This Week in Healthcare: 6/8 – 6/12

Top news from around the healthcare industry this week: 

Walgreens, MDLive expand telehealth collaboration to three more states 
Walgreens has expanded its relationship with telehealth service provider MDLive, bringing remote physician access to customers in three new states and, for the first time, to PCs as well as mobile devices. Users of Walgreens mobile apps and the walgreens.com portal in Colorado, Illinois and Washington state now can consult 24/7 with board-certified MDLive physicians for $49 per encounter, the two companies announced Tuesday.

Outraged, engaged patient takes aim at paternalistic physician 
It’s hard to know how many patients out there are truly “empowered,” and I suspect it is a relatively small number, but one of the louder voices out there is Duncan Cross, a longtime engaged patient with Crohn’s disease.

Arizona hospitals, doctors avoid 5 percent Medicaid pay cut 
Arizona hospitals, doctors and other health providers will get a reprieve after the state's Medicaid program announced it will cancel a planned 5 percent payment cut because of lower-than-expected use among enrollees and a prescription-drug rebate.

One nation, under sedation: Medicare paid for nearly 40 million tranquilizer prescriptions in 2013 
In 2012, Medicare’s massive prescription drug program didn’t spend a penny on popular tranquilizers such as Valium, Xanax and Ativan. The following year, it doled out more than $377 million for the drugs. While it might appear that an epidemic of anxiety swept the nation’s Medicare enrollees, the spike actually reflects a failed policy initiative by Congress.

Game Changer: CMS’ Proposed Medicaid Managed Care Regulation 
The Centers for Medicare and Medicaid Services (CMS) released its long awaited Medicaid managed care proposed rules on May 26; the rules were published in the Federal Register on June 1 (80 Fed. Reg. 30198-31297). The last time the federal government seriously tackled Medicaid managed care was in a 2002 regulation (67 Fed. Reg. 40989, June 14), a response to the Balanced Budget Act of 1997 (Pub. L. 105-33), which itself amounted to a major new chapter in Medicaid’s relationship to what by then had become known as managed care.


Happy reading! Have a great weekend. 

Prevention, Incentives and Medicare Costs

By Nalini K Pande, JD

A little over a year ago at my previous consulting job, I served as the project director for a very interesting prevention project.   The project was for the Bipartisan Policy Center’s (BPC) Health Care Cost Containment Initiative¹.   BPC had asked us to develop a financial model of the costs and benefits of a diabetes Type 2 prevention program.  Our report illustrated how the financial incentives for three different payors  (commercial plans, Medicare, and ACOs) vary given different assumptions of who would pay for these prevention services and the age at which individuals would first receive prevention services. We chose to model Type 2 diabetes prevention services given that Type 2 diabetes is reversible and given the tremendous amount that the US spends on Type 2 diabetes² .   What we learned was fascinating.

Prevention Efforts Can Yield Cost Savings

The key finding from our report was that a diabetes prevention program “can produce overall cost savings which increase over time for an individual.” Given this, why wouldn’t we roll out these prevention programs on a widespread basis?  Well, the answer may surprise you.  To delve into this, you will need to understand three key issues:

• - First, who pays for the diabetes prevention program? 
• - Second, who benefits?
• - Third, when do the savings kick in?

Our report showed that if private commercial plans bear the cost of the diabetes prevention program, they may not reap all the benefits.  This is because of two reasons.  First, if individuals switch health plans over time, another plan would reap the benefits – allowing for only small benefits for the plan that implemented the prevention program.  Second, if you’re 55 or older, there is no incentive for a private commercial plan to cover your participation in a diabetes prevention program.  Simply put, by the time the cost savings would kick in (10 years), you would be on Medicare and Medicare, not the plan, would reap the benefits. 

So, what if Medicare paid private plans to cover these diabetes prevention programs?  Perhaps, then, we would all win.  Those with private commercial plans would benefit from diabetes prevention services and Medicare would benefit from healthier beneficiaries who save the program money. Our report found that while the Government does recoup savings when it pays for the program, it only did so for those who are near 60.  In fact, the Government receives very little savings from a younger population who would stay with the private sector and continue to be with a commercial plan during the timeframe when most of the savings would be realized over a 25-year period.

Where does this leave us?

In essence, what we have is a scenario where payors are reluctant to pay for prevention services since they won’t benefit completely.  Has our patchwork system of health care created disincentives around prevention?  Not quite.  Our study found that if patients could join an ACO when they are under 65 (as a commercial ACO) and then stay in the same ACO when they are over 65 (as a Medicare ACO with shared savings between the ACO and Medicare), perhaps the ACO would get the best of both worlds.  In this scenario, an ACO could invest in its patients through prevention programs and recoup the benefits, assuming limited plan switching.

Investing in prevention appears to be a game of “what’s in it for me?” How do we change it to a “win-win” scenario? The answer is simple.  We do so by utilizing new systems like ACOs that allow payors to reap long-term savings. 

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, prevention, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.


Follow @nalinipande

                                           

¹ Under the leadership of former Senate Majority Leaders Tom Daschle (D-SD) and Bill Frist (R-TN), former Senator Pete Domenici (R-NM), and former White House and Congressional Budget Office Director Dr. Alice Rivlin, BPC’s Health Care Cost Containment Initiative  “explored and evaluated strategies to contain health care cost growth on a system-wide basis, while enhancing health care quality and value.” 
 ² In Appendix D of our report, we noted a study by Dall and colleagues that estimated the costs associated with Type 2 diabetes as $105 billion for medical costs (along with $54 billion for non-medical costs such as lost work days).  

Register for the FDA/CMS Summit for Payers by Friday 11/14 to Save $300!

Attend the FDA/CMS Summit for Payers to initiate the collaboration, with top government and key regulatory bodies working closely with healthcare leadership to join forces and build an open culture of harmonization to provide efficient and affordable healthcare to all patients.


This meeting stemmed from the infamous Solvaldi case, as the FDA approved the specialty drug to go to market but with it being so expensive, it caused major problems for the CMS and health plans. No longer can regulatory bodies work in silos, it's time for collaboration!

But hurry—time is running out! Register by this Friday 11/14 and save up to $300 off the two-day rate. Or, if budgets and time are tight, choose the one-day option and attend for only $895. Be sure to use the code XP1917BLOG to save.

Register Now! 

If you haven’t already done so, download the brochure to see the full speaking faculty, including some of the most influential people in health care.

See you this December!

Dual Eligibles and ACOs: A Blueprint for Success

By: Nalini K Pande, JD

Background:  Why Duals Need Stronger Focus and Attention

You may notice that when we talk about health reform, most health policy experts tend to bring the conversation back to the dual eligibles.  These beneficiaries are covered under both the Medicare and Medicaid programs and are generally sicker and costlier than Medicare and Medicaid beneficiaries as a whole.  Thus, it is no surprise that duals have been the focus of those trying to bend the cost curve.


ACOs May Be Uniquely Situated to Address Key Duals Issues

How do we improve the care of these beneficiaries while also working to reduce costs?  Accountable Care Organizations (ACOs) that take on dual eligibles, are uniquely positioned to provide effective solutions. An ACO is a group of coordinated providers in which provider reimbursements are linked to quality metrics and reductions in the total cost of care for an assigned population of patients. Given their emphasis on patient-centered, integrated care and coordinated Medicare and Medicaid benefits and funding streams, ACOs could facilitate greater quality improvements and reduce cost-shifting between programs as well as overall costs. Yet, the fundamental question still remains:  What is the blueprint for success?

Two core frameworks will need to be developed as part of a blueprint for success:
   • ROI Framework
   • Measurement Plan

Certainly additional key components will be necessary.  However, two critical components of the blueprint for ACO success are ROI (return-on-investment) and Measurement frameworks. First and foremost, a successful ROI framework is needed to ensure financial viability of the ACO structure: (e.g, hospitalization costs must be significantly reduced to pay for increased expenses in care coordination, care transitions, and care management). 

Second, a measurement framework will be needed to test improvements in quality.  Key measures should include patient-reported outcome measures, beneficiary experience, care coordination measures, utilization and cost measures, etc.

As part of this blueprint, the ACO must consider the barriers and challenges to changing the current system. How can the ACO overcome these barriers?  This will depend on whether the ACO can achieve a true culture change at three levels:

• • at the governing level with a stronger focus on clear and attainable management goals and benchmarks with diverse stakeholder input
• • at the clinical level with team-oriented care in order to improve care coordination and
• • at the community level with a focus on population health and collaboration with community organizations.

Can ACOs that take on duals bend the cost curve and improve quality? This has yet to be seen.  Setting ACOs up with a blueprint for success may be just what the doctor ordered.

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

Join the Largest MMCC Ever | Last Chance to Register

The 22nd Annual Medicaid Managed Congress is less than a week away, and this year will be the largest and best attended meeting to-date. With more attendees and companies attending than ever before, you can’t afford to miss the industry’s leading event. Reserve your seat today before time runs out…

Don’t just take our word for it—the numbers speak for themselves:
350+ attendees representing 39+ states   
75 speakers representing 27 states   
187+ companies   
19 health plan case studies    
10+ hours of dedicated networking time   
9 luncheon roundtables hosted by government officials   

Reserve your seat before time runs out! Plus save 15% when using the code: XP1926BLOG

Register now & download the brochure to view the full agenda.

The numbers don’t lie—based on this year’s turnout, your healthcare peers are ready to harness the new opportunities due to healthcare reform including Medicaid Expansion, exchanges, providing higher quality care, partnering with ACOs and more! Join us May 19-22 in Baltimore as we drive next generation Medicaid managed care alongside health plan and government heavyweights.

P.S. Interested in decoding your exponentially-growing data points to drive data-driven decisions? Check out IIR’s all-new Healthcare Data Insights event here.

Call for papers for MMCC

We are pleased to announce 22nd annual Medicaid Managed Care Congress, taking place on May 20-22 in Baltimore. After dozens of conversations with industry experts, we’re ready to start recruiting speakers for the event! The agenda is currently under development, and we are currently looking for health plan and state government speakers who can speak to the following topics:

• Best practices for LTC
• Who is enrolling in exchanges and what their needs are, based on the services being used once coverage begins
• Examples of payment reform
• New care delivery models, including ACOs and PCMH
• Medicaid expansion
• Lessons learned from duals demonstrations
• Strategies to improve quality measurements

If you are interested in speaking on any of these topics, or would like to suggest another topic, please email, SGordon@iirusa.com, the Program Director for the event. If you would like to get in front of our audience of health plan executives working on exchanges, please contact Sarah Scarry at SScarry@iirusa.com for sponsorship and exhibition opportunities.

We look forward to hearing from you soon!

Cheers,
The MMCC Team

MMCC Homepage
Opt-in for updates all year round
MMCC LinkedIn
MMCC Twitter

Download the Brochure for IIR's Medicare Congress

Inquiries about IIR’s Medicare Congress 2014 event have been pouring in daily, so we are pleased to announce – the website and registration are now live!

You’ll see that we’ve expanded the program for 2014, and are excited to introduce the only event allowing you and your team to be "one and done” at the Medicare Congress, providing you with everything you need to excel in the upcoming year.

One of the ways that we’ve created your all-in-one event experience is by joining the Medicare Congress with IIR's D.U.A.L.S. Forum, providing Medicare and Medicaid executives an exclusive opportunity to network and learn from one another, creating the ultimate peer learning experience to maximize opportunities to serve this lucrative and complex population.

Additionally, the Medicare Congress has expanded to include:

• The re-energized Stars University
• An increased focus on networking with ACOs
• A full track dedicated to Increasing Membership & Creating the Ideal Customer Experience
• Another track devoted to Medical Management and Care Coordination for Medicare and Dually Eligible Members

The broader perspective at the Medicare Congress 2014 ensures your entire team will find something relevant and excel in your quest to provide higher quality, cost-efficient care to current and potential members. Your learning and networking experience will be the most productive one yet!

Want to learn more? Download our agenda!

Use code XP1907BLOG to register for the conference that helps drive next generation Healthcare through improved Clinical Care Management & Customer Centricity. If you have any questions about the agenda or event, feel free to email Kate Devery at kdevery@iirusa.com or visit the homepage.

We hope to see you, February 10-12 in New Orleans!

Cheers,
The Medicare Congress Team

The Medicare Congress Homepage
The Medicare Congress Twitter
The Medicare Congress LinkedIn

Which Medicare topic areas are most important to you?

Over the past couple weeks, I've had research calls with dozens of your peers: some of which have attended the Medicare Congress, some who have spoken at the Medicare Congress, and some who didn't know what the Medicare Congress was until I told them about it. As always, some are feeling positive about the industry, some are feeling not-so-positive, and EVERYONE had insight into what matters most in the Medicare industry.

One of my favorite parts of being a conference producer is getting to translate all of this feedback into a tangible program that attracts high level, provocative speakers, which in turn attracts a larger audience. I’m just starting to put together a loose agenda, and although I'm not quite ready to show all of my cards, I can tell you that we’re planning on adding a few full day summits to the mix, in order to provide you with deeper insight into the areas that matter most (and are the most lucrative).

We'd love to hear from you! Which topic areas would you like us to cover for next year's event?

Save the Date! 2011 Annual Medicaid Managed Care Congress

Join us May 18-20th, 2011 at the Hilton Baltimore for the 19th Annual Medicaid Managed Care Congress, the premiere Medicaid Managed Care event featuring the top industry leaders. Last year we had more than 250 attendees from across the country, representing Massachusetts, Michigan, California, Arizona, Texas and Washington, DC, to name a few.

At the 2011 Conference, you will:
• Obtain the latest information on healthcare reform and the current political climate for best plan positioning in uncertain times
• Gain insight about ACOs and learn how to effectively work with them in a mutually beneficial environment
• Explore the Health Insurance Exchange and discuss its affect on the managed care industry
• Work within economic, fiscal and state budget constraints to develop cost effective Medicaid managed care programming
• Discuss various ways of utilizing technology to connect with subscribers and keep their information confidential
• Discover specific ways to implement Patient Centered Medical Homes to increase the quality of care you offer while decreasing expenditures
• Get updates on CMS including information on the Council on Technology and Innovation Improve overall quality of your managed care program without increasing expenditures

Additionally, if you are interested in speaking about one of these topics, or if you are interested in speaking about another relevant topic, please email Sarah Gordon at sgordon@iirusa.com.

Visit The Medicaid Managed Care Congress webpage to find out more about the event:
http://bit.ly/f7XGAh

Register by Friday, February 25, to receive up to $600 off the standard registration rate. Call Customer Service at 888-670-8200 to reserve your spot today. Be sure to mention you are a reader of our Health Care Policy Blog. Don’t miss this one-of-a-kind event. Our 18 years of experience prove that we are experts in the Medicaid managed care industry.