Monthly Archives: February 2015

Market Forces at Play in for Premiums in Federal Health Insurance Marketplaces

A key policy and architectural piece of the ACA-created health insurance market place was to use market forces to help stabilize rising premiums by giving consumers a choice in insurers.  The thinking was that the more competition the better it would be for consumers to shop and ultimately select the coverage that best suits their needs for a good price.

This article shows anecdotal evidence that this is happening around the country after the first full year of the federal market place being in existence.


How Will IT Systems Adapt to Value Based Reimbursement Models?

In a previous post, I mentioned CMS as well as a grouper of payers and providers pledged to increase their share of claims paid under value based reimbursement (VBR) schemas such as ACOs and bundled payments and away from fee for service.  That’s all fine and well but how will corresponding IT systems on both payers and providers handle these claims in both the preparation, adjudication at the payer, and retrospective analysis with the least amount of manual intervention possible?  Oh, and the data has to be accurate.  And timely.

In a previous WEDI conference where Geisinger presented some of their then current challenges with the bundled payment model.  Since they are both a provider and plan, the plan part negotiated a price for a type of service for one of their employer groups such as knee replacements.  The employer recognized a good portion of their covered employee and dependent population had received these in the past and since they are a self-insured group, had paid quite a bit in these claims.  Just like Costco and Sam’s Club, the employer had negotiated a bulk discount rate for knee replacements for their employees and dependents and not the previously contracted fee for service rate.  This sounds easy enough in real life but here were a few of the challenges that Geisinger faced in processing these claims:

1) How does the adjudication system know which claims are all a part of the particular event?  In the case of the knee replacement surgery, there are multiple visits leading up to the diagnosis, the pre-op, surgical event, post-op, and follow-up care.  What happens when the patient has to go to multiple providers for this one event?  In this case, the provider sees a PCP first; then the orthopedic surgeon; the PT/OT for rehab; and then maybe some DME for home care.

2) What happens if the care occurs with providers that are non-par but the member does not have an alternative?  How will this non-par provider get paid?  How will this payment impact the pre-negotiated price of the service?  How can the actuaries determine the negotiated rate if this is unknown?

3) How is the reimbursement divided up amongst the different providers especially if the providers are not financially a part of the same health system or group practice?

Read more here.

Congress Feels We’re Finally ICD-10 Ready for 10/1/15. Fingers (and Toes) Crossed We’re Not Headed for a Deja Vu

Earlier this month, The GAO released a report stating the move to a 10/1/15 deadline is on track and that CMS has taken sufficient action through numerous outreach channels in engaging different sectors of the healthcare industry (especially physicians) to assist with ICD-10 preparedness.  A bipartisan group of senators has even put their vote of confidence in the industry’s preparedness as well.

Let’s hope this swell of momentum will be enough to push the industry over the 10/1/15 finish line.

Read more here.

Salesforce Ventures into Healthcare. Say What?!?

More and more organizations are realizing that the healthcare sector has tremendous growth opportunity and venturing into it.  This ranges from Apple to Microsoft, IBM, and now Salesforce.  If they can pull this off, it will have a unique footprint on the ever-crowded healthcare technology landscape:

“We’re bringing this panoramic view of the patient,” Pierce says. “We can bring data from any source. Being open cloud technology, we can aggregate data whether it’s from devices or EMRs or other sources. Salesforce is really going to highlight how we can help all the different players in this new era with what we call our Customer Success Platform.”

That platform, which spans patient acquisition, care delivery, engagement and analytics, consists of software-as-a-service offerings for marketing, sales, service, and a community option that enables patients to share information with caregivers, be those clinicians or family members.

The newest piece, Wave, is an analytics platform. TriCore Reference Laboratories is one of the pilot customers.

Read more here.

ICD-10 Has Another Hearing in Capital Hill. What Transpired?

The Health subcommittee of the Energy and Commerce Committee held a public hearing regarding the state of the ICD-10 implementation within the healthcare industry.  My first thoughts were, “No!  Not yet another opportunity to inject politics into this discussion!!!”  However, by most indications, the discussion went pretty well for ICD-10 proponents.  Representatives from AHIMA, providers, and vendors spoke on the importance of staying the course and why the transition from ICD-9 is sorely needed.  To present both sides of the argument for and against implementation, there was a physician representative present that made his case on why the implementation should not occur or at least should be delayed.  Some accounts state this witness did not do the best job at stating the anti-implementation case.

Read more here.