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Aetna CEO: New Math for Medicare

October 22, 2014
5:02 pm

(We have made the point often in this space that, even with the private sector’s successes in containing healthcare costs and reducing Medicare per-capita spending to historic lows, the sheer magnitude of baby boomers reaching 65 and reaching Medicare eligibility necessitates significant changes to the program.  Moving away from a fee-for-service model that incentivizes volume rather than value is essential.  As Mark Bertolini, CEO of Aetna (a Healthcare Leadership Council member) points out in this Forbes op-ed column, innovative approaches to Medicare payment and healthcare delivery can achieve better patient health and improved system sustainability.)

By Mark T. Bertolini

The Medicare Part A trust fund will be exhausted by 2030. As 11,000 baby boomers become eligible for Medicare daily, Medicare spending is projected to exceed $1 trillion in 2020. We can’t change the numbers that define our population but, we can apply new math to them.

Focus first on helping the chronically ill

The sickest 5 percent of fee-for-service Medicare patients with chronic conditions drive more than 40 percent of the total cost of health care in the program. We should use the lessons learned in Medicare Advantage and other proven innovations. Encourage Medicare Part A and B enrollees with multiple chronic conditions to participate in new integrated care programs with top-notch physicians to ensure high-quality service. Pay managed care organizations rates that guarantee savings for taxpayers out of the gate.

Use the successes and learnings of this approach to phase out the Medicare fee-for-service payment model

The fee-for-service model has doctors getting paid by the number of procedures they do or tests they run, rather than on how well their patients do. We need to move to a system that pays for quality over quantity.

These two changes alone will mean lower cost coupled with better integrated, quality care for the members of our families that need that care the most.

While the Congressional Budget Office recently reported that estimated costs of Medicare and Medicaid have dropped, our country’s coffers are still being drained by a too-costly health care system. This was reconfirmed in July, when the Boards of Trustees of the Federal Hospital insurance and Federal Supplementary Medical Insurance Trust Funds projected that Medicare costs will grow from their current level of 3.5 percent of the gross domestic product (GDP) to at least 5.3 percent of the GDP in 2035.

Consider this: As baby boomers become Medicare eligible, the number of beneficiaries will grow from 50.7 million in 2012 to 81 million in 2030—a 60 percent increase in less than 20 years. Add to this that the tax base is shrinking: Baby boomers are retiring, leaving the country with a much smaller workforce paying a much higher Medicare tax burden. With average life expectancy projected to reach 81.5 years by 2030, on average those seniors will use Medicare benefits for three times as long as when Medicare was enacted in 1965. Chronic conditions among Medicare beneficiaries also are on the rise, making them a sicker and more expensive population than existed in 1965.

The current fee-for-service payment model unintentionally incentivizes the wrong kinds of behaviors—spending less time with patients, or having more tests and procedures. There is little reward for finding more efficient ways to make people better or for keeping them healthy in the first place.

Bringing innovative collaboration to traditional Medicare

Many programs that have been so effective for caring for Medicare Advantage’s sickest beneficiaries, including enhanced home-based care, care coordination and medication review, are not always covered under traditional Medicare. Our experience in Medicare Advantage shows the promise of these models. For several years, we have worked with health care providers to establish reimbursement models based on risk-sharing that encourages higher-quality performance. Aetna Aetna’s Medicare Advantage Provider Collaboration program, and its work to create accountable care organizations (ACOs), are examples of cooperative arrangements that are improving care quality and health outcomes while also reducing costs. In many instances, these programs have resulted in fewer inpatient hospital days, fewer hospital admissions and fewer readmissions for patients, which can reduce health care costs by as much as 30 percent.

Bringing innovative provider collaborations and managed care approaches to traditional Medicare is a winning proposition for everyone. Patients could get a full team of experts providing customized and focused attention, and be rewarded with incentives for adhering to treatment. Doctors could get greater support, information and resources to help their patients get and stay healthy. Managed care companies could serve a broader Medicare population, as long as they meet the required quality and outcomes results. Taxpayers could get a lower-cost, better-quality healthcare system.

In the past, we have shied away from making significant changes to Medicare, since the issues seemed to be so far down the road. That is no longer the case. Our Medicare spending has a tremendous impact on our economy now, and that will only increase over the next decade. Our population is aging too quickly and our nation’s Medicare costs are growing too rapidly for us to be timid. We need to take dramatic action now, and revolutionize how we approach the problem. The numbers can work if we are ready to adopt a new model. We can achieve a result that includes both healthier seniors and a lower tax burden.

The Burwell Direction

September 08, 2014
3:22 pm

If her first public address as Health and Human Services Secretary is any indication, Sylvia Burwell has her department headed in a positive and much-needed direction.

Speaking to an audience at George Washington University, Secretary Burwell made it clear that she has no interest in maintaining the partisan strife that has characterized the handling of healthcare issues in recent years.  In describing her governing philosophy, she said “What’s central to all of this is not politics.  It’s progress:  setting aside the back and forth and continuing to move forward.”

Secretary Burwell also emphasized the need for transparency in HHS actions and decisionmaking, bipartisanship and listening to stakeholders.

The last of those points is going to be particularly important given the challenges facing HHS in the coming months.  All parties hope that the next open enrollment period for the Affordable Care Act will go more smoothly than the initial sign-up efforts.  Making that happen will, by necessity, involve listening to the expert, hands-on perspectives of healthcare insurers and providers.  The Healthcare Leadership Council has, in fact, developed and provided a number of recommendations, generated from the insights of its member companies, on how to improve upon the previous open enrollment period.

Also, there is rulemaking scheduled this fall related to the Medicare Part D prescription drug program.  I like to think that the regulatory controversy over Part D earlier this year – when the Centers for Medicare and Medicaid Services ceased action on aspects of a proposed rule because of strong response from hundreds of healthcare and patient organizations over the prospects of fewer Part D plan choices and higher drug costs – could have been avoided with more communication between federal authorities and those groups working to preserve a strong, affordable Medicare prescription drug benefit.

With such important issues on the horizon, we strongly applaud the direction Secretary Burwell has set for her department and welcome the opportunity to work with her in achieving shared goals for American healthcare.

When in Doubt, Always Opt for Choice

August 08, 2014
11:16 am

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued proposed regulations that would have made significant, sweeping changes in the Medicare Part D prescription drug program.  Among other aspects, the proposed rule would have placed new limitations on the number of Part D plans that plan sponsors could offer in a particular region.

In a logical world, policymakers would have first asked seniors if they felt the Part D program was inflicting too many plan choices upon them.  They didn’t, so the Healthcare Leadership Council (through our Medicare Today initiative) did.

We recently released our annual nationwide survey of U.S seniors evaluating their perspectives regarding their prescription drug coverage.  As has been the case in past years, satisfaction with Part D remains high, with almost 90 percent saying they’re pleased with their coverage and find it affordable.

More interesting, though, in context with the earlier CMS proposed rulemaking is the survey’s finding that three of every four seniors value having a wide choice of plans from which to choose and expressed concern with any changes that would limit those choices.

Ever since the inception of Medicare Part D, those who take a more patronizing view toward older Americans have asserted that they would be confused by having a number of plan choices before them.  This survey makes it abundantly clear that is not the case.

CMS pulled back on its efforts to make such drastic changes to the Medicare prescription drug program.  Before any further rulemaking takes place, federal regulators would do well to take into consideration what beneficiaries actually want.

Medicine, Exercise and the Importance of Patient Adherence

July 18, 2014
12:41 pm

(This month, the Healthcare Leadership Council sponsored a Capitol Hill briefing on the importance of patient adherence in improving the quality and cost-effectiveness of healthcare.  The briefing featured expert perspectives from inVentiv Health, Novartis, SCAN Health Plan and Walgreens.  We were pleased to see commentary about this briefing on the “Be Active Your Way” blog sponsored by the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health promotion.  The blog post is reprinted below.)

On Monday, July 14th, the Healthcare Leadership Council hosted an excellent briefing on non-adherence to medication, highlighting the fact that 1 out of 3 patients never fill their prescriptions, and nearly 3 out of 4 Americans don’t take their medications as directed.

The panelists discussed innovative strategies for improving adherence, such as targeted and timely communication. Each strategy was based on the reality that a one-size-fits-all approach to communication is both inefficient and ineffective. Clearly, the digital age is creating medical providers with new opportunities for engaging patients and tracking their adherence, but there are no simple solutions for getting folks to take their medicine.

The problem of non-adherence to medication raises an uncomfortable question for physical activity advocates.

If 1/3 of patients are signaling that a visit to the pharmacy is a barrier too high to overcome, and 75% are finding it too difficult to take medication properly, how many patients can we reasonably expect to fill an exercise prescription that typically requires 150 minutes/week of exertion?

Although evidence suggests that patients are more likely to exercise if their doctors prescribe exercise, we suspect very few patients will stick to an exercise program unless medical offices and physical activity providers (e.g. health clubs, personal trainers, community centers) adopt engagement strategies similar to those being implemented by the pharmaceutical industry for medication adherence.

At Novartis, for example, a comprehensive study of patients revealed 4 clusters of patients, each with a distinct set of compliance barriers: “Strugglers,” who seem overwhelmed by the medical condition and necessary medications; “Skeptics,” who view medication as a last resort; “A-Students,” who are fully engaged with their health care and likely to adhere to their prescription; and “Independents” who are likely to adhere but not be consumed with their health issues.

Understanding the four clusters helps Novartis create targeted adherence plans for each patient. The plans include customized messaging, 6 months of support, 3 or 4 email and text messages per week, an interactive website, real-time messaging support, and more.

Can this level of engagement be accomplished by a fitness center? Absolutely. And I know there are some pioneering clubs already on this path and achieving great results. But effective engagement does not happen overnight. It clearly requires an investment of time and resources, both of which are in short supply at most fitness centers.

So let’s make sure we support the great work of the Exercise Is Medicine initiative and champions of the “exercise prescription” movement like Dr. Eddie Phillips and Dr. Bob Sallis, by making sure that fitness facilities are prepared to help patients adhere to those prescriptions.

What do others think? How can we help patients adhere to exercise prescriptions? Do you work at a fitness center with a great member orientation program? Perhaps you work for a software company developing tracking systems for medical fitness providers? We’d love to hear from you.

A Case for Retiring America’s Worst Four-Word Phrase

July 07, 2014
2:44 pm

As summer heats up, so will the mid-year congressional campaigns.  When they do, we can unfortunately expect to hear more of the dreary rhetoric that arises every time Medicare comes up for discussion.  Candidate X will support changes to strengthen Medicare and improve its financial sustainability.  Candidate Y will respond by charging that Candidate X wants to do away with Medicare “as we know it.”

Even though the “as we know it” accusation was dubbed the Lie of the Year in 2011 by the PolitiFact fact-checking service, politicians continue to use it freely to score points against adversaries who propose any sort of change to the status quo.

A column in today’s New York Times – no bastion of conservatism by any measure – makes a strong case that it’s time to retire this four-word phrase for good.

Health economist Austin Frakt writes that enrollment in Medicare Advantage plans, operated by private health insurers, is increasing significantly, even after the federal cuts to Medicare Advantage plans that were part of the Affordable Care Act.  Today, approximately three of every ten Medicare beneficiaries are enrolled in one of these private plans and current trend lines tell us that proportion will continue to increase.

Frakt speculates that a reason for this growth is the comfort baby boomer beneficiaries have with private plans, having been enrolled in them throughout their working years.  He writes, “…baby boomers, who are just entering Medicare-eligibility age, are more accustomed to the types of insurance Medicare Advantage offers, such as H.M.O.s, than their predecessors were. Newly retired Americans have probably been enrolled in similar, employer-based plans for years if not decades — perhaps by the very same companies that offer Medicare Advantage plans — making it a relatively easy choice to enroll in such a plan for Medicare coverage.”

At the Healthcare Leadership Council, we have commissioned focus groups of middle-aged and older Americans to discuss their perspectives on Medicare.  Our findings closely mirror Frakt’s column.  We have found that Americans in their 40s and 50s are not at all averse to choosing between private plans for their Medicare coverage, and even seniors are adapting well to consumer choice after having experienced it for a decade now in the Medicare Part D prescription drug program.

We also found that, when assessing various options to address Medicare’s financial challenges, middle-aged and older Americans would rather use private sector competition as a tool to contain costs than see deeper cuts to physician and hospital reimbursements.

So when political candidates talk about fighting for Medicare “as we know it,” this phrase rings increasingly hollow.  Millions of beneficiaries are already rejecting the idea of an inflexible Medicare status quo and are gravitating to privately-run plans.  Perhaps it’s time for politicians to follow where the people are already leading.