Quality. Ask a hundred people to define it, and you’ll get a hundred answers. In the last decade we’ve collected more performance data and industry rankings than ever to sharpen that fuzzy definition. Members, health coalitions, purchasers, consumer advocates and the media all rate Group Health’s quality in different ways.
Monthly Archive for July, 2010
Federal health reform will produce major changes, with coverage mandates bringing more than half a million new people in Washington state into the health care system starting in 2014. Much of the focus of the federal reform bill is on getting people covered – a critical and historic step – but we must also think about how these people will access health care, and how to ensure they get high-quality, affordable care.
While the health reform bill precipitates sweeping changes and greater federal role, it does not sufficiently address how to provide effective, high-quality care to patients while keeping costs down. Here is where the state can and must have a significant role.
Group Health has always been a strong proponent of preventive care and evidence-based medicine, so we were very pleased to see preventive services stand out as an important aspect to federal health care reform for health plans.
When the U.S. Departments of Health and Human Services, Labor, and Treasury released the highly anticipated interim final rule (IFR) for preventive services last week, it moved the health care system in the right direction by helping Americans receive the preventive health care they need and thereby helping to prevent more costly and painful illness and disease down the road. The regulation, which as an interim final rule has the full force of law despite being open to comment by stakeholders and the public, requires health plans to cover in-network preventive services with zero out of pocket cost for the patient. Health plans may still require enrollees to share a portion of the cost for preventive services delivered by out-of-network providers.
You’re a patient getting care from a Group Health physician in a Group Health facility. All of the conditions are right for an evidence-based, medically appropriate, smooth and integrated experience. Our care model, our people, our technologies and incentives make it possible.
But here’s the reality: we don’t own all of the buildings where our members receive care. We rely on thousands of contracted medical providers in dozens of non-Group Health facilities. Two-thirds of our clinical costs are incurred outside our own walls and in many cases care is provided by non-Group Health staff. And I believe in the future we’re going to have to look outside our own walls even more.
Medicaid, the health care coverage program for low-income individuals, is administered at the state level but funded jointly by the state and federal governments: for every dollar spent by the states for Medicaid, the federal government kicks in a matching amount, according to the Federal Medicaid Assistance Percentage (FMAP) for that state.
The stimulus bill Congress passed in early 2009 included a provision that temporarily increased the FMAP for all states, aiming to help states make it through the economic downturn when less tax revenue is generated and more people are likely to enroll in support programs like Medicaid.
Continue reading ‘States need federal support to “bridge” to health reform’
The health reform legislation sets a minimum percentage of a health care premium that must go toward medical costs. This percentage is called the “medical loss ratio.” Beginning in 2011, 85 percent of premiums for large group and Medicare Advantage plans must go to services and activities related to quality of care. The minimum will be set at 80 percent for small group and individual plans. The goal of these provisions, which will take effect in 2011, is to limit health insurance administrative costs. Only 15 percent or 20 percent, depending on the plan type, will be allowed administration as well as profit (for for-profit carriers) or sales and marketing costs.
Until now, different companies calculate medical loss ratio (or MLR) differently. But in the interest of comparing apples of apples and enforcing the new minimum levels, the health reform law also requires the development of a standard new definition.
Continue reading ‘Medical Loss Ratio – what is it and why is it important?’
As you may have noticed, a lot is happening in the small group market. Here’s a run-down of a couple of the big changes taking place over the next few months.
For plan years beginning October 1, 2010, the small group market will include “groups of one” – such as sole proprietors. This change is due to a bill that passed in the Washington State Legislature during the 2010 session, ESSB 6538. According to the new law, in order to qualify as a “group of one,” an individual must have been employed by the same employer for at least 12 months prior to application for small group coverage and verify that at least 75 percent of his or her income is derived from the business of which they are sole proprietor. This verification would come from the 1040 tax form filed in the previous taxable year. Individuals in agriculture are required to derive only 51percent of their income from the business of which they are sole proprietor in order to qualify.
Continue reading ‘Big changes coming to the small group market’
As controversy smolders in the other Washington over the nomination of Dr. Donald Berwick to head the Centers for Medicare & Medicaid Services (CMS), some here may be wondering: What’s not to like?
As president of the Institute for Health Innovation (IHI), the Harvard professor has successfully shown health organizations can improve patient care and safety—and decrease costs. Nationwide, he has helped providers adopt science-based approaches to reduce medical errors, increase efficiency, and improve outcomes. Such experience, along with his leadership and vision, could bring needed transformation to CMS. The agency manages a third of all U.S. health care spending—and will implement much of the new health reform law, including the creation of a new CMS Center for Innovation to explore new care and payment models to boost quality and control cost.
Continue reading ‘Beyond the politics of Dr. Berwick’s nomination: Cost solutions require evidence’
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