Is There Life After Mandates?

By Kim Bellard, March 29 2012

This week the health policy, legal, and political worlds have been focused on the Supreme Court hearing oral arguments about the constitutionality of the Affordable Care Act (ACA).  If the passage of ACA was a once-in-a-generation piece of legislation, the Supreme Court review has been the inevitable sword of Damocles hanging over it.

After two years, ACA remains unpopular, with roughly equal percentages of the population opposed to it as supporting it (see, for example, Pew or Kaiser Family Foundation surveys), with the mandate requirement of the bill driving much of the unpopularity.  Ironically, the provisions that health insurers must cover all comers, without preexisting condition exclusions, are widely popular, even though the mandate was included explicitly to offset the risk of those provisions. 

I have to confess that the mandate never bothered me too much.  I’ve been following health policy long enough to remember that the idea of a mandate is neither new nor a Democratic proposal; it has as many Republican roots as Democratic.  I also remember that candidate Obama opposed the mandate before he became President.  Still, the slippery slope – aka, the Judge Scalia “buying broccoli” – arguments are not without merit: where does the federal government draw the lines of its authority?  The Solicitor General Verrilli had no good response for that line of questioning, which may have doomed ACA.  In the oral arguments earlier this week, several of the Justices showed skepticism towards the mandate, but were less clear about its potential severability – i.e., can ACA survive without the mandate?

There are two reasons why I’ve never been too troubled by the mandate.  For one, it’s not that strong a mandate in the first place.  The mandate never applies to low income individuals – who are most likely to be without insurance – and the penalty for not having insurance caps out at $2000 per family/2.5% of family income.  Depending on one’s age and income, not having insurance might be a rational trade-off; the mandate won’t sweep all those low risk young people in.  Despite having a mandate there for five years now, The New York Times recently reported that 120,000 residents of Massachusetts – some 2% -- still remain without insurance, of whom only 48,000 paid a penalty, so we shouldn’t expect ACA’s mandate to work miracles either.

More importantly, the mandate is, in my mind, less important than the subsidies.  Despite the horror stories trotted out by the Administration and other supporters of ACA, by far the vast majority of people who lack health insurance lack it because they cannot afford coverage, or choose not to buy it – not because they cannot qualify for it.  As evidence of this, HHS admits that only 50,000 people have enrolled under the high risk pools set up by ACA as an interim measure – far short of the 375,000 initially projected.  Think about that: 50 million uninsured, and the most optimistic estimate projected less than 1% of them would take advantage of guaranteed access to health coverage – and those projections proved wildly high.  HS has tried dropping rates to entice more high risk individuals, but they’re not buying.  The problem isn’t access, it is cost.

There is considerable passion on both sides of ACA – people seem to either love it or hate it (and Kaiser Family Foundation says 40% think it has already been struck down!).  The law was carefully designed so that most of the taxes/penalties would not kick in until after the 2012 elections, yet here we are with ACA as one of the focal points of the election anyway, with the Supreme Court decision expected to be delivered in June, just in time for the final campaigns.   One likes to think that the Supreme Court will base its decision purely on the constitutionality of the law, as opposed to the desirability of what the bill accomplishes or the politics of the situation – but that would be naïve. 

Despite the pundits’ predictions, it’s pointless to predict how the Court will rule.  If the mandate does end up being stripped out, there are several options that could help take its place (assuming anything can get through the hyper-partisan Congress).  For example, simply keep the subsidies and the high risk pools.  We might need the health insurance exchanges to help set the market prices for the subsidies, but maybe not.  We could also allow uninsured persons an annual limited enrollment period, similar to how an employer plan operates, and as a last fallback we could always open up the Federal Employees Health Benefit Plan to uninsured citizens – it is one of the largest health insurance programs in the country and so could accept the risk, and it is already closely overseen by the federal government. 

Of course, with a small shift in the political winds, conservatives may find themselves hoist by their own petard – instead of a mandate to buy private coverage, some future Congress could pass a broad-based tax to fund universal coverage, which would almost certainly be constitutional.  Such a program could come with a public option – or simply with “Medicare for all.”  Some cynics think that has been the goal of ACA all along.

I can’t help but to equate, on some level, the opposition to a mandate to the recent (and ongoing) furor over covering contraceptives.  Opponents of contraceptive coverage do not seem to recognize a difference between being required to pay for something they object to from being required to do that something themselves.  We all pay for things that we may morally object to: my federal taxes pay for members of Congress to go on junkets, my state taxes fund the death penalty, and even my auto insurance premiums subsidize premiums of drivers with DUIs.  I don’t approve of those actions, but I’m not forced to drive drunk or to perform the lethal injection.  It’s the same for subsidizing other people’s contraceptive coverage, or coverage generally.  People who live in a democracy, particularly the uniquely American version of democracy – have to accept that they don’t always get their own way, that compromise is necessary.  Other people have rights too.  Democracies require shared sacrifices.

The sad thing about the debate on the mandate, like ACA in general, is that it simply doesn’t address the real problem: exploding health costs and how to reshape our health system to better deliver value.  Mandates and insurance reform should be corollaries to the outcome of that debate, not the core of the debate.

Managing Medicaid Patients with Physical and Behavioral Health Dual Diagnoses through Advanced Analytics

By Claire Thayer, March 28, 2012

MCOL’s Healthcare Web Summit announces a complimentary webinar event, co-sponsored by Elsevier/MEDai: Managing Medicaid Patients with Physical and Behavioral Health Dual Diagnoses through Advanced Analytics, scheduled for Tuesday, May 1st, 2012 at 1PM Eastern.  This webinar will provide a high-level briefing on how using a combination of analytical tools can be used to improve clinical and financial outcomes in state Medicaid programs, particularly for high-cost, high-risk Medicaid beneficiaries with dual medical and behavioral diagnoses.

More information: http://www.healthwebsummit.com/medai050112.htm

Fail to Prepare, Prepare to Fail

By Lindsay Resnick, March 27, 2012

For health plans looking at the period leading up to the Affordable Care Act’s 2014 big launch, it’s a critical time. We’re about to see the most jarring market reforms ever. Even with the uncertainty of the Supreme Court decision and 2012 election, can Plan’s really afford to sit on the sidelines and watch valuable time tick away? The retailization of healthcare is coming, and preparation is key.

Which of reform’s changes are going to stick…which will fade away? How will existing competitors react…which new ones will appear in your markets? Can you move from a B2B to B2C marketing culture?

Tough questions need to be asked (and answered) about legacy core competencies in tomorrow’s reformed marketplace. In other words, sustainability of your health plan’s value chain—the series of individual activities within your enterprise that when linked together, combine to add comparative value to a final products or services.

It’s time for a serious look at four critical areas of focus.  Here are some questions to spark internal debate and begin an ACA transformation assessment:

1. Brand Position What’s your unique selling proposition in a reformed marketplace likely to see increased competition and disintermediation the individual and small group markets by Exchanges?
2. Customer Segmentation Are you quantifying and profiling new customer segments that you’ll be serving in 2014: previously uninsured, pre-ex time-bombs, newly subsidized, abandon employees, Medicare boomers, etc. to be sure you have the right product mix?
3. Customer Acquisition Are marketing’s multi-channel lead generation tactics (e.g., traditional direct response, digital, social media, mobile) being optimized across all distribution outlets (e.g., field agents, telesales, online, mobile, retail)?
4. User Experience Is your health plan delivering a personalized customer experience driven by retention metrics and built around superior member engagement using a managed touchpoint discipline?

Retail healthcare, product standardization and price transparency levels the playing field. Health plans need to refresh their toolkit of customer acquisition and retention tactics. It means protecting and expanding relationships with their existing customer base across product-lines and market segments. And, to grow market share it means strengthening direct-to-consumer marketing tactics and bolstering sales distribution to facilitate (and influence) customer choice.

For a free copy of the Solutions Brief, "Healthcare Reform Readiness: A Transformation Toolkit", click here:  http://bit.ly/z3VLkE

The 3rd Annual Contracting Web Summit

By Claire Thayer, March 23, 2012

MCOL’s Healthcare Web Summit announces The 3^rd Annual Contracting Web Summit, scheduled for Thursday, May 10th, 2012 at 1PM Eastern.  The Third Annual Health Plan Contracting Web Summit will address value based contracting, bundled payments, readmissions financial incentives and more. Join us for the live 90 minute webinar and also access pre-recorded sessions featuring national experts providing key insights, trends, strategic recommendations, actionable intelligence and more on these critical topics.

More information: http://www.healthwebsummit.com/contracting.htm

Celebrating an Anniversary Under Threat of Divorce

By Clive Riddle, March 23^rd , 2012

The Affordable Care Act turned two today. If we consider this a birthday, some would say the Act is entering its terrible twos, but DHHS and other are referring to this as an anniversary, which in this context is bittersweet as the Act now sits under a Supreme Court cloud starting next week, with plenty of partisan positioning from both sides. Will the Anniversary result in Divorce, Annulment, Trial Separation, a Second Honeymoon or settle in a routine marriage with ups and downs?

Here’s some key accomplishments that White House touts, in their six page white paper regarding the Act at the two year mark: Affordable Care Act: The New Health Care Law at Two Years:

• A one-time $250 Medicare rebate check to seniors who hit the “donut hole” coverage gap in 2010, and a 50 percent discount on brand-name drugs in the donut hole in 2011.
• Insurance companies can no longer deny coverage to children because of a pre-existing condition.
• In 2014, discriminating against anyone with a pre-existing condition will be prohibited.
• No more lifetime dollar limits on coverage
• Insurance companies prohibited from rescinding coverage because of an unintentional mistake on an application.
• Starting this fall, health plans provide consumers standardized Summary of Benefits and Coverage forms
• Health insurance companies now have to meet the 80/20 Medical Loss Ratio rule.
• Insurance companies must publicly justify any rate increase of 10 percent or more.
• Tax credits for small businesses, in 2011 affecting an estimated two million workers from an estimated 360,000 small employers who will receive the credit in 2011.
• Early Retiree Reinsurance Program (ERRP) has provided $5 billion in reinsurance payments to employers to benefits for retired workers not yet eligible for Medicare.
• 2.5 million young adults who were uninsured have gained coverage by being able to stay on their parent’s health plan,
• 54 million additional Americans now receive coverage through their private health insurance plan for many preventive services without cost sharing such as copays or deductibles.
• More than 32.5 million seniors have already received one or more free preventive services, including the new Annual Wellness Visit and like mammograms and other cancer screening tests for free
• More than 50,000 Americans with pre-existing conditions have gained coverage through the new temporary Pre-Existing Condition Insurance Plan.
• Advancement of Medicare Accountable Care Organizations  with Thirty-two “Pioneer” ACOs already up and running
• Thirty-three States have  received at total of nearly $670 million in Health Insurance Exchange Establishment Grants.
• The Act creates a new type of non-profit health insurer, called a Consumer Operated and Oriented Plan (CO-OP),  run by their members, with seven non-profits intending to offer coverage in eight states h awarded more than $638 million in loans to get up and running.

So what are others saying about the state and fate of the Act on this second anniversary?

Bloomberg BusinessWeek notes huge numbers of the population are enjoying the benefits included in the Act, even as they are caught up in the politics of it, and quotes Paul Keckley, executive director of the Deloitte Center for Health Solutions: "The coverage improvements are very popular. I think all of that will stay regardless of the individual mandate.”

The Center for Studying Health System Change  released a new study: The Great Recession Accelerated Long-Term Decline of Employer Health Coverage and found that “between 2007 and 2010, the share of U.S. children and working-age adults with employer-sponsored health insurance dropped 10 percentage points from 63.6 percent to 53.5 percent.” They conclude that “while there has been vigorous debate about the effects of national health reform on employer-sponsored insurance, the study findings  indicate that the debate often misses a key point—employer-sponsored insurance likely will continue to erode with or without health reform, especially for lower-income families and those employed by small firms.”

The Wall Street Journal reports in an article Untangling Unknowns in Health-Care Law, that as guidance continues to be developed, and the details continue to unfold, we really don’t know enough today about the Act as we think we do. They summarize: “Two years after Congress passed President Barack Obama's health-care legislation, despite all the assertions about what it will or won't do, no one really knows how it's going to work. The U.S. has rarely attempted anything of this scale before.”

Kaiser Health News comments on the possibility that the Supreme Court might strike down the Individual Mandate while keeping the other components of the Act intact, in their article The New Jersey Experience: Do Insurance Reforms Unravel Without An Individual Mandate  in which they state that” or some clues, the justices could examine what happened in New Jersey, a state that tried to reform its insurance markets without a mandate -- and failed pretty miserably”

The Wall Street Journal also informs us the health plans are making their contingency plans, in their article Insurers Set Plans in Case Mandate Is Quashed.

And, The New York Times notes that politicalization of the issue in their article ”Publicity Push as Health Law’s Court Date Nears”, reporting that “Republicans on Capitol Hill have put together a highly coordinated two-week renewed assault on the health care law, seizing on the legislation’s second anniversary and the next week’s oral arguments before the Supreme Court concerning its constitutionality. “

Health Plan Readmission Strategies: Contracting and Care Management Approaches

By Claire Thayer March 17, 2012

MCOL’s Healthcare Web Summit announces Health Plan Readmission Strategies: Contracting and Care Management Approaches, scheduled for Wednesday, May 9th, 2012 at 1PM Eastern.  Health plan readmissions management encompasses a variety of approaches that often incorporate new provider payment structures, data tracking, education and engagement. Some initiatives are designed for specific care delivery settings, while others are system-wide programs. Please join Drs. Joe Gifford and Robert Herr from Regence, and Dr. Brian Wolf from BCBSRI as they provide a Medical Director's perspective on aspects of their organization's current approaches to drive accountability by reducing unnecessary readmissions.

More information: http://www.healthwebsummit.com/readmissions050912.htm

Walgreens and Express Scripts: The PBM-Pharmacy Feud

By Clive Riddle, March 16, 2012

Once upon a time, pharmacies and PBMs seemed like one happy family – experiencing minimal conflict in the health benefits arena while hospitals and health plans duked it out.  But as the marketplace pressures matured, a full blown family feud  - or pharmacy feud – has erupted in the form of the ongoing Walgreens – Express Scripts saga.

Walgreens walked away from their Express Scripts contract effective January 1^st, due to an impasse over low reimbursement.  Stock analysts so far say the loss of volume does not bode well for Walgreens. But will Walgreens, and other major pharmacies for that matter attempt to turn the table through the merger & acquisition arena, consolidating to improve their contracting clout just as hospitals somewhat successfully did to health plans at the dawn of the new millennium.  Or is it that PBMs will out merge them?

Here’s what’s been expressed in this saga’s script during the past year:

Walgreen’s owned their own PBM, but decided to get out of the business (just as many hospitals shed their regional health plans before going into consolidation mode in the late 90’s and subsequently). Express Scripts was a strong suitor to purchase Walgreen’s PBM, but then Walgreens sold to Catalyst Rx in March last year.

Express Scripts and Medco Health Solutions entered into a Definitive Merger Agreement for the two PBM giants in July 2011, which is still undergoing regulatory scrutiny and thus under a veil of uncertainty.

Walgreens couldn’t re-negotiate a PBM contract with Express Scripts to their satisfaction for 2012 and beyond, so as of January 1^st, they were no longer a participating pharmacy provider.  Walgreens touted its Prescription Savings Club was helping them keep Express Scripts patients, but Reuters reported earlier this month that Walgreen Co's comparable sales fell more than expected in February, the second month that the largest U.S. drugstore chain did not fill prescriptions for patients in the Express Scripts Inc.  pharmacy benefits network.  Reuters cited that the “number of prescriptions filled at Walgreen's comparable stores decreased 9.5 percent during the first 28 days of February after falling 8.6 percent in January. No longer being part of the Express Scripts pharmacy network slashed 10.7 percentage points from comparable prescriptions filled in February, Walgreen said. In February 2011, 12.6 percent of Walgreen's prescriptions were for Express Scripts.”

Adding fuel to this fire were various articles across the country, such as in the March 6^th Oregonian, that Express Scripts users settle in with new pharmacies.  Then this week PCMA, the PBM association, released survey results that tout the headline: New Survey: Walgreens’ Customers Flock to Independent Pharmacies.

But the future may not be so gloomy for holders of Walgreens stock, despite a rash of analysts saying “sell” earlier this year.  Now a possible Rite Aid – Walgreens merger is rumored with the New York Times reporting that a major motive must be that “a merger could create a big new drug store company capable of pushing back against increasingly strong pharmacy benefit managers like Express Scripts.”

Stay tuned. 

Health Plan Readmission Strategies: Contracting and Care Management Approaches

By Claire Thayer, March 14, 2012

MCOL’s Healthcare Web Summit announces Health Plan Readmission Strategies: Contracting and Care Management Approaches, scheduled for Wednesday, May 9th, 2012 at 1PM Eastern.  Health plan readmissions management encompasses a variety of approaches that often incorporate new provider payment structures, data tracking, education and engagement. Some initiatives are designed for specific care delivery settings, while others are system-wide programs. Please join Drs. Joe Gifford and Robert Herr from Regence, and Dr. Brian Wolf from BCBSRI as they provide a Medical Director's perspective on aspects of their organization's current approaches to drive accountability by reducing unnecessary readmissions.

More information: http://www.healthwebsummit.com/readmissions050912.htm

Reducing Readmissions: Collateral Effects

By Claire Thayer, March 13, 2012

MCOL’s Healthcare Web Summit announces Reducing Readmissions: Collateral Effects, scheduled for Thursday, March 29th, 2012 at 1PM Eastern and co-sponsored by Payers & Providers.  Changes to the Medicare program will financially penalize hospitals whose patients are readmitted within 30 days of their discharge. The readmission penalty affects other providers as well, including physicians and hospitalists in particular. Join Warren Hosseinion, M.D., the chief executive officer of the hospitalist firm Apollo Medical Holdings and Daniel C. Cusator, M.D., vice president of The Camden Group, as they discuss upcoming changes in the finance of hospital readmissions, and how the effects will ripple far and wide.

More information: http://www.healthwebsummit.com/pp032912.htm

The Microinsurance Opportunity - Understanding the market and its implications

By Claire Thayer, March 12, 2012

MCOL’s Healthcare Web Summit announces The Microinsurance Opportunity - Understanding the market and its implications, scheduled for Thursday, April 19th, 2012 at 1PM Eastern.  Microinsurance has emerged over the last decade on a global scale. First seen as a poverty alleviation strategy, it was embraced by donors and NGOs as a compliment to the burgeoning micro credit field. More recently commercial insurers and reinsurers have been more significantly involved.  Join Michael McCord, President of the MicroInsurance Centre and Rick Koven, an independent consultant working with the Centre, as they provide an understanding of the market and its implications for the emerging microinsurance opportunity.

More information: http://www.healthwebsummit.com/micro041912.htm

The Current Facts on Alzheimer's

By Clive Riddle, March 8, 2012

The Alzheimer's Association this week released their 2012 Alzheimer's Disease Facts and Figures, with the full report available from their web site.

Harry Johns, President and CEO of the Alzheimer's Association, tells us "Alzheimer's is already a crisis and it's growing worse with every year. While lives affected and care costs soar, the cost of doing nothing is far greater than acting now. Alzheimer's is a tremendous cost driver for families and for Medicare and Medicaid. This crisis simply cannot be allowed to reach its maximum scale because it will overwhelm an already overburdened system."

Johns goes on to say "this disease must be addressed on parallel tracks: supporting research to find treatments that cure, delay or prevent the disease, and offering assistance and support to the more than 5 million Americans now living with Alzheimer's and their more than 15 million caregivers. This is what the National Alzheimer's Plan is all about. Caring for people with Alzheimer's and other dementias costs America $200 billion in just one year. By committing just one percent of that cost, $2 billion, to research it could begin to put the nation on a path to effective treatments and, ultimately, a cure. Given the human and economic costs of this epidemic, the potential returns on this one percent solution are extremely high."

Here's a selection from the boatload of information provided in their 72 page report on Alzheimer's and other dementias:

• $140 billion will be paid by Medicare and Medicaid in 2012 for care and treatment
• Total costs by payer for 2012 will be $200 billion, broken down as follows: Medicare $104.5B; Medicaid $33.5B; Out-of-pocket payments $33.8B; Other $26.2B
• Medicare payments for an older person with Alzheimer's and other dementias are nearly three times higher and Medicaid payments 19 times higher than for seniors without Alzheimer's and other dementias.
• A senior with Alzheimer's and diabetes costs Medicare 81 percent more than a senior with diabetes but no Alzheimer's.
• An older individual with cancer and Alzheimer's costs Medicare 53 percent more than a beneficiary with cancer and no Alzheimer's.
• An estimated 800,000 individuals have Alzheimer's and live alone, and up to half of these individuals do not have an identifiable caregiver.
• The 15.2 million friends and family members of the 5.4 million individuals with Alzheimer's and other dementias provide 17.4 billion hours of unpaid care valued at more than $210 billion.
• 200,000 of the Alzheimer's population are under age 65 with “younger-onset Alzheimer's”
• 45% of seniors over age 85 have Alzheimer's
• 16 percent of women age 71 and older have Alzheimer’s disease or other dementias compared with 11% of men
• Someone develops the disease every 68 seconds
• Alzheimer's is the sixth-leading cause of death in the country and the only cause of death among the top 10 in the United States that cannot be prevented, cured or even slowed.
• Based on final mortality data from 2000-2008, death rates have declined for most major diseases – heart disease (-13 percent), breast cancer (-3 percent), prostate cancer (-8 percent), stroke (-20 percent) and HIV/AIDS (-29) − while deaths from Alzheimer's disease have risen 66 percent during the same period.
• Alzheimer's accounts for somewhere between 60-80% of all dementia cases

Pioneer ACOs: Quantifying Risks & Identifying Opportunities

By Claire Thayer, March 5, 2012

MCOL’s Healthcare Web Summit announces Pioneer ACOs: Quantifying Risks & Identifying Opportunities, scheduled for Wednesday, May 23, 2012 at 1PM Eastern.  This session discusses the elements of risk associated with Pioneer ACOs as well as potential strategies for controlling costs and identifying opportunities for savings. Organizations not participating in the Pioneer ACO program but either wishing to monitor Pioneer ACO issues and activities, or wishing to adapt applicable risk and cost control strategies discussed to other populations, can also benefit from this session.

More information: http://www.healthwebsummit.com/milliman052312.htm

Improving Chronic Care Outcomes: Depression Management Coaching

By Claire Thayer, March 3, 2012

MCOL’s Healthcare Web Summit announces Improving Chronic Care Outcomes: Depression Management Coaching, scheduled for Thursday, April 12, 2012 at 1PM Eastern.  This event is co-sponsored by the Center for Health Value Innovation.  Hear from leaders in the Center, Chief Medical Officer Jack Mahoney MD, and President Cyndy Nayer, along with Fred Newman, Founder and CEO of Interface EAP Coordinated Health Solutions. There are real-world outcomes to be shared, and questions that attendees will want to ask about outcomes-based contracting for emerging services.

More information: http://www.healthwebsummit.com/chvi041212.htm

Midwest Business Group on Health’s Quest to Reduce Elective Preterm Deliveries

By Clive Riddle, March 2, 2012

Last week,  Larry S. Boress, President & CEO of the Midwest Business Group on Health was one of three featured speakers in the HealthcareWebSummit event: Managing an Increasing Trend of Elective Preterm Deliveries.

MBGH has taken a keen interest in facilitating a reduction in elective preterm deliveries, and Larry shared why purchasers have gotten involved, and what they are doing about it.

Larry’s opening arguments were:

• Maternity care is the number one reason for hospitalization among employee populations
• The highest cost for maternity care is when underdeveloped infants are treated in the neonatal intensive care units of hospitals
• Preterm infants are less likely to survive to their first birthday than infants delivered at full term
• Those preterm babies who do survive are more likely to suffer long-term costly disabilities than infants born at term

He shared 2009 Data compiled by Thomson Reuters for the March of Dimes, which compared average expenditures for newborn care yielding $4,551 for uncomplicated cases vs. $49,033  for premature/ low birth weight cases.

So what exactly is an early elective delivery. Larry offered these characteristics:

• The newborns delivered with a gestational age between the 37th and 39thcompleted week, that were delivered electively
• Early elective deliveries are performed on women of all backgrounds and incomes.
• These are distinct from early deliveries performed due to clinically-appropriate reasons to avoid health problems facing the mother or the infant

And what is the scope of early elective deliveries? We learned that the national average is up to a rate of 17% of deliveries, while the Leapfrog group has set a current target at 12%. Minnesota, South Carolina, Indiana and Arizona all have rates above 25%. Virginia, Florida, and New York exceed 20%. While 53% of hospitals are at or below the Leapfrog target of 12%, 33% of hospitals have rates of 20% or higher (6% of hospitals have rates of 45% or higher.)

What are the motivations to have an elective preterm delivery, despite the dangers and costs? Larry cites these delivering physician convenience factors: (A) Guarantee attendance at birth;  (B) Avoid potential scheduling conflicts; (C)  Reduce being woken at night; and (D) the NICU can handle it. Furthermore, Larry offered these motivations for the mothers:

• Prior bad pregnancy
• Desire to deliver on special date or holiday
• Special circumstances
• Cultural factors
• Ability to  plan in advance for birth
•  Convenience
• Ability to be delivered by her doctor
• Maternal intolerance to late pregnancy
• Excess edema, backache, indigestion, insomnia

But there are serious quality implications of non-medically indicated early deliveries beyond cost that Larry cited:

• Increased NICU admissions (and separation from mother)
• Increased respiratory illness
• Increased jaundice and readmissions
• Increased suspected or proven sepsis
• Increased newborn feeding problems and other transition issues
• Under developed brain and lungs
• Potential development of cerebral palsy

The good news is this is now a national quality measure for the National Quality Forum (NQF); Leapfrog Group; The Joint Commission; and AMA Physician Performance Consortium Measure.

Larry closed by noting that in the twelve months since MBGH made its initial Call to Action to reduce elective preterm deliveries, over 70% of hospitals reduced their early elective delivery rates below previous levels, and many have set 5% as their goal.

The Business of Clinical Integration: Payment Models, Structures, Governance, Strategic Issues and More

By Claire Thayer, March 2, 2012

MCOL’s Healthcare Web Summit announces The Business of Clinical Integration: Payment Models, Structures, Governance, Strategic Issues and More, scheduled for Wednesday, April 18, 2012 at 1PM Eastern.  Join nationally renowned experts Doug Hastings, Chairman of Epstein, Becker & Green, and Dr. Mark Browne, Principal of Pershing Yoakley & Associates, as they construct the foundation of business considerations for health care organizations in pursuit of clinical integration. This session will address payment models, structures, governance, strategic issues and more, for organizations seeking: to manage populations and patients based on a culture of patient focused “Clinical Teaming”; utilizing systems and data which enable seamless coordination and continuity-of-care; and optimization of applicable incentives.

More information: http://www.healthwebsummit.com/integration041812.htm

Medicare: Predictive Analytics, MSSP & Star – Hidden Compliance & Enrollment Patterns

By  Claire Thayer, March 1, 2012

MCOL’s Healthcare Web Summit announces Medicare: Predictive Analytics, MSSP & Star – Hidden Compliance & Enrollment Patterns, scheduled for Thursday, April 5, 2012 at 1PM Eastern.  The Medicare Shared Savings Program and the Medicare Advantage Part C "Star" rating program both provide significant potential financial rewards if participating organizations meet applicable criteria. Join Milliman's Rong Yi and Bruce Pyenson as they explore how the two sets of quality measures relate to each other, and discuss what types of these Medicare members are less likely to be compliant and therefore require more targeted communication or intervention.

More information: http://www.healthwebsummit.com/milliman040512.htm