Posts Tagged ‘managed care’
Thank you, Congress, for doing what’s right
Author : OurHealthCareSource.com
Mar 23rd, 2010 | by
On behalf of the 15 million Americans who will be eligible for Medicaid as a result of health care reform…we thank you.
On behalf of the children that need health care to support every possible opportunity for a successful and productive life…we thank you.
On behalf of Americans who must choose between buying food and getting health care…we thank you.
On behalf of the senior citizens who are wondering how to maintain their health on a modest budget…we thank you.
Despite the contentious year-long debate, Congress has done what’s right for the American people. Making health care a right – not a privilege – is a fundamental element that has been sorely missing from the ideals of our nation…until now!
Was this the best possible outcome? Probably not.
Does the new legislation fix every problem that ails the current health care system? No, not really.
But it is definitely a start. We elected our leadership to do what is best for the American people given the challenges our country is currently facing. Right now, what is best has arrived in the form of a new and improved health care system that will turn away no one; that will take care of our children; and most importantly, that is in reach to all Americans.
CareSource applauds our Congressional leaders for the following provisions included as part of health reform measures:
- Expansion of Medicaid to everyone (under age 65) below 133% of the Federal Poverty Level by 2014– removing categorical eligibility which currently forces many individuals in poverty to go uninsured.
- Creation of state-based health exchanges through which individuals can purchase coverage, with premium and cost-sharing credits available to individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four.
- An individual mandate for all to ensure all Americans participate in the insurance risk pool resulting in lower cost coverage options for all. Requires insurers to cover those with pre-existing conditions, removes lifetime limits, prohibits rescission of coverage and mandates prevention services be covered at 100 percent.
- Equalization of treatment of managed care and fee-for-service under the Medicaid drug rebate program.
- Closure of the Medicare prescription drug “doughnut hole” by 2020.
- Reauthorization of the Medicare Advantage Special Needs Plan program.
- Improved coordination for Medicare and Medicaid dual-eligibles.
Each of these provisions propels our country into a new era in health care for which we should embrace and build upon. There are many that vow to fight the passing of this bill, and that’s to be expected. But we should applaud all of our policymakers for remembering why and how this nation was created…to be a land of opportunity, of freedom, and of equality. Thank you, Congress, for doing what’s right for all people.
Article Tags
congress • cost of health care • drug rebate program • Federal Poverty Leve • fee-for-service • health care costs • health care exchange • health care reform • health insurance • individual mandate • managed care • Medicaid • Medicare • Medicare Advantage • poverty level • state based health exchanges
Money Can’t Solve Everything…Some Issues Require a Shift in Behavior
Author : OurHealthCareSource.com
Mar 8th, 2010 | by
I read an interesting opinion piece today by Rep. Joe Baca (D-California) in the Huffington Post. He brings up an issue that he feels hasn’t been addressed enough in the health care reform debate – “emergency care in many of our nation’s hospitals is in bad shape, and doctors and patients are paying the price.” The article goes on to explain that hospitals are in bad shape because of their requirement to provide emergency care for any and all people whether they have insurance or not. He cites the unfortunate fact that over 70 hospitals in his state have closed down due to financial pressures.
His solution: “adequately reimburse for the mandated emergency services they provide.”
This is certainly a solution, and probably a fair one at that – hospitals should be reimbursed appropriately for the services and care they provide. But part of the reason why the financials of our hospital’s emergency rooms are an issue is due to how they are being used. Too many people use emergency rooms as a primary care facility – seeking medical care for the flu or a sore throat or a minor fever.
This is a behavioral issue, not necessarily a money issue. We as an industry need to do a better job in educating people on how to responsibly engage the health care system. This is particularly important for the underserved population that accepts publicly funded health coverage. As a Medicaid managed care company, we believe this is a significant part of our role since many of our members are faced with poverty and typically access health care when and where it is most convenient. It’s why we assign case managers to our members. It’s why we look closely at ER utilization rates to identify opportunities to reach out to our members and educate them on appropriate usage. It’s why we have a 24-hour nurse line devoted to helping our members determine if their medical condition is a true emergency. It’s why we provide value-added services to our members like transportation to doctor appointments.
But providing these services must be balanced with patient accountability and sufficient access to primary care providers. The entire industry – insurance plans, providers, hospitals, advocacy groups, government – needs to embrace the idea that educating people about proper health care engagement is a critical strategy to lowering costs and increasing quality of care.
We certainly see the prospect of increasing Medicaid eligibility nationwide as a positive step toward helping underserved people access care without sending them to bankruptcy court. But giving people a shiny, new medical card means little without investing in resources which guide people to the appropriate setting – especially those who are more worried about where to get their next meal or how to put off an eviction.
People need to understand the difference between an emergency and non-emergency medical need. People need to understand the potential impact they have on the system when they miss a doctor’s appointment. Or the effect it has on the system when a person decides not to take his/her medication as prescribed.
This needs to become an industry effort. We can keep on throwing money or taking away money from various aspects of the health care system. But when it comes down to it, we need to address the behavioral aspect of users. We need to educate people about how to engage, and we need to find creative ways to do so.
What ideas do you have around how to better educate people about accessing the health care system?
Article Tags
doctor • emergency care • emergency medical needs • emergency room • ER • ER rates • flu • health care reform • insurance • Joe Baca • managed care • Medicaid • Medicaid managed care • medical • patient • primary care facility • provider • sore throat
Dissecting the Senate Finance Committee Proposal
Author : Toni Bigby
Oct 9th, 2009 | by
Senate Finance Committee Completes Mark-up; Expected to Vote Out of Committee on Oct. 13
The Senate Finance Committee completed debate on proposed health care legislation at 2:18 am last Friday. The Finance Committee was the last congressional panel to consider a health care reform bill and plans to vote this week after the bill’s final language has been made public and the Congressional Budget Office has provided final cost figures. Democrats hold a 13-10 committee majority which clears the way for the full Senate to begin debating the measure on October 13, 2009.
The panel considered many amendments over a two-week period and voted to reduce or waive fines for people who fail to buy coverage and give states money to help insure low-income Americans.
The legislation, estimated to cost $900 billion over 10 years, mandates that Americans get insurance and provides subsidies to those who need them, creates nonprofit cooperatives to offer an alternative to private insurance companies, and prohibits insurers from denying coverage to people with pre-existing medical conditions.
Instead of approving a public option amendment, the finance panel voted 12-11 for a compromise plan offered by Sen. Maria Cantwell, D-Wash., that would give federal funds to states to negotiate with private managed care plans to buy coverage for people who would not qualify for the Medicaid program. This compromise option would be eligible to people with income between 133-200% FPL. For individuals, that means income between $14,403 annually and $21,660. For families of four, the eligibility would be $29,326 to $44,100.
Individual mandate – Lowering the Penalty & Allowing Exemptions Dismays Insurers
An amendment proposed by Senators Charles Schumer (D-NY) and Olympia Snowe (R-ME) was also approved that reduce the penalty for those who fail to comply with an individual insurance mandate to $750 per adult, from $1,900 per family as originally proposed. It also waives the penalties in 2013 and phases them in through 2017. In addition, people who would have to pay more than eight percent of their income to buy insurance would be exempt from the penalties, down from 10 percent.
This amendment is of significant concern to commercial insurers as it could allow 2 million Americans to remain uninsured without contributing to the insurance pool.
Insurers are outraged by the risk involved as they would be required to guarantee coverage for all Americans should the health reform measure pass. A strong individual mandate made this option feasible.
Other notable items:
- By a vote of 13 to 9, the committee approved an amendment by Senator Jay Rockefeller (D-WV) that would keep low-income children in the Children’s Health Insurance Program (CHIP), instead of covering them through the Exchanges. This was a key interest for CareSource as we hope to continue to provide coverage to children who qualify through CHIP in Ohio and Michigan.
- Physician groups were upset to find out that the hospital industry is exempt from a crucial cost-cutting measure related to Medicare payments included in Senate Finance Chairman’s mark. Hospitals were held exempt because they were able to negotiate a $155 billion cost-cutting agreement with Baucus and the White House.
What’s Next?
The bill that emerges from Baucus’s panel must be merged with one that passed the Senate Health, Education, Labor and Pensions (HELP) Committee for debate and vote by the full Senate and eventually reconciled with a House measure.
Across the Capitol, Democratic leaders in the House met privately with moderate members, with liberals, and then with first-termers as they struggled to achieve a consensus on legislation to bring to the floor. Majority Leader Steny Hoyer announced it would probably be at least two more weeks before House legislation was ready.
Article Tags
Charles Schumer • CHIP • co-op plan • exchange • health care reform • health insurance • Jay Rockefeller • managed care • Maria Cantwell • Max Baucus • Medicaid • Medicare • non-profit • Olympia Snowe • public plan • senator • Steny Hoyer
Physician-Know Thy Patients!
Author : Craig Thiele, M.D.
Aug 18th, 2009 | by
So here’s an interesting story:
A doctor I work with encountered a pretty common situation with a patient. She’d prescribed an inhaler for a patient complaining of shortness of breath. On a follow-up visit, the patient said his symptoms had not changed. Normally, the doctor’s response would be increased dosage, new medication, or perhaps additional tests. But in this case, the physician had the Member Profile CareSource provides at hand, showing that the patient had not filled the first prescription in the first place. What ensued was five minutes of patient education explaining the importance of the medication, exploring why the prescription was not filled, a new copy of the prescription, and a successful treatment at no unnecessary cost.
We hear a lot about the need for digital medical records to provide complete, detailed, accessible record of treatment: they will certainly help cut costs and improve care in the long term.
But valuable as such records are, what they can’t provide is the topline overview of an individual’s health status that can help doctors when they first meet a patient or provide information for quality ongoing care…the kind of broad-spectrum profile of age, family status and other personal information, prescriptions ordered and filled, preventive screenings, previous providers, even non-medical issues affecting health and well-being.
With such a record in hand, any doctor—whether, in any emergency room, urgent care facility, clinic or private office in the U.S.—could jump-start the process of caring for a new patient, or providing quality long-term care for a current patient with a holistic picture that goes beyond the medical situation at hand.
A concise profile like the one CareSource has developed gives physicians, specialists and other providers integrated, up to date information about their patients electronically, so they can provide faster, more accurate assessments and diagnosis, treatment decisions that integrate with the patient’s other care, insights into behaviors that could affect outcomes, and potential problems that may not be presented in the office visits. All that adds up to better information, better care…and lower costs.
Care Management: Where Aggregated Patient Information Lives
The reason currently utilized personal health records, valuable as they will be, can’t do this job alone is simple: they may or may not be accurate or complete. Physician records are more reliable, but only cover care the specific doctor provided directly. They likely don’t contain information about which prescriptions were filled (and who prescribed them), what emergency room visits transpired across the state, nor important medical diagnoses from the patient’s past. Knowledge of this information can affect patient diagnosis, care and health.
But that’s precisely the information CareSource gathers using multiple information sources. We realized that the information we already have on our members could be put to excellent use by providers to the benefit of their practice, their patients, and health care costs overall.
Granted, it was no simple matter to find a way to make all this information easily available to providers. But now, CareSource Member Profiles are up and running. Physicians now have critical information at their fingertips including:
- Member demographics
- Primary care provider information
- Prior prescribing information (updated daily)
- Historical diagnoses
- Patient-specific quality metrics (such as mammography screening, A1C value, and more)
- Prior hospital admissions
- Emergency room visits
- Specialist visits
- Case management activity
It’s About Relationships, Too
What we’ve already discovered since CareSource Member Profiles have been available is that they create a virtuous cycle. Patients have a better feeling about a doctor who understands them, so they rely on that doctor’s opinion more, in lieu of using providers who are not familiar with their medical history. In addition to reaching positive outcomes, physicians with enough information can empower patients to take better care of themselves. By investing in tools physicians appreciate and use every day, CareSource builds stronger relationships with providers based on a lot more than making payments to providers caring for our members. And that means, as our nation moves toward health care reform, we will be able to work together to evolve a system that puts the resources of physicians and care management companies to their best and highest use.
As an emergency room doctor asked when we first presented Member Profiles, “why don’t all care management companies do what CareSource is doing?” The answer: I hope someday they will.
