Healthcare reform is upon us – what will be affected?
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

The healthcare reform bill passed and was signed into law in March.  As it comes to fruition over the next decade, there will be many different changes.  I have spent much of the last 6 – 8 months talking to various aspects of healthcare reform, all of which have the potential to dramatically affect the manner in which care is doled out, to whom and the subsequent outcomes achieved.  Let’s talk about this further.

I wanted to note though, change is afoot, and it has not taken the legalities and formality of the recent bill to catalyze reform within our healthcare system.  It has been reforming in a variety of ways over the last several years.  Many of the changes have been initiated by progressive health plans which are always seeking new ‘out-of-the-box’ approaches to both improve the overall health services and outcomes provided, while simultaneously reducing the cost footprint.  Programs like the patient-centered medical home (PCMH) are one such program.  At last count, there are over 27 multi-stakeholder pilots underway in 20 states.  Other programs like Accountable Care Organizations (ACOs), Utilization Management (UM), Population Health Management (PHM) and others continue to contribute to the evolution of our healthcare system.  I believe that the market will continue to drive better outcomes and efficiencies in tandem with any legislative changes that are implemented.  Collectively, this will help the system equilibrate to meet the changing landscape. (more…)

Although costly on the surface, addressing mental health has benefits far exceeding the costs to both employers and health plans
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

Mental health parity is the term that describes the practice of managing any ailment termed ‘mental health’, in the same manner as any other physical ailment.  Mental health parity is not new though.  The Mental Health Parity Act (MHPA) was signed into law in 1996.  This law required that any annual or lifetime limits and other financial requirements on benefits paid be no different than the similar dollar limits for other medical benefits offered by health insurance or group health plans[1].  In 2008, mostly under TARP[2], the MHPA was extended and added to with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 signed into law by then President Bush.  The MHPAEA preserves the key aspects of the MHPA, but adds some new protections as well.  The program was further supported with the issuance of new rules by President Obama in January of this year for all employers with 50 or more employees and choosing to offer mental health coverage as part of their insurance package.  This program amends both ERISA[3] and PHSA[4] and was effective as of July 1, 2010. (more…)

Can health plans drive the collaboration between physicians and other clinical stakeholders while maintaining a focus on the patient?
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

It seems that healthcare continues to make the headlines on many fronts and hence there are great topics to write about.  I continue to be intrigued about healthcare reform and the direction it will take.  Several weeks ago, I wrote about whether Accountable Care Organizations (ACOs) could deliver healthcare reform.  In a recent blog post from National Journal.com[1], the question is asked, “ACOs: Who’s the Boss?”  Interesting question since it implies who is in control.  Since an ACO can be defined as a local healthcare organization and related group of providers that can be held accountable for the cost and quality of care delivered to a defined patient population[2], maybe the question is valid, but not in the sense of control, but more in the context of collaboration and direction in meeting a common goal.  So the ACO in practice then will perform as we hope all of healthcare reform does – improve outcomes while reducing cost.  (more…)

Collection, analysis, centralization and access make the EMR an essential component in optimizing utilization
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

It seems intuitively obvious that in order to drive optimum utilization, you need to have systems for data collection, analysis, dissemination and access. We’ve been talking about the vital role of utilization management (UM) in advancing healthcare reform. It would seem that to drive fundamental changes to our healthcare system, the first goal would be to make sure the system is running optimally efficient. Simply put, preventive care would be the standard discipline, effective triage and the subsequent doling out of the right care for the right patient at the right time (and precisely no more), would be routine. These practices would not only streamline the system, but save resources and time. Ah, the Utopian society. (more…)