"Loyalty rewards" in sponsored DM and HRM programs can apply to both providers and consumers. Physicians and hospitals can be paid to "loyally" adhere to payers' guidelines for managing diseases and risks. Many payer and their outsourced vendor programs include significant efforts to create collaborations between payer and provider, rather than relying on unilateral efforts. And growing numbers are rewarding providers for their efforts and results achieved.
Over the past several years, discount medical programs have flourished as a result of double digit increases in health insurance premiums. Given the rapid growth and sometimes questionable practices of such programs, several states have taken notice and have begun to regulate discount medical programs. This article summarizes the laws of several states that have chosen to oversee these programs.
Managing anticoagulation therapy has been difficult and costly for providers and for payers, as complications are common. For example, the cost of mitigating a single anticoagulation related hemorrhagic complication can exceed $10,000 per claim. In 2002, CMS initiated a new model of anticoagulation patient management that combines technology with remote monitoring to improve traditional care. Managed care organizations are now adopting this model, and improved outcomes at lower cost should result.
Future research needs to clarify the biases in clinical practice and potential barriers that may exist at both the provider and health plan levels that exclude men with physical disabilities from routine preventive services. As the population of people with disabilities ages and lives longer, it is necessary that routine preventive services are accessible and made available to them, regardless of gender, disability, or health insurance type.
In recent years, health care policy experts have been urging medical institutions to convert their paper records to electronic form as an important step to avoid medication errors and other mistakes caused by incomplete patient information. Electronic systems also facilitate evaluation of individual physicians and the effectiveness of new treatments. Given the technology's enormous cost, coupled with the difficulty of persuading busy physicians to change the way they practice, as well as the privacy concerns, adoption has been slowed.
At a time when many managed care organizations (MCOs) have announced improvements in administrative systems and a desire to ease provider relations and pay providers correctly and timely, many physician organizations continue to experience great difficulty in obtaining prompt and accurate claims payment. To understand this phenomenon better, physician organizations at two leading academic medical centers in the Northeast and South, respectively, compiled an analysis of their recent managed care claims payment experience. This analysis revealed substantial underpayments from MCOs, and documented the added administrative expense required to recover such underpayments.
Today's health care market must balance the demands of many stakeholders. Consumers want choice over providers, benefit flexibility, and freedom from having to obtain permission for health services. At the same time, employer groups demand that plans hold the line on premiums, or pass cost-increases along to employees. Provider organizations, caught in the middle of these conflicting interests--containing costs yet providing unfettered access to care--are struggling to balance their own capital, financial risk, and service levels.
The goal of Care Focused Purchasing is to create a scorecard of providers and physicians enabling health care consumers to make better decisions. The employer group is united around the belief that current health plan designs and cost-sharing strategies are short-sighted. They are looking for additional companies to join this organization.
Several insurers are engaged in price competition, placing downward pressure on policy costs. But overall, insurers are still careful about their underwriting and pricing.
