In 1991, the world's second richest man griped about health care costs. Today, Sam Walton's Walmart empire is striking back with direct contracting. The retail giant is using centers-of-excellence contracts by which it pays high-value provider organizations to treat specific medical problems.
Effective treatment has helped curb the epidemic, but practical cures have been elusive. Now being tested: a "sterilizing cure" that eradicates HIV from the body, and a "functional cure" that effectively reduces the viral load so it cannot be transmitted or progress to AIDS.
CMS and insurers talked about what needed to be done to better address the social determinants of health (SDOH) for beneficiaries. That led to a policy, implemented last year by CMS, that allows for the provision of daily maintenance care using nonskilled in-home providers, the kind of services usually given in assisted-living facilities.
It is a high-tech wonder and the product of generations of heavy investment in trauma care. But the emergency department is also the backdoor of the American health care system-a kind of open wound that is symptomatic of deficiencies of how American health care is organized, delivered, and paid for.
It is a heroic part of the American health system. Lives are saved, the dire consequences avoided. But the air ambulance industry is consolidating, prices are soaring, and insurers and providers continually fight over network issues. One consequence: Surprise billing that leaves patients owing tens of thousands of dollars.
The annual pharmacy costs for single tablet regimens were $6,100 less compared with regimens involving multiple pills, at least among HIV patients who were taking the medicines as intended, according to an Express Scripts analysis. On average, the company found that health plans could save about $4,160 per patient per year.
Doctors returning home from World War II knew that critically ill or injured patients had a better chance of survival if they were treated in a hospital. In 1976, emergency medicine became the country's 23rd recognized medical specialty. A lot happened between points A and B.
Adjusting their vision so it looks past the messenger and focuses on President Trump's stated goal to end AIDS by 2030 isn't easy for HIV/AIDS advocates. But they aren't being entirely dismissive, either. They have some faith in, and working relationships with, federal government health officials who will oversee implementation of the plan.
There was a time when insurers were accused (often rightly) of using wellness to lure healthier beneficiaries into MA. Now, the issue is whether wellness can help health plans manage medical spending. "To the degree they do minimize medical spending, the beneficiaries will presumptively be better off healthwise," says Joseph Newhouse of Harvard.
Artificial intelligence is creating another new frontier in real-world evidence gathering and analysis. AI's algorithms can approximate-and maybe even surpass-human cognition and judgment in the analysis of complex medical data. Sure, humans will sign off, but AI software will do the heavy lifting.
For Medicare for all to truly work for all Americans it must do more than provide uniform, basic insurance. In health care, as in fashion, consumers need different options. To truly reform health care, solutions must allow customization and consumer choice.
PBMs can play an important role in the pharmaceutical supply chain and are positioned to protect consumers and save them out-of-pocket costs. The emergence of new PBMs, whether inside or outside an insurer, should drive new solutions and the development of new models.
The need for real-time data in health care is universal, but it is particularly pressing for post-acute providers, who are now joining their hospital and health system peers in being held responsible for patient outcomes. CMS is watching.
AHPs are not required to cover all of the essential health benefits that ACA-compliant plans do, and they can base premiums on their expected or actual spending for health care rather than setting premiums at the community rate. But critics say you get what you pay for.
It seems that under HHS Secretary Alex Azar, the Center for Medicare and Medicaid Innovation-that ACA-enabled office given almost carte-blanche authority to experiment with new payment and care models-may be getting its groove back. Adam Boehler, hired last April as CMMI director, has cranked up output with a flurry of new models.
As of November 2018, there were 8,774 such centers in the U.S, up 8% from 8,125 in 2017, according to the Urgent Care Association. And although they are not exclusively for people with insurance, just under half (47%) of the patients seen in urgent care centers are covered by commercial insurance.
When patients and their medical records are out of whack, it causes harm and wastes money. It gets worse when organizations try to share patient records. Even if two facilities share the same EHR system, match rates may be as low as 50%. Privacy concerns makes this problem difficult to fix.
The need for a strong pricing strategy is a foregone conclusion. Hospitals and health systems have a window of opportunity now to craft a thoughtful approach to pricing that avoids common pitfalls and ultimately creates a competitive advantage in the market.
The law is supposed to keep physicians from unduly profiting from referrals. But CMS Administrator Seema Verma thinks that it "may prohibit some relationships that are designed to enhance care coordination, improve quality, and reduce waste," and thereby become an obstacle to ACOs and value-based care.
UPMC Health Plan gets a discount if a patient on Brilinta has a heart attack or stroke. The novel sweetener is that UPMC will lower the monthly copay for Brilinta from $45 to $10, which means the patient cost will be about the same as it is for generic Plavix.
