Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.

Top Stories:

A Post-Election Day Certainty: New Scrutiny for the Affordable Care Act
This week’s elections ensure a new round of political attacks on the Affordable Care Act, but they also create potential opportunities to repair provisions of the law that people on both sides of the partisan divide would like to fix.

Big data: Enabling the Future of Healthcare
Everyone’s talking about the importance of big data in healthcare. Yet, as the data piles up – most of it is isolated in different silos, and health systems are struggling to turn big data from a concept into a reality. Here’s how I see it having a substantial impact on the health of populations, today and in the future.

Electronic Medical Records, Built For Efficiency, Often Backfire
Electronic medical records were supposed to usher in the future of medicine. Prescriptions would be beamed to the pharmacy. A doctor could call up patients' medical histories anywhere, anytime. Nurses and doctors could easily find patients' old lab results or last X-rays to see what how they're doing. The computer system could warn doctors about dangerous drug combinations before it was too late.

Steward’s ACO focuses patient engagement efforts on 4 percent of covered lives
According to Girard, there are two fundamental processes in healthcare, information flows and people flows. The ideal, he said, is for both processes to be happening at the right time in the right place.

Coordinated care and patient engagement
The healthcare breakthrough of the 21st century may not come in the form of a miracle drug from the pharmaceutical industry. Rather, it's more likely to emerge from the ways caregivers interact and motivate patients.


Enjoy the weekend!

States Not Expanding Medicaid are Paying 37% of the Cost ($152 Billion) to Extend the Program in Other States

If the 23 non-expansion states continue to do so, they will pay $152 billion to extend to program in the expansion states. Most of this money (nearly $88 billion) is coming from the taxpayers of 5 non-expansion states; Texas, Florida, North Carolina, Georgia, and Virginia.

Will this be the incentive needed for the remaining states to expand Medicaid?

With these aid initiatives looming, what will happen next? Are your states tax dollars being dished out to aid Medicaid in other states? To find out, join us at MDRP 2014 to hear our exclusive session "State Spotlight: Explore the Impact of Medicaid Expansion" with representatives from 13+ states.

  To see which states will be represented at MDRP, download the brochure.

Blog readers receive an extra $100 when using the code XP1958BLOG - Don't miss out on what the state representatives are saying about the future of Medicaid Expansion in these exclusive sessions, register now!

Source: Kaiser Health News

Baby Boomers and Medicare Part D

As Baby Boomers begin to age, many are becoming confused about Medicare. A survey of 377 Baby Boomers born between 1946 and 1964, done by the NAIC, found that less than half of the participants knew eligibility for Medicare for those who are not disabled begins at age 65. And more than half of the participants were unfamiliar with Medicare prescription drug coverage.

Yet despite these findings, more than 37 million Medicare beneficiaries are enrolled in Medicare drug plans this year. That's an increase of 2 million compared to 2013 and 15 million since 2006.

As the nation's largest health insurance program, Medicare currently covers more than 40 million Americans. But many are growing more and more concerned over what will happen when these Baby Boomers become eligible.

As enrollment of Baby Boomers into Medicare increase, cost will continue to rise for the next 20 years, this is due to many factors such as; increased life expectancies as well as the increasing prevalence of chronic diseases.

Since 2011 and continuing for the next 19 years, 10,000 Americans will turn 65 everyday. With this Medicare enrollment boom and the variety of programs available, these Baby Boomers need to start their education about Medicare coverage years prior to retirement, to ensure they make the best choices for future coverage.

Source: Huffington Post

What is the Future of Medicaid Reform?

Welcome to the MDRP Podcast Series. Joining us today is Grace-Marie Turner, President, Galen Institute. 

Download the complete podcast here.

What is the Future of Medicaid Reform?

Grace-Marie: Now, I am distressed that more states did not demand more flexibility with this program in exchange for expanding Medicaid. About half of the states have decided to expand it; about half have not after the Supreme Court re-wrote the ACA and made expansion of Medicaid up to 138% of poverty an option for the states. But I think about 24 states now are resisting expansion for a number of reasons.

First of all, Medicaid is –as I said – really a program desperately in need of reform. When I served on the Medicaid Commission in 2005/2006 we did hearings around the country to look at the Medicaid program – to learn about it – because it’s really 50 different programs because each state runs its own. We found so many instances in our hearings around the country in which people were desperately dependent upon Medicaid and yet it was not serving them. States continue to expand access to benefits, but they also continue to cut payments to providers. States – if they were given more flexibility – could make a significant amount of Medicaid dollars go much further to cover more people. But, they are absolutely constrained by having to go to the Centers for Medicare and Medicaid Services playing “Mother May I?” every time they want to make a change to their program.

So, I think that the states really missed an opportunity for more flexibility with Medicaid. There was just a waiver --- it looks like a waiver is going to be given to Indiana to promote or continue a program that former Governor Mitch Daniels created called: “The Healthy Indiana Program” that really does begin to move Medicaid into a much more modern model. I think that that is a platform that some other states may be looking at. But, I think there’s a lot of resistance to expanding the program because people are seeing increasingly – and a lot of studies are showing – that people can be worse off on Medicaid than being uninsured. It’s just criminal that we are putting tens of millions of more people on this program and not improving it.

So, I think states are going to increasingly resist expansion of Medicaid unless they get more flexibility to control the program themselves and be able to save money and be able to provide better benefits to their citizens often in giving them the option of private coverage. So, I think that the future of Medicaid is more governors demanding more flexibility and then giving the patients on Medicaid more options for private coverage. There is no reason that they should be segregated into this ghetto of a program when so many people really could do so much better if they had options for true private coverage – not necessarily the fake private coverage that many of the states plans pretend to offer.

Click here to download the remainder of the podcast.

To hear more from Grace-Marie, make sure you join her at MDRP 2014 this September 15-17 in Chicago where she will be giving the keynote address. As a blog reader, you can save $100 off the current rate with the code XP1958BLOG. Register now to save! 

See you in Chicago!

Is Medicaid Expansion Feasible?

Welcome to the MDRP Podcast Series. Joining us today is Grace-Marie Turner, President, Galen Institute.

Download the complete podcast & transcript here.

Is Medicaid Expansion Feasible?

Grace-Marie: I just think that it’s going to be very difficult to convince those other states that have resisted so far because more and more evidence is coming down to show that expanding Medicaid as a traditional program as it is currently structured is real harmful to people. And it’s really harmful to the most vulnerable citizens who are on Medicaid today. If people have many chronic conditions, many of them have no place else to go. They are basically not insurable in the private marketplace. If they are under 100 or 138% of poverty, Medicaid really is their only option. As a result, you wind up with more people competing for the same limited number of doctors who will see Medicaid patients and making it even more difficult for people on Medicaid today to find a doctor to see them.

I had a father write to me recently who has a daughter who is on Medicaid – many chronic conditions and in a wheelchair. He said: “It takes me sometimes six weeks to get an appointment with her urologist”. He said: “Do they even think about how much more difficult it’s going to be to get an appointment with the urologist if there are a million more people competing for those same appointments?” So, we must fix it so that it allows the safety net to be intact for the most vulnerable people and give those who have the option to get private coverage to do so, so that they are not competing.

And then finally, I think that the states who want to expand the program need to guarantee that providers will be paid enough that they will be able to see a Medicaid patient. In some states like New Mexico that have a very high match rate, Medicaid pays at very close to Medicare rates. In other states, a doctor may be paid $5 or $7 for an office visit – not even enough to begin to cover expenses. Doctors want to take care of these patients, but they can only keep so many and keep the lights on and pay their own bills. So, we’ve got to be able to pay providers more and that’s the kind of leverage that I think that the states would be able to have if they were not so constrained by an avalanche of federal rules and all the “Mother May I?” waiver requests that they have to get to make any changes to their plan.

If they had more flexibility, then they could make sure that patients on the program today could actually find a doctor to see them and also make sure that those who may be in an expansion population have the option of coverage that looks more like the private insurance and the private marketplace so that it’s a track and a platform to private coverage rather than the cliff that Medicaid is today – either in or out. If you make $1 too much money then you’re out of Medicaid or $1 less and you’re in. It needs to be a smoother ramp to private coverage and there are a lot of ideas to do that, including giving people the option of basically taking their Medicaid allotment as a voucher to buy into private coverage. There are a lot of ideas out there to improve this program, but we need to remember that we’re doing it for the most vulnerable citizens who are on the program today, who have no place else to go, competing for a limited number of appointments with a shrinking number of doctors to actually get appointments.

We can do so much better and I think you’re going to see many more governors actually demanding those kinds of changes and that kind of flexibility in exchange for any expansion.




Click here to download the rest of the podcast.

To hear more from Grace-Marie, make sure you join her at MDRP 2014 this September 15-17 in Chicago. As a reader you can save an extra $100 off the current rate when using the code XP1958BLOG. Register now to save!

See you in Chicago.

340B Entities: Best Practices for Pricing and Compliance Methodologies

Above, you will hear John Shakow, Partner, King & Spalding speaking with MDRP TV about 340B Entities – and the best practices for pricing and compliance methodologies. To hear more insights from John, join him at MDRP 2014, where he will be speaking again. Below you can find a highlight of one of his sessions at the event.

Understand the Implications: A Business Perspective
You’ve heard the presentations and the speeches, the panels and the analysis. In this session of the conference, we will try to tie it all together and give you a 360° view of the government pricing landscape in the coming year. The emphasis will be on key takeaways, which you and your colleagues should keep top of mind as you head back home. 2014–15 promises to be a year of great change and increasing complexity in all aspects of government pricing, and with that come the inevitable compliance, legal, business and operational challenges. Secure the benefits of MDRP 2014 with this roundup of highlights and key observations.

For more session information, download the complete agenda.

And remember as a blog reader you save an extra $100 off the current rate when you register with the code XP1958BLOG - Register by 8/8 to save a total of $300!

See you in Chicago!

Best Collaborative Practices for Resolving or Avoiding Medicaid Disputes

MDRP 2014 Session Spotlight: 

Best Collaborative Practices for Resolving or Avoiding Medicaid Disputes

 

The complexities involved in identifying and resolving Medicaid disputes have only grown since the ACA with the additional claims from Managed Medicaid Organizations. In this session we will discuss some common best practices related to working collaboratively with your state contacts to either avoid disputes or resolve them quickly.

• Communications and documentation required to avoid putting units into dispute
• Key information needed by the states/manufacturers to research and resolve a disputed claim
• How best to avoid recurring unit of measure issues
• The value of informative state invoice cover letters for states and manufacturers
• An update on the work group’s efforts to standardize electronic reporting across the MDRP

Panel:
Lisa Norton, Associated Consultant, Managed Healthcare Services, Lilly USA, LLC
Kelly Geissler, Sr. Analyst, Government Rebate Operations, Johnson & Johnson Health Care Systems Inc.
Daksha Bogdon, Govt Pricing and Contracting, Genentech
Cindy Laclair, Drug Rebate Specialist (HP), Kansas
John Grotton, Sr. Director, Medicaid PBA Operations, Goold Health Systems


For more session information, download the brochure now. 

Blog readers receive an extra $100 off the current rate when you use the code XP1958BLOG. Register by 8/8 to save $300!


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Obamacare May Raise Patient Costs for Specialty Drugs

Via Specialty Pharmacy Continuum

According to specialty pharmacy experts, patients who rely on specialty drugs to treat their rare and complex conditions may be forced to pay a large percentage of the drug’s cost instead of a traditional fixed copay, if they are in an Affordable Care Act (ACA) exchange health plan.

Despite some of the exchange plans having the draw of lower monthly premiums, people should prepare themselves for higher deductibles and unpredictable out of pocket costs. Even though the cost structures do vary between the exchange plans, patients may face this issue no matter what exchange plan they are enrolled in.

Avalere examined 603 unique plan designs offered by 60 different carriers in 19 states to assess whether specialty medications are being put in a higher tier with a larger percentage of coinsurance, said Jenna Stento, a senior manager at Avalere. The analysis found that 59% of silver plans on exchanges across the country use coinsurance on the specialty tier instead of a fixed copay. It also found that 23% of silver plans charged coinsurance rates of at least 30% more than the cost of the drugs on the highest formulary tier, and 60% of lower-premium bronze plans apply specialty tier coinsurance greater than 30% of the drug price.

“This examination highlights the fact that patients relying on specialty medications are going to have to lay down significant finances up front until they hit the out-of-pocket cap, which is $6,350 for most people and $2,250 if that person is 200% below the federal poverty rate,” said Ms. Stento. “The fact that patients will be paying an unknown percentage will make it harder for some to plan financially, and will raise questions about access and availability.”

With the number of underinsured and strained patients continuously growing, how can these concerns be corrected?

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To learn more about Specialty Pharmacies, Specialty Drugs, the Affordable Care Act, and much more, join us in Boston this September for the Specialty Pharmacy Collaboration Summit. 

Register by 7/25 with the code XP1968BLOG and take an extra $100 off the current rate - that is $500 in total savings! Register here.

See you in Boston!

Patient Protection & Affordable Care Act could save as much as $120 billion in five years

With improving efficiency, the Department of Health and Human Services says that at least $120 billion can be saved over the next five years with teh Patient Protection and Affordable Care Act.  Through altering payments to caregivers by setting benchmarks for the quality and efficiency and linking them to payments, Health and Human Services is looking to save $55 billion.  Other forms of savings through this act include curbing excessive payments to Medicare Advantage Providers and saving money through patient safety programs.  Read the full story at Feirce Healthcare here.