Contributers: Joel Peyton and Betsy Dooley
Topic: CO-OPs
Nonprofit, consumer-run health plans are supposed to be one of the options for affordable health insurance beginning in 2014, but the odds are not looking great: The U.S. Department of Health and Human Services predicts that as many as 40 percent of these Consumer Operated and Oriented Plans could default on startup loans granted by the federal government.
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Contributer: Ric Gross
Topic: Healthcare costs, Massachusetts
National healthcare reform may or may not be on the ropes, depending on which prognosticator is weighing in, but when it comes to healthcare reform in Massachusetts, one thing is for certain—just like Rocky Balboa, the state just keeps on swinging.
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Contributer: Sheri Sellmeyer
Topic: ACOs, Medical homes
The Harvard business professor and healthcare expert Regina Herzlinger is known as an iconoclast who has gotten a lot of things right over the years: She predicted in the 1990s that managed care would alienate consumers and ultimately fail at controlling healthcare inflation, and she has long advocated market-driven, consumer-oriented healthcare.
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Contributor: Jenny Kerr
Topic: Health information exchanges
Tulsa, Okla., is a shining example of a city that has committed itself to turning around its second-to-last in the nation health status. It is doing so by taking advantage of federal grants focused on healthcare innovation. These include a $12 million grant that made Tulsa a Beacon Community to support the creation of a health information exchange for patient data sharing between hospitals and physicians. MyHealth Access Network is operating and has more than 1,400 physicians signed up—even those in rural areas, where the state suffers from a major physician shortage—as well as all hospitals. Such expansive exchanges are uncommon nationally.
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Contributer: Jane DuBose
Topic: Medicaid
It’s not a full-fledged love affair, but states lately have had a serious crush on managed care plans. With budgets in crisis from coast to coast, states have turned to suitors to help them better manage as much as a quarter of their budgets.
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Contributor: Carolyn McMeekin
Topic: Healthcare reform, exchanges
Once upon a time in America, a worker expected to:
- Stay at the same company until he (usually it was not a woman) received a gold watch after 25 years of service
- Receive a pension upon retirement
- Be guaranteed employer-sponsored health insurance, which reimbursed physicians for services rendered and today is referred to as indemnity insurance.
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Contributor: Laura Beerman
Topic: Medicare, hospitals
As with hotels, having “heads in beds” is a central way to gauge hospital revenue. But the game is changing under healthcare reform. Medicare has stopped reimbursing for select preventable medical errors and is now turning its attention to preventable readmissions. With the advent of accountable care organizations and payment bundling, hospitals are starting to jump on the cost-control bandwagonpartnering with physicians and commercial payers as well as with CMS to generate shared savings by delivering better care. Best of all, there is evidence that these strategies are working.
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Contributer: Mark Cherry
Topic: ACOs
The original fear of accountable care organizations was that they would turn into monoliths, with healthcare within a particular metro area dominated by two or three companies, each one a Gordian knot of payers, providers and hospital facilities. What we are seeing now are smaller, physician-led ACOs dotting the country, more grass-roots than trickle down. With many health systems shunning CMS-approved ACO projects, does this mean the end of accountable care as envisioned by the Affordable Care Act?
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Contributer: Sheri Sellmeyer
Topic: Medical homes
Looking for doubts about the viability of medical homes? Check out the February 2012 issue of
The American Journal of Managed Care. Looking for affirmation of medical homes? Check out the March 2012 issue of
The American Journal of Managed Care.
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Contributer: Jane DuBose
Topic: PBMs
2012 may well be the year that the pharmacy benefits management business takes a dramatic turn into new territory. Five years ago, small health-plan-owned PBMs such as Regence Rx and FutureScripts were part of a crowded field of competitors.
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