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Health Affairs published a piece that promotes transparency in healthcare pricing, describes efforts to increase it, and offers ideas on how to further the cause. Some previous state-level efforts include requiring hospitals to publish prices and collecting claims data in what are known as all-payer claims databases.

Health Affairs published a piece that promotes transparency in healthcare pricing, describes efforts to increase it, and offers ideas on how to further the cause. Some previous state-level efforts include requiring hospitals to publish prices and collecting claims data in what are known as all-payer claims databases.

The piece notes that an increasing number of states appear to be moving towards the creation of all-payer claims databases and suggests that the federal government could reduce the overall friction in data collection by creating a common standard. The piece ends by noting that while investments in all-payer claims databases might yield substantial benefits, it might take a while before states begin to see those benefits.

The New York Times published an interesting piece that surveyed how the Affordable Care Act (ACA) is doing across the country. Interesting highlights include many states anticipating modest increases in ACA premiums (although Maryland appears to expect premiums to rise by over 30%) and that some insurance companies plan to sell insurance in more counties and states (rather than a contraction of offerings predicted by others).

The New York Times published an interesting piece that surveyed how the Affordable Care Act (ACA) is doing across the country. Interesting highlights include many states anticipating modest increases in ACA premiums (although Maryland appears to expect premiums to rise by over 30%) and that some insurance companies plan to sell insurance in more counties and states (rather than a contraction of offerings predicted by others)

The current White House administration and the current majority party in Congress have been undermining ACA (e.g. denying government funds for ACA risk transfer payments and trying to eliminate protections for pre-existing conditions). The article points out, though, that insurers are generally confident enough about their markets to not withdraw from them.

The New York Times published a piece highlighting the risks of inadequate risk adjustment within the context of value-based payments. People have been increasingly arguing that society should reward outcomes, not the number of procedures -- that payers should pay for value rather than discrete units of work. However, not every patient is an average patient. Some patients have complicating factors, making it more difficult for them to have better outcomes, regardless of which doctor they see for treatment. Hence, the outcomes need to be risk-adjusted so that the doctors won't have too strong of an incentive to only see a certain subset of the population (presumably the healthy patients).

The New York Times published a piece highlighting the risks of inadequate risk adjustment within the context of value-based payments. People have been increasingly arguing that society should reward outcomes, not the number of procedures -- that payers should pay for value rather than discrete units of work. However, not every patient is an average patient. Some patients have complicating factors, making it more difficult for them to have better outcomes, regardless of which doctor they see for treatment. Hence, the outcomes need to be risk-adjusted so that the doctors won't have too strong of an incentive to only see a certain subset of the population (presumably the healthy patients).

While people generally agree that outcomes need to be risk-adjusted, people often disagree with regards to how to risk-adjust. The author of this piece argues that social factors (such as literacy or ability to afford housing) are often overlooked in favor of medical factors (such as other conditions that patients might also have). The argument is that by omitting social factors from the risk-adjustment methodology (and therefore not financially recognizing the difficulty of providing care for patients who have certain social factors) while at the same time moving more and more of the payments to be value-based, payers give providers a very strong incentive to avoid caring for vulnerable population. (Similar arguments probably floated around when people advocated for capitation, a different reimbursement model that might be thought of as an extreme form of value-based payments.) The author insightfully points out this is far more of a problem for values-based payments rather than fee-for-service: under the older system of paying for procedures, payers would still pay the same amount for procedures regardless of social factors (such as whether the patients themselves could pay). Risk-adjustment is indeed complicated, and if not handled carefully, can meaningfully distort the practice of medicine.

Reference pricing is the idea that an employer (or payer) will pay up to a certain amount for a procedure or a product. The employee patient is free to pay the difference between the reference price and a more expensive offering. This policy then puts the onus on the patient to try to figure out whether a certain premium (e.g. institutional prestige or convenience) is worth paying for. As reported earlier, the California Public Employees' Retirement System has experienced success with using reference pricing. Kaiser Health News reported on how Montana's state government has also experienced success with reference pricing for their employees.

Reference pricing is the idea that an employer (or payer) will pay up to a certain amount for a procedure or a product. The employee patient is free to pay the difference between the reference price and a more expensive offering. This policy then puts the onus on the patient to try to figure out whether a certain premium (e.g. institutional prestige or convenience) is worth paying for. As reported earlier, the California Public Employees' Retirement System has experienced success with using reference pricing. Kaiser Health News reported on how Montana's state government has also experienced success with reference pricing for their employees.

In this case, Montana decided to pay more than twice what Medicare pays, and the state was able to get hospitals to agree to their new pricing structure. However, it appears that the state did engage in a public relations battle to secure agreement from one major health system. Two years after deployment of the new pricing structure, the state estimates that it saved over $15 million this year over what it would have paid without the change.

A federal appellate court recently ruled that the federal government does not need to pay payments originally outlined as part of the Affordable Care Act's risk corridor program. The risk corridor program was to help mitigate the risk that an insurer would attract a disproportionate number of patients whose healthcare required higher medical costs. The original idea was that the federal government would contribute billions of dollars in the initial rollout of the Affordable Care Act. However, there were questions as to whether the funds were properly authorized and the current administration has declined to pay beyond what was collected from other insurers. Modern Healthcare published an informative background article in 2017.

A federal appellate court recently ruled that the federal government does not need to pay payments originally outlined as part of the Affordable Care Act's risk corridor program. The risk corridor program was to help mitigate the risk that an insurer would attract a disproportionate number of patients whose healthcare required higher medical costs. The original idea was that the federal government would contribute billions of dollars in the initial rollout of the Affordable Care Act. However, there were questions as to whether the funds were properly authorized and the current administration has declined to pay beyond what was collected from other insurers. Modern Healthcare published an informative background article in 2017.

Politico reported that a divided appellate ruled that insurers should not expect the federal government to pay what was originally planned in the Affordable Care Act, given that subsequent legislation required that the risk corridor payments not require any government funding. This seems like it would be a substantial disappointment for insurers that priced their premiums expecting that the government would subsidize some amount.