Modification of Treatment of Certain Health Organizations. Final regulations.

This document contains final regulations that provide guidance to Blue Cross and Blue Shield organizations, and certain other organizations, on computing and applying the medical loss ratio and the consequences for not meeting the medical loss ratio threshold. The final regulations reflect the enactment of a technical correction to section 833(c)(5) of the Internal Revenue Code by the Consolidated and Further Continuing Appropriations Act of 2015. The final regulations affect Blue Cross and Blue Shield organizations, and certain other organizations involved in providing health insurance.

Medical Home Implementation in Small Primary Care Practices: Provider Perspectives.

BACKGROUND: CareFirst BlueCross BlueShield of Maryland implemented a voluntary patient-centered medical home (PCMH) program in 2011 that did not require formal certification to participate. This study assessed attitudes and awareness of PCMH programs among participating providers in Maryland and Northern Virginia. METHODS: This qualitative study used information from 13 focus groups. In addition, 39 telephone interviews were conducted. An experienced facilitator moderated the focus groups. Written transcripts were analyzed using NVivo software. RESULTS: Several cross-cutting themes emerged. First, the payment bump of 12% was a motivating factor to participate but did not have long-term effects on participation. Second, nurse care coordinators were perceived as the key element of the PCMH program. Third, providers had limited awareness of an external data portal. Finally, small practices were generally receptive to the externally supported program elements. CONCLUSIONS: Implementation of PCMH program elements can be facilitated in small primary care practices even if third-party certification is not a requirement. Participating providers viewed having an external nurse care coordinator as the key element of the PCMH program. Small practices were receptive to external supports, but a lack of trust was viewed as a barrier to implementing a payer-based medical home program.

Use of big data by Blue Cross and Blue Shield of North Carolina.

The health care industry is grappling with the challenges of working with and analyzing large, complex, diverse data sets. Blue Cross and Blue Shield of North Carolina provides several promising examples of how big data can be used to reduce the cost of care, to predict and manage health risks, and to improve clinical outcomes.

Computation of, and rules relating to, medical loss ratio. Final regulations.

This document contains final regulations that provide guidance to Blue Cross and Blue Shield organizations, and certain other qualifying health care organizations, on computing and applying the medical loss ratio added to the Internal Revenue Code by the Patient Protection and Affordable Care Act.

The high cost of fine print. Antitrust case against a major Blue Cross plan may redefine terms of contract negotiations.

With its challenge to Michigan Blues contracts with some hospitals, the Justice Department is doing something it hasn't in more than 10 years. The move means insurers need to carefully vet contracts for similar issues. "This signals they're still in the enforcement business as it relates to healthcare insurance," says lawyer David Marx Jr.