[Reblog] Health insurers using drug coverage to discriminate

From the 28 January 2015 post at Engineering Evil – Intel Portal for Weighted Data and Information

In some US health plans, HIV drugs cost nearly $3,000 more per year than in other plans. If left unchecked, this practice could partially undermine a central feature of the Affordable Care Act.

Harvard School of Public Health

Boston, MA — Some insurers offering health plans through the new federal marketplace may be using drug coverage decisions to discourage people with HIV from selecting their plans, according to a new study from Harvard T.H. Chan School of Public Health. The researchers found that these insurers are placing all HIV drugs in the highest cost-sharing category in their formularies (lists of the plans’ covered drugs and costs), which ends up costing people with HIV several thousands more dollars per year than those enrolled in other plans.

The study appears online January 28, 2015 in the New England Journal of Medicine.

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[Reblog] Rewarding Patient Recovery | HealthWorks Collective

Rewarding Patient Recovery | HealthWorks Collective.

From the 6 November 2014 item at HealthWorks Collective

What if we paid for patient recovery rather than just patient services?

What if we paid to treat patients rather than just conditions?

What if we paid to personalize care rather just population health quality measures?

While these questions may sound academic, there is a groundswell of innovative healthcare providers working on the answers.  To realign the healthcare system to overall patient recovery and well-being, it will take physicians and other healthcare providers transforming the entire system. The good news is that this is quietly happening from within, with physicians, healthcare systems and health plans working together.

They include the over 500 Accountable Care Organizations, 6,500 providers considering bundled payment pilots and providers signing risk sharing agreements with health plans.  Physicians, healthcare systems and insurance plans are sharing data, sharing financial risk and focusing on improving overall patient outcomes and cost.

With little debate or fanfare outside the healthcare industry, Medicare quietly saved $372 million with their versions of the ACO. While some critics predict that ACOs will follow Health Maintenance Organizations (HMOs) demise in the 1990s, ACOs are different.  Patients are assigned to ACOs and remain free to go to any provider.  ACOs can’t limit care or require patients to see providers in their network.  The ACO’s were still able deliver great results even with these two major challenges which they call “churn” (ACO assigned patient turnover) and “leakage” (patients going outside the provider network).

Bundled Payments are just getting started with up to 6,500 providers deciding soon whether to go live Jan 1, 2015 with Medicare’s Bundled Payment for Care Improvement (BPCI) pilot. Provider/Health Plan risk sharing arrangements are expanding rapidly, indicating they are delivering.  This surge began when the Affordable Care Act (ACA) started requiring health plans to write rebate checks if they paid out less than 85% of their premiums in medical claims. This encouraged Health Plans to partner and reward providers for improvements in patient outcomes and cost. Health Plans leaders believe that the “blurring of the lines” between providers and health plans is just getting started.

Patient Recovery vs. Patient Services

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