National Academy of Medicine outlines strategies for high-need patients

On July 6, 2017, the National Academy of Medicine released a valuable report entitled, “Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.” The report describes key characteristics of high-need patient populations, tools that can be adopted to identify evidence-based models of care for them, and strategies to promote successful implementation of such models in collaboration with a broad range of stakeholders at the federal, state, and community level. It stresses the importance of behavioral health issues, social determinants of health, and community-based supports for high-need patients who often struggle at home with functional limitations associated with aging, disabilities, and a wide range of long-term diseases examined in the report. [More]

Five Steps to Ensuring Reasonableness in Cost-Based Reimbursement Programs

As the debate over national health policy continues, many state health administrators are looking for ways to do more with less. A key step towards maximizing the impact of state and federal healthcare dollars is ensuring reasonable spending on existing programs. There are endless factors which impact the cost of healthcare such as geographic location, patient demographics, intensity of services and availability of resources. Consequently, reasonable cost is difficult to pinpoint. [More]

Where is “Prevention” in the ACA Replacement Debate?

The main goal of the Affordable Care Act (ACA) was to extend insurance coverage to millions of Americans left out of the health insurance markets, such as low-income parents ineligible for Medicaid or individuals unable to access employer-sponsored coverage. Rightfully, the terms of the ACA “Replacement” debate have been framed around alternative ways for meeting this goal, with most replacement plans distinguished and measured by the various mechanisms they propose to substitute for the insurance exchanges and Medicaid expansion measures used by the ACA to improve Americans’ access to health care. [More]

NAS issues report on improving health outcomes for at-risk populations

On April 7, 2016, the National Academies of Sciences, Engineering, and Medicine (NAS) issued a report entitled, “Systems Practices for the Care of Socially At-Risk Populations.” The report cites research and case studies showing that collaboration between health care delivery systems and community-based social service organizations can achieve improvements in health care outcomes for at-risk, low income populations afflicted by social isolation and limited health literacy. [More]

CMS finalizes mental health parity rules

On March 30, 2016, the Centers for Medicare and Medicaid Services (CMS) published final rules on mental health/substance use disorder parity requirements applicable to Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and the Children’s Health Insurance Program (CHIP). The final Medicaid/CHIP rules are based on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which generally prohibits more restrictive cost-sharing (e.g., co-payments and deductibles), quantitative limitations (e.g., visit limits), and non-quantitative limitations in mental health/substance use disorder benefits under a health plan than in medical/surgical coverage under the same plan. [More]

Behavioral Health’s Move Toward Value-Based Purchasing

“Alternative payment models are not an option for behavioral health providers,” Arizona Medicaid Director Tom Betlach said, “They are your growth strategy.” Betlach’s point was very clear and it resonated with the more than 5,500 attendees at NatCon, where Payment Reform – be it alternative payment methodologies (APMs) or value-based purchasing (VBP) models like Delivery System Reform Incentive Payment (DSRIP) initiatives – was a key theme. In line with this, New York State’s DSRIP efforts were highlighted repeatedly throughout the conference. (PCG has played an instrumental role in spearheading New York’s initiative). Government agencies have become “first movers” towards VBP, stressing the importance of “whole person care,” not just “sick care.” [More]

CBO revises U.S. health care budget estimates

On March 24, 2016, the Congressional Budget Office (CBO) released a report entitled, “Federal Subsidies for Health Insurance Coverage for People under Age 65: 2016 to 2026.” The CBO report shows that the net costs of all Federal subsidies, taxes, and penalties related to health insurance coverage, for persons under age 65, will be $660 billion in 2016 (3.6 percent of the U.S. gross domestic product). [More]

Supreme Court issues decision on major health care case

States across the country have been nervously awaiting the Supreme Court ruling in Gobeille vs Liberty Mutual Insurance Company given its direct impact on state All-Payer Claims Databases (APCDs). That wait ended on March 1st and, with the decision known, states now have another piece of the puzzle to guide their next steps; however, the full impact on APCDs is yet to be seen. [More]

HHS finalizes ACA benefit and payment parameters for 2017

The U.S. Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) finalized its “Notice of Benefit and Payment Parameters” for 2017 in the March 8, 2016 Federal Register. As in prior years, this annual rules notice adjusts a wide range of policy, operational, and information technology requirements applicable to health insurance coverage obtained through Exchanges under the Affordable Care Act (ACA). [More]

Supreme Court declines review of “Origination Clause” challenge to ACA mandates

On February 29, the U.S. Supreme Court declined to review the Fifth Circuit Court of Appeals’ decision that a physician and his employer lacked standing to challenge the individual and employer mandates of the Affordable Care Act (ACA) under the Origination Clause of the U.S. Constitution. Hotze v. Burwell, No. 15-622, cert. denied (U.S. Feb. 29, 2016). [More]