Posted by Chris Raphaely
on March 28, 2017
With the House GOP pulling the American Health Care Act (AHCA) due to lack of sufficient support even within its own party, Obamacare is not out of the woods.
The ACA’s two pillars, the individual marketplaces and Medicaid expansion, remain vulnerable and could be used as political bargaining chips in Washington as the battle over “health care reform” plays out in the coming months and years.
In response to the House’s failure to pass the AHCA, the President and House Speaker have expressly said that Obamacare will “implode” and the administration has many ways to see to it that it does sooner rather than later. On the other hand, the administration and Congress could also move on to on tax reform and other items while changes to the marketplaces are implemented by regulation. The administration already has proposed regulations on the table that has been characterized as a “good faith” effort to implement minor changes to prop up the marketplaces. Reportedly, however, many insurers will want more in the form of funding for cost sharing reductions and reinsurance to keep sufficient numbers of insurers in the marketplaces long term. Continue reading…
Posted by Chris Raphaely
on March 23, 2017
The U.S. District of Minnesota has ruled in Peterson v. Unitedhealth Grp. Inc., No. 14-CV-2101 (PJS/BRT), 2017 WL 991043 (D. Minn. Mar. 14, 2017) that ERISA does not permit United Healthcare (“United”) to claw back alleged overpayments related to patients from one plan by reducing or eliminating payments related to patients from different self-insured plans, dealing a potential blow to the use of an effective tool that health insurers have used to recoup alleged overpayments from providers.
In Peterson, the Plaintiffs were healthcare providers who brought suit against United as assignees of patients who were enrolled in United-administered plans. United had allegedly overpaid Plaintiffs for services provided to certain patients, and offset these alleged overpayments by reducing or eliminating payments for services that Plaintiffs provided to other patients, who were members of different United-administered self-insured ERISA plans. This practice is known as cross-plan offsetting. Continue reading…
Posted by Rene Quashie
on March 22, 2017
How to properly evaluate and weigh cost savings in health care has long been a controversial subject—perhaps nowhere more so than when technology-enabled health care is evaluated. A recent study is a case in point. The journal Health Affairs recently published a study that has caused quite a stir in the telehealth community. Without getting into details regarding methodology and results—best left for a more in-depth article—the study acknowledges that reimbursement for direct-to-consumer (“DTC”) telehealth visits are lower than would be the case for in-person physician or ED visits. However, the study raised two concerns. First, the researchers posited that there could be increased spending for DTC visits “if the direct-to-consumer telehealth visit is more likely to result in follow-up appointments, testing, or prescriptions, compared to similar visits to other settings.” Second, the researchers believe that DTC physicians “may be more likely to recommend that patients have a subsequent in-person visit with a provider.” The basis for these concerns is not made entirely clear, and quite frankly doesn’t square with my discussions with DTC telehealth stakeholders.
The study also broadly concludes that DTC telehealth may lead to increased utilization as patients will seek care for illnesses for which they would not have sought care had telehealth not been available. More to the point, the researchers calculated that about 88 percent of telehealth usage represents new utilization. In other words, only 12 percent of DTC telehealth usage replaced or substituted visits to other providers. Ultimately, the study argues that DTC telehealth may increase access by making care more convenient for some individuals, and, thereby, may also increase utilization and health care spending. Continue reading…