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CMS issues final ACO rule

Last week, CMS issued a final rule for the Medicare Shared Savings Program. The rule reflects some changes based on public comments. Among other things, it creates a new ACO track based on certain successful aspects of the Pioneer ACO model, including the opportunity to use new care coordination tools; and streamlines data sharing between CMS and ACOs, allowing participants to easily and securely access patient data. The final rule also calls on ACOs to describe (in their applications) plans for promoting the use of health IT to improve care coordination. (iHealthBeat; final rule) 



GOP unveils ACA replacement 

The Republican Study Committee unveiled its blueprint for overhauling U.S. health care if the Supreme Court rules against the administration in King vs Burwell. It repeals the individual and employer mandates and alters the subsidies. Individuals would get a standard tax deduction of $7,500 a year, rising to $20,500 for families, for buying health insurance. That would apply to everyone with private insurance. Insurers would no longer be required to cover a set of 10 essential health benefits. (Washington Post; Wall Street Journal Washington Wire) 

California seeks approval to pay for housing with Medicaid
California is asking the federal government for permission to use Medicaid money to help put the most medically fragile homeless people in housing. Mari Cantwell, deputy director, state health care services department, said health care and housing traditionally have been in distinct silos. "[O]ur belief is that this will improve health care and reduce costs." The money would pay for case managers to help people get whatever they need to stay in housing, except for rent. Any savings could be used by managed care companies to invest directly in providing housing, in partnership with local governments and others. (Kaiser Health News)


Innovation & Transformation

PCMH pilot reports positive results in quality and utilization

A large multi-payer patient-centered medical home program achieved significant reductions in unnecessary health care utilization as well as notable improvements in quality of care, according to research published in JAMA Internal Medicine. The study evaluated the northeast region of the Pennsylvania Chronic Care Initiative, a PCMH pilot. "During a 3-year period, this medical home intervention, which included shared savings for participating practices, was associated with relative improvements in quality, increased primary care utilization, and lower use of emergency department, hospital, and specialty care," researchers conclude. (JAMA Internal Medicine; Patient-Centered Primary Care Collaborative) 



Viewpoint: Develop quality metrics for integrated physical/behavioral care 

A JAMA Viewpoint piece identifies "the interface of behavioral (including mental health and substance use conditions) and general health care" as a promising area for beginning to change the status quo. Even though such integration has been shown to improve outcomes and reduce spending, it has yet to catch on. The authors say adoption's "missing link" may be quality measures for assessing and rewarding well-integrated care. "Developing and validating a set of robust quality measures that targets this high-cost/high-need patient population and is tied to new payment mechanisms can play a powerful role to encourage more cost-effective care." (JAMA; Commonwealth Fund)
In an interview with the Advisory Board, Steven Lipstein, president and CEO of BJC HealthCare, discusses topics including the hospital's role in a world of retail medicine. He also predicts dramatic changes in primary care. "For me, the more interesting question is how the nature and scope of primary care will change in the coming years," he says. "One scenario has primary care physicians designing new models of care delivery and leading teams of non-MD health care professionals who work proactively to reduce the utilization and cost of episodic care delivery and at the same time improve health outcomes." (Advisory Board)
Consumers & Providers

Medicare pays the most to radiation oncologists and dermatologists 

CMS recently released new Medicare data that reveal hospitals' charges and payments, as well as what doctors billed, in 2013. Nearly 4,000 providers were paid at least $1 million, and five doctors were paid more than $10 million. The highest-paid specialists were radiation oncologists (an average of $403,512 in Medicare payments), dermatologists ($331,108), vascular surgeons ($329,874) and ophthalmologists ($326,621). (Advisory Board Daily Briefing) 



N.Y. ACO launches own insurance company 

More than 100 doctors in New York's Hudson Valley have launched a new health insurance company. Modern Healthcare calls Crystal Run Health Plans' launch "one of the most striking examples of the tolerance for high risk that has flourished in healthcare as the industry looks to capitalize on upheaval under the Affordable Care Act." Crystal Run Health Plans' networks will include Crystal Run Healthcare providers as well as other providers, health care facilities and hospitals. Many Crystal Run plans include pharmacy benefits, as well as vision and dental coverage for dependent children. (Modern Healthcare)

At the recent American Society of Clinical Oncology meeting, Anthem presented promising early results from a program that seeks to lower costs by changing how oncologists are paid. Oncology practices, which buy cancer drugs upfront, have traditionally gotten part of their pay based on a percentage of the cost of drugs they administer; that can create an incentive to use pricey drugs, the Wall Street Journal Pharmalot blog explains. Anthem's program pays participating oncologists an extra $350/month "care management fee." This roughly makes up the difference between what practices earn in Anthem's program and what they would earn for using costlier, but not necessarily more effective, drugs. (FierceHealthPayer; ASCO poster; WSJ Pharmalot blog) 
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New & Noted   

Struggling with HIX rates: Forty-four percent of Covered California policyholders are having trouble paying for their premiums, according to a Kaiser Family Foundation survey. A similar percentage of uninsured Californians say the high cost of coverage is the main reason they go without health insurance. (Los Angeles Times)


MLR not harming profits: An examination of the medical loss ratio (MLR) in 2014 suggests the financial performance of insurers has not changed substantially since the years before the Affordable Care Act, according to the Kaiser Family Foundation. (FierceHealthPayer; Kaiser Family Foundation)


Cancer drug cost wrapup: As previously reported, many speakers at this year's American Society of Clinical Oncology's annual conference raised questions and concerns about the skyrocketing cost of cancer drugs. ASCO's annual report on the state of cancer care found seven of the 10 most expensive drugs covered by Medicare in 2013 were cancer medications. Modern Healthcare offers a wrapup. (Modern Healthcareannual report)



ACA roundup: Prof. Timothy Jost provides updates on several ACA-related topics in his regular blog post. Among them: updated enrollment figures; premium increases; and medical loss ratio and broker commissions. (Health Affairs Blog)


Some states are braced for the Supreme Court to rule the federally run exchange subsidies unconstitutional. Pennsylvania and Delaware have already announced they would launch their own exchanges. Many others that stand to lose their subsidies could then pursue a similarly simple strategy, The Hill reports. (The Hill)

MarketVoices...quotes worth reading


"Retail medicine is based on a premise of high demand for easy-access episodic care to relieve symptoms of minor illness." Population health management will require models that reduce utilization of episodic care, which begs the question: Are the two trends in conflict with one another? "Time will tell." -- Steven Lipstein, president and CEO of BJC HealthCare, in an interview with the Advisory Board 

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Wednesday, June 10, 2015































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