Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State.

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.

Medicaid Program; The Use of New or Increased Pass-Through Payments in Medicaid Managed Care Delivery Systems. Final rule.

This rule finalizes changes to the pass-through payment transition periods and the maximum amount of pass-through payments permitted annually during the transition periods under Medicaid managed care contract(s) and rate certification(s). This final rule prevents increases in pass-through payments and the addition of new pass-through payments beyond those in place when the pass-through payment transition periods were established, in the final Medicaid managed care regulations effective July 5, 2016.

The Impact of Judicial Reform on Crime Victimization and Trust in Institutions in Mexico.

This article studies the impact of judicial reform in Mexico. It does so using a survey about crime victimization and perceptions of insecurity (Encuesta Nacional Sobre la Inseguridad [ENSI]) collected in 2005, 2008, and 2009 in 11 Mexican cities, 3 of which implemented the reform in 2007 and 2008. This analysis shows that judicial reform not only reduces victimization but also lowers perceptions of security. Although we find that judicial reform has a negative effect on trust in the local and federal police, judicial reform reduces the probability of being asked by the transit police for a bribe.

Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability. Final rule.

This final rule modernizes the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems. The final rule aligns, where feasible, many of the rules governing Medicaid managed care with those of other major sources of coverage, including coverage through Qualified Health Plans and Medicare Advantage plans; implements statutory provisions; strengthens actuarial soundness payment provisions to promote the accountability of Medicaid managed care program rates; and promotes the quality of care and strengthens efforts to reform delivery systems that serve Medicaid and CHIP beneficiaries. It also ensures appropriate beneficiary protections and enhances policies related to program integrity. This final rule also implements provisions of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and addresses third party liability for trauma codes.

Medicaid and Children's Health Insurance Programs; Mental Health Parity and Addiction Equity Act of 2008; the Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care Organizations, the Children's Health Insurance Program (CHIP), and Alternative Benefit Plans. Final rule.

This final rule will address the application of certain requirements set forth in the Public Health Service Act, as amended by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, to coverage offered by Medicaid managed care organizations, Medicaid Alternative Benefit Plans, and Children's Health Insurance Programs.

AMCP Seeks an End to 20 Years Of Confusion Over FDAMA Section 114.

The FDA never issued regulations to clarify the boundaries of promotion of pharmacoeconomic data, something it's been dragging its feet on for nearly 20 years. In turn, pharma companies, fearful of being penalized for off-lable promotion, have erred on the side of caution, hesitating to take advantage of Section 114.

Assembled Products: The Key to More Effective Competition And Antitrust Oversight in Health Care.

This Article argues that recent calls for antitrust enforcement to protect health insurers from hospital and physician consolidation are incomplete. The principal obstacle to effective competition in health care is not that one or the other party has too much bargaining power, but that they have been buying and selling the wrong things. Vigorous antitrust enforcement will benefit health care consumers only if it accounts for the competitive distortions caused by the sector's long history of government regulation. Because of regulation, what pass for products in health care are typically small process steps and isolated components that can be assigned a billing code, even if they do little to help patients. Instead of further entrenching weakly competitive parties engaged in artificial commerce, antitrust enforcers and regulators should work together to promote the sale of fully assembled products and services that can be warranted to consumers for performance and safety. As better products emerge through innovation and market entry, competition may finally succeed at lowering medical costs, increasing access to treatment, and improving quality of care.

Growth of Accountable Care Organizations in California: Number, Characteristics, and State Regulation.

Accountable care organizations (ACOs) result in physician organizations' and hospitals' receiving risk-based payments tied to costs, health care quality, and patient outcomes. This article (1) describes California ACOs within Medicare, the commercial market, and Medi-Cal and the safety net; (2) discusses how ACOs are regulated by the California Department of Managed Health Care and the California Department of Insurance; and (3) analyzes the increase of ACOs in California using data from Cattaneo and Stroud. While ACOs in California are well established within Medicare and the commercial market, they are still emerging within Medi-Cal and the safety net. Notwithstanding, the state has not enacted a law or issued a regulation specific to ACOs; they are regulated under existing statutes and regulations. From August 2012 to February 2014, the number of lives covered by ACOs increased from 514,100 to 915,285, representing 2.4 percent of California's population, including 10.6 percent of California's Medicare fee-for-service beneficiaries and 2.3 percent of California's commercially insured lives. By emphasizing health care quality and patient outcomes, ACOs have the potential to build and improve on California's delegated model. If recent trends continue, ACOs will have a greater influence on health care delivery and financial risk sharing in California.

The Affordable Care Act and long-term care: marginal advancement on the status quo.

The purpose of this analysis is to evaluate the sufficiency of the Long-Term Services and Supports (LTSS) provisions contained within the Patient Protection and Affordable Care Act (ACA). Beyond the ambitious but fatally flawed Community Living Assistance Services and Supports Act, the ACA's LTSS changes represent only marginal advances over the status quo. Moreover, the impact of the ACA's strategies varies with the extent to which the federal and state governments opt to invest in them, through funding, implementing, and enforcing the modest changes enacted. The ACA's LTSS provisions, while welcome, are unlikely to result in the major changes necessary to meet both current and future demand for care.

Behavioral health services in separate CHIP programs on the eve of parity.

The Children's Health Insurance Program (CHIP) plays a vital role in financing behavioral health services for low-income children. This study examines behavioral health benefit design and management in separate CHIP programs on the eve of federal requirements for behavioral health parity. Even before parity implementation, many state CHIP programs did not impose service limits or cost sharing for behavioral health benefits. However, a substantial share of states imposed limits or cost sharing that might hinder access to care. The majority of states use managed care to administer behavioral health benefits. It is important to monitor how states adapt their programs to comply with parity.

Managed care: right or wrong for North Carolina.

Since 2005, Piedmont Behavioral Healthcare (PBH) has operated North Carolina's only managed care Medicaid waiver program. Legislation was recently passed requiring that the waiver program be expanded statewide by January 2013. Experience with the PBH model suggests that this expansion can result in significant savings without compromising quality or access.

The role of critical access behavioral health agencies in a reformed behavioral health system.

This commentary discusses the role that Critical Access Behavioral Health Agencies (CABHAs) currently play in meeting the behavioral health needs of people in North Carolina, the opportunities and challenges that CABHAs will confront under the state's section 1915(b)/(c) Medicaid waiver, and the future of CABHAs under the Affordable Care Act.

[Experience in organization of drug supply for military personnel and military retirees in the United States].

In the U.S. troops and military retirees realize the right to obtain drugs by participating in a nationwide managed care program TRICARE under the routines TRICARE Pharmacy. Militarily, the U.S. health care holding drug based on the Basic Core Formulary and Extended Core Formulary, which are developed by US Department of Defense Pharmacy and Therapeutics Committee. Realization of subprogram TRICARE Pharmacy is performed by Express Scripts.

The devil is in the details: Managed care and the unforeseen costs of utilization review as a cost containment mechanism.

This article addresses issues of liability when a single-payor in a national health care system makes a decision based on a utilization review program that injures the patient as a result. In Part I, the history of Managed Care Organizations (MCOs) is discussed to establish an understanding of the current health care landscape. Part II explains MCOs' use of utilization review to contain costs and analyzes the manner in which courts have addressed the issue of MCO liability for patient injuries sustained from denial ofcoverage. Finally, Part III concludes that current case law may limit a patient's access to a remedy for injuries sustained from a utilization review decision in a single-payor national health care system.

Parity not perfect: making sense of substance addiction equity for case managers.

In October of 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act became a law. It represents a groundbreaking change in substance abuse treatment policy because it redistributes the bulk of costs for substance abuse treatment from the federal government to group health plans. The law required that employee and public insurances that cover health or surgical care also provide comparable terms of coverage and treatment limitations for substance abuse. This article considers shift within the context of a popular substance abuse motto that "reform is progress but not perfect." Specifically, it examines policy implications and their impact on consumers, insurers, providers, and case managers.

[Transparency as a prerequisite of innovation in health services research: deficits in the reporting of model projects concerning managed care]. / Transparenz als Voraussetzung für Innovation in der Versorgungsforschung: Defizite am Beispiel der Evaluation von Managed-Care-Modellvorhaben.

AIM: Currently, elements of managed care are being implemented in the German health-care system. The legal basis for these innovations are § 140, § 73, § 137, and §§ 63 et seq. of the German Social Code - Part 5 (SGB V). For the model projects according to §§ 63 et seq. of the German Social Code a scientific evaluation and publication of the evaluation results is mandatory. The present study examines the status of evaluation of German model projects. METHODS: The present study has a mixed method design: A mail and telephone survey with the German Federal Social Insurance Authority, the health insurance funds, and the regional Associations of Statutory Health Insurance Physicians has been conducted. Furthermore, an internet research on "Medpilot" and "Google" has been accomplished to search for model projects and their evaluation reports. RESULTS: 34 model projects met the inclusion criteria. 13 of these projects had been terminated up to 30/9/2008. 6 of them have published an evaluation report. 4 model projects have published substantial documents. One model project in progress has published a meaningful interim report. 12 model projects failed to give information concerning the evaluator or the duration of the model projects. IMPLICATIONS: The results show a significant deficit in the mandatory reporting of the evaluation of model projects in Germany. There is a need for action for the legislator and the health insurance funds in terms of promoting the evaluation and the publication of the results. The institutions evaluating the model projects should obligate themselves to publish the evaluation results. The publication is an essential precondition for the development of managed care structures in the health-care system and in the development of scientific evaluation methods.