New Hampshire highly regarded NH HealthCost transparency tool does not always discuss facility fees, which are increasingly common, according to the New Hampshire Union Leader. These fees are applied by medical offices, urgent care centers and clinics affiliated with hospitals to better spread costs across the network to boost revenue, but they’re poorly disclosed and carry a high cost compared to the services provided. Though some insurance companies are working to reimburse more for facilities fees, customers can still be caught off guard. Consumers want more easy-to-use transparency tools.
Legislation aimed at overhauling Massachusetts’ healthcare system was introduced this month, according to the Boston Globe. Among other things, the legislation would require an increase in spending by hospitals and insurers of 30 percent over three years for primary care and behavioral health, without increasing overall spending. This move to reshape the delivery of services reflects the concern that less than 15 percent of total medical expenses are spent on primary care and behavioral health combined. In addition, this legislation would streamline the behavioral health provider credentialing process. Also of note, this legislation would seek to create more extensive state oversight of drugs that cost over $50,000 per person per year, even if bought through the private market.
Recently released data from the New York Department of Financial services has revealed that the state’s arbitration process, created through legislation in 2018, may substantially increase what New Yorkers pay for healthcare, according to a report by USC-Brookings Shaeffer Initiative for Health Policy. New York’s recent law uses what’s known as a “baseball-style” arbitration process, through which the arbiter must decide whether final payment should be the insurer’s initial allowed amount or the provider’s charges. Researchers’ main concern is the state’s guidance that arbiters should consider the 80th percentile of billed charges when determining the final payment amount, and the data reveal that arbitration decisions have averages 8 percent higher than the 80th percentile of charges. Therefore, researchers believe that high out-of-network reimbursement attainable through arbitration has likely increased emergency and ancillary physician leverage in negotiations with commercial insurers, leading to providers dropping out of networks to obtain higher payment, thereby extracting higher in-network payment rates, or some combination, which would increase premiums.
Twenty Mississippi hospitals have filed a civil lawsuit against the companies that manufacture and distribute opioids and drugstore chains such as Walmart, Walgreens and CVS pharmacies that sell opioid-based drugs, according to the SunHerald. Mississippi is one of the top five states for opioid distribution per capita, according to the lawsuit, with 92.9 prescriptions written for every 100 people in 2017, compared to the national average of 58.7 per 100. The lawsuit claims that companies “knowingly and intentionally” concealed facts from the medical community and spent millions on “a misinformation campaign.”
Sunflower, a subsidiary of Centene, will be required to issue more than $25 million in health insurance rebates to nearly 19,000 Kansans who purchased Ambetter individual health plans, reports KCUR. The rebates are required by the Affordable Care Act (ACA), which specifies that insurers must spend a certain proportion of what they collect in premiums — usually 80 percent — on their members’ healthcare. The rest can go toward the company’s own costs and profits. Sunflower’s hefty refund puts Kansas’ average rebate at more than $1,000, or seven times the national average. The state’s insurance department, which regulates premiums, has asked Sunflower for information about how it landed so far above the ACA threshold.
In 2018, Massachusetts met the Total Health Care Expenditures benchmark set by the Health Policy Commission, growing by 3.1 percent to $8,827 per resident, according to analysis by the Center for Health Information and Analysis. The report also notes that the public insurance program, MassHealth, launched its accountable care organization (ACO) program in 2018 and shifted more than 60 percent of its members to an ACO in that year. Alternative payment model (APM) adoption declined slightly among commercial health plans in 2018, especially within smaller plans.
California enacted a first-in-the-nation state law to combat pay-for-delay deals, in which brand-name pharmaceutical manufacturers pay a generic competitor to settle patent litigation and keep a lower-cost version of the drug off the market, reports NASHP. Delaying market entry of generic drugs can keep prices for brand-name drugs high, costing California consumers an estimated $3.5 billion in higher drug costs each year.
Prisma Health Greenville Memorial Hospital will be the first hospital in South Carolina to offer home recovery care, designed to keep patients out of the hospital by bringing key elements of inpatient care directly to their homes, according to GSA Business Report. Home recovery care is often beneficial for individuals suffering from non-life threatening, acute medical conditions, and may lower stress and reduce recovery time. So far, eligible patients using the model at other health systems have accepted the option at a 90 percent rate – the care model has resulted in a 44 percent reduction in readmission rates when compared to hospital care delivered in a traditional acute setting.
In an effort to make healthcare more affordable, Blue Cross Blue Shield and Sanitas Medical Center will offer a full-service clinic to provide primary care, urgent care, lab and diagnostic imaging services, care coordination and wellness and disease management programs in one location, according to Chron. They hope the primary-care driven, value-based model will reduce costs by providing affordable access to preventable care, thereby preventing the need for more serious treatment down the line. The key, the organizations believe, is working together to improve healthcare as a whole.
Blue Cross and Blue Shield of North Carolina and Cambia Health Solutions will drop their plans to combine, following the resignation of the North Carolina insurer's chief executive, Patrick Conway, according to the Wall Street Journal. These insurers had initially planned to combine and generate $16 billion in annual revenue, covering over six million people through Blue Cross Blue Shield plans - the new entity was to be lead by Conway.