PayerFusion Healthcare Insights Round Up – August

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August 31st, 2012
Categories: Healthcare Reform

Cost Management: Strategies for Self-Funded Health Plans

With the demands of the PPACA and the rising cost of medical care driving fully-insured premiums higher, more employers both large and small have been choosing to self-fund. Control of health plan design, management of plan costs and increased quality of care for their employees are seen as some of the main advantages of self-funding.  For many employers, the cost management component is seen as one as one of the main incentives with a variety of strategies that can be implemented.

Comparing Healthcare Payment Reform Models

Article and chart comparing healthcare payment reform models. Healthcare payers and providers have begun to adopt new and innovative ways to pay for healthcare services. These new payment models include incentives that improve quality and reduce the use of unnecessary and costly services.

Concentration of Healthcare Spending

Healthcare spending in the United States is highly concentrated in small portions of the population with high usage.  A recent study by the National Institute for Health Care Management (NIHCM) identifies the percentage of the population with the highest spending, the demographics of the high healthcare spending percentage, the trend of change in spending and the implications these factors have on containing healthcare cost.

Seven Benefits of Data Mining for Health Plan Design

Improving the health of plan members and reducing costs can often go hand in hand for many insurers and self-funded employers. One tactic that accomplishes both of these goals is data mining. Data mining transforms data patterns into valuable information through the use of analytical software. In addition to using traditional approaches to reduce health care plan costs, plan sponsors can use evidence-based data mining as an effective tool for cost management and improving care by focusing on high-cost conditions and atypical utilization patterns.

ACO Risk Sharing Models

Accountable Care Organizations (ACOs) aim to deliver lower costs through a shared payer-provider risk payment model while focusing on the quality of healthcare. We summarize research on four ACO shared-risk payment models focused on private sector payment models that met criteria along three dimensions: provider risk, inclusion of services, and incentives for quality.

Quality Improvements to Reduce Hospital Readmissions

Hospital readmissions are considered by many to be a correctable source of excessive spending and poor quality of care. According to a 2009 study, nearly 20% of Medicare beneficiaries are re-hospitalized within 30 days after discharge, at an annual cost of $17 billion. For hospitals seeking to lower readmission rates, implementing comprehensive care transitions at discharge is essential in helping avoid the deterioration of health that can bring a patient back to the hospital. Outlined are strategies for reducing hospital readmission and improving the overall quality of care delivered.

Top 12 Health Information Technology Issues

The Top 12 Healthcare IT Issues both public and private sectors of the healthcare industry must address in order to meet new quality reporting standards, empower patients and serve as the backbone of emerging care delivery and payment reform models.

Cost Containment Case Study: Heart Condition

A Brazilian tourist's medical case for his heart condition is highlighted. His travel policy offered minimum medical coverage for his condition and amounted to over $500,000. After conducting a claims analysis, our negotiators were able to apply our cost containment methodology to successfully reduce the claim to $30,000, paying all parties, the hospital and physicians.

A Primer on Bundled Payments

The concept of bundled payments has been around since the early 1980s in the form of diagnosis-related groups (DRG) for inpatient care, comprehensive obstetrical care and many surgical procedures.  With the drive to reduce healthcare costs, coordinate care and improve quality, there is a renewed effort and discussion on the utilization of a bundled payment system for a wider array of procedures and diagnoses.