What’s Happening at MCOL | The Accountable Care Directory Version 2.0 released

By Claire Thayer, July 31, 2012

The Accountable Care Directory 2012 Version 2.0 is now available and is a unique resource for Accountable Care stakeholders and others monitoring the industry! Version 2.0 includes an Organizational Directory of over 200 selected ACOs, including the Medicare MSSP, Advanced Payment and Pioneer ACOs as of date of publication, plus a wide range of ACOs serving selected Commercial and other populations. Contact and summary information is provided for each organization, along with a listing of key individuals with leadership or operational involvement. Over 700 of these individuals are listed, with direct phone and email contact information when available.

Choose from book or electronic formats.  An excel database is also available to purchasers of the book or pdf version. More information: https://www.managedcarestore.com/yhlthqst/hqaco.htm


Too Bad About Your Coverage 

By Kim Bellard, July 30 2012

There’s more data that shows health coverage is good for people.  Too bad fewer people than expected will have it. 

The New England Journal of Medicine recently reported on a study by Sommers et. alia which showed that Medicaid expansions can be linked to lower mortality rates in the impacted populations, along with better access to care and improved self-reported health status.  Not surprising, really, especially on top of last year’s study from the Oregon Medicaid program, that also showed that those lucky enough to win their coverage “lottery” did fare better. 

ACA was supposed to greatly increase the population covered by Medicaid, but with the Supreme Court ruling’s loophole on states adapting the expansion, that picture no longer looks quite as rosy.  The Congressional Budget now estimates that 6 million fewer people will get coverage through Medicaid and CHIP, although they obviously do not yet know which states will elect not to expand their programs.  CBO believes that half of those 6 million people will get coverage via the insurance exchanges – although I’m not clear why someone who would have gotten coverage in the Medicaid expansion would have income above the magic 133% of poverty level – leaving a net increase of 3 million more uninsured than under the original ACA estimates. 

CBO also believes those 3 million additional enrollees in the insurance exchanges will cost more than average, and as a result add about 2% to the cost of individual insurance in the exchanges.  That is another hidden “tax” on the private sector.

Whenever I think about the injustice of millions of poor people not having access to coverage while middle class people get subsidies, I remind myself that this is nothing new.  We’ve been doing that with the tax preference for employer health coverage for decades, so this latest indignity merely makes things quantitatively worse, but is not qualitatively new. 

Speaking of employer health benefits, Deloitte’s recent survey of employers forecasts 9% of employers will drop their health coverage, with another 10% uncertain what they will do.  This compares to the GfK study estimate from last winter of 12% drop/32% uncertain, and the now infamous McKinsey estimate from last summer that 30% of employers would drop coverage.  Deloitte’s survey, though, was only of employers with more than 50 employees; if smaller employers were included, the number would no doubt be higher than the 9%.

Reasonable experts can probably agree that the estimate of employers initially dropping coverage is somewhere in that 10-20% range, recognizing that many employers have not yet made up their minds.  The trouble I see is that once this ball starts rolling downhill, it won’t stop; it’s only going to pick up speed.  No one is going to want to be the last one in the benefits pool.

A little history lesson might be helpful.  Health insurance used to be virtually all fully insured and community rated.  That worked for a while, until some employers and insurers figured out that both could benefit by offering lower rates to employers with lower cost populations.  That gradually led to the demise of community rating – HMOs were the last to give up the ghost – in the group market, as fewer and fewer employers were willing to subsidize their higher cost fellow employers.  Use of employer-specific claims experience became the norm, especially for larger employers.  In the early 1970s, spurred by the passage of ERISA, employers also realized even with experience rating, being part of the insurance pool at all still had limitations they wanted to avoid, and they began to adopt various forms of self-funding.  It initially was only for very large employers, but, again, gradually became adopted by employers or more and more sizes – some of whom were/are really too small from an actuarial point of view to justify it.  Again, once some employers escaped being insured, other employers became more uneasy about still being part of the insurance pool.

Self-funding had the specific advantage of escaping state benefit mandates, although recent federal mandates, including ACA’s, are rapidly eroding this advantage of self-insurance.  The ACA requirements have added costs to most employer plans – e.g., coverage dependents, unlimited maximums, no coinsurance on preventive services – and the government’s involvement in their benefit design is probably not sitting well with many employers who thought they had escaped it.

At this point in time, most group business is self-funded.  Kaiser Family Foundations’ 2011 Employer Health Benefits survey found 60% of employees were in self-funded plans, up from 49% in 2000.  Over 80% of employees in firms with 200 or more employees are in self-funded plans.   I.e., to the extent they can, employers have made rational business decisions not to subsidize anyone they don’t have to.

Why anyone would believe employers would not act the same way once some employers start dropping their health plans is beyond me. 

Employers have invested a lot in their current health plans.  They have shown much thought leadership in driving changes to both insurers and providers, but the auto and steel industries, to pick two, have shown us how legacy health costs can hamper domestic and local competitiveness.  Right now, not offering health plans is a huge disadvantage in attracting and retaining employees; Deloitte’s survey shows over 80% of employers cite attracting/retaining employees as a key reason for offering health benefits.  However, it would only take a few bellwether employers to start dropping coverage to start a rush by other employers for a similar exit.

Employer coverage still has the advantage of the tax preference, plus the fact is that the health insurance exchanges are not up and running and the individual market is not yet reformed or robust.  Come 2014 or 2015, though, the exchanges may be a more appealing option, especially for smaller employers, and if anyone believes the tax preference will survive as is in the coming deficit reduction wars, well, good luck with that.

People aren’t going to keep their current health plan.  Many poor people will still not be protected by Medicaid.  We will still have some 30 million uninsured.  And we’re still not getting good value for our exorbitant health care spending.  Until that problem is solved, everyone’s coverage is in danger.


ACOs by the numbers

By Clive Riddle, July 27, 2012

CMS now touts that with the 88 ACOs brought on line effective July 1, 2012. “the total number of organizations participating in Medicare shared savings initiatives to 153, including the 32 ACOs participating in the testing of the Pioneer ACO Model by the Center for Medicare and Medicaid Innovation (Innovation Center) that were announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011.  In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.”

On the commercial side, Cigna has been a national leader in the ACO arms race, with Aetna also making waves, and a wide range of plans have well-developed regional initiatives. Cigna states they are now engaged in 38 patient-centered initiatives in 19 states, including six multi-payer pilots and 32 Cigna-only collaborative accountable care initiatives, covering more than 300,000 Cigna customers, with more than 4,500 participating primary care physicians. Aetna Inc. is developing commercial ACO and Aetna currently has 10 commercial ACO agreements in place and hopes to 20 by the end of the year.

Perhaps the most prevalent commercial strides with attributed membership to date involve the self-funded employee populations of the hospitals and physician organizations that have developed ACOs, using their own employees as the initial pilots for their respective programs.

Using MCOL research in compiling Version 2 of the Accountable Care Directory 2012, the following are ten identified ACOs with large attributed membership (combining Medicare and Commercial when applicable) at this juncture:

  1. Advocate Health Partners, serving Illinois with 350,000 attributed members
  2. Partners for Kids, serving 37-county coverage area, stretching from urban Columbus to rural Appalachia with 290,000 attributed members
  3. Healthcare Partners Medical Group, serving Los Angeles and Orange Counties, CA with 89,000 attributed members
  4. Accountable Care Coalition of Texas, Inc. , serving Houston/Beaumont area, Texas with 70,000 attributed members
  5. Heritage Provider Network, serving Southern, Central, and Costal California with 70,000 attributed members
  6. Aurora Accountable Care Network, serving Eastern Wisconsin and Northern Illinois with 58,000 attributed members
  7. Sharp Healthcare ACO, serving San Diego County, California with 56,700 attributed members
  8. Atlantic Accountable Care Organization, serving Bergen, Morris, Somerset, Sussex, and Union counties, New Jersey with 50,000 attributed members
  9. Hill Physicians Medical Group, serving Sacramento, El Dorado, Placer counties, California' with 46,000 attributed members
  10. Partners Healthcare, serving Eastern Massachusetts with 45,000 attributed members

What’s Happening at MCOL | New Video – What is MCOL?

By Claire Thayer, July 23, 2012

What is MCOL?

Listen to a new three minute video describing what mcol does for those in the business of healthcare. MCOL means memberships, newsletters, webinars, directories, e-learning, healthcare social media, web sites and promotional solutions.

Learn more via mcol's healthsharetv site at: http://www.healthsharetv.com/content/what-mcol-0


The Role of Pharmaceuticals in Value-Based Healthcare

by Clive Riddle, July 19, 2012

Who is the “Working Group on Optimizing Medication Therapy in Value-Based Healthcare” you ask? They consist of National Pharmaceutical Council (NPC), the American Medical Group Association (AMGA) and the Premier health care alliance, along with seven provider organizations, formed to develop a “framework for considering the role of pharmaceuticals in achieving value-based success.”

It could seem somewhat self-serving, given the National Pharmaceutical Council was a driving force in the initiative and issued the press release about their newly published framework. However the group does say some interesting things. Their entire thoughts on the matter are published in a web article,  Role of Pharmaceuticals in Value-Based Healthcare: A Framework for Success, in the American Journal of Managed Care.

NPC Chief Science Officer Robert Dubois, MD, PhD tell us “Providers are shifting to value-based care models to provide better care for individuals, improve population health and slow cost growth. Many of these models, such as the Centers for Medicare & Medicaid Services' Medicare Shared Savings Program, include quality benchmarks and incentives for reducing costs. As providers evaluate optimal care for their patient populations in these new models, prescription medications should be thoughtfully integrated into the process.”

Here’s the components of the framework they have constructed:

  1.  Success in a value-based environment will depend on understanding the unique contribution of medications and utilizing them optimally across conditions and populations.
  2. Medications cannot be viewed as a siloed expense item in a value-based environment. They need to be integrated so that the cost offsets and quality benefits resulting from optimized pharmaceutical use can be recognized and calculated.
  3. Services meant to optimize patient outcomes cannot be undertaken as a one-size-fits-all approach; the role, impact and characteristics of these services will vary by a patient's condition.
  4. Overall risk factors can be used to identify patients who are candidates for medication therapy management strategies to watch for drug-drug, drug-disease, or polypharmacy concerns.
  5. In each circumstance where there are condition-specific incentives to achieve cost savings, there should also be a quality metric to detect under-use of pharmaceuticals.

The group views ACOs as a centerpiece of value based programs. Doctor Dubois leaves us with this thought: "It is crucial for ACOs to view prescription drugs as a tool, not simply an expense.”