Framing the front door: co-creating a home health care assessment of service need for children with disabilities.

This paper details the co-creation of a home health assessment tool for children with disabilities in the context of state-level systems change from traditional Medicaid to Medicaid managed care. A community based, sequential, mixed methods design was used to co-develop the assessment. A process evaluation highlighted community members' experiences with Medicaid managed care. Community members identified issues related to appropriateness of items and loss of services and recommended a dual assessment process to address concerns. Results indicated that 72% of items functioned well. Community members felt that organizational policies and the accuracy of clinical information obtained during assessment processes led directly to loss of services. Co-creating the assessment with caregivers of children with disabilities led to a comprehensive, person-centered, and holistic tool. The process buttressed several concrete systems and policy actions to improve home health care for children with disabilities in Medicaid managed care.

Precision of provider licensure data for mapping member accessibility to Medicaid managed care provider networks.

BACKGROUND: In July 2018, the Centers for Medicare and Medicaid Services (CMS) updated its Medicaid Managed Care (MMC) regulations that govern network and access standards for enrollees. There have been few published studies of whether there is accurate geographic information on primary care providers to monitor network adequacy. METHODS: We analyzed a sample of nurse practitioner (NP) and physician address data registered in the state labor, licensing, and regulation (LLR) boards and the National Provider Index (NPI) using employment location data contained in the patient-centered medical home (PCMH) data file. Our main outcome measures were address discordance (%) at the clinic-level, city, ZIP code, and county spatial extent and the distance, in miles, between employment location and the LLR/NPI address on file. RESULTS: Based on LLR records, address information provided by NPs corresponded to their place of employment in 5% of all cases. NP address information registered in the NPI corresponded to their place of employment in 64% of all cases. Among physicians, the address information provided in the LLR and NPI corresponded to the place of employment in 64 and 72% of all instances. For NPs, the average distance between the PCMH and the LLR address was 21.5 miles. Using the NPI, the distance decreased to 7.4 miles. For physicians, the average distance between the PCMH and the LLR and NPI addresses was 7.2 and 4.3 miles. CONCLUSIONS: Publicly available data to forecast state-wide distributions of the NP workforce for MMC members may not be reliable if done using state licensure board data. Meaningful improvements to correspond with MMC policy changes require collecting and releasing information on place of employment.

Payer Collaboration Leaders Could Ease Payer, Provider Tensions.

Having a payer collaboration leader is especially important for large health systems that have yet to fully consolidate revenue cycle operations following a merger or have far-flung operations in multiple states. They may vary in some details, but the same payer issues tend to crop up across a health system.

Social Determinants of Health: Stretching Health Care's Job Description.

Providers and payers are being asked to tackle the 'upstream' causes of poor health. Medicaid managed care organizations are being asked to screen enrollees for social needs. Some targeted efforts have translated into cost savings and make sense in value-based arrangements. But are we asking the health sector to take on too much?

Revisiting Incentive-Based Contracts.

Incentive-based pay is rational, intuitive, and popular. Agency theory tells us that a principal seeking to align its incentives with an agent's should be able to simply pay the agent to achieve the principal's desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States' behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care's recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising. But there is a problem: mixed preliminary evidence and potential mal-effects on vulnerable third-party patients. This Article employs a new lens-the legal and behavioral literature on optimal contract specificity-to suggest why incentive pay is problematic and why the health-care experience will be no different than other industries. The use of incentive pay is a change in contractdrafting strategy, a decision to write a more detailed, control-based contract rather than one that relies on discretion. The contracts literature suggests that this strategy will only work well where simple compliance is the goal rather than creativity or innovation. The health industry will not succeed in implementing incentive pay better than other industries have. What it needs is to recognize the limits of incentive pay and implement it sparingly. The new Trump Administration may be particularly primed to heed this call.

Does Contracting with Managed Care Organizations Remain A Barrier for Nurse Practitioners?

Upon implementation of the Affordable Care Act (ACA), many managed care organizations (MCOs) initially increased their nurse practitioner (NP) contracting. This trend has not continued, potentially frustrating ACA efforts to expand primary care provider capacity. In this study, about 25% of the responding MCOs did not contract with NPs as primary care providers. only 62.5% of respondent MCOs offering Medicaid products reported contracting with NPs as primary care providers, suggesting this will place a disproportionate burden on low-income patients seeking to access care. Findings from this study also have important geographic implications, suggesting the decision to contract with NPs is made individually, not necessarily influenced by the numbers of newly insured or available primary care physicians.

CDHPs: as enrollment goes up, a time to tune up.

One of the clearest findings of Mercer's annual National Survey of Employer-Sponsored Health Plans is that more companies are thinking of adopting a consumer-directed health plan (CDHP) approach, and more employees are enrolling in CDHPs at the companies that offer them. The authors discuss the advantages for organizations that offer CDHPs, as well as outline key considerations for companies looking to update, optimize and align their CDHPs with the realities of health care reform. They also explain how CDHPs go hand in hand with wellness and health management strategies, both of which increase collaboration between employees and employers to control costs and give employees more personal responsibility for better outcomes.

In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians.

States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.

AMCP Pay-for-Performance Principles: Performance-Based Reimbursement and Direct and Indirect Remuneration (DIR) Fees.

DISCLOSURE: At the direction of its Board of Directors, the AMCP Public Policy and Professional Practice committees developed these principles for pay-for-performance to promote the use of these arrangements that lead to improved patient outcomes. This document was first released on the AMCP website on December 14, 2021.

Are Health Insurance Markets Competitive?

To gauge the competitiveness of the group health insurance industry, I investigate whether health insurers charge higher premiums, ceteris paribus, to more profitable firms. Such "direct price discrimination" is feasible only in imperfectly competitive settings. Using a proprietary national database of health plans offered by a sample of large, multisite firms from 1998­2005, I find firms with positive profit shocks subsequently face higher premium growth, even for the same health plans. Moreover, within a given firm, those sites located in concentrated insurance markets experience the greatest premium increases. The findings suggest health care insurers are exercising market power in an increasing number of geographic markets.

[Evaluation of the family-care capacity by a home care score and management of home care].

We report the home care score (HCS) system to evaluate the capacity of care-giving family for the purpose of smooth and stable introduction of home care. We defined the family of low caring capacity characterized by low HCS as a "marginal family (in home care)". The HCS of a "marginal family" is less than or equal to six and decline easily to less than three by the progression of the disease or the environmental change, which means "care failure", the pathological status of home care. In the cases of low HCS, we should bear in mind the existence of a "marginal family", and "care failure". The close follow-up as well as the support of the community is indispensable for home care.

Addressing health care market reform through an insurance exchange: essential policy components, the public plan option, and other issues to consider.

HEALTH INSURANCE EXCHANGE: This Issue Brief examines issues related to managed competition and the use of a health insurance exchange for the purpose of addressing cost, quality, and access to health care services. It discusses issues that must be addressed when designing an exchange in order to reform the health insurance market and also examines state efforts at health reform that use an exchange. RISK VS. PRICE COMPETITION: The basic component of managed competition is the creation an organized marketplace that brings together health insurers and consumers (either as individuals or through their employers). The sponsor of the exchange would set "rules of engagement" for participating insurers and offer consumers a menu of choices among different plans. Ultimately, the goal of a health insurance exchange is to shift the market from competition based on risk to competition based on price and quality. ADVERSE SELECTION AND AFFORDABILITY: Among the issues that need to be addressed if an exchange that uses managed competition has a realistic chance of reducing costs, improving quality, and expanding coverage: Everyone needs to be in the risk pool, with individuals required to purchase insurance or face significant financial consequences; effective risk adjustment is essential to eliminate risk selection as an insurance business model--forcing competition on costs and quality; the insurance benefit must be specific and clear--without standards governing cost sharing, covered services, and network coverage there is no way to assess whether a requirement to purchase or issue coverage has been met; and subsidies would be necessary for low-income individuals to purchase insurance. THE PUBLIC PLAN OPTION: The public plan option is shaping up to be one of the most contentious issues in the health reform debate. Proponents also believe of a public plan is necessary to drive private insurers toward true competition. Opponents view it as a step toward government-run health care and are wary of cost shifting from the public plan to private insurers. FUTURE OF EMPLOYMENT-BASED COVERAGE: The availability of a health insurance exchange may have implications for the future of the employment-based health benefits system and raises major questions for workers. Will employers provide a fixed contribution for the purchase of insurance through an exchange? Would that be large enough to purchase coverage? Would it be flat or vary by such factors as worker health status, age, and/or marital status or the presence of children? Would it be taxed? For both employers and workers, the implications are enormous.

Evolution of the TRICARE Pharmacy Benefit: A Decade of Change.

TRICARE is the military's health plan that provides coverage to 9.4 million active duty and retired uniformed services personnel and their family members. The TRICARE pharmacy benefit has undergone many changes in the last decade. These changes include assigning newly approved drugs to nonformulary status after regulatory approval, the addition of weight loss medications to the benefit, channel management point-of-service requirements for some medications, and copay increases. Several initiatives have resulted in significant cost avoidance to the Department of Defense (DoD). The purpose of this article is to discuss the changes to the TRICARE pharmacy benefit, describe the continual challenges, and estimate cost savings associated with implementation of these changes. DoD implemented its 3-tier Uniform Formulary in 2005. Since then, many changes have been enacted, including more extensive use of prior authorization, step therapy, and quantity limits; coverage of over-the-counter medications; the retail refund program; coverage of vaccines and smoking cessation agents; mandatory mail/military treatment facility requirements; rapid review and initial nonformulary status for newly approved innovator drugs; revisions to the compounded drug benefit; initial deployment of a new medical record system; coverage of weight loss medications; and the ability to exclude medications from the Uniform Formulary. Although the TRICARE pharmacy benefit has evolved significantly, the focus remains on the beneficiaries, with an overall goal of providing integrated, affordable, and high quality health services for the Military Health System. Challenges for the future include maximizing clinical effectiveness in the face of rising pharmaceutical costs and cost avoidance, while supporting the needs of TRICARE beneficiaries. DISCLOSURES: No outside funding supported this study. The authors declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The information discussed here represents the views of the authors and does not necessarily reflect the views of the Defense Health Agency (DHA), the Department of Defense (DoD), or the Departments of the Army, Navy, and Air Force. The authors have nothing to disclose that presents a potential conflict of interest.

Learning from the legal history of billing for medical fees.

INTRODUCTION: When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients. HISTORICAL BACKGROUND: At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures. CONCLUSION: Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.