Blog and Whitepapers

Recon takes an analytical look behind select developments in healthcare

Clear Health Alliance: Debut of the for-profit HIV/AIDS special needs plan

Summary HIV Special Needs Plans (SNPs) offer extra layers of services specialized for the HIV/AIDS patient and can generate attractive savings particularly in reduced in-patient costs A new partnership in Miami-Dade is creating a for-profit model in what has historically been a space pursued by mission-oriented non-profits Recent Florida legislation mandating HIV positive Medicaid members join an HMO specialized in HIV/AIDS sharply expands the potential market for SNPs and was likely critical for the for-profit venture In contact to the condition-specific provider ACO, SNPs are likely better suited for addressing

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Rescuing the condition-focused ACO from CMS

Summary The case for an oncology ACO can be compelling but CMS rules for ACOs within fee-for-service (FFS) make value difficult to demonstrate A new physician-hospital-payer partnership in Florida will test whether the oncology ACO model can succeed outside the CMS rules The payer partner has a limited Medicare position and the hospital partner is reputed to be high priced. Despite these potential issues, there are good reasons to think the partners are well aligned on a growth agenda for the model If the model itself proves out, however, it

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Transitioning from patchwork to quilt: NY and PA’s path to integrating HIEs at the state level

Last month, NY and PA announced plans for how they will integrate data sharing across local HIEs. The state planning efforts share some key parameters: Roughly equal funding with about $20 million in federal grants Initially targeting  the integration of data for about 13 million people (in PA’s case the entire state, in NY’s case the NYC metro area) Using a “thin” umbrella model to knit the various existing local HIEs together into a decentralized model Want community involvement of local doctors, community workers, and payers Beyond those parameters, however, the plans look quite different. NY’s approach: Start

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Heartland Health: Marching towards Kansas City with Mayo on its shoulder

Earlier this month, Heartland Health signed a deal with the Mayo Clinic for its doctors to virtually consult cases with Mayo physicians in return for an undisclosed fee. Heartland Health is a regional medical system in northwest Missouri and includes a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations.  Heartland is now the fifth hospital system to join the Mayo Clinic Care Network (MCCN), a structure launched by Mayo in September 2011. The deal substantially

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The Blues system and PHIXs: not standardizing on a single utility

BCBSMN has licensed the platform for its private health insurance exchange (PHIX) and defined contribution product from eHealth (original announcement April 30). For eHealth, which has seen its government systems revenue fall off by $2M year-over-year in the most recent quarter (per Q1 2012 analyst call), the deal will be a welcome addition to its non-commission revenue stream. It also represents a significant in-road into the Blues system (the previous deal with Blues I could uncover was in mid-2010 for licensing the technology behind Premera’s online Medsupp sales). It appears

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Towers Watson’s bold move in private insurance exchanges: leapfrog Aon and leave Mercer’s alliance compromised

With its acquisition of Extend Health, Towers Watson has ensured that (1) PHIXs will be a key competitive arena among the major benefits consultants and (2) that it has taken the lead. Extend Health serves 170K members and has annual revenues of ~$50M+, EBITDA margins of ~30% and a growth rate in the most recent reported quarter of 40% vs. a year ago (all taken from the S-1 filing and acquisition press release). Two leading competitors have been publicly discussing their capability building: Aon Hewitt began their exchange in April

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Big box retail as health insurance channel: thoughts on the Aetna-Costco deal

Summary Aetna has struck a deal to sell individual health insurance with Costco, the #6 retailer. The deal targets 9 populous states first with more to follow in 2012  While the deal lacks some of the levers of the very successful Walmart-Humana Part D deal, there is real potential for this channel to attract consumers if employers opt-out on a large scale Given that Aetna has some arrangements with Best Buy (the #9 retailer) and an established alliance with CVS (the #7 retailer), it looks like Aetna is building out

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Payment reform: some observations on skepticism

There have been some blog posts (here and here) about a discussion on payment reform at the Massachusetts Health Data Consortium last week. While I did not attend, the commentary is provocative and I would like to offer a few observations. The discussion included some critical perspectives on the prospects for implementing payment reform and whether its implementation will really bend the trend. My main point in response to the dialog is that payment reform needs to be understood as part of a dynamic trajectory, a multi-stage game. Couple variations

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Franchising specialties: model for breaking down geographic barriers to competition?

Summary Geographic barriers to provider competition are a headache for payers By importing capabilities, specialty franchising could help reduce some of the barriers to cross-geography competition It is too early to tell whether the recent Sarasota-Columbia is a good example of what franchising could do given the rapid growth in capacity for high-end cardiology in the area; it may be more about preserving network status and price point But payers should not assume the model will be a disappointing supplement to provider leverage: Instead, consider encouraging providers with differentiated outcomes

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The ASO escape hatch for small group: California says “not so fast”

Next week, the California insurance commissioner will propose legislation to deter small employers from exiting the traditional health insurance market and going self-insured. The legislation will put a floor on the amount of losses an employer must incur with any one employee before the stop-loss coverage is triggered (“attachment point”). This won’t affect larger employers which benefit from the balancing impact of their large numbers and so only need to protect themselves from the most catastrophic risks. The bottom lines of self-insured smaller employers are much more vulnerable to even

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Home health’s LHC Group decoupling from the stock market: where is it going next?

The PE firm TPG is reportedly considering investing in LHC, a publicly-held home health agency (LHC announced earlier this year they were exploring strategic options). PE funding could allow LHC to pursue a much bolder strategy in the wide-open post-acute care market. Home health With home health revenues of ~$560M, LHC is #3 behind Amedisys ($1.25B) and Gentiva (~$1.1B) and ahead of #4 Almost Family. These four operate in an incredibly fragmented industry of $70B/year (though most of their attention is on the $20B year Medicare FFS market). The vast

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Lumeris, NaviNet and the emerging battle for cloud-based ACO enablement

Summary Administrative clearinghouse NaviNet has been acquired by 3 Blues plans and a provider of analytics capabilities for plans and providers (Lumeris).  Both NaviNet and Lumeris appear to need a strategic breakout. The key opportunity is coupling sophisticated cloud-based (=EMR agnostic) analytics with a real time communications platform touching 130K physician offices.  If viable, cloud approaches to ACO enablement could reduce the upfront infrastructure cost for providers to go at-risk, therefore allowing smaller scale provider groups to participate in the new economics – an attractive proposition for payers unnerved by

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Compete by creating more competitors: the Heartland Health deal and Aetna’s strategic jiu jitsu

Yesterday, Aetna announced a deal with Heartland Health (an integrated delivery system serving northwest Missouri, northeast Kansas and southeast Nebraska) to create a new health plan for the small group market (2-50 employees) for 2 counties in Missouri and 1 county in Kansas. Heartland Health has a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations. Most important, recent financial evaluations have given Heartland Health a startling 82% market share in primary service area (!).

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Aetna and Best Buy: a new twist on retail in healthcare

Aetna has struck a deal with Best Buy to sell four online coaching programs (fitness, weight management, smoking cessation and stress management) in new 1,200 sq. ft. “health technology departments” in 3 suburban Chicago locations.   In these departments, Best Buy is selling a broad range of technologies and tools for fitness, sleep, nutrition and beauty alongside the Aetna programs.   The strategy: target Best Buy’s tech savvy customers when they are thinking about health and when they have an expectation to buy (vs. for example being on-line when there is more

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“Savings illusion” can become savings reality in the long haul: baby boomers to the rescue

A recent article in the NEJM argues that cost savings from quality improvements are illusory because of the lumpy nature of healthcare capacity.  Quality’s impact on utilization is just too small to be captured in a heavily fixed cost environment.  Any reduction in utilization results in a trivial savings of direct costs and, more importantly, unchanged fixed costs simply being reallocated across the smaller volume. Cost reduction in a high overhead environment is indeed difficult (ask any of the big process consulting houses).   It can be done, though it will

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Bubble in acquisition pricing of Medicare Advantage lives?

Several recent acquisitions suggest a rapidly growing valuation on Medicare Advantage (MA) lives. Last August, Healthspring paid about $3.6K per adjusted MA life with its acquisition of Bravo. (My adjustments extract the value of the PDP lives using the CVS acquisition of Universal American PDP lives as a benchmark and for the share of Special Needs Plan or SNP lives which typically have higher utilization levels and higher reimbursement). This past November, there were two major MA acquisitions, both with sharply higher prices. Cigna (CI) bought Healthspring for $3.8B —

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XL Health in play: what do the three suitors see?

UPDATE: United buys XL Health! Here’s what we surmised in the original post on this topic:  “That leaves United. A leadership position in C-SNPs would fit well with United’s leading position in Medicare Advantage overall, #1 position in D-SNPs and #2 position in I-SNPs. The capabilities would also seem to be readily applicable to the broader Medicare population (given, for example, the potential transfers back and forth across between C-SNP and regular Medicare Advantage). The curious thing is that United dramatically reduced its C-SNP business last year (went from about

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Emerging Unintended Consequences of Health Care Reform

In complex system, even small changes can have big, unexpected consequences.  These are occasionally beneficial but more often than not have a negative impact.     Over the last year we have started to see some evidence for unintended consequences from the health care reform act.  Negative impacts that we see are of two kinds: Perverse effects that directly affect the objectives of the act and side-effects that manifest in seemingly unrelated areas (see figure below). It is not the intent here to comment on the overall merits or demerits of

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The CIGNA-Healthspring deal: local share key to top-line synergies but still missing from the equation

Summary Provider discounts are a key priority for national accounts – which puts CIGNA (CI) and Aetna at a disadvantage; CI responding in part by trying to get closer to providers A provider collaboration strategy requires a critical mass of patients and provider mindshare. CI does not have it; nor will the Healthspring (HS) acquisition provide it given the limited geographic overlap between the two companies CI must therefore grow share in key markets to capture the deal’s potential provider collaboration synergies (though other synergies are certainly accessible) If CI

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Six strategic choices made by CMS in the final ACO rules

1. The final ACO rules largely maintain the demanding economic parameters for mature ACOs (Track 2) found in the originally proposed version (relative, for example, to the original PGP demonstration project): Potential for both downside and upside reward. Maximum shareable savings of 60% (less than in the original PGP demo); and the rewards are limited to an upper bound of total costs. In this regard, the ACO contract payoff locks a lot like your classic “collar” financial option (see graphic below). The starting cost benchmark based on the ACO’s actual

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Narrow networks: adoption growing among smaller groups

Kaiser’s latest employer benefits survey offers some interesting data on the adoption of narrow (or high performance) network products. See chart below: Couple of observations: Overall adoption at the firm level appears to stand at almost 20%. The data probably under-represents the share of firms with a narrow network product: firms which have narrow networks in their second or third most common plan would not appear in this data. However, the share of lives in a narrow network product is probably lower: I would think narrow network products are adopted

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Private health insurance exchanges and defined contribution: thoughts on Wellpoint’s acquisition of Bloom Health

Why would a health plan want to buy an exchange? Isn’t the only synergy if the owning plan tilts the exchange in their products favor? And won’t that damage the value proposition of the exchange for buyers and see them flock elsewhere? To understand the Bloom Health acquisition, it is important to recognize that the private health insurance exchange (PHIX) space is quite fluid, consisting of three or four distinct market opportunities. (The fourth — capabilities resell — might not really qualify as a PHIX specific opportunity, it is more

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The Steward-Tufts deal and the looming threat of provider-led narrow network insurance

The Stewards-Tufts deal announced today will create a narrow network insurance product targeting the small group segment. As reported, members covered by the plan must get all routine care from Steward providers except for complicated procedures and when authorized by a Steward physician. In return, premiums should be 15-30% below other products. Tufts and Steward will share the premiums. Some local market context: Steward Health Care is owned by Cerberus Capital Management is the only major for profit system in the market. The deal follows at the heels of a

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A gradual roll-out of ACOs will minimize disruption and resistance

Part of the theory of ACO value creation is trading off more primary care (resulting in better care coordination, fewer missed time bombs, and use of lower cost care options) against reduced use of specialists, ERs and hospitals (few stays, shorter stays). Early results seem to describe substantial promise (although not for everyone who tries the model). Let’s assume this promise will be realized in broader roll-out for the purposes of this post. One fear that is ACOs will drain volume away from unaffiliated medical specialists and hospitals, leading to

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Upping in ante in Pittsburgh: the health information exchange arms race

A few weeks ago, UPMC announced an agreement among nine area systems to spend $4M over the next two years to launch a health information exchange called ClinicalConnect. Reportedly, Highmark (and presumably the West Penn Allegheny hospital system it is in the process of purchasing) requested to be a part of the initiative but was refused. Building electronic connections across hospitals – particularly between community systems (such as the non-UPMC participants in ClinicalConnect) and tertiary centers such as the UPMC facilities – helps make transitioning patients easier by making full

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Provider incentives in the commercial ACO: retaining a small share of savings in return for future volme growth

Earlier this month, Blue Shield of California announced 2010 results from an ACO partnership with the Catholic Healthcare West hospital system and Hill Physicians. The ACO achieved savings of $20M on a CalPERS population of 41.5K commercial and Medicare lives (where Blue Shield was the secondary payer) — $480 per person or 13% of sponsor costs (average sponsor premium contribution estimated at $3,735 based on press report that $15.5M equaled to 10% of premiums). These results appear to be significantly better than the results of the Medicare Physician Group Practice

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Partners’ acquisition of Neighborhood Health Plan: reinforcing the role of community health centers in the care continuum

Much of the public speculation (for example here and here) regarding the acquisition of a local high quality safety net health plan — is it about locking in Medicaid volume? or about doing a “good deed” before regulators make decisions about Partners market influence? – is not very persuasive. Partners is already under intense scrutiny — a program of pushing Medicaid volume to its own facilities would contradict its public promises, exacerbate regulator suspicion and not be very profitable anyway. And if regulators believed Partners has the market power to

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The curious absence of payers in public HIEs

Last week, the National eHealth Collaborative published a study of sustainability strategies for 11 leading health information exchanges (actually 12 including the VA). I’ll call these public HIEs to distinguish them from private HIEs – proprietary exchanges among a select group of providers such as an integrated delivery system. Remarkably, payer funding has a relatively small role across the sample: Only 3 report payer funding as an essential part of their current revenue model: Availity (a joint venture among major Blues and Humana), the Rochester RHIO and the Quality Health

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Medicaid going mainstream: thoughts on the IBC / BCBSM / AmeriHealth deal

Historically Blues have shied away from Medicaid. Two thirds of plans do not serve any Medicaid and those that do often have disproportionately small shares. No real surprise: Medicaid specialist plans can fluidly move in and out of markets depending on the rates and redeploy their capabilities wherever are the best returns. Blues on the other hand, are prime “hold-up” targets because they are largely stuck in their assigned states. They can only respond to an offer of low rates with a threat of dismantling their Medicaid operations entirely (and

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ESRX-MHS Part 2: mail facility speculations (…or: Indulging my Inner SWAGer)

Summary ESRX was running at close to maximum capacity at its mail facilities while MHS has room to spare. ESRX is facing a scenario of significantly increased demand as greater mail penetration is achieved in the Wellpoint book and lacked the capacity to meet this demand. Similarly, ESRX would not be able to meet increased demand from reform coverage expansion. By combining, ESRX avoided having to build a new facility and the combined entity appears to have enough capacity to close at least one older mail facility. Given that a

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ESRX-MHS Part 1: Last stand of the PBM pure play: observations on the Medco-Express combination

UNH’s decision to take the commercial PBM business in-house did not force MHS into ESRX’s arms: I would argue that it removed the major roadblock to what the companies wanted to do anyway. MHS and ESRX had been talking about a merger off and on for few years (per WSJ reporting) and the logic (laid out below) is compelling but FTC concerns must have kept getting in the way. UNH’s decision doubled the size of its PBM subsidiary in terms of lives (somewhat less in terms of scripts because the

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Highmark and West Penn: it’s about mitigating consolidation, not transforming the system

Highmark will invest up to $475M in the West Penn Allegheny Health System, a move characterized as a prelude to purchase. This is no bold move to drive closer integration of information flows and care decisions or align incentives in a transformative vertically integrated model. My take: this is about desperately propping up the last competing provider standing in a highly concentrated hospital market. Highmark’s hand was forced by West Penn’s financial bleed out. But, in response, UPMC has thrown down the gauntlet in a move that will reshape the

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Did Wellpoint overpay for Caremore? No….not yet anyway

Summary Wellpoint probably paid full value for Caremore (if that company’s performance is as powerful as limited data suggests) but did not overpay. In addition, Caremore offers several powerful upsides if Wellpoint can continue to grow the model. However, Wellpoint will need to tread carefully to avoid damaging its purchase, given an uncertain record with vertical models (NextRx) and the inherent challenges in integrating fast-growing, PE-fueled innovators into large, mature businesses. Some indicator of Wellpoint’s strategy for Caremore will be given by its approach to Arizona — a key market

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Blue Shield of California’s unilateral profit cap: competitive gambit or PR move?

Summary: Blue Shield of California (BSC) has committed to keeping profits at 2% of revenues or less (and returning any excess). The commitment is economically meaningful: $180M of 2010 revenues will be returned; just a few years ago, BSC made 4.9% net income and, under its promise, would have had to return 2.9% of revenues. However, given BSC’s very large reserves, it has plenty of capital to fund investments or, if necessary, absorb losses. While the PR aspects of the move are interesting, it seems unlikely that this is an

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Employer opt-out as a result of reform: survey vs. model

Yesterday, McKinsey released a report suggesting that 30% of employers will definitely or probably stop sponsoring health insurance after the Federal reform “big bang” in 2014. Although disputed by the White House per press reports and the methodology details are limited in the published article, there are four good reasons to think the McKinsey survey could be correct: Contradictory studies (Urban Institute in January 2011 and RAND in April 2011) use simulation methodologies while McKinsey did a survey. With a change as transformative as Federal health care reform, simulation parameters

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Rapid shift to “bare bones” coverage among Massachusetts small employers: preview of Federal reform impact?

Summary Massachusetts small group went from an average actuarial value (share of expected medical costs covered by the benefit) of 85% in Q1-07 to 73% in Q4-09. In the same timeframe, actuarial benefit levels in another state for which we could find data (Wisconsin) held steady. Given that this trend was well underway in 2007/08, only a portion of the change can be attributed to the economy. The rest may well be a result of 2006 Massachusetts healthcare reform. If true, back-of-the-envelope analysis suggests 50-70% of the decline in actuarial

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Rise of self-insurance in smaller groups: opportunity and threat

Summary  Self-insurance is growing among smaller groups (including those sized 50-250) From a competitive point of view, it will be hard for insurers holding attractive groups in risk products to respond given the enormous profit cannibalization of converting from risk to an ASO offering But they will need to find some solution: risk products today are expensive for many groups given continuing low levels of utilization; “peanut-butter” share nationals at the forefront of these products (Cigna and now Aetna) won’t have cannibalization worries to stop them from pushing the model

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Major health plan Q1 earnings: Profit surprise in commercial risk; multiple reasons why business prospects look good

Public health insurers startled the market with earnings ~25% above consensus expectations. A key driver was lower-than-expected utilization (particularly in the under 65 commercial lives) which kept medical costs down. Management teams offered two theories in the analyst calls: bad weather and the beginning-of-the-year reset of consumer directed (CD) deductibles; neither is compelling: A lot of discretionary care has already been squeezed out of the system by the bad economy; it is hard to imagine that bad weather would drive out a lot more. Also the utilization decline was concentrated

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ACO profitability: Reasons for optimism

Summary A new article in the NEJM suggests ACO economics will be unattractive because of the costly upfront investment and low probability of shared savings payments. However, the results of the Medicare Physician Group Demonstration project show good earnings potential for providers (average >$5K per physician). Further: best-practice sharing, emerging narrow networks and scalability of ACO capabilities are likely to significantly enhance ACO economics for providers. It is likely that the most adept providers will be the ones forming ACOs; given delivery system capacity constraints, however, providers opting out of

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Primary care capacity and the looming Medicaid surge: Medicaid-focused providers must be part of the answer

Summary A new study from Center for Studying Health System Change suggests that new Medicaid eligibles under reform will have trouble getting access because most primary care are not accepting new Medicaid patients. Our view: The study does not take into account the role of focus in Medicaid which makes a big difference: Providers earning more than 25% of revenues from Medicaid are much more willing to take on all or most new patients. In fact, among the providers most likely to care for Medicaid eligibles, the willingness to accept

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Revolution in Roanoke? Perspectives on the Aetna-Carilion deal

Summary  The line between health plan and provider continues to evolve: the Aetna-Carilion deal exemplifies providers backward integrating into insurance (and contrasts with other providers exiting commercial insurance business e.g. art part of last year’s Coventry deals) The Aetna-Carilion alliance appears to have compelling, multi-layered business logic and there will surely be more of these sorts of couplings in markets where there is a strong provider brand and a health plan with low share but deep capabilities and ambition. Using the provider brand to sell insurance creates challenges for health

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How can a health plan weather the MLR hit to profitability? Some clues from Coventry

Summary Health plan profits will be down dramatically in 2011 due to MLR rules Providing care management services to providers building out ACOs and medical homes can open new revenue streams outside the MLR constraints System profitability (health plan + provider) can be enhanced if the health plan allows providers to keep more of the savings from ACOs while requiring larger fees for its care management services * * * Could this be part of the plan behind Coventry’s touted close provider relationships and plans to acquire more health plan

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Conventional wisdom that provider capacity drives cost questioned in new study

Remember the idea that coordination will improve care? Well, if physicians do not get timely reports from other providers, their patients seem to have lower costs!!!  This from a new study out from the Center for Studying Health System Change.  More importantly, this paper throws cold water on the idea that providers generate a lot of unnecessary cost to fill up excess capacity in the delivery system.   As you know, conventional wisdom driven by the Dartmouth Atlas and other studies has it that that care utilization and cost can vary sharply across regions without

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Surprising implication of drivers of Medicare FFS variation – MedPAC

New MedPAC report on Medicare fee for service utilization finds large geographic variation not explained by underlying risk or better outcomes. Another indicator of our HC system gone haywire.    A couple of overarching datapoints highlight the variation.  Only 25% of Medicare enrollees live in regions where Medicare spending is within 5% of the national average (looking only at utilization the # is 30%) Spending in top decile region was 55% greater than spending in the bottom decile region (looking only at utilization, the # is 30%) But that is not the

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Health care reform not so easy to derail

Prediction 1: Despite all the beating of drums we do not think there will be any major legislative changes between now and 2012. controlling the house but not the senate and the White House does not give Republicans sufficient clout to fundamentally change the bill it is politically advantageous for the Republicans to keep the Democrats on the defensive on health care through the 2012 election cycle Prediction 2: Administrative proceedings with implementation of the big milestones will continue though there will be considerable friction and much name calling some

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If you’re on Medicare – don’t fall sick

A friend of mine pointed out some shocking data from a report released today from the Office of Inspector General. More than a quarter of Medicare hospitalizations result in adverse events, half of them “serious” (meaning prolonged hospital stay, permanent harm, need for life sustaining intervention, death).  Strikingly, almost half these situations arise are preventable.  In other words they are the result of medical errors, sub-standard care, lack of patient monitoring and assessment and hospital acquired infections!  According to the study, these cost the taxpayer over $4 billion in 2008

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