Friday, June 27, 2014

Hospital Outpatient Prices vs. Physician's Office or Other Community-Based Setting Prices

According to a study from the National Institute for Health Care Reform (NIHCR), average hospital outpatient department prices for common imaging, colonoscopy and laboratory services can be double the price or more for identical services provided in a physician's office or other community-based setting.

The average hospital outpatient department price for a basic colonoscopy, for example, was $1,383 compared to $625 in community settings. For a routine blood test-a comprehensive metabolic panel-the average price in hospital outpatient departments was triple the price-about $37 compared to $13 in community settings.

The average price for magnetic resonance imaging (MRI) of a knee was about $900 in hospital outpatient departments (HOPDs) compared to about $600 in physician offices or freestanding imaging centers. Likewise, HOPD average prices for physical therapy were much higher than community settings. For example, a 15-minute unit of manual therapy was $58 on average in HOPDs compared to $35 in community settings.

Source: National Institute for Health Care Reform

Wednesday, June 25, 2014

Today's Datapoint

$70 billion ... in “improper” payments were made to Medicare Advantage plans from 2008 through 2013 because of risk-score errors, according to a new series of articles by The Center for Public Integrity.

Quote of the Day

“The other part … of a great customer experience is to have a seamless interaction. The last thing we want to hear is ‘oh, I can’t help you, that’s his department’ or ‘I can’t help you, it’s his operating division’ or ‘I can’t help you because Sally helped you with that; I’m Sue.’ That’s not going to work. A great customer experience is when it is seamless. Customers look at us as a brand, as Nordstrom, as one. However we’re organized with our people, how we operate, customers don’t care about that. They care about what you stand for and the seamless customer experience.”

— Mike Koppel, Executive Vice President and CFO at Nordstrom Inc., speaking recently at America’s Health Insurance Plans’ Institute 2014 in Seattle.

Tuesday, June 24, 2014

The Affordable Care Actand America's Cities

According to a report by the Robert Wood Johnson Foundation that estimated the effect of the Affordable Care Act (ACA) on 14 large and diverse cities: Los Angeles, Chicago, Houston, Philadelphia, Phoenix, Indianapolis, Columbus, Charlotte, Detroit, Memphis, Seattle, Denver, Atlanta, and Miami, among the seven cities in states that have expanded Medicaid, the ACA will likely decrease the number of uninsured by an average of 57 percent. City by city, the reduction is projected to vary between 49 percent in Denver and 66 percent in Detroit by 2016. New federal spending on health care from 2014 to 2023 would range from $4.1 billion in Seattle to $27 billion in Los Angeles.

Among the seven cities in states not expanding Medicaid, the ACA will likely decrease the number of uninsured by an average of 30 percent. The decrease would range from 25 percent in Atlanta to 36 percent in Charlotte by 2016. New federal spending due to the ACA from 2014 to 2023 would increase by between $1.9 billion in Atlanta and $9.9 billion in Houston.

If Medicaid eligibility were expanded in these cities, the number of uninsured would fall by an average of 52 percent, ranging from 45 percent in Houston to 59 percent in Memphis. New federal spending would increase by between $4.8 billion in Atlanta and $16.4 billion in Houston from 2014 to 2023.

Source: Robert Wood Johnson Foundation


$5.4 billion ... per year is spent by WellPoint, Inc. on all forms of cancer for fully insured members.


About 30 million ... nonelderly residents will be uninsured in 2016 but most will be exempt from the ACA’s penalty, according to the CBO and Joint Committee on Taxation, because they are either unauthorized immigrants, people with income so low they don’t have to file tax returns, or have income below 138% of the federal poverty level and are ineligible for Medicaid because their state did not expand Medicaid.

Quote of the Day

“Ideally, consumer cost-sharing levels would be set to encourage the clinically appropriate use of services. Instead, archaic ‘one-size-fits-all’ cost sharing fails to acknowledge the differences in clinical value among medical interventions. Accumulating evidence concludes that cost-sharing increases lead to reductions in both nonessential and essential care, which, in some cases, leads to greater costs.”

— A. Mark Fendrick, M.D., director of the University of Michigan Center for Value-Based Insurance Design and co-author of a new report on V-BID from the National Cancer Policy Forum.

Today's Datapoint

$29 billion ... could be saved by the U.S. over 10 years if Medicare patients were given Avastin instead of Lucentis for two ocular conditions, according to a recent study published in Health Affairs.

According to a recent study that ranked health care systems

... in 11 industrialized nations on measures of quality of care, access, efficiency, equity, and healthy lives, the overall rankings from highest to lowest performance are listed along with the 2011 health expenditures per capita for each country (2010 for Austalia):

1. United Kingdom: $3,405
2. Switzerland: $5,643
3. Sweden: $3,925
4. Australia: $3,800
5. The Netherlands: $5,099
5. Germany: $4,495.
7.New Zealand: $3,182
7. Norway: $5,669
9.France: $4,118
10. Canada: $4,522
11. United States: $8,508

Source: "US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives," The Commonwealth Fund Press Release, June 16, 2014,

Thursday, June 19, 2014

Payment Suspension for Credible Fraud Allegation Turns Up the Heat on Providers

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on Medicare compliance, Stark and other big-dollar issues of concern to health care compliance officers.

By Nina Youngstrom, Managing Editor

June 9, 2014 Volume 23 Issue 20

Providers should brace for more Medicare and Medicaid payment suspensions based on a credible allegation of fraud. CMS and state Medicaid agencies may block payments to large swaths of providers in one fell swoop, which happened in the nation’s capital this spring, and impose suspensions on a variety of services and care providers.

“If someone learns they are under investigation, they need to be prepared for the possibility — moving up to the probability — for payment suspension, especially on the Medicaid side,” says San Francisco attorney Judy Waltz, with Foley & Lardner LLP.

Sec. 6402(h) of the Affordable Care Act requires the suspension of Medicare and/or Medicaid payments to a provider when there is a credible allegation of fraud unless there is “good cause not to suspend payments.” Suspension of payments means shutting down some or all of a provider’s Medicare cash flow while the allegation is investigated. The money is put in a suspense account — akin to escrow — and released to the provider only if a case is not pursued and there’s no determination of an overpayment, Waltz says. Although Medicare payment suspensions max out at 18 months and can’t last longer than six unless there are special circumstances (i.e., OIG or DOJ requests it), states decide for themselves how long Medicaid payment suspensions will last, Waltz says.

As defined in 2011 CMS interim final regulations, a “credible allegation of fraud” includes an allegation from patterns identified by audits, civil false claims cases, law enforcement investigations, hotlines and claims data mining, Waltz says. “Allegations are considered to be credible when they have indicia of reliability,” the regulations state (42 CFR Sec. 405.370 for Medicare and 42 CFR Sec. 455.2 for Medicaid). CMS and states can skip payment suspensions for credible allegations of fraud if there is good cause (e.g., it would hinder beneficiary access or alert the target of an investigation). “A credible allegation is a much lower standard than what used to be required for payment suspensions,” she notes.

There’s more discretion on the Medicare side in terms of whether to suspend a provider’s payments, Waltz says. But states must wield this axe unless they can meet a good-cause exception. If CMS thinks the state had grounds to suspend a provider’s payments but failed to act, the state loses the federal share of Medicaid for the services that are in the vortex of a credible allegation of fraud, Waltz says.

Atlanta attorney Sara Kay Wheeler also sees more payment suspensions based on credible allegations of fraud, which can stem from a Medicare administrative contractor, zone program integrity contractor or other audit or investigation. “We have seen an increase in cases where payment suspensions are at issue,” says Wheeler, who is with King & Spalding.

There’s nothing stopping Medicare or Medicaid from suspending payments for a type of service — joint replacements or cardiac surgery, for example — rather than all payments to a provider based on a credible allegation of fraud, Waltz says, although she doesn’t know of any cases like this yet.

Mass Payment Suspensions Are a New Tactic

But she noted that one new enforcement technique is mass payment suspensions of unrelated providers based on credible allegations of fraud. In Washington, D.C., for example, the Medicaid agency recently suspended payments to 52% of the city’s home health agencies (HHAs) for personal care aid services. Although Judge Rosemary Collyer of the U.S. District Court for the District of Columbia on April 9 granted a temporary restraining order to stop the payment suspension, she later refused to grant permanent injunctive relief after considering the case in more depth. That left the payment suspensions in place, although two HHAs got their payment suspensions lifted and are back in Medicaid while six HHAs face Medicaid termination.

A sweeping payment suspension is eye-opening. “This is such a huge number of providers,” Waltz says. “It is not clear how much differentiation the government can make between providers when these credible fraud allegations are evaluated. Some may be decent providers, some may not.”

The D.C. Medicaid agency, the Department of Health Care Finance, suspended payments without notice to Premier Health Services, ABA Inc., Health Management Inc., Immaculate Health Care Services and other agencies based on credible allegations of fraud. The Medicaid agency alleges the HHAs “repeatedly billed and [were] reimbursed for PCA services that were not supported by the documentation,” the court decision states. While plans were made to transfer patients to other providers, the HHAs were required to continue providing services to Medicaid enrollees. After four weeks, the HHAs sued to force the city to pay them before they went broke, and for breach of contract, violation of their due process rights and other alleged wrongdoing. At an April 9 hearing, the HHAs persuaded the judge there was a good chance they would win their case, so she ordered the Medicaid agency to pay them retroactively and keep the money flowing. For their part, the HHAs had to keep providing personal care aide services because “there was an insufficient number of home health care providers in the District of Columbia to which to transfer Plaintiffs’ patients.”

But after the judge reviewed more court filings, she concluded the HHAs probably wouldn’t prevail. For one thing, the judge wrote that “in contrast to a provider’s right to participate in the Medicaid program, there is no constitutional right to receive Medicaid payments.” Also, the Medicaid agency apparently acquired enough capacity to transfer the plaintiffs’ patients to other providers so the HHAs don’t have to keep treating them for free. And the judge wasn’t persuaded the payment suspension would force the HHAs out of business because Medicaid pays them for other services, the May 9 decision states.

Finally, the HHAs should exhaust administrative remedies before seeking relief from the federal courts, the judge said. “Plaintiffs’ failure to exhaust administrative remedies is yet another reason why they have not shown a likelihood of success here.”

A Mixed Outcome for HHAs

Ultimately, the outcome for the HHAs was mixed. Washington, D.C., attorney Brad Johnson, who represents Premier, said for his client, “the District of Columbia has not disclosed any evidence of fraud and the suspension has been withdrawn.” After failing to get injunctive relief, Premier appealed the payment suspension to the Medicaid Office of Administrative Hearings (OAH). But the two sides worked it out, and everything is back to normal for Premier, which withdrew its appeal, Johnson says. Meanwhile, the Medicaid agency is terminating some of the HHAs, including ABA and Nursing Unlimited Services, from Medicaid. Their attorney, Reggie Richter, says he is appealing the terminations to OAH and once he files the paperwork, the terminations will be stayed pending a hearing. Richter is concerned that providers face payment suspension based on credible allegations of fraud they are not privy to. “I have reviewed what has happened in other states, and I think a problematic aspect of the law is you don’t have the opportunity to basic due process,” Richter says. “The government should not be able to make these claims without putting up the evidence against them.” Meanwhile, he notes that KBC also got its payment suspension reversed and Immaculate and Health Management are allowed to provide Medicaid personal care aide services but their payment suspensions stand.

CMS has also suspended payments en masse. In cooperation with an HHS-DOJ Health Care Fraud Prevention and Enforcement Action Team (HEAT), CMS suspended the payments of 78 Dallas area HHAs, Waltz says. Last year’s Health Care Fraud and Abuse Control program report says 297 providers are under “active suspension” from Medicare in fiscal year 2013 and 105 more suspensions were approved that year.

“Payment suspension is a powerful weapon,” Wheeler says. “By the time the time period runs out, you could be out of money,” especially if Medicare or Medicaid is one of your main payers.

Today's Datapoint

$15 billion ... per year are the savings projected were Medicare to use the colonoscopy screening model recommended by The Value of Colonoscopy, a joint initiative of the American College of Gastroenterology, American Gastroenterological Assn. and American Society for Gastrointestinal Endoscopy.

Quote of the Day

“Actual turnaround for most specialty drugs is two-plus days for clean prescriptions and low prior-auth requirements. Increasingly, higher-cost drugs have more complex prior-auth processes, and that is nudging up their turnaround to three-plus days. The most complex drugs that also require genetic testing and diagnostic tests can delay an approval well past five days.”

— Bill Sullivan, principal consultant with Specialty Pharmacy Solutions LLC, told AIS’s Specialty Pharmacy News.

Wednesday, June 18, 2014

49% of employees surveyed

...have less than $1,000 with which to pay for unexpected out-of-pocket medical expenses

Source: "2014 Aflac WorkForces Report: Executive Summary," Aflac, April 16, 2014,

Tuesday, June 17, 2014

Five Steps to Opening a Health Savings Account

1.    Learn the basics. An HSA is a savings account available to American taxpayers who have health insurance coverage under a high-deductible plan. 

2.    Find out if you are eligible. To be eligible to open an HSA, you must: Be covered by an HSA-compatible health insurance plan with a high deductible and not enrolled in Medicare.

3.    Get real about your budget. In order for an HSA to be beneficial, you have to have funds to contribute in the first place.

4.    Choose how to enroll. While you can enroll in an HSA on your own at any time, they are often available through your employer during their open enrollment period.

5.    Start contributing. For 2013, the maximum amount an individual can add to an HSA is $3,250. Families can contribute a maximum amount of $6,450.
Source: GoHealthInsurance

Health Expenditures Per Capita By Country

1.    United Kingdom - 3,405

2.    Switzerland - 5,643

3.    Sweden - 3,925

4.    Australia - 3,800

5.    Germany - 4,495

6.    Netherlands - 5,099

7.    New Zealand - 3,182

8.    Norway - 5,669

9.    France - 4,118

10.  Canada - 4,522

11.  United States - 8,508
Source: The CommonWealth Fund

According to a recent 4-year study

... the mean rate of adverse events among all surgical procedure groups was 82.8 adverse events per 1,000 hospitalizations, although the rate varied widely depending upon surgical category.

Source: "Incidence of adverse events in an integrated US healthcare system: a retrospective observational study of 82,784 surgical hospitalizations," Patient Safety and Surgery, abstract only, May 27, 2014,

Provider Contracts and Quality Measurement
Quality Measurement Terms in Provider Contracts

  • Issues for consideration when negotiating quality and risk based provisions
  • Use of internal vs. external quality measurement systems; and existing vs. customized standards
  • Setting contractual language that clearly shows how quality measures will be reported and evaluated
  • Addressing specific measure to negotiate into agreements
  • Thursday, June 19th from 1:00 to 2:00 p.m. Eastern

For more information, go to or call 209-577-4888.

According to a recent analysis

the following 10 potential inpatient conditions were associated with almost $2.5 billion in costs, 24,000 potential patient deaths and 920,000 added days in the hospital across approximately 530,000 cases:

  • Acute Renal Failure
  • Hypotension
  • Respiratory Failure
  • Sepsis/Bacteremia
  • Aspiration Pneumonia
  • Acute Myocardial Infarction
  • Gastrointestinal (GI) Ulceration and Hemorrhage
  • Cerebral Infarction
  • Pulmonary Embolism
  • Ventilator Associated Pneumonia

Source: "Analysis reveals most common harm events associated with high rates of mortality, costs and length of stay," Premier inc. Press Release, June 12, 2014,

CMS initiative helps people make the most of their new health coverage


FOR IMMEDIATE RELEASE                                          Contact: CMS Media Relations Group
June 16, 2014                                                                               (202) 690-6145 |

CMS initiative helps people make the most of their new health coverage
“From Coverage to Care” outreach to engage doctors and new patients

Today, the Centers for Medicare & Medicaid Services (CMS) launched a national initiative “From Coverage to Care” (C2C), which is designed to help answer questions that people may have about their new health coverage, to help them make the most of their new benefits, including taking full advantage of primary care and preventive services.  It also seeks to give health care providers the tools they need to promote patient engagement.   

“Helping to ensure that new health care consumers know about the benefits available through their coverage, and how to use it appropriately to obtain primary care and preventive services is essential to improving the health of the nation and reducing health care costs,” said Dr. Cara V. James, director of the CMS Office of Minority Health. Dr. James noted that, “to achieve these goals, we need to make sure that people who are newly covered know that their coverage can help them stay healthy, not just help them get better if they get sick.”

C2C will be an ongoing project.  As more and more people obtain coverage, there will be a continuous need to ensure that people have answers to questions they might have about their new coverage and are appropriately connected to the health care system to help them live long, healthy lives.

Today’s launch also marks the release of the new Roadmap to Better Care and a Healthier You,, which includes 8 steps to help consumers and health care providers be informed about the diverse benefits available through their coverage and how to use it appropriately to access to primary care and preventive services. Among other things, the “Roadmap” contains information on health care coverage terms, the differences between primary care and emergency care, and the cost differences of decisions to seek care in- and out-of-network, where applicable to the consumer’s health plan.  

More information about C2C and other helpful resources, including a 10-part video series, to help those with new health care coverage make the most of their coverage, and raise awareness about the importance of getting routine primary care and regular preventive care are available at: People with related questions about the C2C initiative should write to 


Blog Posts

Today's Datapoint

525,000 … of the 1.4 million people enrolled on Covered California were signed up by insurance brokers, according to a story in the Los Angeles Times.

Today's Datapoint

9.2% … was the drop in the number of prescriptions filled via mail-order pharmacies from 2012 to 2013, while those processed through chain stores and supermarkets with pharmacies increased 2.7%, according to an analysis by Pembroke Consulting, Inc.

Thursday, June 12, 2014

Why Not Just Eliminate the Employer Mandate?

Employees offered coverage deemed affordable and adequate are prohibited from obtaining subsidies, as are their family members, and employers can avoid penalties by offering coverage to at least 95 percent of workers. However, the Administration has delayed the requirements until 2016 for employers of 50-99, for larger employers until 2015, and softened requirements for that first year. Yet there are anecdotal reports of employers changing labor practices even though penalties have yet to be implemented.

Source: Urban Institute

Employer Preparedness for the ACA

According to the Transamerica Center for Health Studies, employers appear more informed about their companies' options for providing health insurance than employers interviewed last year. In a 2013 benchmark study, only 37 percent of employers reported being very informed about their companies' options for providing health insurance; in the 2014 study, 69 percent report being very informed.

Among small businesses, the survey revealed that only six in 10 (59 percent) of those with fewer than 50 full-time equivalent employees are aware of the new Small Business Health Options Program (SHOP), compared to eight of 10 businesses overall (79 percent).

28 percent of employers actually expect their number of employees to increase due to the ACA, compared to 15 percent that expect the number to decrease. Most employers (64 percent) plan on taking some action to comply with the ACA, with 19 percent planning to change plan options and 17 percent planning to change insurers.

Source: Transamerica Center for Health Studies

Injury-Related Emergency Department Visits by Children and Adolescents: United States, 2009-2010

In 2009-2010, an annual average of 11.9 million injury-related emergency department (ED) visits were made by children and adolescents aged 18 years and under in the United States. The injury-related ED visit rate was 151 per 1,000 persons aged 18 years and under, and rates were higher for males than for females for all age groups (0-4 years, 5-12 years, and 13-18 years).

Leading causes of injury-related ED visits among both males and females included falls and striking against or being struck unintentionally by objects or persons. Visit rates were higher for males than for females for both of these causes.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics

Employer and Employee Healthcare Costs

According to Towers Watson and the National Business Group on Health, employer-sponsored health benefits will increase in cost by 4.4% this year. In 2013 employer costs per employee were $9,157 and are expected to be $9,560 in 2014.

Employees' share of premiums increased nearly 7% to $2,975 this year. The total employee cost share was 34.4% in 2011 and is 37% in 2014. Employees pay $100 more a month for healthcare compared to three years ago.

Publication Source: Employee Benefit News, April 15, 2014
Data Source: Towers Watson and the National Business Group on Health

Healthcare Provider Influenza Vaccination Rate's Effect on Community

According to the Association for Professionals in Infection Control and Epidemiology, for every 15 healthcare providers who receive the influenza vaccination, one fewer person in the community will contract an influenza-like illness.

For the 2011-2012 influenza season, the influenza vaccination rate of California hospital healthcare personnel was 68 percent. If 90 percent of California healthcare personnel were vaccinated there would be about 30,000 fewer cases of influenza-like illness in California.

Source: Association for Professionals in Infection Control and Epidemiology

Federal Disproportionate-Share Hospital Cuts Impact on Public Hospitals

According to the UCLA Center for Health Policy Research, public hospitals in California that serve the poorest patients could face a $1.54 billion funding shortfall in 2019, when federal funding cuts go into effect. California's safety-net hospitals rely heavily on federal disproportionate-share hospital (DSH) funding, which compensates them for treating the most vulnerable patients. In 2010, DSH funds paid more than half of $2 billion in DSH costs ($1.1 billion) to the 21 safety-net hospitals included in the study, with county and state funds covering the rest.

But with impending DSH cuts, the the UCLA Center for Health Policy Research estimates payments would drop to roughly $830 million to $980 million and leave hospitals struggling to cover $1.38 billion to $1.54 billion in DSH costs in 2019. As many as 4 million Californians and 30 million Americans nationwide are still likely to be uninsured at that time.

Source: UCLA Center for Health Policy Research

Most and Least Expensive Cities for Common Medical Services

According to Castlight Health, analysis of in-network price differences in a U.S. commercially insured population shows within the 30 most populous U.S. cities, prices vary greatly for the same service:

Up to 23x for a lipid panel in Dallas (from $15 to $343)
Up to 12x for a CT scan (of head/brain) in Philadelphia (from $264 to $3,271)
Up to 11x for an MRI (of lower back) in New York City (from $416 to $4,527)
Up to 4x for an adult preventive primary care visit in Phoenix (from $40 to $195)

Castlight Health also ranked the most expensive and least expensive cities in the 30 most populous U.S. cities for four common outpatient services:

-For a lipid panel, Indianapolis came in most expensive (average price $89) and Pittsburgh the least (average price $19)
-For a CT scan (of head/brain), Sacramento came in most expensive (average price $1,404) and Orlando the least (average price $611)
-For an MRI (of lower back), Sacramento came in most expensive (average price $2,635) and Seattle the least (average price $907)
-For an adult preventive primary care visit, San Francisco came in most expensive (average price $251) and Miami the least (average price $95)

Source: Castlight Health

Three out of four providers are experiencing physician or nurse shortages

...with 42% experiencing shortages in more than one practice area, according to a recent C-suite survey.

Source: "Providers increasingly dissatisfied with EHRs despite heavy investments, according to Premier, Inc. C-suite survey," Premier Inc. Press Release, June 2, 2014,

According to a recent survey of 361 organizations and 3,822 employees:

• 52% of employers offer services for mental health and depression management
• 96% of employees participate in wellness programs to improve their own health
• 43.1% of employers aren’t planning to take advantage of wellness program incentives offered under the Affordable Care Act


Today's Datapoint

26% … of Medicare claims for evaluation and management services in 2010 were upcoded (and 15% were downcoded), according to a new report from the HHS Office of Inspector General.

Quote of the Day

“A lot of people would prefer to pick up [specialty medications] at the store because you don’t have to wait at home, you don’t have to worry about the temperature integrity, you don’t have to worry about the physical integrity, so patients really like it. It helps to make the whole process much less disruptive to their lives.”

— Alan Lotvin, M.D., executive vice president of specialty pharmacy for CVS Caremark, told AIS’s Drug Benefit News when describing his firm’s new Specialty Connect program, which improved optimal adherence from 66% to 79% in an 18-month pilot.

Tuesday, June 10, 2014

According to a recent survey, approval of the Affordable Care Act breaks down by racial/ethnic group as follows:

• Blacks: 76% approve, 18% disapprove
• Hispanics: 57% approve, 33% disapprove
• Whites: 35% approve, 61% disapprove

Source: "Despite Enrollment Success, Healthcare Law Still Unpopular," Press Release, May 29, 2014,

Monday, June 9, 2014

States with Highest Percentage of Medicare Enrollees in Managed Care

1. Minnesota - 46.9%
2. Hawaii - 44.6%
3. Oregon - 41.1%
4. Pennsylvania - 38.4%
5. Arizona - 36.8%

Source: Health, United States, 2013, Centers for Disease Control and Prevention, National Center for Health Statistics

Questions To Ask As You Approach Retirement at 65

1. The availability of coverage for an employer or a spouses’ employer should factor into someone’s Medicare choices
2. Choose between (a) Original Medicare, plus prescription drug Part D plans and possibly Medigap supplemental coverage or (b) a Medicare Advantage plan
3. A spouse and children covered under employer health insurance need to be provided for when moving to Medicare coverage
4. Depending on their employer’s size, the retiree upon turning 65 may need to enroll in Medicare and coordinate coverage with both their employer and the federal program
5. Individuals who didn’t enroll in Part B when they were first eligible may receive a special enrollment period when existing coverage ends
6. Medigap, or supplemental Medicare insurance, must be considered at age 65, waiting can limit the options available

Source: Benefits Pro

May Medicare Advantage Enrollment Summary

1. Local CCPs - 13,955,278
2. PFFS - 305,351
3. MSA - 11,278
4. Regional PPOs - 1,231,124
5. MA Total - 15,503,031

Source: Centers for Medicare & Medicaid Services

Thursday, June 5, 2014

Today's Datapoint

About 1 million people who listed incomes on their health insurance applications for coverage on public exchanges that were different from separate IRS documents may be receiving the incorrect amount of federal subsidies for their purchases.

Wednesday, June 4, 2014

According to a recent survey of health center leaders

...use of electronic health records increased 133% in federally qualified health centers between 2009 and 2013

Source: "New Survey: Community Health Centers Make Substantial Gains in Health Information Technology Use, Remain Concerned About Ability to Meet Increased Demand Following ACA Coverage Expansions," The Commonwealth Fund Press Release, May 16, 2014,

Today's Datapoint

17% … of Americans now receive their health care through an ACO and two-thirds have access to one, according to an analysis from the consulting firm Oliver Wyman.

Quote of the Day

“Many pharmacies, especially independent pharmacies, think that they’re not necessarily informed on pricing changes in a timely manner and then are forced to dispense certain prescriptions at a loss because they don’t know what the maximum allowable cost price is.”

— Matt Eyles, executive vice president at Avalere Health LLC, told AIS’s Drug Benefit News.

HSAs to quadruple in next six years?

Private exchanges will drive ‘huge opportunities’
June 3, 2014

Driven by the emerging private health exchange sector, health savings accounts could quadruple their growth over the next six years, according to a new report.

Analysis from The Institute for HealthCare Consumerism, Consumerdriven, and HSA Consulting Services, predicts 50 million Americans will be covered by HSA-qualified health plans by Jan. 1, 2019, and that HSA adoption will grow to 37 million — up from about 11 million today.

More than half of that growth will be thanks to the exchanges, which massively accelerate growth, researchers predict.

“While health savings accounts have experienced a steady growth rate over the past decade, health exchanges, especially private exchanges, have already demonstrated a tendency to accelerate the rate of HSA adoption among health consumers — both within the employer-sponsored and individual health care markets,” the news release said.

The prediction — from consultants John Young, CEO of ConsumerDriven, and Todd Berkley, president of HSA Consulting Services — comes after interviewing, and analyzing, 33 private exchange vendors.

After examining the choices consumers made in these health care marketplaces, they “found a six- to eight-fold increase in HSA adoption in private exchanges compared to the traditional approaches used today in the commercial marketplace. In exchanges utilizing a defined contribution funding strategy, the potential for HSA adoption is even higher.”

Still, they said, there is more potential than realized. They said many private exchange operators were unaware of the HSA adoption they were driving.

“Exchanges provide the best opportunity for HSA adoption — but not all exchanges are focused on providing the best HSA customer experience,” Berkley said. “In fact, many exchanges are not aware of the HSA revolution happening inside their offering. There is room for improvement here.”

HSAs have experienced swift growth, particularly over the last few years. There were 10.7 million HSAs in the United States at the end of 2013, an increase of 30 percent over the prior year, according to consulting firm Devenir.

Last month, Fidelity Investments reported a 48 percent jump in the number HSAs opened in 2013.

Tuesday, June 3, 2014

Quote of the Day

“Health plan reaction to a provider intrusion [into health insurance] depends on the market where the battle is taking place because the stronger the provider and the more market power, the more dangerous in a sense it is. But absent market power, you can sit on the sidelines as an insurer and watch and see if [the provider] can figure out how not to lose a ton of money by being an insurance company.”

Jack Rovner, a principal for The Health Law Consultancy in Chicago, told AIS’s Health Plan Week.

Today's Datapoint

12% … was the enrollment growth during last fall’s open-enrollment period for three-star Medicare Advantage plans, while five-star plans grew just 6.5%, according to a recent analysis by the Kaiser Family Foundation.

Monday, June 2, 2014

From 2007–2012, the percentage of physicians working... practices with 11 or more physicians increased by 84%, while the percentage of physicians working in practices with 2 physicians decreased by 24%, according to a recent report.

Source: "Trends in electronic health record system use among office–based physicians: United States, 2007–2012," National Center for Health Statistics, National Health Statistics Reports Number 75, May 20, 2014,

Physician Visit Growth by Selected Markets, 2013-2018

Chicago 15.5%
Austin, TX 27.2%
San Antonio, TX 21.0%
Sacramento, CA 28.0%
San Francisco 17.3%
Boston 14.0%

Publication Source: HealthLeaders Media, May 2014
Data Source: Truven Health Analytics