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General competitor details
Summary
The competitive elements of the health care value delivery
system are discussed. These include:
- Veterans Health Administration (VHA)
- Health management organizations (HMO)
providing care plans and insurance cover.
- Accountable Care Organizations (ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination.
- CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
).
- Hospitals, surgery
centers and rehabilitation centers.
- California
health care system including Kaiser.
- patient-centered medical homes and neighborhoods is an extension to the PCMH which supports coordination of care across providers connecting with specialty and subspecialties that are essential to the treatment of chronic illnesses. The PCMH hospital-based specialists and community practitioner team located near where the patients live, must have an effective relationship with ambulatory care, pharmacists, SNF, HHA, and others.
(PCMH).
- Primary
care physicians.
- Kiosks.
- Imaging centers (stand
alone and integrated).
- Reference labs (stand alone
and integrated).
Typical provider problems are discussed: These include:
- Relative power of hospital group and PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
including: Expanding
shortages of PCPs, PCP groups switching affiliations, HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; infrastructure
dependencies;
- Power of CMS is the centers for Medicare and Medicaid services.
including: Hospital cost structure issues;
- Mismatch of business models across care continuum
including: Improving profitability of PAC providers is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low):
- Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
;
- Uncertainty of population health including: Effectiveness
of the care and how it can be coordinated efficiently;
- Readmissions
including: UPMC St Margaret hospital discussion of their historic
discharge process to SNFs;
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.
- Medical situations:
- New entrants: CVS (drop
cigarettes as part of entry strategy & leaves Chamber of
Commerce, Purchase Target's
drugstores),
- State of California,
State of Michigan
HIN, State
of Minnesota,
- Key employers: Alphabet wellness,
Amazon, Apple,
CalPERS
(& private
equity), Comcast Corp,
G.E.: International (Post TPP trade deal
with China); Honeywell: health plan;
IBM: health
program, Customer
experience analytics (Coremetrics);
Trader Joe's, UPS, Wal-Mart: Strategy (under pressure - Jan 2016;),
wages (2016);
Whole Foods
Market,
- Health management organizations (HMO typical
insurance product (2014)) &
Insurance co-ops:
Aetna (ACO, CarePass, Coventry Health care, Healthagen, Surgery assistance
charges), AmeriHealth Caritas,
Anthem Blue Cross (tele-health, ACO, Vivity,
IngenioRx), Arches health plan, Blue Cross Blue Shield (North
Carolina, South
Caolina, Georgia,
Illinois (ACO), Extended Home Care, HealthFirst, Kansas, Massachusetts (ACO), Michigan,
Minnesota (ACO), Mississippi
, New Mexico,
Nebraska
(Steve Martin 2015
interview), Oklahoma, Premera Washington, Regence, Tennessee,
Texas, Wellmark), Blue
Cross (Alabama (ZPIC), Capital Pennsylvania, Idaho, Carefirst
Maryland, Independence
Philadelphia (Hilferty health
summit) CareConnect, Blue
Shield (California
health exchange rates 2014; (ACO)), Cambia Health Solutions
(Mark Ganz 2015
interview), CDPHP, Centene corp: Neidorff; CIGNA (ACO), Community Health
Options, Consumers'
choice, Consumers
Mutual, CoOportunity
Health, Dean Health Plan, Evergreen Health co-op, Fallon Health Plan,
FirstWest Benefit
Solutions, Florida Blue, Group Health: shared
decision-making; Health care
services corp, Harvard Community
Health Plan, Harvard
Pilgrim Health Care, Health Net
(Gellert 2015
interview), Health Insurance
Innovations, Health Republic Insurance of: Oregon, New York; HighMark, Humana
(ACO), International
federation of health plans, Japan Post Insurance: Watson, Kentucky Health, Land of Lincoln
Health, LifeWise, Louisiana Health
Cooperative, Magnolia Health,
Main Health Management Coalition (ACO), Medica, Meritus Health, Moda Health Plan, Molina health (tele-health), NASH
coops, Neighborhood
health plan, Nevada co-op, New Mexico Coop, Oakwood
ACO, Optima Health, Oscar
health, Pittsburgh Health
Plan: Chief Medical Officer (William Shank),
Providence Health and
Services (ACO), Physician
organization of Michigan POM ACO, QualChoice,
Rio Grande Valley ACO, Rocky Mountain
health plans, Scott &
White Health plan, SelectHealth:
Share, Tufts Health plan, United Concordia, United HealthCare (Strategy, Losses on health
exchanges Nov
2015 prompt exit, tele-health,
ACO): OPTUM (Coding, Labs,
PICIS, RX, OptumCare, strategy), VNSNY
Choice, WellCare,
WellPoint (Amerigroup),
Zoom+;
- Integration with health exchanges (Dec 2013
premium deadline extended)
- Behavioral health
insurance: Behavioral
health systems, Magellan
Health;
- Pharmacy Benefits
management (rebates):
- Hospital major
flows in & out of departments (emergency department,
laboratories, radiology, safety, trials, revenue (chargemaster),
accounting) examples: Adventist health
system, Advocate Health Care
/ Advocate health
partners: Advocate
Lutheran General Hospital, performance
measurment and reporting, behavioral
health; Akron
General Health System Ohio, Alameda Health System: Highland Hospital; Alder Hey: Watson; Allina Hospitals and
Clinics, Alta
Vista Regional Hospital, Altus,
Ascension Health, AtlantiCare Medical,
Ann Arbor Healthcare
System (Dr.
Jeremy Sussman), Aultman
Hospital, Aurora Health
Care, Baptist Health
System (Medical
Center (Mohs
surgery), ), Baptist health care Pensacola,
Barnes-Jewish Hospital
(Siteman
Cancer Center), Baxter Regional
Medical Center, Baylor Scott
& White Health: Baylor
University Medical Center; Bellevue Hospital
Center NY, Ben
Taub General, Beth Israel
Deaconness, Bon Secours
Health System, Boston
Children's Hospital (SIMPeds, SMART, IBM's Watson),
Boston University: School of
medicine: Department
of Neurology (Matthew Pase);
School
of public health: Austin
Frakt; Boston Medical
Center: Framingham heart (Dr. Seshadri),
Brigham and Women's
Hospital (Cancer
Center, Sleep
and Cricadian Disorders, Regulation
therapeutics & law: A.
Kesselheim), Buffett Cancer
Center Omaha, CPMC,
Caregroup, Carolinas HealthCare
System, Case
Comprehensive Cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
Center, Catholic Health East
() Initiatives
() West (), CHA, Cambridge Hospital, Cedars-Sinai LA, Centro Medico,
Charity Hospital
New Orleans, Children's
Healthcare of Atlanta: Marcus Autism Center
(Ami Klin); Children's
Hospital of Philadelphia, Children's
National (Patrick
Conway), Christus
Health, Cleveland Clinic
(Business model,
Health centers: Stephenie
Tubbs Jones; institutes,
Insurance and risk, IT
infrastructure, Lerner college
of medicine, performance
management, Cardiovascular
medicine: Jardiance
landmark, evacetrapib
failure, Tausig
Cancer Institute, Pharmacy:
Scott Knoer,
IBM's Watson), City of Hope
Cancer
Center Los Angeles, College Station
Medical Center, Colorado
Plains Medical Center, Columbia
University Medical Center: College of
Physicians & Surgeons (John Markowitz);
Colorado
Foundation for Medical Care, Community Health
Systems (Quorum
spinoff), Community
hospital of the Monterey Peninsula, Cook County
Health (John
H. Stroger, Jr. Hospital), Cottage Health System, Covenant, Crozer-Keystone
Health System, Dana-Farber
cancer institute: Breast cancer
program (Eric
Winer), Dartmouth-Hitchcock
Medical Center, Daughters of
Charity Health System (O'Connor,
Seton Medical Center (Daily City, Coast side at Moss Beach),
St. Francis Medical Center, Saint Louise Regional Hospital,
St. Vincent Medical Center), Dean
Clinic: physician
metrics, unblinded
patient satisfaction data; Dignity Health: population health, ACO; Duke University: School of
Medicine: Deane Drug
Discovery Institute (Allen Roses Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows: - Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
proposal); Medical Center (Cancer institute, Cardiac care (Dr. Robert
Califf: disrupting
clinical trials), Pharmacy:
Kuldip Patel),
School of
Medicine, Eastern
Niagra Hospital, Eaton Rapids
Medical Center, El Camino
Hospital, Emory:
President: Sterk;
Vision, Mission,
Provost: Mcbride;
Business &
Administration division: Augostini,
Medical School:
Pediatrics Warren Jones;
Emory hospital;
Evanston Regional
Hospital, Florida
Hospital, Fox Chase Cancer
Center, Frances
Mahon Deaconess Hospital, Franciscan Health:
Crawfordsville
Hospital; Georgetown
University Hospital: Lombardi
comprehensive cancer center; Gerald
Champion Regional Medical Center, Good Samaritan
Hospital (SanJose,
LA), Grady Memorial
Hospital Atlanta, Greene County
General (ICD-10),
Gunderson Health
System, Harborview
Medical Center Seattle, Harlem
Hospital, Harris
Health System Houston, Harrison Medical, Hartford Healthcare
Connecticut, Health
Management Associates, HealthPartners,
HealthSouth, Henry Ford Health
System: West
Bloomfield; Highland
Hospital Oakland, Hoag: Network,
Hospital
Newport Beach, Orthopedic
Institute (Physician
metrics, performance
feedback strategy, patient care
standardization); Holy
cross hospital Chicago, Hospital
Corporation of America (Sarah Canon Cancer
Center;SMART), Hospital
for special surgery, Houston Methodist, Huntington
Memorial Hospital LA, Fred Hutchinson
Cancer Research Center: Jared Radich,
Indiana University: School
of medicine (Carroll,
DTRC),
Health: Geriatrics (nursing home
issues); Inova, Integrated Health
Services, INTEGRIS
Health, Jackson
Park Hospital & Medical Center, Jamaica Hospital
Medical Center Queens, James
Cancer Hospital, Jefferson University
Hospitals (tele-health,
Watson smart
hospital room), Johns Hopkins
(Sidney
Kimmel Comprehensive Cancer Center, hospital at home,
memory & sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis. Sleep also controls inflammation (Jan 2019) Sleep deprivation undermines the thalamus & nucleus accumbens management of pain. :
Diering; Berman Institute
for Bioethics, School of medicine,
Checklists) University, Jonkoping Hospital
Sweden, Kingman
Regional Medical Center, Kings County
Hospital, Lahey
Hospital, La Pradera Cuba, Los Angeles County
Health Agency: LAC+USC Medical
Center, Lancaster
general health, Lehigh
Valley Health Network, Lenox
Hill Hospital, LifePoint
Hospitals, Lifespan, Lineberger
comprehensive cancer center, LIJ
Health System: House
Calls service; Long
Island College Hospital, Louisianna state
university health
sciences center: school
of medicine, Lourdes
Medical Center (urgent care handover, EHR silos), Martini-Klinik hamburg, Massachusetts General
(Learning laboratory, Cancer Center,
Diabetes
Center, Concierge
service, Pathology),
Mayo Clinic (business structure, Cancer Center, startups, obesity
treatment research, Watson),
McLeod (strategy), Medical Center Hospital,
MedStar Health: Washington
Hospital Center; Memorial
Hermann, Mercy Health of St. Louis: Mercy Hospital
Independence Kansas; Mercy
Medical (tele-health):
Iowa, Memorial Care Health,
Memorial
Sloan-Kettering Cancer center (Innovation: Technology
development (Raskin), Prostate cancer
surgery recovery; using IBM's Watson, Banking stools,
Center for
Cell engineering (Michel
Sadelain) Gene therapy:
beta thalassemia,
melanoma and
immunotherapeutics services: Jed Wolchok; Josie
Robertson outpatient surgery center: Director (Brett Simon),
Center for
health policy; Clinical genetics
service: Kenneth Offit,
Pathology: Klimstra, Computational
Pathology: Fuchs),
MeritCare Health
System, Methodist System, Memorial Medical Center
New Mexico, Michigan State University (HealthTeam:
Radiology; Sparrow hospital),
Midwest Health
Collaborative, Midwestern
Regional Medical Center, Moffitt Cancer
Center & Research Institute, Montefiore,
Mount Sinai Health
System (New York): Koufman; Mount
Sinai Beth Israel New
York, Mount Sinai
Hospital New York(Tele-health,
Infectious diseases: Judith
Aberg), Mount
Sinai Hospital Chicago, Mount Sinai Hospital
Toronto Canada (Diabetes
Zinman), Naples
Community Hospital, National
Jewish: Center
for Health Promotion (Bruce Bender),
Nationwide
Children's Nebraska
Medical Center (special
containment unit), NCH
Healthcare, New York City Health and Hospital
Corporation (HHC),
New York
Presbyterian Health System (Columbia UMC),
New York University Langone MC:
Institute for systems
genetics (Jef Boeke),
Perlmutter
Cancer Center (Leena Gandhi);
Newport
Hospital Spokane Washington, North Carolina (School of
medicine: Cancer
center (Watson)),
Northeast
Georgia Health System, North Mississippi
Medical Center: imaging;
North
Shore-Long Island Jewish Health System, NorthShore
University Health System, Northwestern Medical
(Robert Lurie
Comprehensive Cancer Center), Northwestern Memorial
Hospital, Northwell Health,
North Westchester
Hospital, North
York General Hospital Toronto, Ochsner Health System, Ohio Health, Ohio State University Comprehensive
Cancer Center, Palo-Alto Medical
Foundation, Parkland Health
(Memorial Hospital,
Mobile hot
spot clinics), Parkview
Health, PeaceHealth: Sacred Heart
(hospitalists
unionize); Penn State Hershey Medical
Center, PIH health, PinnacleHealth System, Pomona Valley
Hospital, Pratt regional medical
center, Premier Health
(Dayton Ohio: Miami
Valley Hospital), Palms of Pasadena
Hospital, Phoebe
Putney Health System Georgia, Premier
alliance, Presence Health, Promedica Hospital System,
Prospect Medical
Holdings, Providence
Hospital, Quorum
Health Corp., RegionalCare
Hospital Partners, Rhode
Island Hospital, Riverside Health
System, Rockefeller University Hospital, Roswell Park Cancer
Institute, Royal
Bournmouth & Christchurch Hospital: Day Hospital; Rush
University Medical
Center (CVS
partnership), St.
Barnabus Hospital NYC, Saint Francis Medical
Center Peoria, St. Joseph's Regional
Medical Center Patterson N.J. (ED), Saint
Jude's Childrens
Hospital Comprehensive
Cancer Center Memphis Tennessee, Saint Luke's
Health System Kansas, St.
Lukes Cornwall Hospital, St. Lukes Health System
Idaho, St.
Mary Medical Center LA, St. Patrick
Hospital Montana, Saint Thomas
Heath Services, St. Vincent's
hospital, Sentara
Healthcare, Sanford Health
System, Santa
Clara Valley Medical Center, Schwab
Rehabilitation Hospital Chicago, Scotland memorial
hospital, Scripps
Health San Diego, Seattle Children's
Hospital, Shawnee
Mission MC, Shouldice
Hospital, Sinai Health System,
Singing River
Hospital (Mississippi),
Somerville Hospital, South Shore Hospital MA,
Southwestern Vermont Medical Center (strategic
planning), Stanford
University ( Research: safety (culture),
Cloud (Pamela Hinds);
material science
(Melosh -
Nanoscale
devices) MIPS
(Cheng),
Cloning: Stanley Cohen,
Nuceic acids: Paul Berg;
Rheumatology
and Immunology: Robinson,
Genovese; Radiation oncology,
Deep learning AI and nano tech: Professor Lei Xing, Anesthesiology: Lemmens; Stanford Hospital: Cancer Center, Stroke Center, UHA, Wellness, leading-edge
facilities, Health
policy (Keith Humpfreys - behavioral health);), Steward Health Care
System, Sunnybrook
Health Sciences Center Toronto Canada, Sutter Health, Swedish Medical Center,
Tanner Health System, Tenet Healthcare
Corporation, Texas
Children's Hospital, Texas
Health Resources (Presbyterian (Dallas, Plano,)), Texas Heart Institute, Texas Medical Center, ThedaCare, Torrance Memorial
Health, Triad Hospitals, TriHealth, Trinity Health System, United HealthSystem
consortium, UnityPoint
Health: St.
Lukes, St.
Mary's Grand Junction, United Hospital
of St. Paul, Universal
Health Services, University
Hospital's Seidman Cancer
Center, University of Alabama at Birmingham (comprehensive
cancer center), UC
Health System, University
of California system (UC
Davis Health, UCLA Health (strategies: CHCM models,
CICARE, rekindle
sense of hope; Sleep
disorders center), UC San Diego: (Moores Cancer
Center), Medical
School: Justin Zivin;
UCSF Institute
for Computational Health Sciences Atul Butte, UCSF Medical Center: Health eHeart, Medical Errors
(prescribing), diabetes
policy, Helen Diller
Family Comprehensive Cancer Center, Tug robots; ), UHealth Tower, University of
Chicago medical center, University of Colorado Cancer Center,
University of
Connecticut Health
Center: John
Dempsey Hospital, University of Kentucky Hospital,
University of Maryland Medical
System: Greenebaum
ccc; University of Rochester Medical
Center: Strong
Memorial Hospital, University of Tennessee Health
Science Center, University of Massachusetts (Medical Center,
Memorial
Health Care), University of Michigan (Comprehensive
Cancer Center, Overtreatment: Dr. Caverly),
University of Pittsburgh:
Medical School,
Department of health and
physical activity (Jakicic),
UPMC (predictive
health analytics, acute hospital
to SNF transitions, Big data, Hamot), University
of Texas MD Anderson
Cancer Center: John
Mendelsohn, Immunology
department (Allison),
thoracic/head
& kneck medical oncology (Heymach), VA Atlanta Healthcare
system, University
of Texas Southwestern Medical Center: Touchstone diabetes
(Scherer),
University of Utah (Hospital,
Huntsman Cancer
Institute), VA
Boston Healthcare System, VA Connecticut
Healthcare, VA
San Diego Healthcare System, ValleyCare Health,
Vanderbilt University Medical Center:
Urologic Surgery (David
Penson), Vanderbilt-Ingram Cancer Center
Tennessee, Vanderbilt school of
medicine: cardio-oncology
(Javid
Moslehi; Vanguard
Health Systems, Verity
Health: Seton Medical Center,
c-suite Aug
2016 reorg; Vidant:
Greenville medical
center, Roanoke-Chowan
Hospital; Virginia
Mason Medical Center, Vizient,
WakeMed, Washington
Regional, Wellstar
health system: Kennestone
Regional Medical Center; WESTMED
Medical Group: standardized
patient care; West Virginia
University Medicine, Whidden Memorial, White Plains Hospital, Woman's Hospital of
Texas, xG Health
systems (Chairman: Glenn Steele;
SMART), Yale-New Haven
health system (Arthur Broadus,
Cancer Center: Dr. Herbst,
Smilow Cancer Hospital),
- Independent surgeons
- Admissions process:
admission types
- Urgent care clinics: Action Urgent Care, ASAP Urgent Care, Beacon, Centra Care, Concentra Urgent Care, Coppell ER, Envision Healthcare, FastER, Gohealth, Medexpress, PhysicianOne Urgent
Care, Plushcare Urgent
Care, Urgent Care of
Connecticut, US HealthWorks;
- International
medical charities: MSF (Ebola), Samaritan's purse,
- Value
added surgery centers: Advanced
Dermatology & Cosmetic Surgery, Arkansas Skin Cancer
Center, PAMF's Palo Alto
surgical centers, Paragon
health associates, Schweiger
Dermatology, Surgical
Care Affiliates, Texas
Oncology, United
Skin Specialists;
- Fertility clinics:
- Dialysis centers: American Renal Associates,
DaVita, Fresenius Medical Care, Satellite
Healthcare;
- For-profit medical malls:
Barnert medical arts
complex,
- Integrated solutions:
- Baptist Memorial
health care,
- CareMore Health Plan:
patient
care standardization, de-institutionalization;
- Geisinger Health
Systems:
- Grand Valley
Health Plan,
- Intermountain
Healthcare: Institute
for health care delivery research, SelectHealth
Share;
- Kaiser (Oakland
medical center CEO: Dr. Pearl;
(STHLM3), PCMH, Strategic planning,
Infections
& obesity),
- Veterans
Health Administration,
- ACO: Alliances
- Premier,
- Advance payment ACO:
- Pioneer ACO: Allina Health, Atrius Health, Banner Health
Network, Beacon Health, Bellin-Thedacare
Healthcare Partners, Beth Israel
Deaconess Physician
organization, Brown
and Toland Physicians, Dartmouth-Hitchcock
ACO, Fariview Health
Systems, Franciscan
Alliance (tele-health),
Genesys PHO, Healthcare
Partners Medical Group, Healthcare
Partners of Nevada, Heritage California
ACO, JSA Medical Group,
Michigan Pioneer ACO,
Monarch Healthcare, Montefiore ACO, Mount
Auburn Cambridge Independent Practice Association, OSF Healthcare
System, Park
Nicollet Health Services, Partners Healthcare, Physician Health
Partners, Plus, Presbyterian
Healthcare Services, Primecare Medical
Network, Renaissance
Health Network, Seton
Health Alliance, Sharp
Health Alliance, Steward Health
Care System, Trinity
Pioneer ACO LC, University
of Michigan Health
System (depression
management), Vivity.
- Post-acute
care providers:
- Long-term care providers:
- Skilled nursing
facilities/ long-term care nursing homes: Allenbrooke,
Brius Healthcare, Chase Memorial
Nursing Home, Ensign, Extendicare, Fairfield,
Leonard
Florence Center For Living, Harborview, HCR Manorcare, Medford, Newbridge on the Charles,
Sante Partners, Watermark,
- Rehabilitation
facilities:
- Assisted living
facilities: Assisted
living concepts, Elmcroft
of Twin Hills, Enlivant, Peter Sanborn Place;
- Home care providers: BrightStar Care, CareMinders, Extended home care, Coram, Village@Home,
- Hospice & palliative
care: Aspire, Curo, Hospice of the Valley, Kindred, Vitas;
- Lifestyle & exercise:
Nifty after Fifty;
- Mental health services:
- Outpatient clinics: Harvard Vanguard;
- Community Health
Centers: Baltimore
Medical System, CHC, Friend Family, Hudson River HealthCare,
Parker Jewish Institute;
- Primary care physicians:
Boutique/concierge,
Networked, Employed,
Best Doctors: Watson, Fallon Clinic, reengineered PCMH (Bon Secours
Virginia Medical Group, Camden coalition
of healthcare providers, CareBridge
medical neighborhood, Donna
Medical Clinic, DuPage
Medical Group, Elmhurst Clinic,
Grand Junction Health
System, Hill
Physicians, Innovative
oncology business solutions, Iora
Health: chronic
care; Louisville Family
Health Centers, One Medical,
Mass General's concierge
practice, MD Squared: Maron, Matles;
AtlantiCare's Special
Care Center, Geisinger's PHN, Integrated Health
Partners, Palo Alto Medical Foundation: Encina Practice: Dr. Henry
Jones; VillageMD, West Valley Center; Primary Care
Partners of Grand Junction, Priority Private Care, Private Medical: Chiu, Green, Shlain; Southwestern
Vermont Health Care, Trinity Clinic) home visits (ED
replacement - Carena; Johns Hopkins Hospital at
home), New
Mexico Oncology Hematology Consultants, Saltzer medical
group;
- Hospital real estate development & operating companies:
Brooklyn
Health Partners, Fortis,
Peebles;
- Medical staffing: Envision, Vituity;
- Supplying internists to hospitals: IPC Healthcare, TeamHealth;
- Diet clinics: JumpstartMD, Long Island
Weight Loss Institute, Medi-Weightloss,
Thinique;
- Retail
drugstores, pharmacists and retail
clinics:
- Online pharmacy:
- Specialty pharmacies:
- Accredo, BioRx,
BioScrip, Brothers Specialty Rx, Caresite
specialty, CVS/Specialty (Omnicare), Diplomat Pharmacy, Factor Support Network,
Linden Care, Philidor Rx Services, R&O Pharmacy, Walgreens
specialty: connected
care program;
- Compounding pharmacies:
- Standalone oncology
centers: New
Mexico Cancer Center;
- Imaging
Centers - free standing radiology: Envision, Evergreen Health, Radia, Radiology
Associates of Sacramento, Radiology
Partners;
- Reference laboratories:
- Kiosk delivered healthcare: HealthSpot,
- Stool-banking: Finch Therapeutics, OpenBiome, Rebiotix,
Seres Therapeutics, Vedanta Biosciences;
- Ambulance service: First Med, Medstar
Texas, Rural/Metro, TransCare;
Employers as insurers
Employers obtain
government subsidies when they act as health insurance reduces volatility in standard of living by compensating for losses of income during periods of unemployment, for catastrophic losses from disaster, or death of a family income earner as described by Gordon. Insurance companies must set aside reserves to handle such claims. Britain initially required that insurance buyers also have an insurable interest. That is required in insurance markets to ensure buyers of insurance don't destroy their asset just to obtain the insurance. Health insurance is treated separately being unusual, since the subscriber is likely to know more about their state of health than the insurer is and the subscriber is more likely to purchase the health insurance when aware of their increased risk. This behavior collapses the risk pool by: forcing the insurer to increase the premiums, and encouraging healthy individuals to opt out of health insurance coverage. payers is a hospital's specific mixture of the four different types of payer: - From the 1930s the insurers Blue Cross and Blue Shield catalyzed health care activity by paying a daily per diem to hospitals for the diagnoses and treatments the hospital's dispensed. At their inception in 1966 Medicare and Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism. This forced alignment of the supplier, diagnosis, treatment, billing and reimbursement processes. The health care network is still structurally aligned around PPS. Under scrutiny of ProPAC and its successor MedPAC, as well as pressure of the BBA after 1997, the payments per DRG have been steadily reduced until it was below the cost of care, forcing hospitals to seek margin from their other payers. Medicare outlier payments benefited hospitals that inflated charges and thus became eligible.
- Employers as they experienced cost shifting from the hospital's increased product charges moved their employees over to managed care based payment.
- Private payers pay hospitals directly for their diagnosis and treatment. Typically this group has little power. There are default rates for private payers - typically 40% of billed charges that are not covered by a fixed payment or a fee schedule. For the uninsured poor until 2004 they obtained little discount on the hospital's chargemaster list price, because insurers and CMS required to be charged the lowest value offered to any patients. Medicare has now relaxed this constraint.
. But
they have been threatened by the increasing cost of health care
delivery. By 2016 they are reducing this risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. by cost-shifting is the practice of: - States to shift dual eligibles from Medicaid to Medicare federal funded services.
- Hospitals to maintain margins, when under pressure from reduced reimbursement, by increasing charges for services provided to non-contractually protected patients.
to
their employees (Sep
2016).
- Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
for
all proposals induce health care (hospitals,
PhRMA)
and health
insurance (fear powerful new competitor taking profits)
industries to respond, with advice from Forbes Tate,
to setup Partnership
for America's Health Care Future with Hillary Clinton's
Lauren Shaver in charge, which is pushing for Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. expansion
and maintaining the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and sustaining Employer
based insurance, which pays doctors and hospitals higher
fees than Medicare. ACP is the American College of Physicians.
supports Medicare buyin (Feb
2019)
Key employers:
An expected dis-intermediation of general hospitals is showing signs
of expanding. Wal-Mart's
contracting
with centers of health care excellence is seen as a leading
indicator of a shift from use of costly local general hospitals to
help control costs. Companies are motivated by the need to
rein in health care costs, which continue to rise faster than
overall inflation, but the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
is also changing how
some view their obligations to their employees.
Some firms like Walgreens,
are giving those who qualify money to buy insurance on a private
health exchange. Aon Hewitt, a benefit consultant that will
oversee health plans on Walgreens's behalf, said 18 large employers
had signed up so far, including Sears and Darden Restaurants.
General
Electric is taking the opposite
approach. And it is not seen as unique.
CalPERS -
California Public Employees Retirement System
CalPERS is one of the nation's largest buyers of health care
benefits. It is viewed as an indicator of what other large
employers will do.
2015 CEO and chief investment officer Ted Eliopoulis
2015 Vice President Henry Jones
2016 Chairman of the CalPERS investment committee Michael Flaherman
2016 CalPERS chief of public affairs Wayne Davis
CalPers,
Blue
Shield of California, Hill
Physicians Medical Group, and Dignity Health
formed an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
(2010)
CalPERS bills California cities once a year for their share of
the cost of paying pensioners assuming that its investments will
return 7.5% in the future. But the assumed rate of
return is dropping increasing the state and city's share of the
costs (Dec
2016). And the cost of pensions has been rising --
especially for the police.
CalPERS supports state governments by using actuarial
evaluations of pension commitments. But this is shifting:
- Actuaries, including CalPERS,
yearly government employer valuations of pension liabilities are
systemically low (Sep
2016)
- KQED's Forum on California politics and economics is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
: CalPERS
losses from Great Recession & limited capital growth, City
revenues depleted by pension cost impacts inhibit funding of infrastructure maintenance, No revenue
for single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
health care, Voters still rejecting tax increases; (Jul
2017)
- 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).
Calpers interim reports had been based on its actuarial books (which
are typically used to help employers plan stable annual
budgets). But it also has books that reflect the "market
value" of the pension funds (reflecting the current values of assets
and liabilities of the fund) that have been earned. The market
value must reflect the full cost today of providing a steady,
guaranteed income for life. Even the actuarial valuations of
costs owed by governments to pensioners have been growing as US
populations are aging and public workers retire.
In California, some local governments now doubt they can afford
their pension plans and have asked to exit from CalPERS. But
when they leave CalPERS calculates the market value at that point
and bills for any gap in funding. CalPERS must do that since
it has no way of going back to the employers later and asking for
any additional funds. CalPERS then keeps the money in a
separate "termination pool".
The hidden underfunding is typical of US public pensions.
Retired public workers, local taxpayers and municipal bond buyers
are currently exposed to risk they are not aware of.
CalPERS Amy Morgan noted "CalPERS does not exist to make
money. CalPERS exists to fully pay out benefits that are
promised to its members." Morgan noted the law required
CalPERS to perform a complete evaluation after the termination date
has passed, and to recover all the money needed to ensure retirees
would be paid in full.
But they are also pursuing municipalities which fail to fund their
commitments:
- CalPERS
is pursuing Layalton, a small city that has failed to fully fund
their pension liabilities. And it is also considering
cutting pension payments if such cities fail to make good on
their commitments (Oct
2016).
- CalPERS puts pressure on other pension funds and state
finances as it lowers projected return on investment (Dec
2016).
The California state government does not backstop the pensions of
small towns. CalPERS
Wayne Davis explains "The State of California is not responsible for
a public agency's unfunded liabilities." And CalPERS
can't forgive Layalton, since other towns would demand similar
treatment.
CalPERS has $290 billion in pension assets to protect, but they are
committed to pensioners from other cities which are contracted with
CalPERS and funding their actuarial pension commitments.
Already Stockton's bankruptcy is a legal status for an entity that cannot repay its creditor's loans. It holds creditor lawsuits in abeyance while the restructuring process proceeds to allow the entity to continue operations. It also has legal tools for forcing holdout creditors to accept repayments that are lower than the bond sale initially promised.
resulted in the Judge Christopher Klien, concluding that the city
had the right to break with CalPERS -- but it could not switch to a
cheaper pension plan without abrogating its labor contracts.
Stockton stayed with CalPERS.
Jun 2013 CalPERS
has instituted a program to cap prices of commodity hospital
treatments
CalPERS has agreed pricing caps with a number of hospitals in
California for commodity operations. The NYT reports that
under the program, some employees are being given the choice of
going to one of 54 hospitals, including well known medical centers
including Cedars-Sinai
and Stanford
University Hospital, that have agreed to charge no more than
$30,000 for a hip or knee replacement. Prices for the
operation vary between $15,000 and $110,000 within the state.
CalPERS worked with insurer Anthem Blue Cross
to introduce the program.
Overall costs of operations under the program fell 19 percent in
2011, the programs first year, with the average amount it paid
hospitals for a joint replacement falling to $28,695 from
$35,408, according to an analysis by WellPoint's
researchers that was released Jun 2013 at a health policy
conference. The study found no impact on the quality of
care.
CalPERS
started using reference
pricing constrains a policy holder to a reimbursement for the reference price of a treatment rather than the specific hospitals billed price. Patients have to pay the difference. It can allow subscribers broader access to different health care providers than narrow networks. It is only applicable for elective procedures where the patient can shop around (Aug 2016). - paying hospitals a maximum contribution for 450,000
of its members for: knee/hip replacement, colonoscopies, cataract
removal and several other elective procedures; in 2011. The
patients foot any excess in the price.
At the initiation of the approach 41 of California's several hundred
hospitals could provide knee and hip replacement procedures for
$30,000 with acceptable quality. Some hospitals were charging
more than $100,000.
CalPERS reduced patient cost-sharing if patients chose a free-standing,
outpatient surgical center as opposed to a general
hospital.
UC
Berkeley health economists is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. '
James Robinson and Timothy Brown reported patients with reference pricing constrains a policy holder to a reimbursement for the reference price of a treatment rather than the specific hospitals billed price. Patients have to pay the difference. It can allow subscribers broader access to different health care providers than narrow networks. It is only applicable for elective procedures where the patient can shop around (Aug 2016).
flocked to lower-priced hospitals and out-patient surgical
centers. Prices and total spending for the procedures
plummeted:
- Knee/hip replacement market share for lower-priced hospitals
increased by 28%. Higher-price hospitals responded to loss
of share by reducing prices. Prices on average fell 20%
saving CalPERS $6 million over two years.
- Cataract removal surgery average price dropped nearly 20%
- Colonoscopy prices fell 28%
- Knee and shoulder arthroscopy prices fell 17%
Quality was not found to be affected in the study.
Prices of reference-priced services for CalPERS declined 20% during
a period when health care prices paid by employer-sponsored plans
rose by 5.5%.
Reference pricing can affect the 40% of health care spending which
is elective. But it requires patients to get access to and
understand procedure prices and quality details and there to be
enough providers to develop a competitive local market. There
is an administrative cost in calculating effective reference
prices. So additionally some large employers are contracting
with centers of excellence such as the Cleveland Clinic
to add choice outside of the local market.
Subsiquently (Sep
2014) the activity generated the ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination. - CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
style joint venture Vivity.
2014 CalPERS has $300 billion in assets it is managing. It
liquidated $4 billion in hedge fund
investments. This was a catalyst to investors subsequently
shifting out of hedge funds (Sep
2016). But CalPERS intends to continue investing in private equity.
Even as their performance fails to justify such faith (Jul
2016).
Nov 2015 NYT
CalPERS Paid $3.4 Billion To Private Equity Firms
Alexandra Stevenson reports for years, state pension funds have
invested money earned by teachers, firefighters and other government
employees with private
equity firms without having a full picture of how much they
were earning and what they were paying in expenses.
The pension industry is under public scrutiny, it has had
disappointing performance and is faced with ballooning
deficits.
In 2015 CalPERS will for the first time, pay more to its retirees
than it makes from its investments and contributions (Dec
2015).
Henry Jones, chairman of the investment committee said "Private
equity is a complicated asset class and the board and investment
office staff will now have even more insight into our
program."
CalPERS disclosed it had paid $3.4 billion since 1990 to: Carlyle, Blackstone, Apollo;
on carried
interest is a fund manager's share of the earnings from a profitable investment. It is a performance fee, charged by venture capital firms and private equity firms in addition to the smaller management fee. There is a congressionally granted tax loophole which keeps the tax rate on carried interest low - 15% in 2016. This loophole on capital gains was setup to encourage people investing their own capital to take more risk. But general partners at venture and private equity firms do not have the associated risk. The loophole reduces US tax receipts by $2 billion each year. profits of $24.2 billion. Private equity has
the highest net returns in the CalPERS portfolio yielding 11.1%
since 1990. Not so since
then (Jul
2016).
J.J Jelincic, a member of the CalPERS board said a break down of the
transaction fees charged by the private equity firms was missing
from the released breakdown. "We certainly know more than we
did before, but it's not the complete story yet." Transparency push being undermined
(Jul
2016).
CalPERS bench mark for investment is an amalgamation of domestic and
foreign stock market indexes with 3% added.
CalPERS and California proposition 61
CalPERS is ambivalent about California proposition 61 which aims to
constrain the rise in drug prices (Jul
2016).
G.E. - General Electric
- G. E.
is working directly with its employees providers - pushing for 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.
including transparency of work done for them at
major health systems with a goal of encouraging a transformation
of the health system (Sep
2013)
- G. E. International
- Without 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.
the
pan-Asian participants, and US companies: GE;
are being sucked into China's
economic is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. and
military network (Nov
2016)
- G. E. Capital
- Dodd-Frank issues (Mar
2016)
- GE
results mixed: Power generation still a problem, $121 billion
debt to finance - so plans to cut it by $50 billion selling
assets: rail locomotive, oil field equipment, health care; GE
capital aviation services not for sale, jet engines sold well,
WMC sub-prime mortgage issues settled with DOJ - U.S. Department of Justice. with $1.5 billion
penalty. GE
Capital, still being investigated by S.E.C. is the Securities and Exchange Commission. It was provided with power to regulate the securities industry by the Securities act and Securities Exchange act. , set aside $15
billion reserves for higher
costs to reinsuring long-term
care policies at GE Capital (Feb
2019)
- Berkshire
Hathaway invests in G.E.
- G.E. Healthcare
- G.E. Lighting
- Part of a broader trend with low rates (Nov
2016)
- Risk management focused asset managers: Blackrock; are
capturing more investment dollars than Goldman and J.P. Morgan
Chase, with E.T.F. is exchange traded fund, which tracks stock and bond indexes, adhering to a set of financial rules. These methods can be used to track any financial market segment. They are transparent, and low cost to operate, and invest in. ETFs are priced during normal trading hours. But their performance is impacted when they are forced by changing conditions to sell assets at a loss. Selling of an ETF by one investor to another does not redeem the ETF's underlying investments, limiting the capital gains tax distribution (Jul 2018).
s
(Sep
2016).
Sep 2013
NYT reports GE provided health care plans are connected directly
to doctors and hospitals
General
Electric, one of the largest employers in the USA spends more
than $2 billion a year offering coverage to 500,000 employees and
retirees and their families. It is using its considerable
clout in Cincinnati where it has a giant aviation business to work
directly with doctors and hospitals to improve care and reduce
costs.
Over the last few years, G.E. has pushed for the creation of medical homes are primary care architectures which deliver: patient-centered, accessible, coordinated, comprehensive care of high quality and safety (Dec 2015). The models have been made more significant due to Affordable Care Act payment reform requirements. The goal is to reduce treatment costs and improve population health by reengineering of the traditional silo'd provider network. See PCMH.
with access to all of the patient's medical records,
In Cincinnati, about 118 doctors' practices have converted to medical homes is patient centered medical homes:
- Describes a reorganization of the health care delivery
system to focus on the patient and care giver supported by
EHR infrastructure and some form of
process management
which will be necessary to coordinate interventions by
each of the functional entities resources to treat
the patients specific problems. The
disadvantage of a PCMH is the administrative and
technology cost needed to support its complex
processes. The PCMH
- Was promoted as a way to incent more PCP
which had been seen as a low reward role by medical
students. HCI3 argues
this use of PCMH is flawed. PCMH is driven by
the medical home models
of the ACA. In this model the
PCMH is accountable for meeting the vast majority of each
patients physical and mental health care needs including
prevention and wellness, acute
care, and chronic care. It is focused on treating
the whole person. It is tasked with coordinating the
care across all elements of the health care system,
including transitions and building clear and open
communications. It must ensure extended access and
availability of its services and patients preferences
about access. It must continuously improve quality
by monitoring evidence-based medicine
and clinical decision support tools (NCQA).
Many argue that to be effective it must be connected to a
'medical neighborhood'.
The PCMH brings together the specialized resources and
infrastructure required to develop and iteratively
maintain the care plans and
population oriented system descriptions that are central
to ACA care coordination.
, and all
five of the major health systems are making their primary care
practices move in that direction. G.E. has also pushed for
greater transparency of results.
"If we don't take accountability ourselves for figuring this out,
we're part of the problem," said Sue Siegel, a senior executive at
G.E., who sees transformation of health care both as a business
opportunity and a business necessity.
"We have to be involved in the solution," she said. "We can't
just wait for someone to tell us that it is going to be
fixed."
What distinguishes the effort by G.E. is its direct focus on
hospitals and doctors. Companies looking to the private
exchanges are largely hoping to save money and want to be
freed from the headache of administering health benefits.
In Cincinnati, G.E.
took both a cheerleading and coordinating role. In early 2010,
Jeffrey R. Immelt addressed local business leaders now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model. and urged
them to think strategically and align their efforts to make more of
a difference. There were already significant efforts under way
to foster medical
homes (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
, for example, and G.E. pushed to find more financing to
expand the concept to more medical practices and keep the focus on
that initiative.
"The ever-present vigilance of the employers help nudge things
along," said Craig Brammer, chief executive of three area health
care coalitions, including the Greater Cincinnati Health Council,
which is made up of the area's hospitals, health plans and
employers.
The city's health systems say they recognize that insurers and
employers are increasingly going to reward them for better tracking
their patients in and out of the hospital. "We are clearly
gearing up to change directions from FFS is fee-for-service payment. For health care providers the high profits were made in hospitalizations, imaging and surgery. Due to its inducing excessive treatment activity it may be replaced by FFV bundled payment. to what I'll call
payment for value," said Will Groneman, an executive vice president
for TriHealth, one of the systems.
The medical
home (PCMH) The Patient-centered medical home - Describes a reorganization of the health care delivery system to focus on the patient and care giver supported by EHR infrastructure and some form of process management which will be necessary to coordinate interventions by each of the functional entities resources to treat the patients specific problems. The disadvantage of a PCMH is the administrative and technology cost needed to support its complex processes. The PCMH
- Was promoted as a way to incent more PCP which had been seen as a low reward role by medical students. HCI3 argues this use of PCMH is flawed. PCMH is driven by the medical home models of the ACA. In this model the PCMH is accountable for meeting the vast majority of each patients physical and mental health care needs including prevention and wellness, acute care, and chronic care. It is focused on treating the whole person. It is tasked with coordinating the care across all elements of the health care system, including transitions and building clear and open communications. It must ensure extended access and availability of its services and patients preferences about access. It must continuously improve quality by monitoring evidence-based medicine and clinical decision support tools (NCQA). Many argue that to be effective it must be connected to a 'medical neighborhood'. The PCMH brings together the specialized resources and infrastructure required to develop and iteratively maintain the care plans and population oriented system descriptions that are central to ACA care coordination.
also appears to resonate with employees. When Mary
Farris, a 44-year-old marketing executive for G.E, found herself
going to a local urgent care
center is an efficient and less costly 'alternative' to the ER. There is no accepted standard. Urgent care clinics also compete with Primary care based on extended hours and accessible locations including Medical Malls. Most have a physician on staff and treat ailments like feavers, sprains and sinus and urinary tract infection, but they also can perform X-rays, stitch up cuts and set broken bones. Unlike an ER they can not admit patients to a hospital. Some also offer services like pre-employment drug screening and summer camp physicals. because she could never get an appointment with her
physician, she switched to a practice that had become a medical
home.
What strikes Ms. Farris was how much time the doctor and medical
assistant spent gathering her medical history and making sure there
weren't additional medical issues. While she came in for a
spider bite, the focus was her well-being as a working mother whose
father was seriously ill at the time. "The picture was more on
all of me as opposed to one isolated incident," she said.
"Somebody was trying to connect the dots."
In Cincinnati, there are beginning to be grudging signs of
success. Early results are promissing: patients enrolled in
medical homes had 3.5 percent fewer visits to the emergency room (ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). ) and 14 percent fewer
hospital admissions over the four years from 2008 through
2012. G.E. plans to ask an outside firm to do a more detailed
analysis.
But employers looking to adopt a similar strategy will find "it's
hard to do," said David Lansky, the chief executive of the Pacific
Business Group on Health, which represents West Coast
employers. While "the opportunity is significant," he said,
companies may not have the time or resources to work in too many of
their locations, with different hospitals and health plans in each
market.
G.E. recently signed an agreement with Hospital
for Special Surgery in New York, a high-volume orthopedic
hospital, to oversee the care of some employees getting hip and knee
replacements. That doesn't sit well with Cincinnati's UC Health
System.
G.E. is unapologetic. The company says it will continue to try
a variety of appraoches until it finds a way to tame health care
costs even more than the annual growth rate achieved so far of under
3 percent. "You'll see many, many experiments across the
board," Ms. Seigel said.
G.E. and prediabetes management
G.E. has sponsored pre-diabetic is a condition where the subject's blood sugar levels are higher than normal but they are not yet suffering from irreversible type 2 diabetes. In 2016 the CDC estimates 86 million adults, including at least 22 million people 65 or older, are pre-diabetic increasing their risk of heart disease, stroke and diabetes. Doctors test for pre-diabetes with a blood test: FPG, OGTT, A1C; with fasting required in the first two. Pre-diabetes is treatable but only about 10 percent with the condition are aware they have it. Left untreated, up to one-third of people with pre-diabetes will develop diabetes within five years. The YMCA developed a pre-diabetes treatment program. People can use a test devised by the CDC to assess their risk of pre-diabetes.
workers to help avoid type 2 diabetes is the leading cause of blindness, limb amputations and kidney failure. It is a risk factor for Alzheimer's disease. 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. As we age our muscles become less sensitive to insulin and the pancreas responds by increasing the amount generated. 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
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 now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern 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 is the corporate parent of Google and the other unrelated
businesses.
- Google web
search to
detect flu;
- Alphabet promotes 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. ,
- Google secretly
develops a censored version of their search engine.
Employees want to know about it. China continues to block
Google, Facebook etc. from its network (Aug
2018)
- Google member
of USCC is the United States Chamber of Commerce
.
- Google partners with Mount
Sinai Beth Israel, J&J (Ethicon)
on
robot surgery,
- Google uses: Zipongo;
- Google Android
- Google uses
Android to drive Chrome installations into the market, abusing
its market position, E.U. is European Union, the 1992 Maastricht Council of Ministers meeting agreed evolution of the ECSC & CAP cartels to include:
- A single market across the members' countries supporting the transformation of the ECSC. It maintained the CAP transfers assisting French farmers.
- A fixed currency 'snake' that allowed the ECSC to operate, binding the deutschmark to the other currencies of participating members: a mini Bretton Woods exchange rate mechanism; that became a single currency, the euro, managed by an independent ECB (based on the independent German Bundesbank); but tax gathering was allocated to the states whose leaders control the Council of Ministers and no effective mechanism was provided to reallocate revenues. This has left Germany with an advantage supported by the aggregate valuation of the euro and not having to flow tax revenues to the weaker economies of the south.
commission is the policy initiating & executive arm: implementing already agreed policies; of the EU. Policy proposals are legislated by the Council of Ministers. The European Commission is led by the president who is supported by commissioners, and staffed by a large bureaucracy. The president is appointed for five years nominated by the Council of Ministers and approved by the European Parliament. The commissioners are appointed by the Council of Ministers for a five year term, with consultation from the president & ratified by a vote of the European Parliament. France, Germany, Italy, Spain and, until Brexit, the UK appoint two commissioners each, while the other members appoint one each.
judges & fines Google $5.1 billion (Jul
2018)
- Google life sciences becomes Verily:
- Partners with
Ethicon,
- NIMH is the National Institute of Mental Health.
's Dr. Insel
moves to Verily
- NIH is the National Institute of Health, Bethesda Maryland. It is the primary federal agency for the support and conduct of biomedical and behavioral research. It is also one of the four US special containment units of the CDC. 's million person
precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015).
program All of US makes slow & costly
progress - relative to smaller biobanks: UK, Iceland (deCode), VA - Department of Veterans Affairs. Includes the Veterans Health Administration. , Kaiser, Geisinger;
causing some participants to back out: Kaiser, Geisinger (Regeneron); but Francis
Collins asserts its scope is essential & Verily
is still participating (Mar
2018)
- Verily,
Stanford
& Duke,
work on project Baseline, to identify early markers of: cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
, cardiovascular
disease refers to: - Conditions where narrowed and blocked blood vessels result in angina, hypertension, CHD and heart attacks and hemorrhagic/ischemic strokes. Mutations of the gene PCSK9 have been implicated in cardiovascular disease. Rare families with dominant inheritence of the mutations have an overactive protein, very high levels of blood cholesterol and cardiac disease. Other rare PCSK9 mutations result in an 88% reduced risk from heart disease. Inflammation is associated with cardiovascular disease (Aug 2017).
; from samples of: urine, blood, and stools; by
following 10,000 healthy people's: microbiomes, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome: - Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
, genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes. ,
cognitive health, sleep facilitates salient memory formation and removal of non-salient memories. The five different stages of the nightly sleep cycles support different aspects of memory formation. The sleep stages follow Pre-sleep and include: Stage one characterized by light sleep and lasting 10 minutes, Stage two where theta waves and sleep spindles occur, Stage three and Stage four together represent deep slow-wave sleep (SWS) with delta waves, Stage five is REM sleep; sleep cycles last between 90-110 minutes each and as the night progresses SWS times reduce and REM times increase. Sleep includes the operation of synapse synthesis and maintenance through DNA based activity including membrane trafficking, synaptic vesicle recycling, myelin structural protein formation and cholesterol and protein synthesis. Sleep also controls inflammation (Jan 2019) Sleep deprivation undermines the thalamus & nucleus accumbens management of pain.
patterns from Verily device; for four years. Precision
medicine is the integration of molecular research: genomics, proteomics, transcriptomics, metabolomics, cell signalling; and clinical data through a taxonomy based on CAS modeling overlaid on an information commons. It aims to support treatment of disease and remove the organ and symptom based methodological flaws in the ICD. Supporters of the D.S.M. note the aggressive shift to precision medicine at the NIMH under Dr. Insel, constrained useful clinical research (Nov 2015). data will be shared with participants (Oct
2018)
- Verily
deploys deep
neural networks are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018)
to detect diabetic
retinopathy is damage to the blood vessels of the retina due to high blood sugar levels associated with type 2 diabetes. with retinal scan assistance. W.H.O. is World Health Organization a United Nations organization. reports 70
million Indians have diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. .
Technology used in Indian hospitals: Avarind Eye Hospital; and
clinics, supports the very low levels of trained doctors: 11 eye
doctors per million people, so an A.I. system may massively
improve screening. Currently needs a clear lens for the
neural networks to detect problems. Europe's regulators
have allowed the Verily system on to the market. The US is the United States of America. F.D.A. Food and Drug Administration. also approved a
system, but Verily's is still awaiting approval (Mar
2019)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
- Google moves to 'A.I. first' (Dec
2016)
- Google
demonstrates interpretability is scientific understanding and technology that shows how 'neurons' in a deep neural network arrive at their decisions
decision
making integrates situational context, state and signals to prioritize among strategies and respond in a timely manner. It occurs in all animals, including us and our organizations:
- Individual human decision making includes conscious and unconscious aspects. Situational context is highly influential: supplying meaning to our general mechanisms, & for robots too. Emotions are important in providing a balanced judgement. The adaptive unconscious interprets percepts quickly supporting 'fast' decision making. Conscious decision making, supported by the: DLPFC, vmPFC and limbic system; can use slower autonomy. The amygdala, during unsettling or uncertain social situations, signals the decision making regions of the frontal lobe, including the orbitofrontal cortex. The BLA supports rejecting unacceptable offers. Moral decisions are influenced by a moral decision switch. Sleeping before making an important decision is useful in obtaining the support of the unconscious in developing a preference. Word framing demonstrates the limitations of our fast intuitive decision making processes. And prior positive associations detected by the hippocampus, can be reactivated with the support of the striatum linking it to the memory of a reward, inducing a bias into our choices. Prior to the development of the PFC, the ventral striatum supports adolescent decision making. Neurons involved in decision making in the association areas of the cortex are active for much longer than neurons participating in the sensory areas of the cortex. This allows them to link perceptions with a provisional action plan. Association neurons can track probabilities connected to a choice. As evidence is accumulated and a threshold is reached a choice is made, making fast thinking highly adaptive. Diseases including: schizophrenia and anorexia; highlight aspects of human decision making.
- Organisations often struggle to balance top down and distributed decision making: parliamentry government must use a process, health care is attempting to improve the process: checklists, end-to-end care; and include more participants, but has systemic issues, business leaders struggle with strategy.
in hidden layers of a visual neural
network are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018) (Mar
2018)
- Google DeepMind:
AlphaGo discussed;
- DeepMind
wins protein, a relatively long chain (polymer) of peptides. Shorter chains of peptides are termed polypeptides.
folding modelling competition at
Critical Assessment of Structure Prediction contest.
Academic protein scientists and Pharmaceutical giants: Merck, Novartis; are seen
lagging in applying deep learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
to protein structure work (Feb
2019)
- Alphabet's
Google Duplex critiqued by NYU's
Gary Marcus & Ernest Davis, for being tied to deep learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
neural
networks are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018) , that can only cope with very small domains of
conversation. Marcus & Davis argue the strategy has
failed as a general A.I. approach and that work must shift back
to knowledge
engineering includes the technical, scientific and social strategies required to build, maintain and use knowledge-based computing systems. The technical infrastructure includes a set of rules about the domain, a user interface & an inference engine. to cope with the infinite flexibility of
language (May
2018)
- Doug Lenat's Cyc - common sense rule engine used by Cleveland
Clinic, Goldman
Sachs; features of interest to Allen
Institute & needed by Deepmind
AlphaGo's deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
& IBM's Watson (Mar
2016)
- Google cloud data based jobsearch & recruiting:
- Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
patterns captured from the Internet are competitive control
points for Alphabet,
Amazon, Apple, IBM Watson,
Microsoft (Jan
2017)
- Google Education
- Google Glass:
partners with
Dignity
& Augmedix,
- Google Health
- Google Capital:
funds Oscar which
struggles in ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
insurance markets,
- Google Ventures:
funds
DNA Nexus, One Medical, Rani
Therapeutics, Magic Leap, Foundation
medicine, SynapDx,
funds
23andMe, Flatiron Health,
Calico,
- Google BigQuery leveraged
by QlikView
- Google Consumer
Surveys leveraged by Iodine (Sep
2014),
- Googe digital marketing purchases
Invite Media;
- New York City developed a game changers plan to build up
Silicon Alley, after Lehman Brother's
collapse in 2008, aimed at enabling applied science to induce
new technologies for its key industries: finance: J. P. Morgan
Chase, Goldman
Sachs, Citigroup;
fashion, design, advertising, law, consulting: KPMG; and media;
to be developed in the city - including new courses at Columbia,
NY
University City University, & Cornell Tech graduate
school. But NYC's Silicon Alley was fed by smart people's
interest in coming to NCY to live: museums, theater, opera,
dance, jazz, art galleries, bars, restaurants; and work:
entrepreneurs, technologists, corporate execs; with these
industries. Google
initially entered NYC to gain access to its advertising industry
cluster, a move that was tightened by its purchase of
DoubleClick. Google engineers wishing to live in NYC
initiated an additional technology node which pulled in
researchers from local companies including Bell Labs. As these clusters
grow VC is venture capital, venture companies invest in startups with intangable assets
funding
enables genetic operations to occur
enabling new startup formation (Feb
2019)
- Founders foundations: Brin;
- Funded by: KPCB;
Owned by
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.
;
2015 CEO Sundar Pichai
Sundar
Pichai was born in Tamil Nadu, South India. His father
was an electrical engineer in Chennai working for GEC. The
family did not get a rotary phone until he was 12 years old.
He saw how the phone helped improve productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs. It is a complex capability of agents. It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. :
- Prior to having the phone, finding out the results of a blood
test meant catching a bus to the hospital, waiting in line, and
often being told to return the next day because it wasn't
ready. It was a three hour round trip.
- With the phone it was a quick call to find out the status and
or results.
Pichai saw the value of technology and read all the material about
computers and semiconductors he could obtain. His aspirational
goal was to attend Stanford
University. That led to his working as a process
engineer at Santa Clara's Applied Materials. But he could see
that Google was
becoming a key player on the Internet. He was impressed by the
growth potential, simplicity and accessibility of Deskbar.
In 2004 he joined Google as a product manager, just as the Internet
was deploying Web 2.0 and AJAX is asynchronous JavaScript and XML. It is an architecture and techniques for using Web technologies to provide client server communications without reloading a web page or refreshing the browser. .
He worked on Google Toolbar, which could be added to any browser to
provide access to Google Search. That required the building of
a client engineering team at Google.
By 2006 Google was looking at ways to run applications effectively
on the web. The team proposed development of Chrome so that:
- A multiprocess architecture would protect one application from
any others running on the client.
- A high speed implementation of JavaScript to make the
applications respond like desktop clients.
Chrome was deployed in 2008, aligned with a top-level annual
objective "develop the next-generation client platform for web
applications. The main key result was "Chrome reaches 20
million seven-day active users."
Pichai saw the Chromebook as an additional step allowing a laptop to
directly integrate with the cloud applications.
2017 Senior VP for cloud business - Diane Greene. Greene
argues that "you can turn [machine learning] technology to whatever
field you want, from manufacturing to medicine."
2017 Cloud business Artificial Intelligence chief scientist Dr.
Fei-Fei Li, on sabatical from directing Stanford
University's Artificial Intelligence Laboratory. Dr Li
notes that big-data is the digital gold.
Google Wellness
Director of global food services Michael Bakker.
Google has promoted
healthy eating for years. It has been using Zipongo since
2011. About half of Google's employees have signed up and used
the application for at least a month. Zipongo takes their
preferences and biometric inputs and provides customized menus
resulting in these employees eating more fruit, nuts, calcium, fish,
and fibre rich foods. Bakker argues "We do think we can help
employees make food choices that are better for them as an
individual."
Amazon is based in Seattle, Washington.
- Amazon's purchase
of wholesale licences to sell drugs, and medical devices may disrupt health care markets. Express Scripts
Tim
Wentworth offers to help (Oct
2017)
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- Amazon enters
online drug sales in all fifty states with purchase of Venture
funded: Accel
Partners, Atlas
Venture, CRV,
Founder
Collective, Menlo Ventures,
Sherpa Capital,
Techstars; online pharmacy
PillPack for $ 1
billion, where they can use low price to drive orders from 25
million people without insurance or with HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan.
. Immediate
filling of orders and reordering has kept purchases at physical
stores but that may change. Market values of retail
pharmacists: Walgreens,
Rite aid, CVS Health; tumbled (Jun
2018)
- Goldman
index of 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.
indicates compressed investment increasing risk, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. (Oct
2015)
- Matching UHG's
OptumRx,
Anthem
sets up IngenioRx
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
with CVS, replacing
integration with Express Scripts
(Oct
2017)
- Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
patterns captured from the Internet are competitive control
points for Alphabet,
Amazon, Apple, IBM Watson,
Microsoft (Jan
2017)
- Major hospital
systems is the owner of a set of hospitals and other owned infrastructure and employer of direct staff. : Dignity + Catholic
Health Initiatives, Ascension,
Advocate
+ Aurora;
plan mergers; Tenet
& Community
Health sell off poor performing hospitals & shift
further to outpatient services. All are hoping to capture
patient base before new entrents: UnitedHealth,
CVS Health, Amazon; can.
And scale may help with margin & HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.;
costs.
UnitedHealth's Optum
purchases the Advisory
Board. Republican tax law suggests reduced funding
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 ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
& Medicaid is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; will all
be further impacting revenue to hospitals (Dec
2017)
- Amazon, Berkshire
Hathaway, JPMorgan
Chase partnership aims to disrupt
health care; leveraging their combined consumer choice &
health insurance knowledge to enable technology to simplify
care. (Jan
2018)
- Supermarket chains disrupt: Winn-Dixie/Bi-Lo (Lone Star),
Tops (Morgan Stanley
debt loading), A & P
(2nd bankruptcy in 2015); go bankrupt 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.
under
assault of discount
stores: Dollar
General; Wal-Mart,
& Amazon.
Fairway is
struggling but is getting investment from Blackstone.
Marsh
needed federal assistance. Unionized shop workers who had
pension benefits will loose them (Mar
2018)
- Amazon business model is
pulling in profits from cloud & advertising
businesses. Power allows price
increase for Prime (Apr
2018)
- Apple's
[& Amazon's]
current business model reviewed by Harvard's
Mihir Desai, who notes that Tim Cook has: pushed inventory costs
onto suppliers, captured cash from customers fast; with little
stock required with a just in time operation. Cook has
built up predictable subscription models. But Apple has:
taken on debt, purchased shares in buy-backs and limited
investment in hard assets; which all suggest Apple will avoid
making large risky capital intensive investments that perturb
cash flow (Aug
2018)
- Amazon retail
sales slow - to 17% growth while costing more to generate - 23%
increase in shipping costs to $9 billion, as competitors:
Target, Best Buy, WalMart;
learn to leverage physical infrastructure to fulfill customer
orders faster and cheaper, forcing Amazon to respond and spend
more, & Amazon's dependence on 3rd parties for online
shopping VDS is value delivery system. hurt
revenue, as Amazon has to share it, but increased margin with
lower direct costs. Prime membership plateauing, India
growth strategy constrained, but still huge growth in AWS (45%),
and Advertising based on awareness of consumer choices (Feb
2019)
- Amazon risks monopoly is a power relation within:
- A state in which a group has enough power to enforce its will on other citizens. If this is a central authority with a cohesive military, it can overpower other warlords and stabilize the society.
- An economy in which one business has enough share in a market segment to control margins to its advantage. An economic monopoly can be broadly beneficial: AT&T monopoly, US patent monopoly rights;
/monopsony is a power relation within an economy where a single buyer of a product interacts with many sellers, to its advantage.
actions, attracting the interest of lawyers and economists, who
admit it does not appear to be harming consumers, with marketing
strategies including: private labeling and promotion emails,
word searches, customer review networks and experiments on its
platform. Limited data is provided to branded
suppliers. Analysts conclude Amazon favors its brands in
some channels or crowds out other brands (Jun
2018)
- John
Doerr, Bill Gates, former Gates
Foundation CEO Patty Stonesifer, discuss tracking of OKR is objectives and key results, Intel CEO Andy Grove's methodology for leveraging goals and strategies. Key results are: specific, time-bound, measurable & verifiable. They are expected to change as the actions proceed. The OKR framework is a main subject of John Doerr's book Measure What Matters.
s and its impact on
malaria & vaccine are a core strategy of public health and have significantly extended global wellbeing over 200 years. Smallpox & polio were virtually eradicated. Recent successes include: HPV vaccine: Gardasil. They induce active acquired immunity to a particular disease. But the development and deployment of vaccines is complex: - The business model for vaccine development has been failing (Aug 2015):
- No Zika vaccine was available as the epidemic grew (Mar 2016). No vaccine for: CMV;
- Major foundations: Michael J. Fox, Gates, Wellcome; are working to improve the situation including sponsorship of the GAVI alliance. A geographic cluster is forming in Seattle including PATH (Apr 2016).
- Commercial developers include: Affiris, Cell Genesis, Chiron, CSL, Sanofi, Valeant;
- Vaccine deployment traditionally benefited from centrally managed vertical health programs. But political issues are now constraining success with less than 95-99% coverage required for herd immunity (Aug 2015, Sep 2015, Nov 2015, Nov 2016, Jul 2018).
- Where clinics have been driven into local neighborhoods health improves (Apr 2016).
- Retail clinics (Mar 2016): CVS Minute Clinics focus on vaccination.
- NNT is a useful metric for vaccine benefit. Influenza vaccine has an NNT of between 37 and 77, is cheap and causes little harm, so it is very beneficial.
- Key vaccines include: BCG, C. difficile (May 2015), Cholera (El Tor), Cervical Cancer (Gardasil HPV Jun 2018, Oct 2018), Dengvaxia (Mexico Dec 2015), Gvax, Influenza, Malaria vaccine, Provenge, Typbar-TCV (XDR typhoid Pakistan Apr 2018);
- Regulation involves: FDA (CBER), with CMS monitoring (star ratings, PACE (Aug 2016), Report cards (Sep 2015)) & CDC promoting vaccines: as a sepsis measure, To control C. difficile (May 2015);
- Research on vaccines includes:
- NIH: AIDS vaccines (AVRC), Focus on using genetic analysis to improve vaccine response.
- NCI:
- Roswell Park clinical trial of immuno-oncology vaccine cimavax.
- Geisinger: effective process leverage in treatment.
- Stanford Edge immuno-oncology for cancer vaccines.
- P53-driven-cancer focused, gene therapy (Jun 2015).
investments, including GAVI (2018)
- Davos backroom discussions show corporate CEOs pressured by
profit measures to replace workers with AI on a large scale, as
quickly as possible. It is already occurring, and
acknowledged in Asia: Foxconn, JD; generating business for
consultants: McKinsey,
Infosys; but is hidden behind euphemisms, and promise of
retraining demonstrated on a small scale by Amazon (Jan
2019)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
Amazon has extended into physical retail with the purchase of Whole Foods.
Its expanding access to the wholesale and retail pharmacy: PillPack; and medical
device markets may be disruptive (Oct
2017, Jun
2018).
Apple is based in Cupertino, California
- Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
patterns captured from the Internet are competitive control
points for Alphabet,
Amazon, Apple, IBM Watson,
Microsoft (Jan
2017)
- Google moves to 'A.I. first' (Dec
2016)
- Google
demonstrates interpretability is scientific understanding and technology that shows how 'neurons' in a deep neural network arrive at their decisions
decision
making integrates situational context, state and signals to prioritize among strategies and respond in a timely manner. It occurs in all animals, including us and our organizations:
- Individual human decision making includes conscious and unconscious aspects. Situational context is highly influential: supplying meaning to our general mechanisms, & for robots too. Emotions are important in providing a balanced judgement. The adaptive unconscious interprets percepts quickly supporting 'fast' decision making. Conscious decision making, supported by the: DLPFC, vmPFC and limbic system; can use slower autonomy. The amygdala, during unsettling or uncertain social situations, signals the decision making regions of the frontal lobe, including the orbitofrontal cortex. The BLA supports rejecting unacceptable offers. Moral decisions are influenced by a moral decision switch. Sleeping before making an important decision is useful in obtaining the support of the unconscious in developing a preference. Word framing demonstrates the limitations of our fast intuitive decision making processes. And prior positive associations detected by the hippocampus, can be reactivated with the support of the striatum linking it to the memory of a reward, inducing a bias into our choices. Prior to the development of the PFC, the ventral striatum supports adolescent decision making. Neurons involved in decision making in the association areas of the cortex are active for much longer than neurons participating in the sensory areas of the cortex. This allows them to link perceptions with a provisional action plan. Association neurons can track probabilities connected to a choice. As evidence is accumulated and a threshold is reached a choice is made, making fast thinking highly adaptive. Diseases including: schizophrenia and anorexia; highlight aspects of human decision making.
- Organisations often struggle to balance top down and distributed decision making: parliamentry government must use a process, health care is attempting to improve the process: checklists, end-to-end care; and include more participants, but has systemic issues, business leaders struggle with strategy.
in hidden layers of a visual neural
network are representational models that achieve high performance on difficult pattern recognition problems in vision and speech. But they need specialized training methods such as greedy layerwise pre-training or HF optimization. Researchers are gaining access to the participation of the individual 'neurons' using: visualization, attribution, dimensionality reduction, interpretability; (Mar 2018) (Mar
2018)
- Apple's
[& Amazon's]
current business model reviewed by Harvard's
Mihir Desai, who notes that Tim Cook has: pushed inventory costs
onto suppliers, captured cash from customers fast; with little
stock required with a just in time operation. Cook has
built up predictable subscription models. But Apple has:
taken on debt, purchased shares in buy-backs and limited
investment in hard assets; which all suggest Apple will avoid
making large risky capital intensive investments that perturb
cash flow (Aug
2018)
- High Tech: Alphabet,
Amazon, Apple,
Microsoft, GoEnnounce, GoNoodle, Seesaw, Tenmarks; education
tools strategy transforms teachers into sales consultants and
advocates (Sep
2017)
- Apple adds
Beta of EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
access to
its iPhone health app. It will download from EHR systems
of 12 medical institutions: Johns
Hopkins, Cedars-Sinai
(Jan
2018)
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care 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.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
- PHR is a Personal Health Record. Goal is to place patients in control and make them accessible. Early vision differentiated between standalone PHR and EHR tethered patient portals. There are various PHR services. Privacy, security, data integrity, ownership, cost, and quality are all unresolved issues. Can be loaded onto a cell phone or app but then the health care privacy regulations don't apply.
Comcast is based in Philadelphia.
Comcast is in 2018, the largest cable company in the US. It
has 225,000 employees.
Comcast spends $1.3 billion a year on health care. It reports
over the last 5 years its health care costs have increased at 1% a
year, compared to 3% average for other large employers.
Comcast has rejected:
Instead, Comcast's Shawn Levitt explains "Our model is based on
providing employees support and assistance in making the right
decisions for themselves and their families. Employees should
not feel alone, confused and overwhelmed when it comes to
understanding and selecting their benefits."
Comcast has replaced insurance companies in its health benefits
innovation search. It is leveraging startups instead:
NBGH
agrees "We see the start-up community as where the real disruption
is taking place."
Reed Abelson asserts
that Comcast's success in controlling health costs comes from
directly confronting the problems, rather than depending on
middlemen. It allows Comcast to use multiple strategies which
together limit the number of large claims. Workers with
company health benefits are told to go to Accolade first. And
Grand Rounds helps in handling overtreatment is the application of unnecessary health care. It is a complex problem: - Overtreatment needs to be adaptive. As people age their medicine levels typically need to be changed. Often, as in the case of blood pressure, and blood sugar reduction, they should be reduced to avoid inducing falls (Nov 2015).
- Patients with chronic diseases, such as type 2 diabetes, often require different treatment settings. And again these vary with age.
- Patients who have learned a regime, and been told it was successful, may resist instructions to change it. Some worry that they will impact their health care provider's treatment performance measures.
.
Grand Rounds are able to get access to the EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
and insurance
details. Insurers can be protective of their data, but large
employers, such as Fidelity,
successfully push back.
Morris Plains, NJ
Honeywell is a conglomerate that invents and manufactures solutions
including: Thermostats, Home systems, Mobile productivity is the efficiency with which an agent's selected strategy converts the inputs to an action into the resulting outputs. It is a complex capability of agents. It will depend on the agent having: time, motivation, focus, appropriate skills; the coherence of the participating collaborators, and a beneficial environment including the contribution of: standardization of inputs and outputs, infrastructure and evolutionary amplifiers. ;
CEO David Cote
Honeywell
health plan with sticks and carrots
Employees were sent a health enrolement email from Honeywell
requesting their: Weight, Cholesterol levels and other medical
information. If it wasn't provided the employee would pay upto
$2,250 in health insurance penalties, or $4000 if they were
married.
Honeywell started to levy the charges in 2013. This year the
charges are capped at $1,500.
Federal regulations make wellness programs
voluntary. But it may not feel that way for the workers.
IBM
IBM is building a globally optimized business with 'industry
platforms' based on AI and cloud infrastructure:
- Epic displaces IBM
from Kaiser
EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses:
- The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
development.
- Cerner with Accenture
beat Epic with IBM to
retool DOD - U.S. Department of Defense.
scheduling
HCIT is health care information technology. The AHRQ argues HCIT consists of a complex set of technologies, policies, standards and user sets. Technically they represent it as a set of layers: Application: CPOE, CDS, e-prescribing, eMAR, Results reporting, Electronic documentation, Interface engines, etc.; Communication: Messaging standards (HL7, ADT, NCPDP, X12, DICOM, ASTM, etc,) Coding standards (LOINC, ICD10, CPT, NDC, RxNorm, SNOMED CT, etc.), Process: HIE, MPI, HIPAA security & privacy, etc.; Device: Tablet and PC, ASP, PDAs, Bar Coding, etc.; (Jul
2015).
- IBM uses: Zipongo;
- IBM Consulting:
PwC, Strategy&;
- IBM Cloud (analytics):
Coremetrics;
- 41 major employers including founders: American Express,
Verizon, Macy's; form the Health
Transformation Alliance, to reform the private sector
health care system, starting with PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
relationships: CVS,
OptumRX;
& high cost & volume pricedures, with IBM providing data
analysis (Aug
2017)
- IBM Watson (Jan
2014) platforms group
- Big data encompasses the IT systems and processes necessary to do population based data collection, management and analysis. The very low cost, robust, data storage organized by infrastructure: HADOOP; allows digital data to be stored en mass. Data scientists then apply assumptions about the world to the data, analogous to evolved mechanisms in vision, in the form of algorithms: Precision medicine, Protein folding modeling (Feb 2019) assumes coevolutionary methods can be applied to identify contact points in a protein's tertiary structure. Rather than depending on averages, analysis at Verisk drills down to specifics and then highlights modeling problems by identifying the underlying CAS. For the analysis to be useful it requires a hierarchy of supporting BI infrastructure:
- Analytics utilization and integration delivered via SaaS and the Cloud to cope with the silos and data intensive nature.
- Analytics tools (BI) for PHM will be hard to develop.
- Complex data models must include clinical aspects of the patient specific data, including disease state population wide.
- A key aspect is providing clear signals about the nature of the data using data visualization.
- Data communication with the ability to exchange and transact. HIEs and EMPI alliance approaches are all struggling to provide effective exchange.
- Data labeling and secure access and retreival. While HIPAA was initially drafted as a secure MPI the index was removed from the legislation leaving the US without such a tool. Silos imply that the security architecture will need to be robust.
- Raw data scrubbing, restructuring and standardization. Even financial data is having to be restandarized shifting from ICD-9 to -10. The intent is to transform the unstructured data via OCR and NLP to structured records to support the analytics process.
- Raw data warehousing is distributed across silos including PCP, Hospital system and network, cloud and SaaS for process, clinical and financial data.
- Data collection from the patient's proximate environment as well as provider CPOE, EHRs, workflow and process infrastructure. The integration of the EHR into a big data collection tool is key.
patterns captured from the Internet are competitive control
points for Alphabet,
Amazon, Apple, IBM Watson,
Microsoft (Jan
2017)
- Move into financials with Promontory
purchase (Sep
2016).
- Medical opportunity (May
2015, Oct
2016) with partners: Alder
Hey, Anthem,
Best Doctors,
Boston
Children's, Cleveland
clinic, CVS, Japan
Post Insurance, Jefferson
University Hospitals, J&J,
MS-KCC,
MDACC,
Mayo Clinic, University
of North Carolina SOM,
- Watson
supported genomics combines recombinant DNA editing with tools: CRISPR; DNA next generation sequencing and bioinformatics to sequence, assemble and analyse genomes.
for oncologists with: Quest (Oct
2016), MS-KCC,
Broad Institute;
- Purchased Eplorys,
Merge,
Phytel;
- Global cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
VDS is value delivery system. : ACS,
CHAI,
NCCN,
IBM (Watson), Pfizer, Cipla; will build low
cost supply chain and delivery network to combat a W.H.O. is World Health Organization a United Nations organization. estimated
increasing number of cancer sufferers in Africa (Oct
2017)
- Doug Lenat's Cyc - common sense rule engine used by Cleveland
Clinic, Goldman
Sachs; features of interest to Allen
Institute & needed by Deepmind
AlphaGo's deep
learning is an artificial intelligence approach where engineers deploy data into deep neural networks.
& IBM's Watson (Mar
2016)
- Davos backroom discussions show corporate CEOs pressured by
profit measures to replace workers with AI on a large scale, as
quickly as possible. It is already occurring, and
acknowledged in Asia: Foxconn, JD; generating business for
consultants: McKinsey,
Infosys; but is hidden behind euphemisms, and promise of
retraining demonstrated on a small scale by Amazon (Jan
2019)
- Nov
2015 Ireland adjusts its corporate tax.
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 provides digital analytics to model customer behavior and
cross-channel details
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)
- Congress concludes Chinese distributors ship fentanyl is a synthetic opioid pain medication that acts on micro-opioid receptors in the brain. It is 50 times more potent than morphine. It was originally manufactured by Janssen Pharmaceutica in 1959 which was acquired by Johnson & Johnson. It is branded as: Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen, Subsys, Instanyl, Abstral, Lazanda; with a variety of deployment formulations. It is often used, in a transdermal patch such as durogesic, to treat severe ongoing pain which can be induced by cancer. It has followed heroin into the back-street opioid epidemic (Jun 2017).
via
e-commerce: UPS,
FEDEX, USPS; via third countries, to buyers in US is the United States of America. : Ohio, Pennsylvania,
Florida; who pay with Bitcoins is a set of open-source software, used to provide infrastructure that supports a distributed cryptocurrency and payment system, based on the blockchain. All transaction inputs are unspent outputs from previous transactions. All transaction inputs are signed. Change is provided in an additional output to the transaction.
(Jan
2018)
- Senator Sherrod Brown, develops select committee to focus on
multiemployer pension liabilities: UPS,
Kroger, NCCMP;
and support PBGC is the pension benefit guarantee corporation. It is an independent agency of the US government created by ERISA.
backstop, lobbied for by USCC is the United States Chamber of Commerce
(Feb
2018)
Aug 2013 NYT
reports United Parcel Services told its white-collar workers that,
in an effort to reduce its health care costs, it will no longer
cover some 15,000 spouses who can obtain coverage through their own
employers. The company said its move was prompted primarily by
projected increases in the amount it would have to pay for
employees' medical care and secondarily by various costs associated
with the health care reform
law is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
.
U.P.S. is joining a small but growing number of companies that
decline to cover working spouses who can obtain coverage at their
own workplace. The costs and complications of two separate
policies may vary from family to family. In some cases, the
plans may have different networks of doctors and offer different
benefits. U.P.S. says that eliminating a spouse from a family
plan could reduce the premium paid by many of its employees by
enough to cover some or all of the premium the spouse will have to
pay for a separate policy at another company.
Although U.P.S. is taking other steps, such as a tobacco cessation
program, to improve employee health and reduce medical spending, the
spousal policy will simply shift the insurance burden from U.P.S. to
the other company.
Walgreens
Walgreens, the retail
drugstore, doesn't plan to lower its share of its workers'
health care costs but hopes to foster more competition among
insurers, leading to better prices and more choice for
employees.
- Walgreens: Employer,
Retail drug store,
Specalty
pharmacy,
- Players argue ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
is transforming power - insurers merging: Aetna/Humana, Anthem/Cigna; hospitals
attacked by high street clinics: Wal-Mart, CVS, Walgreens (Sep
2015)
- Huge price drops impact generic suppliers: Teva;
and distributors:
Cardinal Health;
as pharmacies, distributors & PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s: Express Scripts
+ Walgreens;
cooperate to buy generics at lower prices. FDA Food and Drug Administration. commissioner
Gottlieb
says he will make it easier for generics to get to market.
Consumers don't see the savings (Aug
2017)
- Teva
restructures, cutting 25% of jobs, as Copaxone
attacked by generics & Teva's generics suffer from power of
buying groups formed by pharmacy
chains, wholesalers
& PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s (Dec
2017, 2)
- Rx
Savings Solutions helps employers reduce employee drug
costs as PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
: OptumRX,
Express Scripts;
agreements allow generics' prices to rise: crestor;
while BlinkHealth,
which is in litigation with its PBM MedImpact &
has lost access to Publix, Walgreens & CVS, and GoodRx supplied
coupons help Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
generic prescription drug users find low cost offers as
Insurance: UHG,
Cigna, Humana; agreements, co-payment is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016); &
deductible requirements & clawbacks refers to a contractual requirement between a payer and provider or retailer (pharmacy), where the cost of the goods supplied to a subscriber is lower than the reimbursement contracted with the payer, and the payer requires the difference to be refunded. with
pharmacists: Walgreens,
CVS; and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan. bite into the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
regulated
transactions value. PCMA
argues these situations are outliers (Dec
2017)
Wal-Mart
- Wal-mart
contracts directly with health care centers of excellence: Cleveland
Clinic, Geisinger,
Mayo Clinic; for
employee care (2012)
- Players argue ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
is transforming power - insurers merging: Aetna/Humana, Anthem/Cigna; hospitals
attacked by high street clinics: Wal-Mart, CVS, Walgreens (Sep
2015)
- F.D.A. Food and Drug Administration. proposes
guidelines on salt. Consumer pressure drives food
industry: Wal-mart;
to reduce salt (Jun
2016)
- Venture
funds financing increases, including jet.com (Wal-Mart), but Mutual funds
and 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.
hold back because VC funds are seen keeping weak start-ups alive
(Dec
2016).
- Supermarket chains disrupt: Winn-Dixie/Bi-Lo (Lone Star),
Tops (Morgan Stanley
debt loading), A & P
(2nd bankruptcy in 2015); go bankrupt 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.
under
assault of discount
stores: Dollar
General; Wal-Mart,
& Amazon.
Fairway is
struggling but is getting investment from Blackstone.
Marsh
needed federal assistance. Unionized shop workers who had
pension benefits will loose them (Mar
2018)
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care 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.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
- Amazon retail
sales slow - to 17% growth while costing more to generate - 23%
increase in shipping costs to $9 billion, as competitors:
Target, Best Buy, WalMart;
learn to leverage physical infrastructure to fulfill customer
orders faster and cheaper, forcing Amazon to respond and spend
more, & Amazon's dependence on 3rd parties for online
shopping VDS is value delivery system. hurt
revenue, as Amazon has to share it, but increased margin with
lower direct costs. Prime membership plateauing, India
growth strategy constrained, but still huge growth in AWS (45%),
and Advertising based on awareness of consumer choices (Feb
2019)
- Distributors
ramped up the opioid crisis, acting as an infrastructure amplifier. They
devised systems to avoid regulation: limited compliance
operations, helped pharmacies (Wal-Mart, CVS are the largest they
supply) remove restrictions on sales of opioids, warned
pharmacies that were indicating questionable sales trends,
prepared pharmacies for coming audits; helping shipments and
profits grow exponentially. The rewards were huge, and the
penalties light, since the aligned VDS is value delivery system. provided low cost
legal solutions for the big three who distribute more than 90%
of US is the United States of America. drugs and
medical supplies: McKesson,
Amerisource,
Cardinal;
leaving Rochester Drug Cooperative as the typical fall guy (Apr
2019)
CEO is Douglas McMillon since February 2014. He worked his way
up from fishing tackle sales at the company in Bentonville.
Wal-Mart (Walmart) has:
- 2014 revenue $485 Billion.
- 5000 stores and clubs
- 1.4 million Employees.
2015 strategy issues:
- Wal-Mart has spent heavily on increased salaries ($1.5
Billion) and Internet sales infrastructure (several billion)
without a strategic benefit. Sales have not surged.
Wal-Mart has lost price dominance. Its immense network of
distribution centers and stores should help it in on-line
commerce but its system is optimised to deliver goods on pallets
to stores.
- Under siege from Costco and Aldi. Sam's clubs are low
margin worrying analysts.
- Life style speed up is encouraging shoppers to go to
convenient local stores and online (Amazon which has
online sales of $80 billion). Price, selection and
convenience all help Amazon and local shops. Wal-Mart is
being disrupted.
- Wal-Mart web strategy has been operational since 1999 but to
little effect ($12.2 billion sales or 2.5% of total
sales). Now it aims to optimize multi-channel but that is
proving very expensive. Amazon has gone through an
agressive investment cycle over the past 5 years allowing them
to improve fullfilment and focus it on the individual. Its
quick and cost-efficient. It is also focused on the
Intenet only where sales are growing. Amazon can deliver
its 10-100 fold larger selection of goods much cheaper and
faster than Wal-Mart's online operations. Wal-Mart is
building an internal technology team, vast new fulfillment
centers and cloud data centers, to improve its online
offerings. Columbia's
Bruce Greenwald argues they would be better teaming with a
technology company with the analytics and cloud computing
capacity.
- Wal-Mart's customers are relatively poor.
Feb 2016 Wal-Mart under increasing pressure from poor sales
outside of USA: China, Brazil, Britain
Competition from Amazon
and other e-commerce sites has continued to impact sales.
Earnings per share were down year on year.
Jan 2016
Wal-Mart to close 269 Stores Worldwide
Wal-Mart is responding to pressure from Amazon by:
- Closing a record 269 stores worldwide - 154 in the US.
The bulk of the rest in Brazil. These will be offset by the
opening of 300 new stores. Four Sam's Club and 12
Supercenters will close.
- Abandoning Wal-Mart Express (102 stores) - its small format
for urban areas a strategy started in 2011. They were
undermined by Dollar stores etc.
- 10,000 U.S. is the United States of America. job
losses and 6,000 in the rest of the world.
Web retailers are undermining brick retail sales. There huge
online catalogs are very attractive. Amazon accounted for a
quarter of all retail sales in 2015. So Sears, Macy's and J.C.
Penney are also closing stores. Retail sales are flat to
falling. Price is a poor competitive strategy.
Wal-Mart's stock is at its lowest value in five years. A
possible emerging
market initiated recession would add to Wal-Mart's
problems.
Wal-Mart's has spent heavily on e-commerce but its online sales
growth is slowing.
Jan 2016
Wal-Mart responds to increased hiring with pay rises.
1.2 million Wal-Mart stores employees will be paid $13.38 per hour
as of Feb 2016. Part time workers will also get an increase
from $10 to $10.58 an hour. These wages are still less than
the government average wage of $14.95.
2012
Wal-Mart contracts with centers of excellence
Wal-Mart contracted with health systems like the Cleveland Clinic,
Mayo and Geisinger,
among others, to take care of employees who need transplants, heart
and spine care. The company says it will soon expand the
program to other centers of excellence.
Wal-Mart markets
itself as PCP with the opening of clinics with broader offerings.
New Entrants
8th
August 2014 Wal-Mart opens 5 primary care locations with more to
follow
Wal-Mart has been
trying to turn some of its customers into patients for years.
It has accelerated that strategy opening five primary care locations
in South Carolina and Texas, plans a 6th in Palestine Texas, within
a week and will have opened six more by the end of 2014.
Wal-Mart is partnering with QuadMed which will staff and run the
clinics. Still the doctors will not see patients
directly. They oversee compliance and prescription ordering
similarly to the process at Wal-Mart's acute care clinics.
Wal-Mart explains that the new clinics offer a broader range of
services, including chronic disease management, than the 100 or so
Wal-mart acute care clinics already deployed across the
country. Unlike CVS,
Walgreens and Costco,
Wal-Mart is marketing itself as a PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. . Most of the
$1.7B spent on health care in the US is targeted at chronic
care. Wal-Mart accepts Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
, is enrolling
some of its stores with Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. ,
but currently does not accept third party insurance. However,
the clinics can help drive traffic to Wal-Mart's pharmacy which does
accept third party coverage.
Wal-Mart, CVS and Walgreens are all aiming to benefit from the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
driven shift in health
care delivery. Wal-Mart has a vast rural footprint and is
placing its new clinics where PCPs are scarce and medical care is
often prohibitively expensive. It aims to become an entrypoint
into a continuum of care delivery.
Some critics warn that chronic care patients need complex care that
will be difficult for Wal-Mart to provide due to the problems of
managing typical complications of diseases like type 2 diabetes is diabetes mellitus or disease management in health care. .
Dozens of Wal-Mart's acute care clinics have closed as its initial
efforts at delivery stumbled. But in part that is due to the
limited offering which is used by customers in the winter but has
little to offer for the rest of the year. To make it
profitable you need to have more than a clinical encounter.
You need to sell them prescriptions, a bag of chips etc. while they
are waiting. The new focus on chronic conditions could improve
attendence all year round.
Wal-mart like other big retailers are losing sales to online
providers.
5th Feb
2014 CVS announce stopping sales of cigarettes as part of strategy
to enter health care provider market
CVS announced cigarette
products are inconsistant with its health care focus (NYT).
Pharmacy Benefit
Management
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s negotiate with drug
companies on behalf of insurers
(employer plans, Medicare
part D is a federal program to subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as part of the MMA and delivered entirely by private companies. It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad group of elderly voters and a small but influential group of payers: UnitedHealth, Humana, CVS Health; while pharmaceutical companies also benefited from increased sales of reimbursed drugs. It includes: - E-prescribing regulations. Health care providers that electronically prescribe Part D drugs for Part D eligible individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP SCRIPT standard to transmit prescriptions & related information internally but must use NCPDP SCRIPT (or other adopted standard) to transmit information to another legal entity.
- Premium subsidy set by a market average. Medicare collects bids from all plans that reflect their costs of providing the minimum required level of drug coverage. It then sets the subsidy at 74.5% of the average bid.
- Premium coverage gap (doughnut hole) between the 74.5% premium subsidy and the catastrophic-coverage threshold. The BBA of 2018 required Part D insurers cover 5% of the beneficiaries coverage gap and drug companies provide discounts that reduce federal spending by a total of $7.7 billion through 2027.
, Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. ).
They include:
The largest three: Express
scripts, CVS
Caremark and OptumRX
cover 180 million people, control 80% of the PBM market and bring in
more than $200 million a year in revenue.
In theory PBMs can bargain for lower drug prices, using the power of
their formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure. ,
but the system incentivizes them to select the drug with the largest
rebate to
them.
PBM rebates
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s get "rebates" from
drug manufacturers -- they are payed based on sales and other
criteria.
- Biologic 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)
prices supported by patent extensions, data exclusivity, PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. rebates (Feb
2016)
- Manufacturers: Eli
Lilly, Novo
Nordisk, Sanofi;
accused in lawsuit of price fixing scheme with PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s for 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) (Jan
2017).
- Eli Lilly, under
pressure from Congress, move to protect high priced Humalog
100 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)
,
leveraged by insurers and PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s,
by releasing a lower priced generic: Imclone
Insulin Lispro; an 'authorized generic' strategy
previously used by Mylan
& Gilead,
at a price that is still historically expensive (Mar
2019)
- UnitedHealth
signals, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy.
it will
pass on OptumRx
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. drug rebates to
consumers (Mar
2018)
- Brand drug sale rebates
to Insurers: UHC;
& PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s: CVS;
are protecting market share for brand name market leading drugs
as generic competition appears. Shire uses the
technique with Adderall
XR. J&J
with Remicade.
Teva
uses it to cover Copaxone.
(Aug
2017)
- Trump administration: HHS is the U.S. Department of Health and Human Services.
secretary
Azar; considers reducing Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
drug plan
out-of-pocket costs: Pharmaceutical rebates kept by PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s & Insurers:
Humana; would be
driven to patients; reducing political pressure on drug
companies, pleasing Medicare drug end users, increasing
insurance premiums and escalating federal Medicare costs.
PhRMA:
Amgen; defended the
proposal. PBMs: PCMA,
CVS; Part D is a federal program to subsidize the costs of outpatient prescription drugs for Medicare beneficiaries enacted as part of the MMA and delivered entirely by private companies. It is an evolved amplifier with MMA schematic rules ensuring catalytic tax subsidies: reinsurance; flow to a broad group of elderly voters and a small but influential group of payers: UnitedHealth, Humana, CVS Health; while pharmaceutical companies also benefited from increased sales of reimbursed drugs. It includes: - E-prescribing regulations. Health care providers that electronically prescribe Part D drugs for Part D eligible individuals under 42 CFR 423.160(a)(3)(iii) may use HL7 or NCPDP SCRIPT standard to transmit prescriptions & related information internally but must use NCPDP SCRIPT (or other adopted standard) to transmit information to another legal entity.
- Premium subsidy set by a market average. Medicare collects bids from all plans that reflect their costs of providing the minimum required level of drug coverage. It then sets the subsidy at 74.5% of the average bid.
- Premium coverage gap (doughnut hole) between the 74.5% premium subsidy and the catastrophic-coverage threshold. The BBA of 2018 required Part D insurers cover 5% of the beneficiaries coverage gap and drug companies provide discounts that reduce federal spending by a total of $7.7 billion through 2027.
Insurers: AHIP;
disappointed (Feb
2018)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- President Trump signs two laws designed to block: gaging of
best price advice by pharmacists to customers (Collins act of 2018 blocks gag contracts that limit pharmacy staff advising purchasers of the cheapest option to obtain their prescription drugs. The act was sponsored by Senator Susan Collins of Maine and signed into law by President Trump.
),
Outpatient Medicare drug coverage gaging (Stabenow act of 2018 bans gag clauses from outpatient Medicare drug coverage: both Medicare Advantage and traditional FFS plans. It was sponsored by Senator Stabenow and signed into law by President Trump. );
and in an op. ed. he attacked Democrats, signalling, is an emergent capability which is used by cooperating agents to support coordination & rival agents to support control and dominance. In eukaryotic cells signalling is used extensively. A signal interacts with the exposed region of a receptor molecule inducing it to change shape to an activated form. Chains of enzymes interact with the activated receptor relaying, amplifying and responding to the signal to change the state of the cell. Many of the signalling pathways pass through the nuclear membrane and interact with the DNA to change its state. Enzymes sensitive to the changes induced in the DNA then start to operate generating actions including sending further signals. Cell signalling is reviewed by Helmreich. Signalling is a fundamental aspect of CAS theory and is discussed from the abstract CAS perspective in signals and sensors. In AWF the eukaryotic signalling architecture has been abstracted in a codelet based implementation. To be credible signals must be hard to fake. To be effective they must be easily detected by the target recipient. To be efficient they are low cost to produce and destroy. Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
for all
will be bad for retirees. The Senate resisted Democrat's
attempts to block Trump's short term, low cost, skimpy coverage,
insurance plans (Oct
2018)
- HHS is the U.S. Department of Health and Human Services. secretary
Azar, moves to require health insurers and PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s to pass on rebates to
consumers, by making them illegal kickbacks through eliminating
the legal protection provided by CMS is the centers for Medicare and Medicaid services. . The HHS OIG is the HHS Office of Inspector General. enabled the new
interpretation. The government would still provide rebate
protection as long as discounts were applied to the list price
of prescription drugs. Insurers (America's
Health Insurance Plans) were disappointed. Drug
manufacturers (PhRMA),
and oncologists (Community
Oncology Alliance) were pleased with the proposals - as
Democrats noted (Feb
2019)
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.
Represented by the AHIP.
2014 Health
insurance product offer
The health insurance product offering is currently a yearly
subscription. This discourages the payers include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
from focusing on
the long term health of their members since some other insurer may
obtain the benefits. And people tend to change insurers
whenever they change jobs, lose Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. coverage, or
gain access to Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
.
Similarly the yearly nature of the product is misaligned with costs
that occur in one year but provide benefits over a longer
period. For example Sovaldi (sofosbuvir) is Gilead Sciences hepatitis-C drug. It is the first effective cure with acceptable side effects. Sofosbuvir was originally developed by Pharmasset which sold the rights to Gilead for $11 billion. In 2014 Sovaldi costs $84,000 for a typical course of treatment.
cures hepatitis-C is a virus which destroys the liver during infection. In 2016 it affects 185 million people worldwide. Once the virus genome was sequenced in 1989 Dr. Bartenschlager and Dr. Rice worked to replicate the virus in the laboratory. Rice realized the genome sequence was missing details that stopped the lab replication. Bartenschlager was then successful at replicating the virus in cells in his laboratory. The replication technique allowed Pharmasset's Dr. Sofia to develop a new hepatitis C drug, by enhancing an RNA-polymerase inhibitor with a coat that allowed the drug to enter the liver, where the coat was destroyed and the polymerase inhibitor was activated. With high concentrations of the drug, sofosbuvir, in the liver it could eradicate the hepatitis C virus. Sovaldi was the first sofosbuvir approved by the F.D.A.
in a few weeks. This should reduce the long term cost of liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions. It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein. It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels. The embryonic endoderm cells invade the mesoderm to form the liver bud. Subsequently the liver bud vascularizes and is colonized by hematopoietic cells. The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances. In a healthy adult liver cells do not divide significantly. But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver. There are over 100 disorders of the liver. Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide. failure in the
current patient base. However, insurers are loath to pay the
high cost per pill since they are unlikely to benefit long term from
the improved health of the insured who can switch insurers each
year. Medicaid based HMO is a Health Maintenance organization managed care plan as opposed to a PPO plan. It uses the allocated PCP as a gatekeeper who must refer a patient to any health specialist for the patient to gain access. products are particularly
sensitive to annual cost increases. Intermountain
has developed a novel
approach that encourages long term contracting with its health
plan SelectHealth
(share).
Health insurers would benefit from forcing more transparency in
estimating the value of drugs and hence correlations to drug
pricing. They are encouraging transparency legislation in
Congress. They view drug companies as using R&D
costs for justifying price increases. But they say these are
sunk costs and have little to do with pricing. If people are
being cured how is that affecting costs?
Entering a health insurance market such as a new state is difficult
primarily because of financial and network effect based
barriers:
- Network effects: Insurers need to develop contracts with state
local doctors and hospitals. That takes time and limits
the value of the plans offered in the interim making them
unattractive unless the insurer can merge with an insurer that
already has the network built out. Hence the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
pressure
on Anthem,
Aetna, Cigna, Humana, UHC to
consolidate to gain access to built out networks.
- Financial: Entering a new market will require capital to
support payment to patients. Over time the insurers build
experience about their patient base but initially they may guess
wrong (Aug
2015).
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 is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%.
startups entered the health
insurance market based on the support provided by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
. These companies
were designed to provide affordable insurance coverage to
individuals and small businesses. The ACA goal was to generate
competition to the plans sold by large insurance companies.
But the co-ops have been losing money (Aug
2015).
The original ACA architects plan was for a public option to compete
with the big insurance plans. But that would have resulted in
the ACA failing. Senator Kent Conrad proposed the co-ops as a
fallback. But they have to fight network
effects of the big Blues and commercial insurers to become
profitable.
The ACA provided some support to insurers entering new markets,
where there was no data to help them effectively price the policies
they offered. The assistance included:
Some co-ops started to fail just a year into the new system
implementation: Coopertunity
health, Louisiana
health and now the latest Nevada Health Co-op
where ceo Pam Egan told customers that the co-op would stop selling
policies next year, pointing to high medical costs and limited
opportunities for new investment. Even if the co-ops gain new
customers they have to find more capital to cover state requirements
to cover potential medical costs. The federal government had
promised to consider ways to support their initial growth but
insurance experts doubt that the government changes are enough to
prevent failure. One aspect was to require insurers with lots
of healthy patients to cross fund insurers with less healthy patient
bases. But startups are not guaranteed to endup with the
unhealthy patient bases. A small startup in Alabama with just
1,100 members is having to pay the dominant Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. $1.5
million! The ACA loans were not large enough to sustain the Co-ops
through their first years of investments and policy payouts.
At the same time consolidation
among the big insurers is pressuring the co-ops further.
Oct 2015 Eight Co-ops have now failed in: Colorado, Iowa, Kentucky,
Louisiana, New York - Health
Republic, Nevada, Tennessee and Oregon - Health
Repubic.
Nov 2015 Over half have failed: Michigan - Consumers
Mutual.
Dec 2013 NYT
Health Insurers extend premium deadline
To minimize the chance of chaos as people signup for ACA health
coverage, insurers have extended the first month premium deadline by
ten days. If a customer goes to the ED is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). or PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. office after Jan 1st
2014 they will be retroactively covered if they send their payment
by Jan 10th. Wellpoint offered
additional help. The ten day extended coverage generates
little risk for the insurers due to the large deductables that must
be reached before any payouts are required.
Insurers are worried that since the health
insurance markets are lagging in verifying the policies that
are issued invalid applications will cause instability. People
are likely to be scrambling to find coverage if their plans lapse
and they have trouble figguring out their benefits, and which
doctors and hospitals are included.
Some insurers, such as Florida Blue,
have encouraged insurance applicants to sign with them directly so
the contract is recorded accurately.
Aetna
- UnitedHealth
(Nov
2015), Humana
and Aetna (Aug
2016) announce plans to leave the insurance
marketplaces.
- President Trump pushes insurers: Aetna, Humana; from the individual
markets by refusing
to guarantee insurance plan subsidies and then shouts ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
'death
spiral'. Anthem
raises prices (May
2017)
- Nonadherence 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;
is a huge problem in US agree National Jewish's
Bender,
Brigham
& Women's hospital's Rosenbaum, Pittsburgh
Health Plan's Shrank
& Aetna (Apr
2017)
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
- Judge Richard Leon requests monitoring of CVS +
Aetna during the Tunney of 1974 is antitrust legislation:
- Allows a court review of DOJ decisions about mergers and acquisitions.
court
antitrust review (Dec
2018)
- Analysis suggests Amazon
may not succeed in disruption of
prescription drug distribution.
PillPack needs
relationships with PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s:
Express Scripts
(which must renew in July and is owned by Cigna), CVS (strategy
and responds to Amazon's move into prescription drug sales), distributor:
AmerisourceBergen
(part owned by Walgreens)
(Jul
2018)
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and competitive
pressures encourage payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
-delivery
integration across the health care spectrum: UnitedHealth,
Anthem
CVS: IngenioRX PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. , Aetna: Inova, Banner
Health; Cleveland
clinic: Oscar;
(Nov
2017)
- Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left the
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
marketplaces for 2018 and Trump Administration's HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest (Dec
2017)
- Business
model for individual PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
collapses under
pressure from various large organizations executing acquisitions
and mergers: Apple
running own clinics for employees, Large hospitals setting up
urgent care: HCA,
Dignity Health,
Northwell
Health (GoHealth);
CVS Health & Aetna, Wal-Mart & Humana, United Health
employs 30,000 physicians and owns one of the largest urgent care 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.
groups
(MedExpress);
who can leverage employed PCP prescriptions for their PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s, driving some PCPs
to compete with urgent care: Healthy Now; and or leverage nurse
practitioners, and others to explore One Medical
& Aledade (Apr
2018)
- Judges block Humana+Aetna & Cigna+Anthem
insurer mergers (Feb
2017)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
Offers virtual visits as an option for certain employers. Uses
Teladoc.
Aug 2016 After the merger with Humana was blocked by the
federal government, Aetna announced they would pull out of the personal
insurance marketplaces (Aug
2016).
2015 Under market
pressure Aetna is seeking to merge with Humana for $37
Billion. The transaction should close in 2016, subject to
regulatory and shareholder approval.
The combined company would have an estimated revenue of $115 billion
and serve 33 million people. The board will expand to 16
members with 4 from Humana.
The consolidation was assisted by the Supreme Court decision
upholding the part of the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
allowing individuals to receive subsidies when they buy policies
through HealthCare.gov.
The merger was subsequently blocked by the courts (Feb
2017).
CEO Mark Bertolini argued the combination would promote greater
operational efficiencies that enable us to lower costs and create
value for our customers and provider partners. Bertolini
emphasized the need to be large enough to invest the capital and
resources necessary to be competitive in a rapidly changing
environment. Key reasons are:
Kaiser
Family Foundation estimates that the merged companies will
cover 26% of all Medicare Advantage enrollees nationwide making it
the leading provider.
Mr. Bertolini has a golden parachute and so stands to make $131.3
million in a takeover if he is pushed out.
Aetna pushes
back against surgery assistant charges.
Aetna has litigated against excessive use and fees for
out-of-network assistants in surgery.
J. Edward Neugebauer, chief litigation officer of Aetna said the
company sued an in-network neurosugeon on Long Island who always
calls in an out-of-network partner to assist, resulting in huge
charges. The surgeons shared a business address.
Aetna CarePass
Aetna had developed and offered a personalized health data platform
for patients called CarePass. It was discontinued because it
did not deliver on the anticipated results.
Aetna has purchased HCIT companies:
Aetna 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 provides managed care contracts together its subscribing patients with particular groups of doctors and hospitals who agree to provide contracted care for a particular price which the managed care organization reimburses. It was based on the group practice organizations: Kaiser, Mayo Clinic; operations. The initial HMOs, supported by the HMO act and PPOs has subsequently been joined by other forms of managed care. Original capitation based implementations were problematic with only Kaiser succeeding. Managed care is now enhanced by inclusion of upside measures as in alternative quality contracts.
solutions for Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. .
Anthem Inc.
(Wellpoint until
2014)
Anthem is a provider of health plans offered on the public
insurance marketplaces.
- President Trump pushes insurers: Aetna, Humana; from the individual
markets by refusing
to guarantee insurance plan subsidies and then shouts ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
'death
spiral'. Anthem
raises prices (May
2017)
- Anthem
to leave Ohio exchange for 2018 - it is still to decide on its
other markets. 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.
have
announced other market exits recently. Harvard
Pilgrim ramps premiums. Republicans say they will
provide billions of dollars to stabilize them but with deadlines
in June, maybe not soon enough (Jun
2017)
- Weill Cornell
healthcare policy researcher & New
York-Presbyterian physician Dhruv Khullar
notes: Anthem's
CareMore,
Geisinger;
aim to support potential hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. patients
in their homes with full support team deployed into the
neighborhoods (Sep
2017)
- Matching UHG's
OptumRx,
Anthem
sets up IngenioRx
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
with CVS, replacing
integration with Express Scripts
(Oct
2017)
- Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left the
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
marketplaces for 2018 and Trump Administration's HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest (Dec
2017)
- Insurance premiums, for ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual market, popular plans, will be lower in 2019 says CMS is the centers for Medicare and Medicaid services. administrator
Verma, with profits pulling insurers: Anthem,
Wellmark,
Molina, Cigna; back into the
markets (Oct
2018)
- Judges block Humana+Aetna & Cigna+Anthem
insurer mergers (Feb
2017)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
- RWJ
funded RAND study, of 1,598 hospital treatment's insurance
claims, shows Parkwiew
Health, in Indiana, charges private
insurers 4 * its Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
prices. States paying the most are: Indiana, Wyoming,
Maine, Wisconsin, Montana, Colorado, Texas, Georgia, Ohio,
Washington; on average hospitals charge 2.4 * Medicare prices to
private health insurance patients. Outpatient care was 3 *
Medicare pricing; angering employers. Employers
say they must exert discipline on health care costs: will gather
data on prices and quality to decide on the best strategy: single-payer is a healthcare architecture in which there is a single financing organization. Significant aspects of single-payer include: - Strengths of single-payer:
- Removes the extensive replication of payer organizations and their different interfaces to the other healthcare entities and subscribers.
- One payment organization, removing the need to allow subscribers the yearly choice to change payer, encouraging payers to help subscribers remain healthy
- Single-payer instantiates a political monopoly on health insurance.
- Problematic implementation of single-payer in the US
- Undermines the alignment of the healthcare network, threatening profits, power structures and financial rewards. This limits the possibility of single-payer in the US: Lobbying juggernaut: Politicians, Providers, Doctors, Insurers; leveraging dislike of tax increases, The 9 out of 10 Americans who are employed or retired are satisfied with their situation, Current insurance costs are hidden from the insured: in lowered pay packages, spread over all tax payers reducing government revenues; Current private insurers would be forced to reduce costs;
- Alters one sixth of the US economy: Commercial health insurance replaced, investors impacted by transformation of business models; a huge change of high uncertainty, something evolution works to avoid by including mechanisms to force small incremental changes.
- A state: Vermont (Jan 2014); can use public funds for all health care financing while the delivery of care is provided by non-state organizations. Analogously Intermountain Healthcare's SelectHealth Share requires organizations to use Intermountain for health care finance (Feb 2016).
,
focus on best value hospitals; Insurers are not incented
to keep prices down when working for self-insured companies -
where insurers are spending the companies money and make more
revenue when the company spends more. Anthem
claims narrow
networks - 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).
of hospitals is its direction to drive down
prices. One-third of all healthcare spending goes to
hospital care. Hospitals are buying physician practices is physician practice management. This consolidation of PCP practices was partly a response to Wall Street's capitalization of HMOs and hospitals in early 1990s. As Wall Street switched to financing PPMs, enabling Medpartners's purchase of Mullikin Inc., hospitals responded by buying up the PPMs. Most PPMs struggled to control costs in the capitated care framework of the 1990s. Some of these PPMs shifted to become PBMs. and
spending on new facilities. Hospitals (AHA is the American_hospital association. ) argue they lose
money on Medicare and Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. , so the
comparison is biased (May
2019)
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:
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
provisions
created 16 million newly insured subscribers.
- Supreme Court upheld ACA subsidies to consumers who buy
policies through online
marketplaces.
- ACA/Marketplace effects creating greater transparency in
pricing lowering plan profit margins.
- ACA catalyzed rules that require insurers to spend a fixed
amount of premiums collected on care.
- ACA effects lowering funding for government plans added
pressure.
- Rush to merge before regulators stop them.
- Hard to build network effects and extensive capital needed to
move into additional states.
As the companies merge their competitors will also adapt. Centene
argues they will use the opportunity to compete more in Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans.
Centene, WellCare
and Molina
Healthcare all specialize in public Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. programs and
are likely targets for merging.
The merger effects will likely differ by region across the country
depending on the local market share. And large employers will
find they can offer employees less options.
Sep 2015 Mr Swedish told a senate committee reviewing the merger
that the merger would "uniquely benefit consumers" by expanding
access to care through a more extensive network of doctors and
hospitals. He noted that the combined company would face
robust competition in many geographic markets and product
lines. The consumers union was skeptical suggesting a dominant
insurer could force doctors and hospitals to cut costs so much that
the quality of care might suffer. They doubt the merger will
pass the requirements of the Clayton act of 1914. It aimed to prevent anticompetitive practices. It specifies particular prohibitied conduct, a three-level enforcement scheme, exemptions (labor union and agricultural organization safe harbor, and major league baseball exemption) and remedial measures. It has four sections which modify the Sherman Act: - Section 2 controls price discrimination between purchasers if it lessons competition.
- Section 3 controls exclusive dealings where purchasers are required to buy a tied product.
- Section 7 control mergers and acquisitions where the effect substantially lessens competition. It allows the government to regulate all mergers and gives the government discretion whether to approve a merger or not. Section 7 was later strengthened to cover asset acquisitions by the 1950 Celler-Kefauver amendments. Section 7a requires companies considering a merger to inform the FTC and DOJ.
- Section 8 limits people from being directors of two or more competing corporations if those two corporations would violate the anti-trust criteria by merging.
.
According to Professor Leemore Dafny, a health economist is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. at Northwestern
University, past history does not indicate that insurance
consolidation leads to savings for consumers or that the large
insurers are likely to be more innovative.
Smaller insurers do not have the resources of big insurers.
The AMA is the American Medical Association. is unhappy
with the possibility of the Anthem/Cigna and Aetna/Humana mergers.
The mergers increase the power of the payers include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
relative to the
hospital groups and doctors. Likely they will respond by
combining as well.
If both hospitals and Insurers consolidate patients may be less
powerful if there is less market competition. Similarly the
increase in power may keep out startups and reduce the motivation to
innovate. Still Express scripts
merger with Medco Health did not significantly undermine
competition.
Increased power is likely to reduce the motivation for the big
insurers to innovate and partner with hospitals and doctors in
innovative ways. They will focus on lowering prices of the
providers and doctors.
The merger was subsequently blocked by the courts (Feb
2017).
Anthem is a board member of the U.S.
Chamber of Commerce.
Anthem's IngenioRx
Anthem partners with CVS to
form PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. (Oct
2017)
Anthem tele-health
Anthem will cover virtual urgent care visits for its 16 million
members in 11 states by the end of 2015.
Anthem Blue Cross
Anthem Blue Cross is part of WellPoint -> Anthem
inc post 2014. It covers 14 states.
It is the for-profit version of the Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. Blue
Shield nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%.
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 has an ACO pilot with Sharp HealthCare medical groups
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.
- Anthem
to leave Ohio exchange for 2018 - it is still to decide on its
other markets. 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.
have
announced other market exits recently. Harvard
Pilgrim ramps premiums. Republicans say they will
provide billions of dollars to stabilize them but with deadlines
in June, maybe not soon enough (Jun
2017)
- President Trump's executive order concerns state
regulators and the Kaiser
Family Foundation but gains applause from the USCOC
(Oct
2017):
- Relaxes legislated:
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
, ERISA is the Employee Retirement Income Security Act of 1974 signed by President Ford. It regulated both pension and health benefit plans once an employer had established one. It setup the PBGC to support voluntary private defined benefit pension plans. Where self-funded health plans under ERISA are exempt from a state's insurance regulation there will be no solvency or consumer protection in place to support providers that do business with ERISA plans. States may consequently require provider networks that do business with employer self-insured ERISA plans be licensed as an insurance company (an HMO, medical insurance plan, preferred provider arrangement or general casualty insurer). ERISA section 404(a)(1)(B) defines the prudent person rule associating prudence with portfolio theory allowing pension funds to invest in stocks (index funds). The labor department's interpretation of an ERISA employer has been modified to support President Trump's executive order to enable more use of AHPs (Jan 2018). ; implementation
of federal insurance regulations and pushes for AHP is association health plan:
- Allow small businesses and individuals in particular
professions, trades or interest groups to join
associations that offer insurance to members.
- Are a form of MEWA
s, in move that NAIC
& BCBS
and other insurance plans will resist (Oct
2017)
- Labor department acts on executive order issuing proposed
new rules for AHP is association health plan:
- Allow small businesses and individuals in particular
professions, trades or interest groups to join
associations that offer insurance to members.
- Are a form of MEWA
s,
updating its ERISA is the Employee Retirement Income Security Act of 1974 signed by President Ford. It regulated both pension and health benefit plans once an employer had established one. It setup the PBGC to support voluntary private defined benefit pension plans. Where self-funded health plans under ERISA are exempt from a state's insurance regulation there will be no solvency or consumer protection in place to support providers that do business with ERISA plans. States may consequently require provider networks that do business with employer self-insured ERISA plans be licensed as an insurance company (an HMO, medical insurance plan, preferred provider arrangement or general casualty insurer). ERISA section 404(a)(1)(B) defines the prudent person rule associating prudence with portfolio theory allowing pension funds to invest in stocks (index funds). The labor department's interpretation of an ERISA employer has been modified to support President Trump's executive order to enable more use of AHPs (Jan 2018).
interpretation, and weakening the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
's constraints on skimpy health
insurance coverage (Jan
2018)
- Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left the
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
marketplaces for 2018 and Trump Administration's HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest (Dec
2017)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
In more than 30 states nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%.
Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. sells
the most policies to large employers, with almost a dozen capturing
three-quarters of the market according to Kaiser
family foundation data. It is the key presence in
Massachusetts, Minnesota, Oregon and Washington. Anthem Blue Cross
is the for profit BCBS.
During the great depression the AHA is the American_hospital association. encouraged the
development of Blue Cross, and other medical societies
supported the development of Blue Shield to help catalyze use of medical services.
Both payers include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
reimbursed is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
the
hospitals with a per patient daily per diem and some additional
margin.
The BCBS
association has been accused of cartel practices.
They must offer a competitive alternative to a combined Aetna-Humana or Anthem-Cigna. They are
faced with decreasing revenues and more competition from new
entrants, such as co-op plans enabled by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
and Ascension, Catholic
system and North
Shore-LIJ in New York which can leverage their local
standing.
- Pharmaceutical companies: Merck with Januvia
& Januvet, Novartis
with Entresto,
Amgen with Repatha
contracting with Harvard
Pilgrim & treating patients at Lahey;
propose outcomes-based
contracts require suppliers to return money to the health system if the drugs fail to work as expected. Typically drug makers pay rebates to insurers based on the number of drugs sold. The manufacturers gain easier access to insurers' members for their products. It appears unlikely that outcomes-based contracts reduce prescription drug prices (Jul 2017).
- with promotion by PhRMA,
but little evidence that they lower prices asserts MS-KCC
& PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s: Express Scripts,
Prime
Therapeutics (Jul
2017)
David Lassen of Prime is seeing an increased request for narrower formularies are lists of drugs that a health plan will cover. The health plans control where and if the drug is listed in the plan. A less expensive drug can be assigned a lower copayment to encourage patients to use it. To counter this attack on their profits drug companies responded with coupons to help patients pay copayments removing the incentive to select the lower-priced drugs. Health plans reacted to the copayment cards by dropping some drugs from the formulary altogether. That encourages drug companies to bid for their drug to be the only one listed resulting in some downward price pressure. and
excluded drugs. However, Prime was worried about the
disruptions for patients forced to switch drugs.
Blue Health Intelligence
Blue Health Intelligence manages integrated medical and pharmacy
claims for 110 million individuals.
2013 It has purchased Intelmedix its analytic solution
provider.
BlueCross of Alabama
Blue Cross of Alabama includes a division that is a Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
ZPIC is Zone Program Integrity Contractor. A CMS Medicare benefit integrity MIP contractor for one of the seven national CMS designated zones. It has a benefit Integrity unit with the primary goal of identifying and acting upon benefit fraud. .
Blue
Cross Blue Shield of North Carolina
Seeking a 2016 rate increase of 25% for its 397,000 consumers.
Justified by:
- Inpatient costs particularly in treatment of cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
and heart
conditions,
- Emergency room utilization
- Cost for specialty
drug medications 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).
to treat 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. , breast cancer is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018)
and cystic
fibrosis is a deadly, recessive genetic disease caused by a variety of single gene mutations in the CFTR gene, most commonly occurring in people of northern European background. Screening would work best if applied to couples prior to conception but this is not how carrier screening is organized as of 2015. Cystic fibrosis can result in: fibrous cysts in the pancreas; which does not secrete its normal digestive enzymes inducing serious malnutrition, intestinal blockages, infertility in males and lung damage due to accumulation of a thick, sticky secretion followed by recurrent infections. Symptoms vary among sufferers because: - Modifier genes which vary between individuals.
- Environmental differences:
- Second hand smoke exposure is a significant contributor to cystic fibrosis effects
- Medical interventions such as: pancreatic enzyme capsules, chest physical therapy, antibiotics, aerosolized enzyme therapy, saltwater mists and double lung transplants; can reduce the effects
- Diet
.
Blue
Cross Blue Shield of South Carolina
BCBS South Carolina is working with Zipongo.
Blue Cross Blue
Shield of Georgia
Dec 2017 Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy.
Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. of
Georgia is exiting from the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
markets in 74 of the 159 counties in Georgia (Dec
2017).
Blue Cross of Idaho
- CMS is the centers for Medicare and Medicaid services. administrator
Verma enforces ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
legislation, blocking Idaho's plan to allow the sale of
stripped-down health insurance (Mar
2018).
BlueCross
BlueShield of Illinois
Seeking a 2016 rate increase of 23%
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".
2017 Dana Gelb Safran BCBSMA chief performance measurement &
improvement officer
Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. Blue
Shield of Massachusetts has developed the Alternative
Quality Contract (AQC) is: - A 2009 payment arrangement developed by Blue Cross Blue Shield of Massachusetts. It was developed to support change. It differs from capitation in including upside measures for patient safety, appropriateness of care and patient satisfaction. Its key components are:
- Integration across the care continuum
- Accountability for performance measures for ambulatory and inpatient care. Includes a 10% incentive for performing.
- Performance measures are selected that are: Nationally accepted, Vary across providers, Include sufficient data on provider being measured, measured at the level that can influence the outcome.
- Global payment for all medical services with health status adjustment and with margin retention.
- Five year contract to create a sustained partnership
(AQC). Ezekiel
Emanuel notes
an executive from BCBS concluded:
- More than half the AQC savings were associated with shifting
to lower-cost
settings.
- Initially switched settings in areas where no relationship
was threatened: lab tests, imaging & colonoscopies.
- Later hospitals and specialists with lower prices were
selected.
- There was no change in the amount of care provided.
Dana Safran believes:
- A multifaceted program for sharing data and best practices is
key to:
- Success fo physician groups using AQC alternative quality contract 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
s
- Transforming the payer include four types:
- From the 1930s the insurers Blue
Cross and Blue Shield catalyzed health care activity
by paying a daily per diem to hospitals for the diagnoses
and treatments the hospital's dispensed. At their
inception in 1966 Medicare and
Medicaid followed this reimbursement model.
- From 1983 Medicare and Medicaid switched to the PPS reimbursement mechanism.
This forced alignment of the
supplier, diagnosis, treatment, billing and reimbursement
processes. The health care network is still
structurally aligned around PPS. Under scrutiny of
ProPAC and its successor MedPAC,
as well as pressure of the BBA
after 1997, the payments per DRG
have been steadily reduced until it was below the cost of
care, forcing hospitals to seek margin from their other
payers. Medicare outlier
payments benefited hospitals that inflated charges and
thus became eligible.
- Employers as they experienced cost shifting from the
hospital's increased product charges moved their employees
over to managed care based
payment.
- Private payers pay hospitals directly for their
diagnosis and treatment. Typically this group has
little power. There are default rates for private
payers - typically 40% of billed charges that are not
covered by a fixed payment or a fee schedule. For
the uninsured poor until 2004 they obtained little
discount on the hospital's chargemaster
list price, because insurers and CMS
required to be charged the lowest value offered to any
patients. Medicare has now relaxed this
constraint.
-provider
relationship to a collaboration; including via HEC Forum:
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.
Blue Cross Blue Shield of Minnesota American Well for
Tele-health is the use of remote health care. It includes telepharmacy and clinical telehealth for stroke and psychiatry. It also includes sessions between primary care providers and patients and assisted caregiving such as medication reminders and DME usage monitors. .
Blue Cross
BlueShield of MN request 50 percent rate increases for 2016
Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. and Blue
Shield of MN requested rate increases of 50% for 2016 for plans of
the health exchanges. They argue their claims have not slowed
at all over 2015. The trend has gotten a little worse.
They reported a surge in prescription drug expenses. Two
high-cost specialty
drugs cost tens or hundreds of thousands of dollars a year when used to treat complex or rare diseases: cancer, rheumatoid arthritis, hemophilia, HIV. By 2015 they account for one-third of all spending on drugs in the United States and should reach 50% by 2025. With the MMA constraining Medicare drug price negotiations many old generic drugs appear to be being rebranded with controlled distribution as specialty drugs and re-priced with vast margins (Sep 2015). for rheumatoid
arthritis is an autoimmune disorder where the immune system attacks the joints and can generate inflammation around the lungs and heart. It can be treated with: Enbrel, Humira, Ilaris, Xeljanz; , Enbrel
and Humira,
account for one-fourth of prescription drug costs in the company's
individual health plans.
The ratio of claims paid to premium revenue was more than
115%. The company said it lost more than $135million on its
individual insurance business in 2014. They argue 2015 deficit
will be higher.
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:
- Certain types of condition where sophisticated counseling
substitutes for a person doing an internet search will lead to
fragmentation. Physician knows you best is also
poor. Steve prefers physician as leader now aims to develop plans and strategies which ensure effective coordination to improve the common good of the in-group. Pinker notes the evolved pressure of social rivalry associating power with leadership. Different evolved personality types reinforced during development provided hunter-gatherer bands with alternate adult capabilities for coping with the various challenges of the African savanna. As the situation changed different personalities would prove most helpful in leading the band. Big men, chiefs and leaders of early states leveraged their power over the flow of resources to capture and redistribute wealth to their supporters. As the environmental state changed and began threatening the polity's fitness, one leader would be abandoned, replaced by another who the group hoped might improve the situation for all. Sapolsky observes the disconnect that occurs between power hierarchies and wisdom in apes. In modern Anglo-American style corporations, which typically follow Malthus, and are disconnected from the superOrganism nest site, the goal of leadership has become detached from the needs of this broader polity, instead: seeking market and revenue growth, hiring and firing workers, and leveraging power to reduce these commitments further. Dorner notes that corporate executives show an appreciation of how to control a CAS. Robert Iger with personality types: Reformer, Achiever, Investigator; describes his time as Disney CEO, where he experienced a highly aligned environment, working to nurture the good and manage the bad. He notes something is always coming up. Leadership requires the ability to adapt to challenges while compartmentalizing. John Boyd: Achiever, Investigator, Challenger; could not align with the military hierarchy but developed an innovative systematic perspective which his supporters championed and politicians leveraged. John Adair developed a modern leadership methodology based on the three-circles model.
of a team
which builds team relationships and trust with consumers
(physician only involved 20 percent of the time). Apple
introduced stores because it builds the relationship via a team
of varying skills. BCBS is building the back room of a
clinic which is trying to appear like an apple store with the
consumer IT tool being as important as the clinical
record.
- ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
is
important. It will be changed under the next President:
replaced or rebuilt.
- ACA group coverage and hybrid exchanges are very costly.
Employers should go to the individual exchanges with defined
contributions. Employers will like that. Health
plans are pressurized too as it is a break even business.
We are well capitalized and work like a property casualty
insurer - we fund 1 - 2% of risk priced for 10 years at less
than 1% - with 80 basis points of margin.
- Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
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. is too
expensive. Consumers, businesses and international can't
afford this.
- How can the consumer be provided with understandable messages
about insurance, diagnosis and treatment within ten years?
Electronics makes the sale of a complicated product clear with
great design. Quality data and analytics must go to the
consumer and be useful to them in making decisions.
Blue Cross
Blue Shield of Oklahoma
Seeking a 2016 rate increase of 31%
Blue Cross Blue
Shield of Texas
Offers narrow
network - When all health insurance plans are comparable on line people are expected to choose narrower less costly plans. This has the effect of encouraging providers and PCP to compete to be part of the narrow plan by reducing their charges and driving down the prices of the plans. By limiting the number of providers/doctors offered in the plans the few that are included should get more business. Across the US in 2015 39% of health plans offered in public exchanges are narrow (30 - 70% of areas providers) or ultra-narrow (30% or less of providers). In large cities narrow networks are even more common. Typically if consumers go outside of the choices offered in their narrow network they will be responsible for the high bills. There are problems induced by narrow network constraints: - Queuing issues - while a surgeon and a hospital may be in-network other agents in an operation, such as anesthesiologists or anesthetists, may not have the same set of insurance contracts. Even if a subset do, once these are allocated to a task the hospital must then manage a complex set of resource constraints to keep its ORs running. If it does this by ignoring the 'out of network' status of these necessary resources the patient will be impacted by a high bill.
- Success is more likely when the plan maintains a broad list of PCPs but a narrow list of specialists and hospitals (Oct 2016).
plans on the exchange. HCA
has effectively gained access to most of these plans in Apr
2014.
Asked for 60%
increases for 2017 ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
insurance
exchange policies.
Blue cross
Blue Shield of Tennessee
Seeking a 2016 rate increase of 36%
Lost $141 million because they were not very accurate in predicting
the utilization of health care in 2014.
Tennessee insurance commissioner JUlie Mix McPeak said she would ask
"hard questions of the companies we regulate, to protect
consumers."
BlueShield of California
Blue Shield of California uses Teladoc.
BlueShield
describes 2014 California health exchange rates
Its premiums for individual customers would increase about 13
percent on average next year over current premiums; about 8 percent
of that increase would cover rising hospital and medical costs,
which would have happened anyway. The other 5 percent pays for
better benefits, guaranteed coverage for pre-existing conditions,
and taxes and fees imposed on insurers by the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
.
Nov
2015 California fined Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. of
California for inaccurate provider directories for its health
plans.
2012 Blue Shield of California has two ACOs in Northern
California:
- CalPers,
Blue
Shield of California, Hill
Physicians Medical Group, and Dignity Health
formed an ACO is an Accountable Care Organization. These are accredited bundles of companies which together try to offer Dartmouth-Hitchcock like business models (Dec 2015, Sep 2016) focused on wellness, improving the provision of primary care to a large group of Medicare patients, and rewarding doctors for preventing problems. Advocate health illustrates the idea. Robert Pearl notes that the transition is difficult: hospitals that find their efficiency improving should reduce the number of doctors they utilize. But any doctors that are pushed out of the ACO will likely take their patients with them, undermining the revenues that support the FFV business. The ACA regulates qualification to be a Medicare ACO. Individual organizations within a Medicare shared savings ACO continue to submit their own claims and are paid by Medicare for FFS. But the ACO is eligible for shared savings. Within the shared savings program the CMS innovation center has setup advanced payment ACOs. As an alternative to shared savings, in a Pioneer ACO, over time 50% of the FFS payments flow directly to the ACO as a bundled payment. CMS has established quality measures for ACOs for Medicare. The CMS program's purpose is to reward providers for reducing total cost of care for patients through prevention, disease management, and coordination.
- CMS initiated its Physician Group Practice Demonstration in 2005. By 2008 the congressional budget office reported on Bonus-eligible organizations.
- CMS defines ACOs as organizations that "create incentives for health care providers to work together to treat an individual patient across care settings - including doctors' offices, hospitals and long-term care facilities."
- CMS has developed APMs which include ACOs, and advanced APMs where the ACOs must be risk bearing.
- CMMI accepts providers' proposals to test various payment systems including shared savings and partial capitation.
- Private market ACOs have formed including: Providence Health & Services, Blue Shield California, Anthem Blue Cross, United Health Care, BCBS Minnesota, BCBS Illinois, Humana, CIGNA, Main Health Management Coalition, BCBS Massachusetts, Aetna.
(2010)
Cambia Health Solutions is a nonprofit is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%. 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. Damasio notes prokaryotes and social insects have developed cultural social behaviors. 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. Damasio suggests culture is influenced by feelings:
- As motives for intellectual creation: prompting
detection and diagnosis of homeostatic
deficiencies, identifying
desirable states worthy of creative effort.
- As monitors of the success and failure of cultural
instruments and practices
- As participants in the negotiation of adjustments
required by the cultural process over time
- Produces consciousness according to Dennet.
of control.
Capital BC is a Harrisburg, Pennsylvania BlueCross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy. health
insurer.
Capital
District Physicians' Health Plan (CDPHP)
CDPHP offers New York health insurance and Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
Plans.
It is offering employers a plan that caps any rate increases at
under 10% in the first and third years.
CareConnect
CareConnect is the insurance plan for North
Shore-Long Island Jewish Health System. It has enrolled
28,000 customers but is not yet profitable (Sep 2015).
CEO Alan Murray.
By June 2016 CareConnect has 100,000 subscribers which are insured
through either large or small employers. That is a 'well
understood' population which allowed CareConnect to plan and operate
effectively. Alan Murray noted "If we only had the individual
market, we would have taken undue risk because we would not have
understood that market." He said Careconnect is close to
turning a profit.
Northwell Health's
Michael Dowling is closing its CareConnect
Insurance division because it has been generating large
losses.
13% of CareConnect's customers use the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
personal
exchanges.
Most of CareConnect's customers use small business plans.
Dowling notes "It has become increasingly clear that continuing the
CareConnect health
plan is financially unsustainable, given the failure of the federal
government and Congress to correct regulatory flaws that have
destabilized insurance markets and their refusal to honor promises
of additional funding."
The regulatory problems are:
CareFirst Blue
Cross of Maryland
- Minnesota provides MPSP is the Minnesota Premium Security Plan. It provides reinsurance to support the ACA individual markets. The program pays 80% of a claim from $50,000 to $250,000. The insurer is responsible for claims over $250,000. It is funded based on the assumption that lower premiums will allow the federal government to provide half the cost via the ACA's risk adjustment. It is expected the lower premiums will reduce the federal payments for high premium tax credits.
reinsurance provides protection to insurers covering a high risk pool of subscribers by paying the reimbursements for health care services of the most costly individuals in the pool. Legislation, including the MMA, ACA and BBA of 2018, which include reinsurance flows to compensate insurers for subsidizing subscriber expenses, catalyze the transfers and support distortions
for ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
market insurers: HealthPartners;
and successfully reduces premium increases. CareFirst
hopes for a similar federal law (Sep
2017)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
Rates were initially set low for the state marketplace but have been
rising allowing Evergreen
a foothold.
CareMore is a health plan (Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. ) that is structured as an integrated
health system focused on pro-active health care for its
members to limit hot
spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community. costs and improve overall outcomes and welfare.
CEO 2017 Sachin H. Jain
Leeba Lessin is a non-physician leader.
CareMore is part
of Anthem.
CareMore
is a Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. health plan and health system in California which
specializes in caring for chronically ill patients. Medicare
provides CareMore with an overall payment for the expected costs of
each beneficiary and benchmarks its quality of service and coverage
levels. CareMore provides its own care which is highly
effective:
CareMore's Sachin Jain comments "In hospitals, we're great at
customizing care. We have different intensities for patients
with different needs: an observation unit, a general medical ward,
an intensive care unit. But on the outpatient side, we haven't
done that. In your average clinic, all patients get scheduled
for 15 or 30 minutes, regardless of whether their problem list is
empty or 10 pages long. Our model tries to fix that."
CareMore
patient care standardization
CareMore adopts standardized protocols from government and
professional societies; which they apply to the major illnesses they
treat.
Ezekiel Emanuel notes that CareMore has to be careful that they can
afford to adopt the protocols, since many of their Medicare
Advantage (MA) is a private provider administered health insurance plan providing access to Medicare benefits. It was originally enacted as part of BBA Medicare + Choice or Part C plans. The government funded the plan with an annual fee, based on age and severity of the subscriber's medical conditions, rather than FFS. When a Medicare eligible person enrolls in a MA plan the government pays the private provider a set amount each month. The participant pays the Medicare part B premium and if required a part C premium each month. The MA plans offer a PCP who coordinates care. And the plans have an annual limit on out-of-pocket expenses unlike traditional Medicare. When they obtain treatment they will have to pay a copayment which may be quite high for some specialists. It is the health plan's responsibility to contract the physician network that will provide the care, leaving the risk with the insurer. About 36% of Medicare beneficiaries are enrolled with Medicare Advantage by 2019. The ACA introduced quality outcome and patient satisfaction based differential payments into MA. To measure the performance it added a five-star quality rating scheme. MA plans report their quality and patient satisfaction data to CMS annually and based on the results are awarded one to five stars. The highest rated plans are provided with large additional payments. It was assumed that subscribers would shift to the highest rated plans and the other plans would improve or drop out of MA. And the ACA eliminated subsidies which the federal government used to establish Medicare Advantage. However, the Obama administration has used a $8.5 Billion demonstration project to maintain this funding. It is intended that it will eventually taper off so that the cost of Medicare Advantage coverage will be equivalent to standard Medicare. plan subscribers have fixed incomes. Caremore
apply an affordability constraint, to ensure that patients can
adhere to their treatment plans. CareMore explicitly selects
medications, treatments etc., to minimize costs to patients.
CareMore
chronic care coordination
Caremore see their chronic care strategy as different:
- Physicians intuit which are the hot spot is a highly connected agent with an outsize influence. In medicine these are very high cost patients often with very poor personal health care strategies (Sep 2017). The logic of hot spots is reviewed by Atul Gawande. Glenn Steele & David Feinberg describe how Geisinger has successfully identified and reduced the cost impact of its hot spot patients. Robert Pearl argues the strategy has limited applicability in the current health care network. He asserts a revolution can/must happen that will help this strategy to become broadly applicable. Ezekiel Emanuel asserts practice transformations have allowed chronic care operations: CareMore; to identify and support hotspot patients in the community.
patients. These are tracked on a central white board,
ensuring they get team focus. The physicians are on a
capitation is a global payment for all care for a patient during a specified time period. It forces the provider of care to take a high risk. Managing the risk implies successful population health management.
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.
contract with CareMore.
- Patients are initially examined and classified by
CareMore's own nurse practitioners. CareMore captures:
- Medications,
- Past medical history - including all comorbidities &
prior hospitalizations,
- Requirements
- Mental health issues,
- Cognitive deficits,
- Social situations
- Uncovered acute & chronic problems: hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers. ,
CKD is chronic kidney disease
- Where there is permanent damage to the Kidneys. Diabetes and high blood pressure are the leading causes of CKD. This has driven up the percentage of American's suffering from CKD.
- CKD is diagnosed via a GFR of less than 60, or another marker such as protein in the urine, for atleast three months.
- The disease, classed as having five stages, causes no symptoms until the later stages. The fifth stage of CKD is ESRD. CKD is associated with: Atherosclerosis, Cardiovascular disease, Iron deficiency anemia from reduced EPO synthesis, Fluid volume overload, Hyperphosphatemia, Hypertension, Metabolic acidosis, Mineral bone disorder, Potassium accumulation, & Urea accumulation.
, depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. 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 with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. 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;;
- Red flags: Two high A1c test is a blood test that assesses a person's average level of blood glucose over a 3 month period. Because glucose attaches to hemoglobin the 3 month lifetime of red blood cells can be used as a buffer of blood glucose.
measurements, Patients being prescribed anticoagulants,
Currently seeing many doctors while elderly;
- Hot spot patients are proactively cared for.
- Chronic care coordinators who work alongside the rest of
the care team.
- Extensivists - hospitalists are internists based at a hospital, where they handle the care of all the patients on site. It's a recently created role developed in response to the economic pressure of managed care in the mid-1990s. Formerly doctors saw patients at the hospital in the morning before heading to the office for the next eight hours. Internists would go to a hospital if one of their patients needed them. Dr. Diane Craig argued it would be better for dedicated physicians to be available to care for hospital patients throughout the day. And hospitalists were initially very profitable for hospitals. Even though the hospitals had the additional cost of their salaries the hospitalists were able to discharge patients as soon as possible emptying beds that could be used to get more revenue. But hospitalists' Medicare treatment reimbursements are typically less than the hospital must pay them. This is the opposite of the situation with surgeons. Hospitalists are responsible for maintaining accurate metrics on their patients: readmission rates, HAI. As of 2015 there are 50,000 hospitalists.
with their role expanded to perform chronic care are
leveraged. They have a relatively light load of
hospital patients and spend the afternoon participating in
team discharge - have costly handoff problems reviewed by project BOOST. When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue. Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs. Discharge information can include: - Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
reviews. The patients are categorized as: Only needing
a follow-up appointment with a local physician (green), all
the way to the 20% of (red) patients who need contact from
the case manager within one day, and are seen at the
CareMore clinic by the extensivist, within two to four
days. End stage CHF 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. Heart expansion in CHF distorts the mitral valve which exacerbates the problems. MitraClip surgery trials found effective in correcting the mitral valve damage (Sep 2018). Treatments include: digoxin;
and emphysema is the long term destruction of the tissues that support the shape and function of the lungs.
patients, for example, will be attended by an extensivist
for the rest of their lives.
- CareMore has developed focused education clinics:
Anticoagulation, Diabetic foot care; where particular
problems are solved with education and connecting with the
coordinators, which otherwise would result in 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 and
hospitalizations.
As the management of chronic illness became more standardized and
efficient, CareMore has viewed behavioral
health as increasingly significant.
CareMore
behavioral health integration
When a subscriber has their Healthy Start exam with a CareMore nurse
practitioner, it includes screening tests for depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. 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 with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias. Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women. Women are four times more likely to suffer from anxiety. Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children. Michael Pollan concludes anxiety is fear of the future. Sufferers of mild autism often develop anxiety disorders. Treatments for anxiety differ. 50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac). Cognitive anxiety (extreme for worries and anxious thoughts) is also helped by yoga. But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT. Tara Brach notes that genuine freedom from fear is enabled by taking refuge. , cognitive
deficits etc. And CareMore include an annual depression screen
in its diabetic includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections.
treatment pathways and EHR refers to electronic health records which are a synonym of EMR. EHR analysis suggests strengths and weaknesses: - The EHR provides an integrated record of the health systems notes on a patient including: Diagnosis and Treatment plans and protocols followed, Prescribed drugs with doses, Adverse drug reactions;
- The EHR does not necessarily reflect the patient's situation accurately.
- The EHR often acts as a catch-all. There is often little time for a doctor, newly attending the patient, to review and validate the historic details.
- The meaningful use requirements of HITECH and Medicare/Medicaid specify compliance of an EHR system or EHR module for specific environments such as an ambulatory or hospital in-patient setting.
- As of 2016 interfacing with the EHR is cumbersome and undermines face-to-face time between doctor and patient. Doctors are allocated 12 minutes to interact with a patient of which less than five minutes was used for recording hand written notes. With the EHR 12 minutes may be required to update the record!
.
Then CareMore careteams assess the contribution of behavioral health
and psychosicial issues in shifts in care plan results.
CareMore setup a behavioral health SWAT team: psychiatrist,
psychologist, social worker[, addiction results from changes in the operation of the brain's reward network's regulatory regions, altering the anticipation of rewards. Addictive drugs mediate the receptors of the reward network, increasing dopamine in the pleasure centers of the cortex. The learned association of the situation with the reward makes addiction highly prone to relapse, when the situation is subsequently experienced. This makes addiction a chronic disease, where the sufferer must remain vigilant to avoid relapse inducing situations. Repeated exposure to the addictive drug alters the reward network. The neurons that produce dopamine are impaired, no longer sending dopamine to the reward target areas, reducing the feeling of pleasure. But the situational association remains strong driving the addict to repeat the addictive activity. Destroying the memory of the pleasure inducer may provide a treatment for addiction in the future. Addiction has a genetic component, which supports inheritance. Some other compulsive disorders: eating, gambling, sexual behavior; are similar to drug addiction. specialist
to assist seniors addicted to prescription medications]; to rapidly
see: within 2 to 3 days; patients who test positively in their
screening tests and provide medications or CBT is cognitive behavioral therapy. It was originally designed to treat depression. Depressed patients demonstrated problems with how they perceived themselves in the world (cognitive style). Aaron Beck proposed to identify their negative beliefs and then replace them with more positive thoughts. CBT leverages cognitive and behavioral principles to cope with behaviors, induced by prior conditioning, which cannot be managed directly with rational thoughts. Instead it assumes that one's relationship with maladaptive thinking and emotional bindings can be changed through antecedent strategies. CBT is problem focused and action oriented. Errors in thinking like: overgeneralizing, magnifying negatives, minimizing positives and catastrophizing are replaced with more realistic and effective thoughts. CBT has been extended with prolonged exposure therapy and virtual reality exposure therapy, which have been used to treat PTSD, where the BLA learns the signals are no longer dangerous. .
CareMore
de-institutionalization
CareMore extensivists can manage across the care continuum. So
they can constrain over-testing & -treatment in all
settings. CareMore standardizes
techniques across settings. But they work in a 'high
touch' care team that builds a relationship with the patient,
overcoming the fear that early discharge is a profit driven
strategy. And because CareMore's financial agreement with the
institutions is per diem based rather than a DRG is a diagnosis-related group. It transformed the health care operating model, when 467 DRGs with standard payments were introduced by Medicare in the 1980s, enabling for-profit business strategies to seek ways to cut expenses and hence increase profits. The DRG is a classification, designed by Yale's Robert Fetter and John Thompson, intended to define the products that a hospital provides. It assumes patients within a grouping are clinically similar. Grouping is based on ICDs adjusted for age, sex, discharge status and comorbidities. For Medicare hospital inpatient claims the DRG is used to select the fee that will be reimbursed. , the financial
incentives align too.
Upon admission the care team: extensivist, case manager is defined by American Case Management Association as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost effective outcomes. Case management productivity, discharge planning, utilization, coding and documentation, denials (RAC), Patient satisfaction (HCAHPS) and performance improvements are often measured to constrain overheads. Patient flows can be assessed via numbers of: admissions, observation days, patient days, outpatient visits, discharges, E.D. volumes, occupancy, and denial rates. ,
nurse practitioner; start planning for
discharge - have costly handoff problems reviewed by project BOOST. When discharge takes too long it ties up acute bed space which can result in adding up to 30% more (unnecessary) capacity when improved discharge would translate into additional revenue. Various interventions aim to improve the execution of the process including: CTI, TCN and RED for discharge to outpatient; InterAct for discharge to SNFs and BPIP to HHAs. Discharge information can include: - Patient info
- Behavioral summary
- Treatment history
- Medical history
- Treatment objectives
- Insurance policy
- Discharge plans
and how to transition over to home care.
SNF is skilled nursing facility. s are preferred to
hospitals, whenever ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs.
support is not needed, since they charge less, giving CareMore a
higher SNF bed day rate than the Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
average. With the CareMore team practicing on site, patients
typically get discharged before the last day of Medicare reimbursement is the payment process for much of US health care. Reimbursement is the centralizing mechanism in the US Health care network. It associates reward flows with central planning requirements such as HITECH. Different payment methods apportion risk differently between the payer and the provider. The payment methods include: - Fee-for-service,
- Per Diem,
- Episode of Care Payment,
- Multi-provider bundled EPC,
- Condition-specific capitation,
- Full capitation.
.
Prior to discharge to home, CareMore coordinates with DME - Durable Medical Equipment describes any medical equipment using in the home to aid in a better quality of living. providers and HHA is home health agency. s to ensure all
necessary equipment has been delivered and installed. The care
team will see the patient after discharge, at home or a CareMore
center.
CareMore geographic
expansion
CareMore is working to expand, from Southern California, into Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. markets in
Atlanta with Emory,
Memphis and Des Moines by replicating its most successful Southern
California practices. They use their chronic
care coordination strategy to shift patients out of hospital
to lower cost
facilities is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low): - Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
and their homes. This requires trained
extensivists and care-managers is transitioning to mean an aggregate of utilization management, case management, disease management, and independent review for populations. But it sometimes refers to geriatric care management which is the process of planning and coordinating long term care of the elderly. Such care managers have typically been trained in nursing, social work, and gerontology. They integrate health care and psychological care with other services such as housing, home care, nutrition, socialization, financial and legal planning.
to ensure home care and DME - Durable Medical Equipment describes any medical equipment using in the home to aid in a better quality of living.
providers are integrated and coordinated.
In Memphis, CareMore needed to:
Sachin Jain explains "We have done things like extend hours, so now
our offices are open 7 a.m. to 7 p.m. Ii is a
nurse-practitioner-based primary care consists of providing accessible, comprehensive, longitudinal, and coordinated care in the context of families and community. Interpreting the meaning of many streams of information and working together with the patient to make decisions based on the fullest understanding of this information relative to the patient's values and preferences is key to PCP providing value.
system with long visits. We have also implemented an ER
avoidance program to try to get them to use CareMore offices before
going to the E.R.
Catamaran
Is a PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. .
- Specialty
pharmacies 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.
: Prime Aid
Pharmacy; take Express
Scripts to court for its PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. blocking their
dispensing to subscribers. The pharmacies see it as
driving their business to Accredo (Jan
2017).
- PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
Express scripts
covers PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors.
cholesterol drugs: Amgen's
Repatha,
Regeneron's Praluent (Oct
2015)
- Cigna acquires PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
Express Scripts
for $52 billion (Mar
2018)
- Huge price drops impact generic suppliers: Teva;
and distributors:
Cardinal Health;
as pharmacies, distributors & PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s: Express Scripts
+ Walgreens;
cooperate to buy generics at lower prices. FDA Food and Drug Administration. commissioner
Gottlieb
says he will make it easier for generics to get to market.
Consumers don't see the savings (Aug
2017)
- Teva
restructures, cutting 25% of jobs, as Copaxone
attacked by generics & Teva's generics suffer from power of
buying groups formed by pharmacy
chains, wholesalers
& PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s (Dec
2017, 2)
- Lobbyists: PhRMA,
AAM,
NCPA is the national community pharmacists associations, a lobby for pharmacists.
; move to
constrain drug price concerns (Sep
2015) in Congress by: Fundraising for friendly
Congressmen: John Skimkus; Excluding Turing
from PhRMA, Shifting blame to PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. s whose lobbyists,
the PCMA,
are active in courting the Trump administration, Killing CMS is the centers for Medicare and Medicaid services. Slavitt's
Innovation
center is the CMS Innovation Center. It was created by the ACA to test new models of health care delivery and payment including the Pioneer ACO and the Advance Payment ACO. It also offers technical support to providers to improve the coordination of care and share lessons learned and best practices. In 2016 Andy Slavitt proposed testing a new Medicare part B drug pricing rule, which was furiously resisted by PhRMA and blocked by Representative Skimkus collection of 242 Representative's signatures. Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
Part B
drug pricing There is a monthy premium for Part B. It may be paid directly from Social Security. Higher earners may have to pay IRMAA. Medicare payments to doctors and hospitals for Part B drugs have been based on the average sale price of the drug plus 6%. MedPac advised Congress that this may encourage prescribers to select the highest priced alternative to maximize the 6% payment. Increasingly prescribed high priced biologics increase the impact of the nudge. rule test (May
2017)
- Matching UHG's
OptumRx,
Anthem
sets up IngenioRx
PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
with CVS, replacing
integration with Express Scripts
(Oct
2017)
- CVS Health, continues
its UHG
like diversified health services strategy:
merging with Aetna;
responding to Amazon's
potential disruption of pharmacy
market (Oct
2017)
- CVS Health purchases Aetna for $69 Billion - developing
community-based sites of care; a big deal argues Leerink
Partners' Gupte (Dec
2017)
- Assessments of the merger vary (Dec
2017)
- CVS +
Aetna merger is
allowed by regulators with the requirement that some Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
plans are
sold to WellCare
Health Plans. No discrete large PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. is left: UHG (OptumRx),
Cigna +
Express Scripts,
Anthem
building a PBM; limiting drug cost management for smaller
insurers and PBMs. PBMs have been criticised for secret deals
that have helped keep drug prices high. Health plan
control of where prescription drugs are purchased will limit Amazon's disruption of pharmacies,
and likely limit consumers opportunities to bargain. State
regulators will start to look at the operations of
PBMs. Large insurers are also entering health care
provision of low cost care for chronic conditions and chain care
in the community (Oct
2018)
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:
- $1600 ointment to treat diaper rash
- $8500 cream to reduce scaring
- $2300 salve to relieve pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. 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. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation.
Centene is a major supplier of Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births. plans.
- State health insurance regulators, with inputs from health
access california & review of Centene
acquisition of Health
Net, asked NAIC
to review insurance mergers (Nov
2015)
- Centene
enters additional individual
health insurance markets even as uncertainty is when a factor is hard to measure because it is dependent on many interconnected agents and may be affected by infrastructure and evolved amplifiers. This is different from risk, although the two are deliberately conflated by ERISA. Keynes argued that most aspects of the future are uncertain, at best represented by ordinal probabilities, and often only by capricious hope for future innovation, fear inducing expectations of limited confidence, which evolutionary psychology implies is based on the demands of our hunter gatherer past. Deacon notes reduced uncertainty equates to information.
mounts (Jun
2017)
- Centene
health plans not accepted by physicians & hospitals because,
doctors say, the insurer refused to pay legitimate claims, and
subscribers found Centene's 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).
was too limited causing problems, including 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). surprise
billing is where a contracted service is used by a patient and the bill contains huge out-of-network charges from doctors who were consulting to the health care provider. The opportunity to catalyze profits for: hospitals, physician staffing companies; while coping with rural E.D. staff shortages is encouraging this situation. Examples include: E.D. billing (Nov 2016, Jul 2017) . Subscribers locked out of health care
network file law suit (Jan
2018)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
2017 Centene
CEO Michael Neidorff
With the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
catalyzed
2015 mergers of Aetna/Humana
& Anthem/Cigna
and major hospital groups, Centene says it might move more into Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
insurance
buying some of the plans that could be divested if some of its
competitors merge. It announced it would buy Health Net.
Centene is entering additional individual markets as others exit
(Jun 2017)
Centene's Neidorff
commented "It's a good business for us. Centene has done
well. Centene recognizes there is uncertainty" in the new
health care legislation (May
2017).
Centene has experience being the only insurer in a market: Maricopa
County, Arizona; and it had found this market no worse than its
others.
Centene provides coverage to 1.2 million people through state
marketplaces.
CIGNA
Cigma CEO David Cordani planned to become president and COO of merged
Anthem/Cigna. The merger was subsequently blocked by the
courts (Feb
2017).
- Rx
Savings Solutions helps employers reduce employee drug
costs as PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
: OptumRX,
Express Scripts;
agreements allow generics' prices to rise: crestor;
while BlinkHealth,
which is in litigation with its PBM MedImpact &
has lost access to Publix, Walgreens & CVS, and GoodRx supplied
coupons help Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes: - Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
generic prescription drug users find low cost offers as
Insurance: UHG,
Cigna, Humana; agreements, co-payment is a fixed payment for a covered service after any deductible has been met. It is a key strategy of the ACA to make subscribers aware of the costs of treatment and to put pressure on high cost health services. As such suppliers and providers are keen to undermine the copayment: value based health insurance, Paying the copayment (Oct 2015), Place on the USPSTF list of preventative services (Sep 2016); &
deductible requirements & clawbacks refers to a contractual requirement between a payer and provider or retailer (pharmacy), where the cost of the goods supplied to a subscriber is lower than the reimbursement contracted with the payer, and the payer requires the difference to be refunded. with
pharmacists: Walgreens,
CVS; and HDHP is a high-deductible health plan which has lower premiums and a higher deductable than traditional health insurance plan such as a HMO plan or PPO plan. bite into the ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes: - Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
regulated
transactions value. PCMA
argues these situations are outliers (Dec
2017)
- Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left the
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
marketplaces for 2018 and Trump Administration's HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest (Dec
2017)
- Insurance premiums, for ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual market, popular plans, will be lower in 2019 says CMS is the centers for Medicare and Medicaid services. administrator
Verma, with profits pulling insurers: Anthem,
Wellmark,
Molina, Cigna; back into the
markets (Oct
2018)
- Cigna acquires PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
Express Scripts
for $52 billion (Mar
2018)
- Insurers: Cigna (Express Scripts),
Harvard
Pilgrim, Medicaid is the state-federal program for the poor. Originally part of Lyndon Johnson's 1965 Bill, eligibility and services vary by state. Medicaid currently pays less for care than Medicare, resulting in many care providers refusing to participate in the program. Less than 10 percent of Medicaid recipients, those in long-term care including nursing homes where 64% are dependent on Medicaid, use one-third of all Medicaid spending which is a problem. The ACA's Medicaid expansion program, made state optional by the SCOTUS decision, was initially taken up by fifty percent of states. As of 2016 it covers 70 million Americans at a federal cost of $350 billion a year. In 2017 it pays for 40% of new US births.
;
worried at the high price and lifelong commitment of Amgen's Repatha
& Regeneron/Sanofi's Praluent, PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors. inhibitors, are
limiting their use by prior-authorization is a constraint imposed by some insurance companies prior to their agreeing to cover some prescribed medications or medical procedures. The constraint may be due to: age, medical necessity, availability of a generic alternative, or to check drug interactions. After a healthcare provider orders a service for a patient, the provider's staff will contact the patient's insurer to determine if they require prior authorization. This should result in an exception process which may involve the provider's staff manual faxing a prior authorization form to the insurer. If the service is rejected, the healthcare provider may file an appeal based on the provider's medical review process. It may take 30 days for the insurer to approve the request.
constraints, even to the one million heterozygous F.H. is Familial Hypercholesterolemia, which causes heart attacks at a young age with symptoms of very high cholesterol levels. A mutation in chromosome 19 inhibits removal of low density lipoprotein. sufferers in the US is the United States of America. where the F.D.A. Food and Drug Administration. has allowed
their use, causing problems for the patients and their
providers: Cleveland
Clinic; (Oct
2018)
- Analysis suggests Amazon
may not succeed in disruption of
prescription drug distribution.
PillPack needs
relationships with PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
s:
Express Scripts
(which must renew in July and is owned by Cigna), CVS (strategy
and responds to Amazon's move into prescription drug sales), distributor:
AmerisourceBergen
(part owned by Walgreens)
(Jul
2018)
- Judges block Humana+Aetna & Cigna+Anthem
insurer mergers (Feb
2017)
- Startups: Capsule,
DispatchHealth,
Dose Healthcare,
Heal, I.V. Doc, MedZed, Pager; with funding
from: IRA Capital,
Questa Capital,
Alta Partners,
Angels: Paul Jacobs, Lionel Ritchie; aim to be the Uber of
healthcare, treating nonemergency problems: prescriptions, strep
throat, sprained ankle; but hurdles are high: state based
regulations, insurance costs, health care network is powerful
and hard to integrate with; although health insurers are
offering on demand: Anthem,
Health Net, Blue Shield initially developed in the early 1930s to provide health insurance for physician visits. , Aetna, CareFirst,
United
Healthcare, Cigna,
Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
; cover
Heal visits in many PPO
plans 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. for chronic hypertension is high blood pressure. It is directly associated with death rate due to pressure induced damage to the left ventricle and in general to cardiovascular diseases. Treated with antihypertensives: Diuretics, Calcium channel blockers, Angiotensin receptor blockers or Beta blockers.
and diabetes includes type 1 and type 2. Common side effects include: increased heart disease, hypertension, kidney disease, vision loss, nerve damage, and infections. ; risks, is an assessment of the likelihood of an independent problem occurring. It can be assigned an accurate probability since it is independent of other variables in the system. As such it is different from uncertainty. are significant
and powerful tech companies are also interested: Amazon through PillPack, Apple, Alphabet (Feb
2019)
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 has a Medical home contract with Piedmont Physicians Group
Community of Maine has captured more than half of its market and
achieved a surplus of $5.9 million.
- Insurers: Aetna, Anthem,
Blue
Cross Blue Shield of Georgia, Cigna, Humana; have left the
ACA is the Patient Protection and Affordable Care Act amended by the Health Care and Education Reconciliation Act of 2010 (Obama care). In part it is designed to make the health care system costs grow slower. It aims to do this by: increasing competition between insurers and providers, offering free preventative services to limit the development of serious illnesses, constraining patients' use of expensive services, constraining the growth of payments to Medicare providers and piloting new ways for PCPs to manage patient care to keep patients away from costly E.D.s. It funds these changes with increased taxes on the wealthy. It follows an architecture developed by Heritage Action's Butler, Moffit, Haislmaier extended by White House OMB health policy advisor Ezekiel Emanuel & architect Jeanne Lambrew. The Obama administration drafting team included: Bob Kocher; allowing it to integrate ideas from: Dartmouth Institute's Elliot Fischer (ACO). The ACA did not include a Medicare buy in (May 2016). The law includes:
- Alterations, in title I, to how health care is paid for and who is covered. This has been altered to ensure
- Americans with preexisting conditions get health insurance cover - buttressed by mandating community rating and
- That they are constrained by the individual mandate to have insurance but the requirement was supported by subsidies for the poor (those with incomes between 100 & 400% of the federal poverty line).
- Children, allowed to, stay on their parents insurance until 26 years of age.
- Medicare solvency improvements.
- Medicaid expansion, in title II: to poor with incomes below 138% of the federal poverty line; an expansion which was subsequently constrained by the Supreme Court's ruling making expansion an optional state government decision.
- Hospital Readmissions Reduction Program (HRRP) which was enforced by CMS mandated rules finalized in 2011 and effected starting Oct 2012.
- Medical home models.
- Community transformation grants support the transformation of low income stressed neighborhoods to improve their lifestyles and health.
- Qualifications for ACOs. Organizations must:
- Establish a formal legal structure with shared governance which allows the ACO to distribute shared savings payments to participating providers and suppliers.
- Participate in the MSSP for three or more years.
- Have a management structure.
- Have clinical and administrative systems.
- Include enough PCPs to care for Medicare FFS patient population (> 5000) assigned to the ACO.
- Be accountable for the quality and cost of care provided to the Medicare FFS patient population.
- Have defined processes to promote: Evidence-based medicine, Patient-centeredness, Quality reporting, Cost management, Coordination of care;
- Demonstrate it meets HHS patient-centeredness criteria including use of patient and caregiver assessments and individualized care plans.
- CMMI Medicare payment experimentation.
- Requirements that pharmaceutical companies must report payments made to physicians (Sunshine Act).
- A requirement that chain restaurants must report calorie counts on their menus.
individual
marketplaces for 2018 and Trump Administration's HHS is the U.S. Department of Health and Human Services. has automatically
reenrolled their former subscribers in new, sometimes costly,
plans: Optima
Health, Harvard
Pilgrim, Community
Health Options; enrollment counselors: Community Health
Works; have a surge of interest (Dec
2017)
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 is a tax strategy selected by many hospitals in the US. These hospitals, which include: Cleveland Clinic, Johns Hopkins, Massachusetts General, Mayo Clinic; are exempt from federal and local taxes because they provide a level of community benefit. They are considered charitable institutions and benefit from tax-free contributions from donors and tax-free bonds for capital projects, explains Bellevue Hospital's Dr. Danielle Ofri. Prior to 1969, community benefit had to include charity medical care, but then the tax code was altered to allow many expenses to qualify as community benefits including: Accepting Medicaid insurance at a hospital estimated loss; and charitable care became optional. The ACA encouraged hospital networks to consolidate and with this additional pricing power, revenue at the top seven nonprofits has increased 15%, while charitable care decreased 35%. health care
enterprises of similar size." Burgess is also president of the
Tennessee coop which pays half his salary.
Consumers'
Mutual Insurance of Michigan
Co-operative startup.
Posted a notice on its website saying it will not sell health plans
in 2016 on the insurance
market place.
CoOportunity Health
CoOportunity is a federal insurance cooperative in Iowa. It
was given $145 million in federal loans to get started.
Its lack of subscribers and profits came to the attention of the
Iowa insurance commissioner and it was declared insolvent by a state
court.
Coventry Health Care
Coventry is a unit of Aetna
(acquired in 2013). It is based in Bethesda, Maryland.
It is a national insurer.
Coventry is seeking rate increases of 19% for 2016 in
Missouri. They explained the rates reflected the cost of
care. For 2016 we expect medical costs will grow by 8 - 10 %
in the individual market. They also noted that the federal
government is scaling back a transitional program that helped
insurers pay certain very large claims.
Dean Health Plan
Dean Health Plan is an HMO
plan is a Health Maintenance organization managed care plan as opposed to a PPO plan. It uses the allocated PCP as a gatekeeper who must refer a patient to any health specialist for the patient to gain access. in Madison Wisconsin. It started as a response to
the Wisconsin state legislatures mandate that all state workers be
offered a HMO option to build competition to the Blue Cross Blue
Shield Plan. It was formed and owned by physicians at the Dean Clinic.
Dean is a very highly ranked HMO. It is a 5-star Medicare
Advantage Plan. J.D. Power ranked it the highest health plan
in Minnesota-Wisconsin. It offers the lowest cost silver plan
on the Wisconcin individual
exchanges.
Evergreen Health is a co-op in Maryland. It competes with a
large Blue Cross initially developed in the early 1930s to provide health insurance for hospital treatments. Blue Cross introduced the mechanism of individuals paying premiums into a collective pool that a third party can then use to pay for medical expenditures. The subscriber base was limited until World War 2 when wages were frozen and employers offered a benefit of health insurance tied to employment. Being associated with employment made the facility regressive since those working part-time or in small businesses had to pay for services out of pocket and could induce bankruptcy.
plan CareFirst.
It has 22,500 customers with plans to double in a year.
CEO Dr. Peter Beilenson
As CareFirst has raised its rates Evergreen's plans have become more
competitive.
Express Scripts
Express Scripts is the largest pharmacy benefits manager is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. .
- Specialty
pharmacies 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.
: Prime Aid
Pharmacy; take Express
Scripts to court for its PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies. blocking their
dispensing to subscribers. The pharmacies see it as
driving their business to Accredo (Jan
2017).
- PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
Express scripts
covers PCSK9 is proprotein convertase subtilisin/kexin type 9 an enzyme activator. It is encoded as zymogen and autocatalysed in the ER. It plays a major role in cholesterol homeostasis. It binds EGF-A domain of LDLR inducing LDLR degradation. Academic researchers Dr. Helen Hobbs and Jonathan Cohen, studying large populations found reduced LDLR results in reduced metabolism of LDL which can lead to hypercholesterolemia. Drugs that can inhibit PCSK9 can lower cholesterol much more than first generation cholesterol inhibitors.
cholesterol drugs: Amgen's
Repatha,
Regeneron's Praluent (Oct
2015)
- Cigna acquires PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's formularies.
Express Scripts
for $52 billion (Mar
2018)
- Huge price drops impact generic suppliers: Teva;
and distributors:
Cardinal Health;
as pharmacies, distributors & PBM is pharmacy benefit manager. These companies, such as Caremark, were often originally PPMs. PBMs are used by payers, such as insurance plans, to manage drug provision from pharmacies to the payer's plans subscribers. PBMs can constrain drug flow to the pharmacies: CVS, Rite-Aid, Walgreens; through the PBM's
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