Category: Managed Care

Insurance Plans Piloting Primary Care Programs

Healthcare operations continue to stride forward in new directions; Forbes published an article this week detailing how BCBSGA, UHC and Aetna are running pilot programs where they are directly employing providers that circumnavigate the existing healthcare delivery systems.  From the plans’ perspective; exerting more control on the delivery system has led to reportedly positive impacts; including improved quality metrics and reduced cost.  While this is certainly an admirable objective and a focus of the overall healthcare model being rolled out today from CMS to all other payers; there is no universality in measuring these objectives and how the health plans are meeting these goals is a matter of self-analysis and reporting.

What is particularly concerning about this is that health plans have full knowledge of the provider rates that they have established in every market giving them a significant competitive advantage to ensure that they are driving patient volume to their own physicians and clinics.  From a regulatory perspective regarding anti-competitive rate setting; it will be fascinating to follow any legal challenges that health plans may face in the coming years based on the redirection of services away from established providers in their markets.

While this is not something that we anticipate will be rolled out anytime soon; it is imperative to monitor the developments and understand the impact that it could have on your business as plans push into this new realm.

Physicians that receive poor reimbursement still don’t drop payers, survey says.

Physicians and Hospitals experienced over $68 billion in Medicare and Medicaid reimbursement shortfalls. The cost of care is out growing the reimbursement from Medicare and Medicaid. Yet few physicians are leaving their contract new survey shows.

Anthem/Cigna and Aetna/Humana Merger Update

Developments continue regarding the proposed mergers between Anthem/Cigna and Aetna/Humana. Yesterday,  the Justice Department reported they will likely file lawsuits this month to halt both proposed mergers.  If the Justice Department does take action, it may significantly delay any merger.  Additional details can be found at the link below:

                http://www.modernhealthcare.com/article/20160719/NEWS/160719879/aetna-anthem-mega-deals-appear-headed-for-trouble

Pending such action by the Justice Department, Georgia’s Department of Insurance continues their own review of the proposed mergers and has scheduled the required public hearing for the Aetna/Humana proposed merger:

Aetna/Humana Public Hearing

https://www.oci.ga.gov/ExternalResources/Documents/RegServices/AetnaFormAFiles/10%20-%20FormA-Aetna-Humana%20(NoticeofPublicHearing)%20%20June28,2016.pdf

Tuesday, July 26

9:00 a.m.

Georgia Department of Insurance

DOI has not yet announced the hearing date for the proposed Anthem/Cigna merger; SHP will provide this date once announced. 

If you have any questions regarding these developments, please contact us.  Thank you!

Health Exchange Webinar

Strategic Healthcare Partners (SHP) continues our series on Health Exchanges and impact on providers.  Please join us this Wed, 10/16 from 4pEST – 5pEST.  Contact Jason Crosby at jcrosby@shpllc.com or 912-544-0421 with any questions. 

Space is limited, please reserve your seat now at:

 https://www1.gotomeeting.com/register/141992617

Title:  Health Exchange Webinar

Date:  Wednesday, October 16, 2013

Time:  4:00pm – 5:00pm EDT

 

After registering you will receive a confirmation email containing information about joining the Webinar.