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…)

PCMH is but one element of the changing landscape – we’re broadening the view to cover a broader range of key issues facing health care executives
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

We have had such a good response to the PCMH Community Blog since its inception last June. Thank you all for reading and sharing your thoughts. The comments and feedback we have received from you and others have been very positive.

Over the last year, we have facilitated the discussion around the PCMH and how this program could positively affect a health plan in today’s environment. There is no doubt that the potential impact of PCMH on health care remains strong. That said, you have asked that we address other key issues that you face on a daily basis in the constantly changing and dynamic healthcare environment we are all a part of today. We have heard your request.

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Can the ACO align with the PCMH to deliver improved patient and financial outcomes?
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated

Let me start by defining Accountable Care Organization (ACO). In the healthcare reform debate, one of the main issues was to find a way to incent physicians to deliver quality of care vs. a focus on additional services or volume of patients. An ACO offers one method of incentive. An ACO is a local healthcare organization and related set of providers (nominally primary care physicians, specialists and associated hospitals) that can be held accountable for the cost and quality of care delivered to a defined patient population[1]. The ACO by definition has a focus on quality care by offering incentives to increase the integration of clinical services and care coordination. The foundation of an ACO could be considered primary care and the PCMH. (more…)

The bill has become law, now let’s hope PCMH can catalyze Primary Care Reform
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

It happened.

Whether we supported the bill or not, the Senate version[1] of healthcare reform, HR 3962, has passed the house. Really though, it is just ‘insurance reform’ since there is so little in the bill on quality of care or other improvements which are actually needed to significantly move the needle on true healthcare reform – meaning improvement in quality of care while really reducing the associated cost. That said, I was particularly interested in the Primary Care and PCMH sections of the bill and how they will be enacted. I have been writing on these since August of last year. I thought it would be particularly timely to recap these discussions. (more…)

The bill is primarily insurance-focused, but PCMH and Primary Care do get some play
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

Just when you thought you had read the last chapter of a book, you find it is only book one of a series. So goes Washington and Healthcare Reform. The bill in question, now the latest Senate version, is at the center of the debate. It will either rise from its own ashes as did the phoenix, or fall back to earth like a shattered clay pigeon -it is truly up in the air at this point. (more…)

Will the upcoming discussions resurrect the Healthcare Reform discussion?
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

It would seem that government-led healthcare reform may have more lives than a cat. With the constant back and forth, legislative wrangling, backroom deals and the threat of reconciliation, your guess might be as good as mine. I’m not sure that I would count on this resurgent effort bearing any significant fruit however. It seems that the same barriers exist within and between the two houses of Congress (not to mention public opinion), and this ‘do-over’ may end the same as the last efforts. That said, the success of actual healthcare reform on a healthplan-by-healthplan basis continues in real life, with real results for patients, physicians, practices and healthplans. Here are several additional examples of medical homes that are working as planned and truly reforming healthcare. (more…)

Even though the majority of healthcare cost and improvement in quality of care are not being addressed, but insurance might be reformed – right?
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

As the debate in our nation’s capital continues, it seems that the buzz is masking some of the most critical issues that face any true healthcare reform. As I discussed in last week’s posting, the ‘bending of the cost curve’ really is not bending at all. The rhetoric continues to focus on increasing coverage – this is really an insurance issue and still does not address over 85% of the costs that burden the current healthcare system, not to mention the quest to improve overall healthcare. If you really think about it though, not even insurance will get the overhaul it so desperately needs if you believe the demonizing commentary (e.g. health insurance will still be bound within state lines, etc.). But that is for another discussion. (more…)

The current debate only addresses insurance (and it is a minor component of cost) – what are we going to do to stem real healthcare costs?
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

I have spent a great deal of time reading, listening and reviewing the current healthcare reform proposals – both from the House and the Senate, and the dialog that has ensued regarding any number of hybrid solutions that might ultimately become the bill that becomes ‘healthcare reform’. As I mentioned last week, the debate over a single-payer system (proposed to be the government), abortion funding and a keen focus on the insurance aspects are clearly dominating the discussions and will likely become the central theme of any announced conclusion to the debate. Interestingly though, the insurance (or lack thereof) is such a small portion of the money we spend on healthcare, I continue to be surprised that so much time continues to be spent there. It would seem, as Howard Dean proposed, to solve the insurance dilemma, “…insert competition into insurance markets, force insurers to cut unnecessary administration expenses and spend healthcare dollars caring for people…” might be the best, if not the most obvious answer. Sounds simple and it should be done, right? The thing is that this approach only addresses about 15% of the cost within the healthcare system. (more…)

With the healthcare reform bill still in conference and PCMHs monies allocated for more ‘study’, can the states better move the process forward?
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated

As the healthcare debate rages, it may be that primary-care reform becomes an afterthought. The focus continues to be on the ‘public option’ and federal funding of abortion as the pivotal issues within the current bill. Unless these are addressed, the bill will likely not move forward, or not in its current form. (more…)