PCP compared to specialists. 
, immediate access and rapid treatment.  Since 2008 300 have opened each year.  Typically copayments are more than 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 low FFS leverage of the PCP compared to specialists. 
office visit but less than an ER visit.  A typical co-payment for a PCP office visit is $10 - 20 on many insurance plans.  The center for studying Health System Change found that few of the clinics accept Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
.  Some offered discounts for patients that paid in full at the time of service. 

Private Investment has sunk $2.3 billion into urgent care clinics between 2008 and 2014. 

The clinics often emphasize a pleasant experience for patients.  Some are independent.  Others are owned by hospitals or health insurers.  Services offered vary. 

It is unclear if the clinics save money for the health care system overall.  To the extent that clinics divert inappropriate ED visits they will save money, but they may divert patients from visiting the PCP which are lower cost and where their history is known.  PCPs are offering extended hours and same day visits for ill patients to compete with the urgent care value proposition.  As urgent care centers expand their reach, regulators in some states are looking at their activities.  Most states do not currently require them to be licensed. 


The business model is simple: Treat as many patients as quickly as possible.  It is low margin, high volume.  The national average for charges is $155 per patient visit.  The average charge to treat acute bronchitis is an inflammation of the medium size airways in the lung.  It is defined clinically as a persistent cough with mucus.   at an urgent care center in 2012 was $122, compared with $814 at an ED.  The price of treating a middle-ear infection was $100 versus nearly $500 in an ED.  While Hospital EDs are required to treat uninsured and Medicaid patients urgent care can cherry pick. 


Action Urgent Care
Action is a physical urgent care center at 1375 Blossom Hill Rd, San Jose, (408 4408335).  Has 4star rating on yelp. 

ASAP Urgent Care
ASAP Urgent Care is based in Connecticut, promotes perks like heated robes, and iPads for patient use. 


Beacon Urgent Care
Beacon is based in Santa Clare, CA. 
They provide walk-in medical care from 9.00 am to 8.30 pm Monday to Saturday and 9.00 am to 5.00 pm Sunday.  They do not take 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. 
patients or some other plans that restrict their patients from urgent care walk-ins. 

Typically the care is administered by an EC is eligible clinician, a CMS term for a physician, nurse practitioner, physician assistant, clinical nurse specialist and nurse anesthetist cooperating in a practice.  After 2018 under MACRA EC will also include physical and occupational therapists, nurse-midwifes, clinical social workers, clinical psychologists etc. 
: nurse practitioner or physician's assistant.  A doctor attends infrequently increasing the profitability. 

Beacon is described in its literature as an advanced medical center with on-site X-ray, EKG, IV therapy, minor surgery, basic orthopedic care, lab testing and pharmacy. 

Treats non-life threatening illnesses:

Centra Care
Centra Care is an urgent care chain owned by Florida Hospital
Concentra Urgent Care
Concentra Urgent Care is part of Humana and one of the largest urgent care chains.  It was purchased in 2010 for $800 million.  It is one of the largest chains with 300 clinics as of 2014. 

The average co-payment at its clinics for an insured patient is $45, compared with a national average of $180 for  an 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). 
visit. 

Envision Healthcare
Envision Healthcare extended across the value chain from its start in 24/7 urgent care when it was called Emergency Medical Services Corp.  To cover health care more broadly it acquired:
FastER
130 Speedwell Ave, Morris Plains, NJ (Morris County and Morristown N.j.)
Medexpress Urgent Care
Medexpress operated 47 clinics in four states when General Atlantic and Sequoia Capital invested and they expanded to 130 clinics in 10 states. 
It is based in ?. 

PlushCare Urgent Care
PlushCare does not have a physical clinic.  It uses telehealth to perform diagnosis focused on San Jose.  (408) 549 1001. 
It has many 5 star ratings on yelp. 

PhysicianOne Urgent Care
PhysicianOne in 2014 is an eight clinic operation, the largest of its kind in Connecticut.  It plans to expand further. 
It is bankrolled by two private investment companies PineBridge and Pulse equity partners.  . 

Most people are in and out within 30 minutes. 

It includes:
Urgent Care of Connecticut
Dr. Robert Rohatsch
Accepted investments from PineBridge and Pulse equity partners. 
US HealthWorks

US HealthWorks is part of Dignity Health.  It has 176 clinics. 
It is based in Valencia CA. 




Pioneer ACOs 

Pioneer ACOs were selected to participate in 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
Pioneer ACO is a CMS Innovation Center initiative to support ACOs in providing more coordinated care to beneficiaries (individuals and populations) at lower cost to Medicare.  It leverages the ACA shared savings program and tests an alternative 'pioneer ACO' model.  Pioneers are assumed to be organizations with experience offering coordinated, patient-centered care, and operating in ACO-like arrangements.  A first performance period Jan 1 2012 - 2014 tests a shared savings and shared losses payment arrangement with higher levels of reward and risk than in the shared savings program.  In year three Pioneer ACOs that have showed savings over the first two years can move to a population based payment model.  Two alternative payment models were added which allow pioneer ACOs more flexibility in the speed at which they assume financial risk.  Pioneers must also commit to having greater than 50% of primary care providers meet meaningful use of certified EHRs for receipt of payments through Medicare and Medicaid EHR Incentive Programs.  Pioneers must have > 15000 beneficiaries enrolled in original FFS part A and part B Medicare.  Organizations were selected using these criteria. 
program.  They include
Allina Health
Allina Health (was Allina Hospitals and Clinics) is based in Minnesota and Western Wisconsin. 

Atrius Health
Atrius Health is based in eastern and central Massachusetts. 

Banner Health Network
Banner is based in Phoenix Arizona Metropolitan Area (Maricopa and Pinal counties)

Beacon Health
Beacon is based in central, eastern and northern Maine. 

Bellin-Thedacare Healthcare Partners
Bellin is based in northeast Wisconsin. 


Beth Israel Deaconess Physician organization
Beth Israel is based in eastern Massachusetts. 

Brown and Toland Physicians
Brown is based in San Francisco Bay Area. 

Dartmouth-Hitchcock ACO
Dartmouth-Hitchcock is part of the Dartmouth-Hitchcock health system which is based in New Hampshire and Eastern Vermont. 

This ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
was formulated by Dartmouth-instititute researchers and was a major influence on 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
planners use of bundled payments is where the purchaser disburses a single predefined payment to cover certain combinations of hospital, physician, post-acute, or other services performed during an episode of care relating to a particular condition (unlike capitation).  This bundling is assumed to allow the value delivery system to optimize around low cost high quality long term health care.  With one bundled payment physicians & hospitals must coordinate care and reduce the unit costs to remain profitable.  And to avoid taking on risk of expensive complications physicians & hospitals are incented to standardize and focus on quality.  This optimization is dependent on quantifying the value of the outcome of the episode of care.  Previously FFS payments induced excessive treatment activity.  Bundled payment is included in CMS ACE demonstrations and BPCI initiatives.  There are significant impacts on IT. 
  1. It is argued that effective pricing of the bundle requires marketing data which must be extracted from the historic transaction base.  
  2. Billing and payment systems must be updated to handle the receipt and distribution of the bundled payments. 
  3. Care delivery must be re-architected to reduce costs and improve quality. 
  4. Monitoring sensors can be used to feed reports to ensure re-architected operations conform.  


It was a shock when Dartmouth-Hitchcock announced they could not continue to operate the ACO profitably and were abandoning the program (Sep 2016). 


The government did an evaluation of the Dartmouth-Hitchcock ACO and found the ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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.  
had reduced 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 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 hosptial. 
    • Part B: Medical insurance
    • Part C: Medicare Advantage 
    • Part D: Prescription drug coverage 
  • 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. 
    • 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.  
  • Premiums
    • Part A premium
    • Part B insurance premium
    • Part C & D premiums are set by the commercial insurer. 
spending on:
  • Hospital stays
  • Medical procedures
  • Imaging and tests
The ACO had also achieved its quality of care goals. 
But it was subject to financial penalties because it did no meet federal money-saving benchmarks. 

Dartmouth EVP Dr. Robert Greene noted "We were cutting costs and saving money and then paying a penalty on top of that.  We would have loved to stay in the federal program, but it was just not sustainable." 



Fairview Health Systems
Fairview is based in Minneapolis, MN Metropolitan Area. 

Franciscan Alliance
Franciscan is based in Indianapolis and Central Indiana. 

Genesys PHO
Genesys is based in southeastern Michigan

Healthcare Partners Medical Group
HP California is based in Los Angeles and Orange Counties, CA. 

Healthcare Partners of Nevada
HP of Nevada is based in Clark and Nye Counties of Navada. 

Heritage California ACO
Heritage is based in southern, central and coastal California. 

JSA Medical Group
JSA is based in Orlando, Tampa Bay and surrounding south Florida. 

Michigan Pioneer ACO
Michigan Pioneer is based in southeastern Michigan. 

Molina Healthcare
Molina is based in California.  It was founded by Dr. Molina. 
Molina Healthcare specializes in providing care to low-income individuals under the Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
program.  It is a mainstay 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
Individual insurance markets

May 2017 Chairman Dale B Wolf. 
May 2017 Dale Wolf argued the company's business remains strong. 

Acting CEO Joseph White noted it would be difficult to remain in the exchanges without subsidies. 
Molina will be executing a search for a new CEO.  It is a potential acquisition target by insurers: WellCare Health Plans, Aetna, UnitedHealth, Anthem, Centene; if they consider the deal could pass the regulators' requirements. 

May 2017 Acting CEO Joseph W. White (Board removed Dr. Molina, a son of the founder). 
2017 CEO Dr. j. Mario Molina
Dr. Molina is a major critic of the Trump administration and its steps to overhaul 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 SCOTUS 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 patent-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. 
  • A requirement that chain restaurants must report calorie counts on their menus. 
.  Dr. Molina's strategies made Molina a leader in ACA individual market insurance. 
Molina lost hundreds of millions of dollars in the individual exchanges in 2016.  Executives blamed a flawed government formula for the losses. 

May 2017 CFO ? (Board removed John Molina, a son of the founder)
2017 CFO Dr. John Molina

May 2017 The Molina brothers remain board members of Molina Healthcare. 

Molina Insurance has one million customers in state marketplaces
Molina Insurance offers Medicaid plans in 12 states and Puerto Rico. 


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. 
Insurer in Washington state. 
Molina is the largest Medicaid is the state-federal program for the poor.  Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state.  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. 
plan in Washington state. 

Molina tele-health
Molina has started to cover virtual urgent care. 
Peter Adler president of Molina said "We are jumping in with both feet on this.  We think it's the future, and it's here now." 
Monarch Healthcare
Monarch is based in Orange County California. 

Montefiore ACO
Montefiore is based in New York City and lower Westchester County New York. 

Mount Auburn Cambridge Independent Practice Association
Mount Auburn is based in eastern Massachusetts. 

OSF Healthcare System
OSF is based in central Illinois. 

Park Nicollet Health Services
Park Nicollet is based in Minneapolis Metropolitan Area. 

Partners Healthcare
Partners is based in eastern Massachusetts.  It was formed in 1994 by the merger of Harvard's two most prestigious hospital affiliates: Massachusetts General Hospital and Brigham and Woman's Hospital. 

The president of Massachusetts General acknowledged in 2010 that one purpose of the merger was to take away the ability of insurance companies to demand lower prices from one hospital with the threat that they could just send patients to the other.  After the merger, insurers (Tufts) had to take both of them or neither. 

Partners proposes to acquire South Shore network. 
Partners has continued to expand its network.  Already the largest provider in Massachusetts with 6,000 doctors and 2,800 licensed beds in its AMC is Academic medical center.  They perform education, research and patient care.  They include one or more health professions schools, such as a medical school and a hospital.  The major AMCs are represented by the United HealthSystem Consortium.   The costly strategies of the AMCs and increased difficulty of finding enough targeted patients for research studies (Aug 2017) is forcing integration with larger hospital systems. 
s and community hospitals it proposed to acquire South Shore Hospital and related doctors. 
The Massachusetts Attorney General has negotiated an agreement that allows the acquisition in exchange for constraints on pricing and further expansion. 

It has an award winning EHR refers to electronic health records which are a synonym of EMR.  EHRs have 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-patent setting. 
  • As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient.  
implementation, longitudinal medical record, built in-house over 30 years, which is CCHIT is the certification commission for health information technology.  HHS provided funding for CCHIT to develop standards certification guidelines and evaluation criteria for HIT products including EHR and NHIN architectures. 
certified. 

Partners was one of two organizations in the US awarded a five year AHRQ is the Agency for Healthcare Research and Quality.  It provided the definition of a medical home (PCMH) as both a place and a model of the organization of primary care that delivers core functions of primary health care. 
contract to develop methods to advance the effectiveness of clinical decision support in EHR. 

Partner's hire Accenture (june 2012) to deploy Epic.  It will go live in June 2016 at a cost of over $1.2 billion. 
Physician Health Partners
Physician Health is based in Denver CO Metropolitan Area. 

Plus
Plus is based in Tarrant, Johnson and Parker counties in North Texas. 

Presbyterian Healthcare Services
Presbyterian is based in central New Mexico. 

Primecare Medical Network
Primecare is based in San Bernardino and Riverside counties in southern California. 

Renaissance Health Network
Renaissance is based in southern Pennsylvania. 

Seton Health Alliance
Seton is baseed in central Texas including Austin. 

Sharp Health Alliance
Sharp is based in San Diego County. 

Steward Health Care System
Steward is a hospital group.  It is based in eastern Massachusetts. 

Trinity Pioneer ACO LC
Trinity is based in North West central Iowa. 

University of Michigan. 
University of Michigan is based in Ann Arbor, southeastern Michigan.  It was one of 6 pioneer is a CMS Innovation Center initiative to support ACOs in providing more coordinated care to beneficiaries (individuals and populations) at lower cost to Medicare.  It leverages the ACA shared savings program and tests an alternative 'pioneer ACO' model.  Pioneers are assumed to be organizations with experience offering coordinated, patient-centered care, and operating in ACO-like arrangements.  A first performance period Jan 1 2012 - 2014 tests a shared savings and shared losses payment arrangement with higher levels of reward and risk than in the shared savings program.  In year three Pioneer ACOs that have showed savings over the first two years can move to a population based payment model.  Two alternative payment models were added which allow pioneer ACOs more flexibility in the speed at which they assume financial risk.  Pioneers must also commit to having greater than 50% of primary care providers meet meaningful use of certified EHRs for receipt of payments through Medicare and Medicaid EHR Incentive Programs.  Pioneers must have > 15000 beneficiaries enrolled in original FFS part A and part B Medicare.  Organizations were selected using these criteria. 
ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Kaiser 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.  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 programs 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 that dropped out of the pioneer program July 2013.  It dropped out for efficiency, physician partnerships and integration reasons to move from the pioneer program to a larger ACO (Physician Organization of Michigan ACO) in Medicare's shared savings ACO program in which it already participated.  As a Pioneer UM's ACO had only achieved savings of 0.3 % and needed to reach 2% to obtain Medicare funding.  They felt they could increase cost savings if they had empolyed more care coordinators to reduce chronic care costs and working closely with HHAs.  But in an analysis they concluded it was better to combine their two ACO programs.

Michigan 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. 
study
UOM overtreatment author Dr. Tanner Caverly
Dr. Caverly noted that in older people with 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
, maintaining very low blood sugar 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. 
can do more harm than good.  "People can feel fatigued and weak, get cold sweats, feel like they're going to pass out."  The fainting and falls that may result can have devastating consequences.  But the 2015 JAMA study shows deintensification occurs rarely. 
University of Michigan Health System



UMHS depression management project
Dr. Michael Klinkman of University of Michigan Health System is the principal investigator on a 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.  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; 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. 
project.  It is based on the Wagner Chronic Care Model is Ed. Wagner's framework for producing healthy communities.  It has six major components:
  1. The community - Resources and polities. 
  2. The health system - organization and payment model. 
  3. Self-management support - education, tools, motivational techniques, patient empowerment;
  4. Delivery system design
  5. Decision support - allowing evidence based guidelines to support care. 
  6. Clinical information systems - EHR, decision support, reminders
.  It is performed on a set of partner primary care 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 low FFS leverage of the PCP compared to specialists. 
practice patients such as Allegiance Health, Medical Practice Management Depression Management Program patients. 

Participants complete an initial screening along with one-, three-, and six-month follow-up sessions, while maintaining normal care with the primary care provider 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 low FFS leverage of the PCP compared to specialists. 


A health coach, a licensed medical social worker, contacts participants by telephone to complete follow-up, monitor core clinical outcomes and provide one-on-one support.  The coach feeds all results back to the primary care physician. 

Between office visits, patients participate in regular follow-up calls with a coach, who monitors how well the patient is responding to treatment and provides feedback to the patient's primary care doctor.  The coach answers the patient's questions and provides support, education and self-management skills in areas such as diet, exercise and sleep. 

UMHS hopes to demonstrate the program can be successful outside of the educational community.  Patients are being surveyed throughout the program, but UHMS has not begun to assess the results. 

UMHS DMP Personalized Care, Ready Access

Patient/coach interaction happens via email, patient portal provides web and or application based access to a patient's EHR based health care information and services.  Specific portal services are mandated by meaningful use.  They include at a minimum lab test results, problem list, medication list, and medication allergy list. 
or phone.  With 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.  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;, this is an advantage.  The stigma of having to deal with behavioral health goes away.  The coach makes contact at the time and date that works best for the patient. 

During a regular office visit, a clinician may not have enough time to uncover the underlying reasons for non-adherence is focused on improving how effectively patients take their medicines.  In the US in 2017 the problem is huge and costly (Apr 2017).  Chronic diseases such as Malaria illustrate the complexity of the task.  A coherent medical network with shared access to EHR should help.  So do blister packs with the days of the week marked.  M-health glow caps with a wireless transmitter that lights up if medication has not been taken as expected.  An improved prescription label is less open to confusion.  Codes on drugs can be scanned by smartphones to initiate download of an informational video.  Smart pillboxes control when pills are dispensed.  Measuring the contents of a medication bottle can alert for intervention if too much or too little is in the bottle.  Drug manufacturers see ways to get closer to the patient: Sanofi Toujeo deployment; Pharmacies are implementing VDS to support medication adherence: Connected Care;
to a plan of care outline the patient's current and long-term needs and goals for care, identifies coordination needs, and addresses potential gaps.  This is consistant with the biopsychosocial model.  It also clarifies how the patient will reach the goals and who is responsible for implementing each part of the plan.  HL7's FHIR has defined a CarePlan resource.  .  Most patients with chronic conditions tend to have underlying behavioral issues that affect the condition itself, or erect barriers to following the clinician's instructions.  The coach can leverage time and the skill set to discover the barriers.  Patients often tell physicians what they want to hear, but they are more likely to confide in a social worker.  Identifying and addressing the barriers are simple but essential steps. 




UMHS DMP Team-Based Approach

Each practice has its own team-based care coordination process. 

UMHS DMP Community connections

The coach connects patients to community resources as needed.  The coach spends time with the local federally qualified health centers to be able to direct patients there for extended services.  The coach connects patients with broader community service through organizations like United Way.  The coach must understand what's available to each practice location and what fits 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 the practice and the community. 

UMHS DMP Coordinated Medication Management

The physician and mid-level practitioners have the primary responsibility to teach medication management includes product selection, product administration and monitoring for side effects.  Baxter, B. Braun, Carefusion, Hospira provide facilitating products and services.  Scriptrx provides IT solutions. 
and adjustment.  The coach reviews the medications with the patient and understands any issues with their following the regime. 


Hospitals 


Acute care hospitals are associated with their proximate geography.  It will drive their:
But there are other aspects that affect the hospital and which they can alter:

Christensen chronic disease & therapy business model type: