Health Reform Resources

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Articles

Perspectives: Six strategies to improve your health plan's performance in 2012
At Optum, we not only share your passion for health care improvement, we are committedto being part of the solution. This inaugural issue offers industry experts’ thought-provoking discussions—drawn from our recent webinar series—plus real-world examples of proven strategies for improving health plan effectiveness, profitability, and sustainability.

Changes to the star payment system: implications for plans
On July 27, 2011, CMS released its 2012 star ratings measures, which added new measures and removed or recalibrated others. While there were few surprises beyond a less-than-expected HEDIS inflation, it still has a material impact on plans’ strategies for monitoring, intervening, and improving performance.

Health Care’s New Frontier: Quality Program Integration
By integrating quality programs, such as case management, disease management,member outreach, and provider outreach, plans will be able to achieve a consistently high star rating and also generate the most revenue.

Prominent industry group taps Ingenix consultant for new book on medical loss ratio
Ingenix consultant David Tuomala examines actuarial implications of medical loss ratio in Atlantic Information Services’ (AIS) newest book, A Guide to Federal Medical Loss Ratio Requirements.

Health Reform Overview
Even before the post-election uncertainty about the survival of certain provisions, the Affordable Care Act had health plans and insurers scrambling to make sense of the health care landscape.  A mixture that will include all or at least some of the following—intensified rate reviews, new medical loss ratio (MLR) requirements, removal of lifetime limits, the requirement that individuals carry health insurance, guaranteed issue, accountable care organizations (ACOs), and changes to Medicare Advantage (MA)—will change how health insurers operate.

Navigating MLR Rules Requires Preparation and Planning
There is no question that the health insurance industry will be affected by new medical loss ratio (MLR) standards set forth by the Patient Protection and Affordable Care Act (PPACA). Final MLR regulations—designed to focus premiums toward direct patient care and away from administrative activities—have not yet been enacted by the Department of Health & Human Services (HHS). However, a model regulation was sent to HHS by the National Association of Insurance Commissioners (NAIC) on Oct. 21, 2010. [Note: Interim final regulations were released by HHS on Nov. 22, 2010.]

Plans Need to Start Gauging Member Movement Impact
Under health care reform, roughly 32 million Americans will be entering the healthinsurance risk pool primarily through participation in either an expanded Medicaidprogram or in health benefit exchanges. As health insurance plans prepare toaccommodate this impending new member influx and shifts in the types ofcoverage sought by these individuals, they will need to anticipate and plan for futuremarket dynamics.

Ingenix and Aetna in the HIE Market
First it was United Health Group’s (UHG) Ingenix Division’s acquisition of leading HIE vendor (and top competitor to Medicity) Axolotl. Then this morning Aetna counters by acquiring Medicity. In just a few short months these two payers have completely changed the landscape of the HIE market by acquiring the two leading HIE vendors in the market today. Now that both of these vendors are in the hands of payers what are the implications both to the HIE market and more broadly the healthcare sector? Following is our assessment based on our continuing research of the HIE market and a number of interviews today, not only with the Aetna and Medicity, but also several other active participants in the HIE market.

Recommendations for Minnesotas Personal Care Assistance Program
"Minnesota has a long history of implementing policies and programs to allow older adults and persons with disabilities to live in community settings rather than in institutions. The State’s Personal Care Assistance (PCA) program, operated by the Minnesota Department of Human Services (DHS) Disabilities Services Division, is an integral part of the State’s efforts to assist individuals to live in the community. Recognizing that the PCA program facilitates these goals, Minnesota has modified and enhanced its PCA program over the years."

Can We Reduce Health Care Spending? Searching for Low-Hanging Fruit in the Garden of Health System Reform
Can We Reduce Health Care Spending? Searching for Low-Hanging Fruit in the Garden of Health System Reform

Will Health Reform Slow Cost Growth?
"To many Americans, health care reform is more about preserving the status quo than it is about change. Surveys show that most of the 85 percent of Americans who have insurance like the coverage they have and do not want to change it. Consequently, advocates have promised that the newly passed Patient Protection and Affordable Care Act will protect the coverage Americans now have by slowing the growth in health care costs."

Comprehensive Application of Predictive Modeling to Reduce Overpayments in Medicare and Medicaid
"Improper payments for health care goods and services are estimated to be in the range of 3% to upwards of 10% of total health care expenditures nationally.1 Improper overpayments for fee-for- service medical claims in Medicare and Medicaid are estimated by the Center for Medicare & Medicaid Services (CMS) to be on the order of $10.4 billion for Medicare and $12 billion (federal share) and $21 billion (total computable) for Medicaid in FY 2007. 2"

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White Papers

Preparing for star ratings in 2012, Laying the Foundation for Success
The Centers for Medicare & Medicaid Services (CMS) are raising the stakes in measuring whether Medicare Advantage plans are delivering quality care with the implementation of a new star rating system.To move toward better quality ratings, plans need to fully understand the basic tenets of the star program, select a customized approach to identifying their core capabilities, establish best practices, and determine how to improve lagging scores on specific star quality measures.

Insights for Payers and Providers on Bundled Payment Models
The recent passage of health care reform legislation is increasing the pace of thesechanges with numerous mandates to reform payment practices. Many of these changesare based on successful pilot programs. For example, Medicare has been exploringquality-based reimbursement programs for a number of years through a series ofbundled payment demonstration projects. Likewise, commercial payers have adoptedquality-based payment methods to reduce costs through reimbursement models thatshift a larger percentage of financial risk onto the shoulders of providers. In all ofthese models, the providers that deliver the most efficient and highest quality care arerewarded with increased profits.

HIPAA 5010: A Second Chance for the Industry to Implement Transaction Standards to Reduce Costs and Increase Efficiency
The healthcare industry stands at familiar crossroads as it prepares to implement new electronic transaction standards.

HIE Sustainability Formula Using Analytics and HIPAA Transactions to Fund Current Operations Today
As the health care industry works to move health information exchange (HIE) forward by transforming how administrative, clinical and financial data are shared, the endgame is clear: improved health care quality and patient safety, better compliance with evidence-based protocols, enhanced care coordination, increased administrative efficiencies, reduced redundancies and, ultimately, lower costs.

Evaluating Solutions to Reduce Health Care Fraud, Waste, and Abuse on a Prospective Basis
With the intensified focus on reducing health care costs across the board, more and more software and services vendors are offering program integrity solutions. These offerings vary from software designed to identify fraud, waste (including errors), and abuse, to fully outsourced solutions designed to prevent and/or recover inappropriate payments. These offerings vary widely in their approach, and ultimately, in their ability to succeed.

Five Essentials for Evaluating Predictive Modeling Solutions
Predictive modeling solutions draw on payers’ vast stores of information to identify and characterize health risk and forecast future needs for medical resources. In many settings these solutions have been able to demonstrate a measurable return-on-investment (ROI) for three key areas of a health care payer’s operation: care management, underwriting, and benefit design

A NEW MODEL THAT WORKS Sustainable Health Information Exchange That Promotes Patient-centric Care
With health information exchange (HIE) being touted as an important tool in the federal government’s health care reform arsenal, the stakes for the success of individual HIEs could not be higher. Although existing HIEs—many of which are Regional Health Information Organizations (RHIOs)—have worked hard to advance the goal of improving the quality and delivery of patient care by sharing data, there is one obstacle that remains elusive: achieving HIE sustainability

Beyond clinical messaging: Integrating HIPAA transactions in real time with HITSP T85
The real-time exchange of clinical information between health care organizations is becoming increasingly important. In an effort to meet industry needs, many organizations are working to expand the capabilities of how that information is exchanged.

Will Opportunities be Leveraged or Squandered? Why Organizations Should Approach 5010, ICD-10 and HITECH Act Compliance with a Single Strategy
Will the health care industry squander the opportunities that lay ahead? The industry’s history is littered with squandered opportunities, particularly when those opportunities come through legislation and regulation. Why should anyone expect new opportunities to result in different outcomes?

Using Technology to Enhance Pre-Payment Fraud Detection: A Multi-Dimensional Strategy
It’s difficult to accurately estimate the full financial impactof health care fraud and abuse because much of it goesunreported, or worse yet, undiscovered. Conservativeestimates indicate the health care industry lost $51 billion in2003 to fraud, yet other estimates place the annual loss ashigh as $170 billion.

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Case Studies

Trumbull Medical Practice Reduces Costs, Increases Revenue per Patient, and Improves Patient Care With Ingenix CareTracker
Trumbull Medical Practice will gain a cumulative, projected five-year net benefit of $224,655 from the use of Ingenix CareTracker, due to savings in licensing costs and revenue increases.

Ingenix Consulting Partners with North Memorial in Epic Deployment, Improves Clinical Outcomes, Improves Efficiency, and Increases Cash Flow by $31.2 Million
Ingenix Consulting provided project management, planning, training, and implementation services for North Memorial’s Epic deployment and ongoing engagement.

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Videos

EMR Inside Look

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