PODCAST: Roadmap to a High Performance Employee Health Plan

By Eric Bricker MD

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COMMENTS APPRECIATED

Thank You

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CITE: https://www.r2library.com/Resource/Title/082610254

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PODCASTS: Employer Sponsored Health Plans Explained [Part I and II]

Self and Fully Insured Fundamentals and Basics

[A Two Part Presentation]

DR. ERIC BRICKER MD

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COMMENTS ARE APPRECIATED.

Thank You

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CITE: https://www.r2library.com/Resource/Title/0826102549

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PODCAST: Why Tech Companies Fail at Health Care

HEALTH PLAN “AGE” AS RISK FACTOR

BY ERIC BRICKER MD

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CITE: https://www.r2library.com/Resource/Title/082610254

COMMENTS APPRECIATED

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RISK MANAGEMENT: https://www.routledge.com/Risk-Management-Liability-Insurance-and-Asset-Protection-Strategies-for/Marcinko-Hetico/p/book/9781498725989

THANK YOU

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PODCAST: Unique Kaiser Permanente Success Factors

A VERTICAL INTEGRATED HEALTH PLAN AND HOSPITAL SYSTEM

BY ERIC BRICKER MD

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YOUR COMMENTS ARE APPRECIATED.

Thank You

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KP STRIKE: https://www.msn.com/en-us/money/other/some-32000-workers-at-kaiser-permanente-ready-to-strike-on-november-15/vi-AAQvYi5

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PODCAST: Health Insurance Plan Trends and Clauses

Medical Trend for 2020 is Estimated to be 6%.

Where Does That Number Come From?

Insurance Companies and Hospitals Negotiate Their Contracts Every 3-5 Years.

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YOUR THOUGHTS ARE APPRECIATED

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MORE: https://www.amazon.com/Financial-Management-Strategies-Healthcare-Organizations/dp/1466558733/ref=sr_1_3?ie=UTF8&qid=1380743521&sr=8-3&keywords=david+marcinko

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PODCAST: Domestic CEOs and Healthcare in America

WHY THEY DO NOT CARE?

By Eric Bricker MD

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Your comments are appreciated.

THANK YOU!

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PODCAST: First Quarter 2021 Health Plan Financial Results

THE SHERLOCK COMPANY

This podcast features a brief discussion by colleague Doug B. Sherlock CFA, Senior Health Care Analyst and President, Sherlock Company http://www.sherlockco.com featuring his insights into the quarterly financial reports of health plans, for the first quarter 2021.

The Sherlock Company | LinkedIn

PODCAST: https://www.healthsharetv.com/content/first-quarter-2021-health-plan-financial-results-podcast

Your thoughts are appreciated.

Citation: https://www.r2library.com/Resource/Title/0826102549

THANK YOU

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PODCAST: Direct Employer Contracting for Medical Services

Employers Can Enter Into Direct Contracts with Doctors, Hospitals and Other Healthcare Facilities for Medical Services for Members of Their Employee Health Plan.

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Texas CEO Magazine 2016 Economic Forecast: Dallas - Texas ...

BY ERIC BRICKER MD

Reimbursement Typically Takes the Form of a Bundled Payment or a Lower Rate of Fee-for-Service.

Employers with Greater Than 500 Employees Tend To Engage in Direct Contracting.

Mid-Market Employers with a High Concentration of Employees in One Geographic Area Tend to Engage in Direct Contracting as Well.

The Employer Frequently Uses an Independent TPA to Process the Claims for the Direct Contract.

Also, the Employee Health Plan Changes the ‘Benefit Level’ Such that Care at the Direct Contract Facility is Often at $0 Out-of-Pocket Cost for the Member.

Engaging the Plan Members with Navigation Services is Helpful to Make the Experience Integrated with the Overall Health Plan Offerings.

YOUR THOUGHTS ARE APPRECIATED.

CITE: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

THANK YOU

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The Percentage of Covered Employees by Type of Health Plan

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From 1988 to 2000

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Health Plans

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

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Health Plans and the Three Levers of Innovation for Affordable Care

Unlocking Affordable Care

Number 2 in a Series of 6

By Sam Muppalla – Vice President, McKesson Health Solutions, Network Performance Management (NPM)

Last week, for the ME-P, I wrote about the increasing Pressure to Deliver Affordable, High-Quality Care.

In the face of those pressures, many health plans have begun to explore innovative approaches to product, care model, and reimbursement designs. What are they doing?

In this second installment of our series about unlocking affordable care, I’d like to take look at how some of the pilots in these areas show promise.

Product Innovation

One path health plans are using to achieve affordable care is through the deployment of value-based insurance designs (VBID). At the heart of this approach is the utilization of member incentives to reduce barriers to high value Rx and services. Conversely, it also incorporates disincentives for low value services or Rx. Typical member incentives include premium reduction, co-pay/coinsurance waiver/reduction, and health reimbursement accounts (HRA). Co-pay increase or cost sharing are typical disincentives. Member steerage to high value providers is another typical goal of VBID. The design of the supporting networks is critical to the success of VBID products. The network design has to ensure that the composition, the quality and the value of the participating providers can fulfill the benefit design and match steerage goals of the member incentives. Furthermore, the network level provider reimbursement guidelines should be complimentary to the member incentives.

For example, member incentive for a preventive exam during a Primary Care Physician (PCP) office visit could be matched by a Pay for Performance (P4P) provider incentive (on top of regular capitation) to perform the examination. Without the incentive, the Per Member Per Month (PMPM) capitation might be a disincentive for the PCP to perform the preventative exam.

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Figure 1: Network steerage is a critical component of product innovation.

Care Model Innovation

Innovative care models provide another approach to the delivery of affordable, high-quality health services. Population management-based care model designs, such as Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) designs, are an important advancement towards affordable care. These designs deploy a care team-based approach rather than a traditional siloed services approach to ensure a continuity of care.

The PCMH care model results in continuity of care via a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. The emphasis for PCMH is about collaboration to manage a population’s health.

Another example of a care model with a team-based approach is the ACO care model. In this care model, the emphasis is on accountability for providing the required healthcare services for a defined population. Health plans are rolling out ACO pilots across the nation.

For example, the Pension System (of the California Public Employees’ Retirement System) formed a partnership with the Blue Shield of California Health Maintenance Organization, Catholic Healthcare West, and Hill Physicians Medical Group with the goal of improving quality of care while reducing costs. Some of the early findings are showing positive results:

  • 17 percent reduction in patient re-admissions since the pilot began
  • Length of stay reduced by one half day
  • Almost a 14 percent drop in the total days patients spend in a facility
  • 50 percent reduction in the number of patients who stay in a hospital 20 or more days

These results show that it is possible to utilize care models to improve the quality of outcomes while reducing the cost of healthcare.

It is worth noting that health plans are not limited to adopting one care design innovation over another. Greater benefits can accrue to both consumer and provider by combining approaches—leveraging both collaborative and accountable care designs.

Adoption of population management is forcing a change from paying for individual providers’ services to paying for health management of a population across a team of providers. Supporting this requires the reimbursement systems to understand the structure of the care team, role of the various providers within the care team and the relationships between the providers in the care team.

In other words, it will need to understand the provider network structure to calculate the reimbursement. Another complexity is that providers participating in PCMH or ACO care models may also be directly contracted with the health plan. Selecting which payment arrangement to use in these scenarios will require an understanding of providers’ relationships with the plan.

Reimbursement Innovation

Along with innovations in product and care model designs, health plans are also innovating in the area of provider reimbursement. These innovation efforts primarily focus on enabling incentives for quality and performance, while controlling the rate of medical cost growth. These objectives reflect the need to move away from a healthcare system that bases provider reimbursement on volume to one that bases provider reimbursement on the value of the outcome. Within this approach, a variety of different models are evolving (see Figure 2). 

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Figure 2: Mixing and matching payment models.

Evolving in parallel with individual models is an understanding that the ability to mix and match different reimbursement designs will deliver greater value than the utilization of just one design. Health plans are mixing and matching different reimbursement methodologies to optimize provider performance. This implies that a provider is likely to have multiple valid payment arrangements at any given time. Picking the appropriate payment arrangement will require the reimbursement engine to understand the role of the provider in the network and the full context of all of the provider’s relationships.

Assessment

Next week, I’ll be discussing why the alignment between products, care models, provider reimbursement, and network design is so important when it comes to scaling these innovative approaches.

If you can’t wait that long for that discussion, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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A Nutrition Label for Health Insurance Plans?

Appreciating “Search Frictions”

By Dr. David Edward Marcinko MBA CMP™

[Editor-in-Chief]

Because products vary so much across many characteristics, health insurance is not easy to shop for. Comparing plans is an apples-to-oranges problem.

Of Search Frictions and Economic Externalities

As a former insurance agent for more than a decade, this is a situation by design – to obfuscate the patient and consumer.  

The challenges of comparison – health insurance plan – shopping then, creates what economist and colleague Austin Frakt PhD calls “search frictions” or inefficiencies in the ability to wisely choose. This may be likened to economic “externalities” and perhaps even motivated the recent development of (draft) standards for health plan labeling.

Beginning March 2012

So, how much will the new health plan labels, required starting next March, help consumers in their search for plans? How much grease will they add to the otherwise highly frictional process? I sure don’t know.

A good place to start however, is an examination of those frictions. What are they and how much do they matter?

Link: http://www.healthcare.gov/news/factsheets/labels08172011b.pdf

Assessment

Did food nutrition labeling, and the old food pyramid help – or confuse – consumers? What about the old and new cigarette warning label warnings? Or – the prohibition of alcohol for pregnant women – helpful or not! Any labeling for that matter?

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest ME-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

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Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed.

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Joe Flowers New Healthcare Reform Strategy

Selling Patients like Baseball Players – Seriously

By Staff ReportersFuture Physicians

Here is a health care reform strategy that we have not heard of before. It was formulated by healthcare futurist Joe Flowers, and is reposted below for your review.

It first posits this question, and then gives a plausible answer, with unique new operational strategy.

Question

Why aren’t health plans more aggressive in promoting the long-term health of their members, like getting them to eat better, stop smoking, get a little exercise, and all that?

Answer

Because of health insurance industry “churn”

Strategy

Give Joe’s idea a read and tell us what you think?

http://www.thehealthcareblog.com/the_health_care_blog/2009/11/sell-patients-like-baseball-players-seriously-.html

More: www.imaginewhatif.com

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Defining Comparative Medical Effectiveness

An Emerging Health Economics Issue

By Staff Reportersdhimc-book8

Comparative Medical Effectiveness [CME] is not a new healthcare term or health economics concept. Federal initiatives specifically promoting CME were authorized under the Medicare Modernization Act of 2003, but the genesis took root decades before.

Finally … a Hot Topic

Comparative Medical Effectiveness has recently become a hot topic again throughout the arena of health care stakeholders, due to funding and initiatives advanced by the Obama administration, and the positive and negative reactions drawn by different sectors of stakeholders.

Related to Evidence Based Outcomes

For stakeholders including numerous health care policy organizations, the health plan industry, and various health care provider organizations: public and private promotion of Comparative Medical Effectiveness reviews and processes offer the potential for more evidence-based, outcome-benefit or even cost-benefit driven information to improve the health care decision making for all parties. And, for stakeholders concerned about limiting the role of government and third parties in their level of regulation and control over the direct delivery of specific patient care, Comparative Medical Effectiveness may become a lightening rod due to perceived potential as to how the process and information could ultimately be applied.

Definition of the CBO Report

The Congressional Budget Office Report “Comparative Effectiveness: Issues and Options for an Expanded Federal Role” offers the definition that follows:

“As applied in the health care sector, an analysis of comparative medical effectiveness is simply a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients. Such a study may compare similar treatments, such as competing drugs, or it may analyze very different approaches, such as surgery and drug therapy. The analysis may focus only on the relative medical benefits and risks of each option, or it may also weigh both the costs and the benefits of those options. In some cases, a given treatment may prove to be more effective clinically or more cost-effective for a broad range of patients, but frequently a key issue is determining which specific types of patients would benefit most from it. Related terms include cost–benefit analysis, technology assessment, and evidence-based medicine, although the latter concepts do not ordinarily take costs into account.”

Assessment

For related financial, economics, managed-care, insurance, health information technology and security, and health administrative terms and definitions of modernity, visit: http://www.springerpub.com/Search/marcinko

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. How do you define this term, and is its’ very definition evolving?

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

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