A project of the George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation

Health Care Quality and Delivery System Reform

Rating the Quality of Qualified Health Plans Sold in the Marketplace

Posted on January 7, 2014

On November 19, 2013, the Obama Administration published a Notice with comment that describes the overall Quality Rating System (QRS) framework for rating the quality of health plans (QHPs) sold in the health insurance Marketplace (another term for Exchanges). The purpose of the Notice is to solicit comments on the framework. Comments must be received by January 21, 2014. Comments are sought on both the proposed quality measures that QHP issuers would be expected to report, as well as on ways to preserve the integrity of QHP ratings and on areas for future measurement…

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Premier report discusses ACO payer partnerships

Posted on June 6, 2013

A report released by Premier found that commercial payers do not offer many of the low-risk, well-received Accountable Care Organization (ACO) payment models to providers that Medicare typically offers. Under the Affordable Care Act (ACA), the Medicare Shared Savings Program (MSPP) initiated two types of payment models: a savings model and a shared savings and loss model. The upside-risk track within the shared savings model is very popular with public programs, as there are no penalties for providers that do not meet their cost-savings goals. Payor Partnerships: Insights from Premier’s PACT Population Health Collaborative found that upside-risk arrangements were not common in commercial payer partnerships. Additionally, the report emphasized that establishing a partnership with a payer makes the transition to an ACO more financially palatable for providers.

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Medicaid expansion allows for coordination between CMS and HRSA

Posted on May 2, 2013

The Centers for Medicare and Medicaid Services (CMS) and Health Resources and Services Administration (HRSA) released a joint information bulletin detailing the opportunity to coordinate care between Medicaid and the Ryan White HIV/AIDS Program. The expansion of Medicaid under the Affordable Care Act (ACA) will provide health care access to many people living with HIV/AIDS, therefore necessitating the need for CMS and HRSA to ensure that Medicaid and Ryan White HIV/AIDS programs are poised to collaborate and coordinate care for this population. The two federal agencies will offer webinars and training in the following areas: eligibility, enrollment, essential community providers, managed care practices, and integrated care models for those living with HIV/AIDS.

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New Kaiser analysis predicts rise in health care costs

Posted on April 22, 2013

The Henry J. Kaiser Family Foundation (KFF) is out with a new study today that predicts a rise in health care costs. The analysis concludes that by 2019, health care costs will likely grow at a percentage closer to the national historic average, which is above 7%, compared to the 3.9% increase observed in 2009 – 2011. The authors found that the recent lag in health care cost growth was a result of the economic downturn, and pending recovery will likely coincide with increasing health care costs. The study did state that growth may be mitigated by the health care delivery-system reform attributable to the Affordable Care Act (ACA), but the most promising predictor of health care costs remains to be the country’s economic status.

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BPC releases health savings plan

Posted on April 19, 2013

The Bipartisan Policy Center (BPC) recently released a new national health care cost-containment strategy. Funded in part by the Robert Wood Johnson Foundation, A Bipartisan Rx for Patient-Centered Care and System-Wide Cost Containment, proposes strategies that would save $560 billion in health care expenditures over the next 10 years. BPC’s main source for cost-containment is the alteration of the Sustainable Growth Rate (SGR) formula, which accounts for nearly $300 billion of the proposed savings. Other cost-containment measures prescribed included the expansion of Medicare networks, a concept very similar to Accountable Care Organizations, and instituting the competitive bidding practice among Medicare Advantage plans.

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Health care industry presents cost-saving ideas

Posted on April 11, 2013

Five entities in the health care industry, including America’s Health Insurance Plans (AHIP) and Families USA, coalesced to present a document containing several ideas that, if incorporated, may help decrease health care costs. Potential provisions to accomplish this task include:

  • Altering payment models and infrastructure to incentivize effective treatment;
  • No longer using fee-for-service to pay providers;
  • Encouraging patients to visit quality providers;
  • Designing plans that permit savings for states capable of reducing health care costs.

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AHIP study shows hospital price increases

Posted on March 22, 2013

America’s Health Insurance Plan (AHIP) released a study indicating that hospital prices increased 8.2% per year between 2008 and 2010, even after adjusting for the quantity and complexity of the procedures performed. The study, recently published in the American Journal of Managed Care, found that bronchitis and asthma treatment costs rose 10.3% per year and the cost for spinal fusion increased 15.2% per year. The study concludes that the underlying costs of medical care must be addressed in order make health care coverage affordable.

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Commonwealth Fund publishes field report on ACOs

Posted on March 14, 2013

In a field report published yesterday, the Commonwealth Fund discusses the progress made by accountable care organizations (ACOs) in improving health care quality and efficiency. ACOs, established by the Affordable Care Act (ACA) as a Medicare delivery system option, are designed to systematically improve health care delivery and mitigate cost increases by forming contractual relationships between physicians and payers.

This report details the successes and challenges experienced by seven hospital-physician groups that are considered early-adapters of the ACO model. These entities are involved, or will soon be involved, in risk-sharing arrangements with public and private payers. Representatives from the featured ACOs discuss their strategies for integrating clinicians, managing practices, designing incentives, and sharing rewards. The goal of this report is to educate providers in methods that promote partnership and success in ACOs.

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Dartmouth study identifies problems with risk-adjustment methods

Posted on February 22, 2013

In a study led by the Dartmouth Atlas Project and The Dartmouth Institute for Health Policy & Clinical Practice, researchers raise questions regarding the risk adjustment that Medicare and others apply to insurance claims data in an effort to make effective comparisons about the performance of doctors and hospitals and to credit providers for treating patients who are sicker than average. The study examines commonly used risk-adjustment methods and finds that regions and hospitals with more physician visits, referrals, tests, and imaging can make some patient populations appear to be sicker than others when they are not. As a result, these regions and providers with more diagnoses receive higher reimbursements.

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OIG finds most states on track to comply with ACA technical demands

Posted on February 21, 2013

According to a report published by the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG), 35 States reported that they anticipate implementing streamlined eligibility and enrollment systems, streamlined application forms, and data sharing and matching by January 1, 2014, as mandated under section 1413 of the Affordable Care Act (ACA). However, the report also describes challenges reported by States, such as implementing the requirements by the target date and upgrading outdated eligibility and enrollment systems. The report details various funding issues related to implementing needed changes. According to the paper, States also reported needing information and guidance, particularly on the Secretary’s application form, the planned Federal data services hub, and the calculation of Modified Adjusted Gross Income (MAGI). The OIG report concluded that the Centers for Medicare & Medicaid Services (CMS) should continue to provide guidance to States as they prepare to implement the streamlined eligibility and enrollment systems.

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