Preparing for Medicaid managed care

As Medicaid enrollment continues to rise, hospitals and health systems could benefit from contracting with Medicaid managed care plans. Providers need to establish a Medicaid managed care strategy before beginning the contracting process. Revenue cycle leaders need to ensure that their front-end processes related to patient access, billing, and denials management are compatible with Medicaid managed care.     

Das Geschäftsmodell des selektiven Kontrahierens — Eine Analyse wertschöpfender Aktivitäten gesetzlicher Krankenkassen

By establishing Integrated Care sickness funds are introduced the possibilities of signing individual contracts with single or a group of health care providers (selective contracting). So far, this topic has been discussed a lot from the health care system’s point of view. The research presented in this paper however focuses on business aspects from a single sickness fund’s point of view. By selective contracting of providers a sickness fund creates additional value for insurants. Besides the traditional payer function this is especially done by pre-selecting quality-proved providers, stipulating diagnosis and therapy methods, stipulating guarantees and negotiating remunerations. Customer-orientation requires identification of the patient’s different needs and preferences. To satisfy those individually varying demands a sickness fund has to choose carefully its contract partners. A sickness fund’s success depends on the quality of its contracted providers. As selective contracting means that only a chosen number of providers will be contracted, value is created for those by mediating patients with the opportunity of raising both income and utilisation. The value creation by selective contracting can be summarized both for patients as well as for providers as a strong reduction of transaction costs.     

The consumer-driven approach: can it pick up where managed care left off?

Managed care has failed and health care costs are once again out of control. Given the current political, social and economic environment, there are now two options: a single-payer health care system, or an aggressive and global employer health benefits redesign that strongly encourages consumer-driven behavior. This article discusses the failure of managed care and ways that employers can promote consumer-driven behavior now using available tools and plan provisions.     

The impact of health care reform on older workers, retirees and employers

The Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010 impacts everyone who uses or pays for the health care system. Among the new law's effects will be changes in older workers' health care choices as they transition from full-time employees to part-time work or other jobs and, ultimately, to retirement, and the retiree health benefit choices facing their employers. This article reviews the major issues surrounding these changes, including those affecting retiree health benefits, benefits for Medicare-eligible retirees and health care options for older Americans not yet eligible for Medicare. The authors conclude that although employers will be reacting in 2010 and 2011 with regard to some issues surrounding FASB ASC 715-60 and the early retiree reinsurance program, employers should consider waiting to make major changes until regulations are issued and the health plans for active employees have been fully vetted.     

Measuring the economic value of HMOs

The economic efficiency of HMOs varies dramatically, affected by such factors as market share, provider contracting agreements and utilization management techniques. Employers that establish HMO strategies without conducting quantitative assessments may incur unnecessary costs. A combination of both quantitative and qualitative analyses can lead employers to a best practice system of health care.     

Hospital managed care diversification and reinsurance strategies

As increasing numbers of patients enroll in managed care plans, health care providers are faced with new operational and financial challenges. This article, the fourth in a series on the financial perils of managed care contracting, addresses issues related to diversification of risk and reinsurance.     

Consumer-driven health care: tangible employer actions

In response to double-digit health care cost increases, leading employers are aiming aggressive strategies at changing participant and provider behaviors--strategies that go well beyond the narrow idea of a new cost-sharing design. This article describes the elements of a comprehensive consumer-driven health care strategy and provides examples of tangible consumer-driven health care initiatives in the areas of design, pricing, contracting, support and public policy.     

Managed care: the strategic future for education in quality

This paper discusses the needs for future education in quality assurance, assessment and improvement, particularly in relation to managed care. The pressures for increased education about quality are derived from different components of the health care system; e.g., regulatory and governmental agencies, purchasers of care, and competitors of health institutions. The content of future education in health care quality is defined in six areas: (1) organization and management; (2) health systems; (3) quality theory and methods; (4) management information systems and research; (5) governmental policy; and (6) economics and finance. Education in health care quality in these content areas is delivered at both the primary and continuing education levels by universities, professional associations and private training and development corporations. Future oriented, strategic thinking education in health care quality is needed. The pressures for education about quality, including traditional concepts of quality assurance, methodologies for quality assessment and the newer approaches to continuing quality improvement, are clearly growing stronger. This article discusses the need for education in health care quality, the content areas and levels of education and the delivery system.     

Negotiating the Network: The Contracting Experiences of Community Mental Health Agencies in New Zealand

Structural options for reforming New Zealand'spublicly funded health services included a hierarchy, a market model, or hybrid arrangements such as quasi-markets and networks. A survey of 28 community mental health agencies, contracting with the four regional health authorities, found that three structures emerged: a quasi-market, a coercive network and a beneficent network. Further reforms to the publicly funded health services created a single purchaser and preferred a network structure. Performance assessment of these reformed health services requires assessment of the whole network and not just individual components. The accounting profession, although closely involved in the public sector reforms, appears to have overlooked this task.     

Ethical values: the real crisis in health care

This author argues that the growth of apathy and greed and loss of ethical values in the current health care delivery system is due to the change in the foundation of the expectations between the consumer and the provider of health care. The agendas of the "third parties" involved with the provision of health care has caused confusion in the mind of the consumer and loss of autonomy for the health care provider. A historical perspective is provided that includes discussion of the issues of culpability for the current outcomes. Finally, the author discusses possible remedies to the current system.     

PERFORMANCE BASED COMPENSATION IN HEALTH CARE — A SWEDISH EXPERIENCE

In recent years most attempts at reforming health care in Sweden appear to be guided by ideals of decentralization and market orientation. Based on a longitudinal case study of five clinics in a large university hospital this paper questions the general applicability of the market framework in health care. The case story describes how a traditional overall budgeting system was replaced by a performance compensation system in which the clinics were paid a fixed price per unit produced. The new system involved the use of results, balance and funds statements and was also soon to be accompanied by another major reform introducing a purchaser-provider split organization in the county. The story ends by showing how the bold ambitions of establishing strict market like contracting forms fail to materialise and eventually get abandoned.     

The return of capitation preparing for population-based health care

To succeed under population-based health care, organizations need to understand thoroughly how this approach differs from traditional fee-for-service health care. To manage care under capitation, the contracting organization should have a population of sufficient size and a clear means of assigning patients to that population. To assess performance, the organization requires metrics that view performance in terms of per member per month, while avoiding common pitfalls of misapplying such metrics.     

Choosing health care online: a 7-Eleven case study

This article describes 7-Eleven's success in offering Web-based health care enrollment to its diverse workforce, which made the introduction of such service delivery strategy unusually challenging. Through its efforts, 7-Eleven was able to meet several important objectives, including helping employees better appreciate the value of their benefits, providing employees with increased services and convenience, and encouraging employees to make more cost-effective choices in their health care coverage.     

Health insurance and outcomes: comprehensive assessment of health system outputs

Outcomes analysis in health care has historically meant the examination of clinical results of inpatient hospitalization. In response to climbing health care and health insurance costs, the organization of health care providers, the location of service delivery and reimbursement mechanisms have changed. As the health care industry changes, so too must the definition of outcomes. This article presents a conceptual framework for the analysis of health outcomes as health industry outputs, with an emphasis on the ways in which such outputs are being assessed and improved.     

Managed Mental Health Care: Stakeholder Effects and Policy Implications

ABSTRACT: During the past several years, healthcare delivery in the United States has shifted from a primarily fee-for-service system toward managed care. Mental health care has been affected disproportionately by this trend. The existing literature on managed mental health care is abundant, but narrowly focused. The purpose of this study is to take a broader public-policy approach, considering simultaneously the effects on system stakeholders: patients, providers, employers, insurers, and society.     

Managed care, consolidation among health care providers, and health care: evidence from mammography

We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.     

Grenzüberschreitende Gesundheitsleistungen als Handlungsfeld für die Gesetzliche Krankenversicherung

The TK customer survey gives insights in the current experiences of patients with cross-border health care in Europe and illustrates their expectations regarding the future of the German health care system within the EU. Currently emergency care during temporary stays in another member state accounts for the vast majority of cross-border care. The use of care concentrates on a small number of countries. The survey shows that the E111-process has a number of significant practical problems. As a result most cross-border cases are dealt with by cost reimbursement. As mobility of the insured is likely to increase, demand for cross-border care will follow suit. However, even with a liberalisation of the European health care markets following recent ECJ decisions, a boost in demand is unlikely. The findings show that an increase in demand for cross-border care can be expected for highly specialized medical care, medical products, specially pharmaceuticals as well as non-urgent treatments. Patients require significant support when considering a treatment abroad leading to a number of interesting options for statutory sickness funds to develop innovative services and benefits. However, implementation of additional benefits with regard to cross-border care, requires modification of the national legal framework.     

Health Care Reform,Efficiency of Health Insurers,and Optimal Health Insurance Markets

This research examines the efficiency of the U.S. health insurers. It shows that more insurers are less efficient than in the previous sample year; however, the results suggest that the federal health care reform has no significant effect on the overall efficiency of all insurers as a whole, which is very low but does not change much over time. This research explores how to improve the efficiency of the health insurance market by proposing state, regional, and national efficiency-based goal-oriented market models and an efficiency duplicating system, and it discusses important implications to the health care compacts, the health insurance exchanges or marketplaces, and the national multistate programs. It also analyzes further moves for efficiency enhancement with regard to payment methods and the health care delivery system. One interesting finding is that the Medicaid program is very efficient because it provides support to the offering of Medicaid coverage and further expansion, which enhances the health welfare of society with fewer resources inputs from the perspective of efficiency. This research should provide important insights for state and federal governments, policy makers, regulators, the health insurance industry, and consumers.     

NOT REPORTING A PROFIT: CONSTRUCTING A NON‐PROFIT ORGANISATION

Public sector reformers advocate contracting‐out as a means of improving cost‐effectiveness. In the health sector, market‐based contracts with for‐profit organisations can reduce equity of access and divert public funds to private gain. Such issues have prompted policy makers to seek alternative contracting strategies. This paper examines a primary health care policy whereby government contracts with private non‐profit organisations to increase efficiency and meet World Health Organisation ideals. The study found that the policy's implementation has not achieved these aims when for‐profit providers masquerade as non‐profit organisations. The implication is that governments may find it more effective to manage for structural diversity than mandate homogenisation.