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Humana will pay Texas a $700,000 fine for failing to maintain an adequate number of in-network anesthesiologists at its contracted hospitals in four counties, according to Modern Healthcare. After patients receiving out-of-network bills for anesthesiology services contacted the insurer about balance bills, Humana has agreed to hold enrollees responsible only for the in-network charges and not for the balance bills. Texas has lagged in addressing the surprise billing issue after becoming one of the first states to establish a mediation system for resolving these billing disputes in 2009, which has only been accessed by 3,824 people since its inception. More than 300 Texas hospitals did not have a single emergency physician who was in-network with at least one of three major carriers, Humana, Blue Cross Blue Shield and UnitedHealth Group. Lawmakers have proposed legislation that would require insurers and providers to resolve out-of-network bills while shielding consumers.
According to a report by Virginia Health Information (VHI), healthcare costs vary dramatically depending on where consumers live, highlighting the need for local cost of care information. For example, a colonoscopy in 2016 averaged as little as $1,075 in Southwest Virginia physician offices and as much as $2,940 in Central Virginia hospitals, according to Augusta Free Press. In a 2017 national report card published by Altarum, Virginia was just one of six states earning a passing grade in pricing transparency.
Lowering overall cost of healthcare is a nonpartisan issue, according to a report from United States of Care. United States of Care profiled the Minnesota healthcare system because the state has a history of being a national leader in expanding coverage and access to healthcare, resulting in one of the highest rates of coverage in the nation. One imminent healthcare issue Minnesota is looking at is funding the Health Care Access Fund (HCAF), which is responsible for funding Medical Assistance Medicaid, MinnesotaCare and other public assistance programs. The provider tax that funds HCAF expires in 2020, so Minnesota legislators need to start thinking about ways to make up this $241 million line item. Other 2019 priorities for Minnesota include modernizing access for patient information, reducing costs of drugs and the future of medical assistance. Some longer term goals include funding for mental health and substance abuse, access to care in rural areas and health equity. Successful solutions to these short- and long-term goals will require continued collaboration and creativity.
Virginia and Tennessee have issued certificates of public advantage (COPAs), a legal mechanism through which states can approve mergers that reduce or eliminate competition in return for commitments to make public benefit investments and control healthcare cost growth, according to the Milbank Memorial Fund. The report describes Virginia and Tennessee's experiences after they used their COPA laws to approve a large health system merger that spanned the states' border. While it’s too early to know what will happen as a result of these states’ COPA decisions, state health policymakers and other stakeholders can learn from Tennessee and Virginia as they address future proposed hospital system mergers.
Arkansas, like many states, is targeting drug middlemen in attempt to reign in high pharmaceutical prices, according to the Washington Examiner. The state enacted a law earlier this year requiring licensure for pharmacy benefit managers (PBMs), which manage drug plans for employer- and union-sponsored health plans, to conduct business in the state. PBMs must provide a “fair and reasonable” compensation program for the reimbursement of pharmacist services in order to get a license. Four other states have passed similar laws requiring PBMs to obtain licenses: Florida, Louisiana, Maryland and Tennessee.
Rhode Island has implemented a statewide health information exchange to help coordinate care and improve population health management through real-time admission, discharge, and transfer alerts and prescription drug monitoring messaging, according to Health IT Analytics. Half of the state’s population is enrolled in the CurrentCare system, which is available to all healthcare providers in the state. The system has helped the state save money; hospital readmissions have decreased by 19 percent and repeat ED admissions have dropped by 16 percent, which has helped the state save $13.3 million, and has saved hours of manual work from providers’ daily schedules. This CurrentCare initiative has helped to improve the quality and continuity of care for patients in Rhode Island.
Virginia has submitted a 1115 waiver application that would add work requirements, premiums and emergency department co-pays to beneficiaries above the federal poverty level to their expanded Medicaid program, according to Modern Healthcare. Under the waiver proposal, eligible Medicaid enrollees would need 20 hours per month of work-related activities for the first three months that they're eligible for the program, which would gradually increase to 80 hours per month. The state also wants permission to impose a monthly premiums for beneficiaries above the federal poverty level, assessed on a sliding income scale.
A 90-day evaluation of a nursing triage line at D.C.’s 9-1-1 call center revealed that the program has yet to meet one of its intended goals: reducing ambulance trips for patients who don’t need them, according to The Washington Post. The program, known as “Right Care, Right Now,” aims to avoid unnecessary and costly trips to the ED by diagnosing callers who have non-life-threatening conditions and ordering quick, private transportation to clinics through a ride-share service. While the goal is to deploy ambulances, medics and fire crews more wisely, the evaluation showed that nearly half of all calls routed from a 9-1-1 dispatcher to triage nurses still resulted in a fire unit being sent out after the nurses heard a caller describe their medical need. Early evidence suggests that the nurses have become more comfortable with referring callers to clinics over time, although similar efforts in Philadelphia and Richmond have failed due to lack of return on investment.
Iowa saw almost three times higher Medicaid costs after moving to a new managed care program called HealthLink, according to Healthcare Dive. Dozens of states have moved their Medicaid program to managed care organizations (MCOs) in attempt to reduce costs. However, after the first full year of privatization Iowa saw per-member costs increase an average of 4.4 percent, almost triple the average increases of the past six years. A recent Iowa Department of Human Services report found that higher per Medicaid member costs are expected to rise in 2018 and 2019 because of prior period rate adjustments. However, despite these setbacks in Iowa, many states view MCOs in Medicaid positively; 38 states and DC have Medicaid contracts with MCOs with over 74 million Medicaid beneficiaries enrolled in an MCO plan in 2015.
Delaware ACO Aledade achieved $5.6 million dollars in Medicare savings in 2017, according to Delaware News Journal. Aledade credits the bulk of its improvements to its data portal which alerts primary care physicians to recent emergency department visits by their patients as well as needed patient tests and screenings. The ACO also provides on-call access to a doctor or nurse 24 hours a day, 7 days a week. As a result, emergency department visits have decreased by 9 percent among the ACO’s Medicare patients.