PayerFusion Healthcare Insights Round Up – September

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September 27th, 2012
Categories: Healthcare Reform

Understanding Healthcare Reform – Glossary of Terms

As the implementation of healthcare reform continues to evolve and change the US Healthcare system, many are seeking definitions on the myriad of terms that have emerged and clarification on some existing health insurance terms. Our glossary of terms does just that and is yours free to download.

Highlighting the Challenge: The Primary Care Shortage in the US Health System

As we move towards the full implementation of the ACA, primary care is being positioned as the foundation of our healthcare system, but there's just one problem- the shortage of primary care providers, widely believed to be a contributor to the fragmentation of care and inefficiency in the health system. Less accessibility promotes the inappropriate utilization of specialists and emergency rooms and drives the overall cost of care even higher. In this post we highlight this looming problem as well as offer some potential solutions.

Private Sector ACO Models Gaining Prominence

ACOs are regarded by many as the ideal way to align patient, provider and payer interests while overcoming several of the challenges facing the US healthcare system. The ACO model rewards providers for being more judicious in the amount and type of care provided while promoting greater coordination and care management of patients with chronic conditions. Because of this potential, ACOs have seen significant interest from the private sector which has been leading the way in the growth and innovation of ACO models.

6 Payment Reforms to Support Accountable Acute Care

Many of the cost and quality problems present in the US healthcare system are either shaped or worsened by the way healthcare services are paid for. These six payment reforms have potential to alleviate these issues, some of which have already been implemented in one form or the other by payers both public and private.

The Dark Side of Leased PPO Networks

According to some reports, nearly half of PPOs operating in the United States qualify as a leased PPO network. A leased PPO network provides access to a third party payer, such as insurance brokers, third party administrator, local/regional PPO or self-insured employer. If the original intent of the PPO contract is maintained, a leased PPO can produce a win-win situation for the PPO and the provider, however, leased PPOs can disadvantage providers and put insurers at risk through the use of Silent PPOs, Cherry Picking and Stacking PPOs.

Infographic: Health Information Exchange Scorecard

Health Information Exchanges (HIEs) provide the capability to electronically transfer clinical information between healthcare systems to facilitate a more coordinated and efficient patient care.  As of 2012, eHealth Initiative (eHI) has identified over 230 HIEs spanning from multi-state, single state, counties, cities and even single health systems. Our infographic summarizes the challenges of HIEs, a snapshot of HIE current status, and components of successful HIEs.

Spotlight on Success: ACO Impacts on Cost & Quality

Partnerships between private insurers and healthcare organizations have been leading the way in driving growth in the number of ACOs as well as developing innovative models and methods of collaboration. We highlight a few private ACOs that have reported success in coordinating care, increasing efficiency, and improving the overall quality of care while reducing costs.