PubH 6564 Private Purchasers of Health Care: Roles of Employers...

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PubH 6564 Private Purchasers of Health Care Roles of Employers and Health Plans in the US Health Care System Fall 2013

Credits 2

Meeting Days Mondays September 9 ndash December 11 2013

Meeting Time 125 ndash 320 pm

Meeting Place 2-580 Moos Tower

Instructor Jon B Christianson

Office Address 15-225 Phillips Wangensteen Building

Office Phone 612-625-3849

Fax 612-624-2196

E-mail chris001umnedu

Office Hours By Appointment

I Course Description

For health care providers payments received from private insurance companies with these funds coming for the most part from employer contributions towards employee health care expenses are critical to their financial survival The purpose of this course is to help future health care managers understand the goals of their ldquobest customersrdquo and how health plans and employers pursue these goals The course examines the role of employers and health plans in the health care system and specifically how the ldquopayers of the billsrdquo for health care develop and implement strategies to achieve their organizational and health care system goals

II Course Prerequisites Students must be admitted to the University of Minnesotarsquos Master in Healthcare Administration Program or have consent of the instructor

III Course Goals and Objectives Specific goals and learning objectives are listed in for each class period

1


IV Methods of Instruction and Work Expectations Each class will include a didactic presentation on the part of the instructor significant issues will be identified and discussed referencing the readings for the class period There are no ldquorequiredrdquo readings for the course The amount that students learn in this course and their performance on assignments will depend to a large degree on the time and effort they devote to the readings for each topic In most class periods students will present results from individual or group assignments Students will be expected to prepare for each class by engaging with the readings prior to class participating in the discussion during class and completing group and individual assignments as scheduled ldquoFurtherrdquo readings are provided as starting points for students who wish to explore specific topics in greater depth and to assist in the completion of individual and group assignments

V Course Text and Readings

1 To access readings click on link immediately following cite If you have any problems accessing assigned readings online contact Jane Raasch at raasc001umnedu If you do not have a University of Minnesota Internet ID and password call 301-HELP and support staff will help you set up an account (or set up your own account at wwwumneduinitiate and follow the directions)

2 Optional background reading for this course 1) PowerPoint lecture on the basics of health insurance posted on Moodle 2) Kongstvedt Peter Essentials of Managed Care Aspen Publishers Gaithersburg MD This book is the most frequently used reference in the field It covers most of the ldquobasicsrdquo but may not be current on all topics

3 For each class session overheadsPowerPoint slides andor audio will be posted on the Moodle website for downloading and viewing To learn more about Moodle watch Moodle Online Orientation for Students andor visit the Moodle support website at httpwww1umnedumoodle which has a link for ldquoStudent supportrdquo with user guides help and FAQs

VI Course OutlineWeekly Schedule

Date Module Topics Background

September 9 Employer Goals for the Health Care System and Their Strategies for Achieving Them

September 16 23 Present State of Americarsquos Health Insurance Industry bull Presentation of Group Assignment 1 (10 pts) ndash September 16

Health PlanProvider Relationships September 30 Measuring Provider Performance The Foundation of Purchaser Strategies to Reform Americarsquos

Health Care System October 7 Provider Contracting and Network Management

bull Discussion of Individual Assignment 1 (15 pts) October 14 Fundamentals of Provider Payment Incentives and Rewards October 21 New Payment Arrangements BundledEpisode-Based Payment

bull Discussion of Individual Assignment 2 (15 pts) October 28 New Payment Arrangements Total Cost of Care (TCOC)

bull Guest Lecture November 4 Utilization Management

bull Discussion of Individual Assignment 3 (15 pts) Health PlanEnrollee Relationships

November 11 Supporting EmployeesEnrollees in Choosing Providers Reporting of Provider Performance November 18 Supporting EmployeesEnrollees in Choosing Treatment Options

bull Discussion of Individual Assignment 4 (15 pts) November 25 Supporting EmployeesEnrollees in Maintaining and Improving Their Health

2


Date Module Topics December 2 Supporting EmployeesEnrollees in Managing Chronic Illnesses

bull Discussion of Individual Assignment 5 (15 pts) December 9 What is on the Horizon for Purchasers and Health Plans

bull Presentation of Group Assignment 2 (15 pts)

September 9 2013 Employer Goals for the Health Care System and Their Strategies for Achieving Them The two-decade period from the mid-1970s through the mid-1990s encompassed the ascendancy of a particular type of health plan ndash the managed care organization minus in the private health care marketplace and also as a contractor to Medicare and Medicaid Responding to pressures from employers and government to control health care costs these organizations (in collaboration with risk-bearing provider systems) instituted a variety of supply-side mechanisms financial and non-financial to influence provider behavior Accompanying steps were taken to manage access to care on the part of plan enrollees The result eventually was managed care backlash on the part of consumers and providers precipitated in part by a redefinition by employers of their health benefitsrsquo objectives Since then payers and health plans have initiated a variety of new approaches directed at restraining cost growth and improving quality In this first session we will describe the transition over the past decade towards a new paradigm of ldquomanagedrdquo or ldquofacilitatedrdquo consumerism one that has much broader support among significant actors in the health care arena than traditional managed care We will discuss the challenges faced by this new facilitated consumerism and the tools at the disposal of health plans Learning Objectives Students should be able to

1 Describe the origins and evolution of managed care organizations 2 Explain the origins and nature of the managed care backlash of the 1990s and its influence on the ongoing development of the

new facilitated consumerism 3 Explain the factors influencing present employer demands on the health care system and the role these demands have played in

changing Americarsquos health care system Suggested Readings Employer Involvement in Health Care

1 Christianson JB ldquoManaged carerdquo Enycylopedia of Health Economics Elsevier United Kingdom forthcoming (posted on Moodle) 2 Galvin RS ldquoStill in the game mdash Harnessing employer inventiveness in US health care reformrdquo The New England Journal of

Medicine 359(14)1421-1423 2008 Available at httpwwwnejmorgdoipdf101056NEJMp0805021 Field of Practice

1) Moutray C ldquoNAMIndustryweek 2013 Q2 survey Outlook positive in the face of mediocre growthrdquo IndustryWeek June 6 2013 Available at httpwwwindustryweekcomglobal-economynamindustryweek-2013-q2-survey-outlook-positive-face-mediocre-growth

Employer Strategies for the Health Care System 1 Christianson JB Ginsburg PB Draper DA ldquoThe transition from managed care to consumerism a community-level status

reportrdquo Health Affairs 200827(5)1362-1370 Available at httpcontenthealthaffairsorgcontent2751362fullpdf+html 2 RAND Corporation ldquoExpanding consumer-directed health plans could help cut overall health care spendingrdquo May 7 2012

Available at httpwwwrandorgnewspress20120507index1html 3 Robert Wood Johnson Foundation and Aligning Forces for Quality ldquoHow employers can improve value and quality in health

carerdquo January 2013 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research201301how-employers-can-improve-value-and-quality-in-health-carehtml

4 Thomas S OrsquoKane M ldquoValue-based purchasingrdquo American Journal of Managed Care 18(11)rdquo750-752 2012 Available at httpwwwajmccompublicationsissue20122012-11-vol18-n11Value-Based-Purchasing

5 Goodell S Swartz K ldquoCost-sharing Effects on spending and outcomesrdquo Policy Brief No 20 Robert Wood Johnson Foundation Synthesis Project December 2010 Available at httpwwwrwjforgcontentdamfarmreportsissue_briefs2010rwjf402103

3


Field of Practice 1) Murphy T ldquoHumana CEO preaches power of health care consumerrdquo Seattle News online February 24 2011

Available at httpseattletimesnwsourcecomhtmlbusinesstechnology2014319626_apusceointerviewhumanahtml 2) Baker S ldquoEmployers shifting toward high-deductible healthcare plansrdquo The Hill July 25 2012 Available at

httpthehillcomblogshealthwatchhealth-insurance240089-employers-shifting-toward-high-deductible-healthcare-plans

3) Mathews AW Big firms overhaul health coverage The Wall Street Journal September 26 2012 Available at httponlinewsjcomarticleSB10000872396390444549204578020640220260374html

4) Los Angeles Times ldquoCalPERS picks four new HMO plans for 5-year contractsrdquo Los Angeles Times April 17 2013 Available at httparticleslatimescom2013apr17businessla-fi-calpers-hmo-changes-20130418

5) The New York Times ldquoHealth care where you workrdquo September 2 2012 Available at httpwwwnytimescom20120903opinionhealth-care-where-you-workhtml_r=0

The Role of Self-Insurance 1 Weaver C Methews AW ldquoOne strategy for health-law costs self insurerdquo The Wall Street Journal May 27 2013 Available at

httponlinewsjcomarticleSB10001424127887323336104578503130037072460html lsquo 2 Lucia K Monahan C Corlette S ldquoCross-cutting issues Factors affecting self-funding by small employers Views from the

marketrdquo Princeton NJ Robert Wood Johnson Foundation April 2013 Available at httpwwwrwjforgcontentdamfarmreportsissue_briefs2013rwjf405372 Field of Practice

1) Pear R ldquoSome employers could opt out of insurance market raising othersrsquo costsrdquo The New York Times February 17 2013 Available at httpwwwnytimescom20130218usallure-of-self-insurance-draws-concern-over-costshtmlpagewanted=1amp_r=1ampnl=todaysheadlinesampemc=edit_th_20130218amp

2) Viebeck E Study Self-insured health plans on the rise for private-sector employers The Hill November 28 2012 Available at httpthehillcomblogshealthwatchhealth-insurance269827-self-insured-health-plans-on-the-rise-study-finds

Employer Perspectives on Health Care Reform 1 Darling H ldquoHealth care reform perspectives from large employersrdquo Health Affairs 201029(6)1220-1224 Available at

httpcontenthealthaffairsorgcontent2961220fullpdf+html 2 Abraham JM Graven P Feldman R ldquoEmployer-sponsored insurance and health reform Doing the mathrdquo National institute

for Health Care Reform Research Issue Brief 11 December 2012 Available at httpwwwnihcrorgESI-and-Health-Reform 3 Buettgens M Blumberg LJ ldquoSmall firm self-insurance under the Affordable Care Actrdquo The Commonwealth Issue Brief

November 2012 Available at httpwwwcommonwealthfundorg~mediaFilesPublicationsIssue20Brief2012Nov1647_Buettgens_small_firm_self_insurance_under_ACA_ibpdf

4 Kliff S ldquoObamacare requires employers to offer insurance What if itrsquos too expensiverdquo The Washington Post March 4 2013 Available at httpwwwwashingtonpostcomblogswonkblogwp20130304obamacare-requires-employers-to-offer-insurance-what-if-its-too-expensive Field of Practice

1) Hall SD Survey Most employers wonrsquot drop health coverage FierceHealthPayer August 29 2012 Available at httpwwwfiercehealthpayercomstorysurvey-most-employers-wont-drop-health-coverage2012-08-29

2) Hancock J ldquoHealth care act No thanks wersquoll take care of ourselvesrdquo Delaware online March 17 2013 Available at httpwwwdelawareonlinecomarticle20130318BUSINESS13303180038Health-care-act-Owners-say-No-thanks-we-ll-take-care-ourselves

Further Readings

1 Blumenthal D ldquoEmployer-sponsored health insurance in the United States ndash Origins and implicationsrdquo New England Journal of Medicine 355(1)82-88 2006 Available at httpwwwnejmorgdoipdf101056NEJMhpr060703

2 Blumenthal D ldquoEmployer-sponsored insurance ndash riding the health care tigerrdquo New England Journal of Medicine 355(2)195-202 2006 Available at httpwwwnejmorgdoipdf101056NEJMhpr060704

3 Draper DA Hurley RE Lesser CS Strunk BC ldquoThe changing face of managed carerdquo Health Affairs 200221(1)11-23 Available at httpcontenthealthaffairsorgcontent21111fullpdf+html

4 Hartocollis A ldquoInsurer steps up fight to control health care costrdquo The New York Times January 25 2010 pA1 Available at httpwwwnytimescom20100125healthpolicy25insurehtmlpagewanted=allamp_r=0

5 Izlar AC ldquoThe corporate role in reducing disparities Initiatives under way at Verizonrdquo Health Affairs 30(10)1992-1996 2011 Available at httpcontenthealthaffairsorgcontent30101992fullpdf+html

6 PR Newswire ldquoNew study shows lower costs increased consumer engagement in account-based health plansrdquo Available at httpwwwprnewswirecomnews-releasesnew-study-shows-lower-costs-increased-consumer-engagement-in-account-based-health-plans-58789467html

4


7 Robinson JC Ginsburg PB ldquoConsumer-driven health care promise and performancerdquo Health Affairs 28(2)w272-w281 (published online 27 January 2009) Available at httpcontenthealthaffairsorgcontent282w272fullpdf+html

8 Swartz K ldquoCost-sharing Effects on spending and outcomesrdquo Research Synthesis Report No 20 Robert Wood Johnson Foundation December 2010 Available at httpwwwrwjforgcontentdamfarmreportsissue_briefs2010rwjf402103subassetsrwjf402103_1

September 16 23 2013 Present State of the Health Insurance Industry Health plans represent employer interests in the health care system competing for contracts with employers They structure their products and actions to gain and retain the business of employer clients which is critical to their own financial success In doing so they provide a wide range of products and services in addition to traditional health insurance In these two sessions we trace the development of the health insurance industry and describe its current state We discuss market concentration premium setting and differences among health plan products describe how plans are evaluated by employers and consumers and discuss public perceptions of the health insurance industry Learning Objectives Students should be able to

1 Describe the structure of the health insurance industry 2 Distinguish among different types of health plans and health plan products 3 Understand premium cycles in the health insurance industry 4 Explain how employers assess health plan performance and choose among health plans 5 Identify the major issues relating to health plan performance from the perspective of employers and the public

Suggested Readings Overview of the Private Health Insurance Market

1 Archer D ldquoPrivate insurance is bankrupting Americans Is Congress paying attentionrdquo Health Affairs Blog June 26 2012 Available at httphealthaffairsorgblog20120626private-insurance-is-bankrupting-americans-is-congress-paying-attention

2 Americarsquos Health Insurance Plans ldquoMedical loss ratio ndash What you need to knowrdquo December 5 2012 Available at httpwwwahipcoveragecom20121205medical-loss-ratio-what-you-need-to-know-2

3 Austin DA Hungerford TL ldquoThe market structure of the health insurance industryrdquo Congressional Research Service Report R40834 April 8 2010 Available at httpwwwfasorgsgpcrsmiscR40834pdf

4 American Medical Association ldquoNew AMA study finds lack of competition among health insurersrdquo February 1 2011 Available at httpwwwama-assnorgamapubnewsnewscompetition-health-insurerspage

Field of Practice 1) PR Newswire ldquoBlue Cross Blue Shield of Michigan continues providing funding for free clinics to help strengthen

Michiganrsquos health care safety netrdquo June 12 2013 Available at httpwwwprnewswirecomnews-releasesblue-cross-blue-shield-of-michigan-continues-providing-funding-for-free-clinics-to-help-strengthen-michigans-health-care-safety-net-211270581html

2) Manos D ldquoHumana ranked top payer in 2013rdquo Healthcare IT News June 26 2013 Available at httpwwwhealthcareitnewscomnewshumana-ranked-top-payer-2013

3) Fellows J ldquoProviders grade health plans Guess who still stinksrdquo HealthLeaders Media May 1 2013 Available at httpwwwhealthleadersmediacompage-1HEP-291713Providers-Grade-Health-Plans-Guess-Who-Still-Stinks

4) Murphy T ldquoAetna chairman CEO compensation climbs 26 pctrdquo The Big Story April 8 2013 Available at httpbigstoryaporgarticleaetna-chairman-ceo-compensation-climbs-26-pct

5) Humer C Analysis Employees to face health care sticker shock Reuters October 28 2012 Available at httpwwwreuterscomarticle20121028us-usa-health-benefits-idUSBRE89R0EP20121028

6) Rau J Appleby J Brokers seek to preserve role in health insurance marketplace Kaiser Health News March 16 2011 Available at httpwwwkaiserhealthnewsorgstories2011march16brokers-press-for-relief-from-health-lawaspx

7) Wisenberg Brin D Blue ldquoCross plans feeling pressure to consolidate competition high costs lead more to weigh for-profit conversionsrdquo The Wall Street Journal August 25 2008 pB7 Available at httponlinewsjcomarticleSB121963099177268101html

8) Appleby J ldquoHealth insurance from both sides KHN interview of Aetna CEO Bertolinirdquo Kaiser Health News April 7 2011 Available at httpwwwkaiserhealthnewsorgStories2011April08bertolini-aetna-q-and-aaspx

9) Kliff S ldquoBusinesses think the growth of health insurance premiums s slowing Yes reallyrdquo Washington Post online August 62012 Available at httpwwwwashingtonpostcomblogsezra-kleinwp20120806the-growth-of-health-insurance-premiums-is-slowing-yes-really

5


10) De La Merced MJ ldquoAetna agrees to buy Coventry in $57 billion dealrdquo New York Times online August 20 2012 Available at httpdealbooknytimescom20120820aetna-is-said-to-strike-deal-for-coventry-health-for-5-7-billion

11) Rabin RC Some hospital networks also become insurers The Washington Post August 25 2012 Available at httparticleswashingtonpostcom2012-08-25business35491800_1_private-insurers-insurance-product-hospital-systems

Products Offered by Health Plans 1 Kulkarni SS ldquoFAQ on HSAs The basics of health savings accountsrdquo Kaiser Health News November 9 2011 Available at

httpwwwkaiserhealthnewsorgstories2011november04frequently-asked-questions-on-health-savings-accountsaspx 2 Warner JP ldquoHigh deductible health plans with HSAs or HRAsrdquo August 25 2010 Available at

httpwwwwarnerbenefitscomfileformsHigh_Deductible_Health_Plans_Explainedpdf Field of Practice

1) Abelson R ldquoHigh-end health plans scale back to avoid ldquocadillac taxrdquo The New York Times May 27 2013 Available at httpwwwnytimescom20130528businesscadillac-tax-health-insurancehtmlpagewanted=allamp_r=0

2) Weaver C Mathews AW ldquoEmployers eye bare-bones health plans under new lawrdquo The Wall Street Journal May 19 2013 Available at httponlinewsjcompublicresourcesdocumentsReprint_Samplespdf

3) Andrews M ldquoSome individual policies offer a way to shrink deductiblesrdquo Kaiser Health News May 21 2013 Available at httpwwwkaiserhealthnewsorgfeaturesinsuring-your-health2013052113-michelle-andrews-on-shrinking-deductiblesaspx

4) Blue Cross Blue Shield Minnesota ldquoNo more one size fits all in choosing health care coveragerdquo March 22 2012 Available at httpwwwbluecrossmncombcwcsidcplgIdcService=GET_DYNAMIC_CONVERSIONampRevisionSelectionMethod=LatestampdDocName=POST71A_170724

Developing Strategies of Health Plans 1 Johnson A ldquoReforms prod insurers to diversifyrdquo Wall Street Journal May 12 2011 p B1 Available at

httponlinewsjcomarticleSB10001424052748703643104576291022457851278html 2 Blue Cross Blue Shield of Michigan ldquoBlue Cross Blue Shield of Michigan saves an estimated $155 million over three years from

patient-centered medical home programrdquo Press Release July 8 2013 Available at httpwwwbcbsmcomcontentmicrositesblue-cross-blue-shield-of-michigan-newsenindexnews-releases2013july-2013bcbsm-saves-155-million-pcmhhtml

Field of Practice 1) Miliard M ldquoAetna to cite Leapfrog safety scoresrdquo Aetna News Hub June 5 2013 Available at

httpnewshubaetnacompress-releasehealth-care-professionals-and-networksaetna-highlight-leapfrog-groups-hospital-safety

2) Health Care Service Corporation ldquoHealth care consumers realize significant cost savings through benefits value advisor programrdquo The Wall Street Journal April 18 2013 Available at httponlinewsjcomarticlePR-CO-20130418-906054html

3) UCare Media Release ldquoUCare honors high-performing health care providers at June 18 salute to excellence eventrdquo June 19 2013 Available at httpwwwucareorgSiteCollectionDocumentsMedia20130618_UCare-P4P-eventpdf

4) Irwin G Topdjian J Kaura A ldquoPutting an I in healthcarerdquo Strategy+Business February 18 2013 Available at httpwwwstrategy-businesscomarticle00167gko=80904

5) Von Bergen JM ldquoIndependence Blue Cross and Michigan insurer to expand into Medicaid marketrdquo Phillycom August 10 2011 Available at httparticlesphillycom2011-08-10business29872468_1_medicaid-market-medicaid-business-independence-blue-cross

6) Weaver C ldquoManaged care enters the exam room as insurers buy doctor groupsrdquo Kaiser Health News July 1 2011 Available at httpwwwkaiserhealthnewsorgdaily-reports2011july051khn-storyaspxreferrer=search

7) Weaver C ldquoHealth insurers opening their own clinics to trim costsrdquo Kaiser Health News May 4 2011 Available at httpwwwkaiserhealthnewsorgstories2011may04insurers-turn-to-clinics-for-cost-controlaspxreferrer=search

8) Daily Finance Cignarsquos gains on health plan quality report card reflect improved health and well-being of customers October 30 2012 Available at httpwwwdailyfinancecom20121030cignas-gains-on-health-plan-quality-report-card-re

9) Reuters Health insurers begin to provide user-friendly plan guides September 24 2012 Available at httpwwwreuterscomarticle20120924us-usa-healthcare-insurance-idUSBRE88N0Y620120924

10) Wall JK WellPoint spends $50M to burnish brand Indianapolis Business News September 17 2012 Available at httpwwwibjcomwellpoint-spends--50m-to-burnish-brandPARAMSarticle36730

11) Nussbaum A ldquoWellPoint to acquire Amerigroup for $49 billion Bloomberg July 9 2012 Available at httpwwwbloombergcomnews2012-07-09wellpoint-to-buy-amerigroup-for-4-9-billion-in-cashhtml

Issues Relating to Health Plan Behavior and Performance 1 Cantlupe J ldquoMore employers unhappy with health insurers says PWC studyrdquo HealthLeaders Media January 19 2010

Available at httphealthplanshcprocomcontentcfmtopic=HEPampcontent_id=245127

6


2 Cohn J ldquoHow Blue Cross became part of a dysfunctional health care systemrdquo Kaiser Health News March 8 2010 Available at httpwwwkaiserhealthnewsorgcolumns2010march030810cohnaspxreferrer=search

3 Drew LW ldquoFinding a path through the health insurance market lsquogobbledygookrsquordquo Kaiser Health News April 21 2011 Available at httpwwwkaiserhealthnewsorgStories2011April22insurance-black-holeaspx

4 United Press International ldquoConsumers give healthcare plans low marksrdquo February 20 2012 Available at httpwwwupicomHealth_News20120220Consumers-give-healthcare-plans-low-marksUPI-17301329785602

5 Terhune C BlueShield of California will return $50 million to customers Los Angeles Times October 31 2012 Available at httparticleslatimescom2012oct31businessla-fi-blue-shield-credits-20121031

6 Reuters LA doctors patients sue Health Net for denying claims September 13 2012 Available at httpwwwreuterscomarticle20120913us-healthnet-lawsuit-idUSBRE88C19T20120913 Field of Practice

1) Terhune C ldquoBlue Shield Anthem owe small firms millions of dollars in rebatesrdquo Los Angeles Times June 4 2013 Available at Overland D ldquoBlue Cross $991M surplus draws criticism fear of monopoly FierceHealthPayer August 10 2012 Available at httpwwwfiercehealthpayercomstoryblue-cross-991m-surplus-draws-criticism-fear-monopoly2012-08-10

2) Scolforo M ldquoPa regulators probe health insurersrsquo practicesrdquo The Associated Press 2010 Available at httpwwwbostoncombusinesshealthcarearticles20100609pa_regulators_probe_health_insurers_practices

3) Mathews AW ldquoInsurer sets earnings caprdquo Wall Street Journal June 8 2011 p B1 Available at httponlinewsjcomarticleSB10001424052702304906004576371902333544990html

4) Appleby J ldquoAnalyst Nonprofit Blues have huge reservesrdquo Kaiser Health News June 29 2011 Available at httpcapsuleskaiserhealthnewsorgindexphp201106analyst-nonprofit-blues-have-huge-reservesreferrer=search

5) Snowbeck C ldquoHMO cash cushions at issue in Minnesota legislaturerdquo TwinCitiescom March 10 2012 Available at httpwwwtwincitiescomlocalnewsci_20141316minnesota-health-care-hmo-cash-cushions-at-issue

6) Lee D ldquoWorries grow as healthcare firms send jobs overseasrdquo Los Angeles Times online July 25 2012 Available at httparticleslatimescom2012jul25businessla-fi-healthcare-offshore-20120725

The Health Insurance Industry and Health Reform 1 Carey MA ldquoHouse spending bill cuts funding for exchangesrdquo Kaiser Health News March 7 2013 Available at

httpcapsuleskaiserhealthnewsorgp=17584 2 Emanuel EJ Liebman JF ldquoThe end of health insurance companiesrdquo New York Times online January 30 2012 Available at

httpopinionatorblogsnytimescom20120130the-end-of-health-insurance-companies 3 Pear T ldquoObama and insurers join to cut health care fraudrdquo New York Times online July 25 2012 Available at

httpwwwnytimescom20120726uspoliticsobama-and-insurers-join-to-cut-health-care-fraudhtml 4 Zamosky L Healthcare reform law to usher in new age of consumerism Los Angeles Times September 8 2012 Available at

httparticleslatimescom2012sep08businessla-fi-future-of-health-insurance-20120908 5 Cunningham PW ldquoMandate delay a lsquofull-timersquo headache for employersrdquo Politico July 15 2013 Available at

httpwwwpoliticocomstory201307obamacare-mandate-delay-muddles-workweek-94131html 6 Baker S ldquoWeek ahead GOP focuses on employer mandate delayrdquo The Hill July 15 2013 Available at

httpthehillcomblogshealthwatchhealth-reform-implementation310909-week-ahead-gop-focuses-on-employer-mandate-delay 7 Fox News ldquoHouse Republicans to vote on ObamaCare say Obamarsquos delay of employer mandate unfairrdquo July 14 2013

Available at httpwwwfoxnewscompolitics20130714house-republicans-to-vote-on-obamacare-say-obamas-delay-employer-mandate-unfair

8 Millman J ldquoObamacarersquos missing mandaterdquo Politico July 13 2013 Available at httpwwwpoliticocomstory201307obamacare-missing-mandate-94105html

Field of Practice 1) Hancock J ldquoBlue Cross-Blue Shield bets big on Obamacare exchangesrdquo Kaiser Health News June 21 2013

Available at httpwwwkaiserhealthnewsorgstories2013june21obama-administration-blue-cross-blue-shield-insurance-exchanges-marketplacesaspx

2) Overland D ldquoCigna opts out of Connecticut insurance exchangerdquo FierceHealthPayer March 6 2013 Available at httpwwwfiercehealthpayercomstorycigna-opts-out-connecticut-health-insurance-exchange2013-03-06

3) Terhune C ldquoBlue Shield and Aetna to raise healthcare rates over state objectionsrdquo Los Angeles Times March 6 2013 Available at httparticleslatimescom2013mar06businessla-fi-health-insure-rates-20130307

4) Mathews AW ldquoCorporate news Health law puts Cigna in Ad moderdquo Wall Street Journal online September 19 2011 Available at httponlinewsjcomarticleSB10001424053111903374004576578533245560822html

5) Weaver C ldquoHealth insurers respond to reform by snapping up less-regulated businessesrdquo Kaiser Health News March 19 2011 Available at httpwwwkaiserhealthnewsorgstories2011march20health-insurers-reform-businessaspx

7


Further Readings 1 Andrews M ldquoAppealing an insurerrsquos denial is often a good strategyrdquo Kaiser Health News June 20 2011 Available at

httpwwwkaiserhealthnewsorgFeaturesInsuring-Your-HealthMichelle-Andrews-on-appealing-insurers-denialaspx 2 Baicker K Chandra A ldquoMyths and misconceptions about US health insurancerdquo Health Affairs ndash Web Exclusive

200827(6)w533-w543 (published online 21 October 2008) Available at httpcontenthealthaffairsorgcontent276w533fullpdf+htmlsid=6007f9ae-03c4-49e5-a693-a8fd37ec4443

3 Baker S ldquoBusinesses predict 7 percent jump in healthcare costsrdquo The Hill August 6 2012 Available at httpthehillcomblogshealthwatchhealth-insurance242349-businesses-predict-7-jump-in-healthcare-costs

4 Dolan PL ldquoInsurer-owned clinics bid to offer more patient carerdquo Amednewscom May 16 2011 Available at httpwwwama-assnorgamednews20110516bil20516htm

5 Draaghtel K ldquoMaximizing your competitive advantage with predictive modeling and consumer datardquo Milliman April 6 2012 Available at httppublicationsmillimancomperiodicalsrsapdfsrsa-03-2012pdf

6 eValue8 Health Care ldquoeValue8 2009 Measuring progress toward value-based purchasingrdquo Available at httpwwwnbchorgNBCHfilesccLibraryFilesFilename000000000640Evalue820200920Annual20Reportpdf

7 Girion L ldquoHealth insurer tied bonuses to dropping sick policyholdersrdquo The Los Angeles Times November 9 2007 pA1 Available at httpwwwlatimescombusinessla-fi-insure9nov0903065397fullstorycoll=la-home-center

8 Haviland AM Marquis MS McDevitt RD Sood N ldquoGrowth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annuallyrdquo Health Affairs 31(5)1009-1015 2012 Available at httpcontenthealthaffairsorgcontent3151009fullpdf+html

9 Jaffe S ldquoConsumers may be unaware of their right to a review of health plan decisionsrdquo Kaiser Health News June 10 2011 Available at httpwwwkaiserhealthnewsorgStories2011June10external-appealsaspx

10 Mathews AW Adamy J ldquoHealth-plan buyers get a look under the hoodrdquo Wall Street Journal (online) August 17 2011 Available at httponlinewsjcomarticleSB10001424053111904253204576512494056148396html

11 Mathews AW Kamp J Humana brings doctors in-house The Wall Street Journal November 5 2012 Available at httponlinewsjcomarticleSB10001424052970203347104578100774135846646html

12 Overland D ldquoExcellus defends proposed rate hikes despite big case reservesrdquo FierceHealthPayer July 22 2012 Available at httpwwwfiercehealthpayercomstoryexcellus-defends-proposed-rate-hikes-despite-big-cash-reserves2012-07-22

13 Overland D ldquoInsurers develop next generation of mobile appsrdquo FierceHealthPayer August 10 2012 Available at httpwwwfiercehealthpayercomstoryinsurers-develop-next-generation-mobile-apps2012-08-10

14 Redig AJ ldquoAdventures in (health-insurance-claim) wonderlandrdquo Health Affairs 200928(5)1515-1520 Available at httpcontenthealthaffairsorgcontent2851515fullpdf+html

15 Robinson JC ldquoConsolidation and the transformation of competition in health insurancerdquo Health Affairs 200423(6)11-24 Available at httpcontenthealthaffairsorgcontent23611fullpdf+html

16 Shannon M Turning consumers into shoppers Using high-deductible plans wisely Health Affairs Blog October 18 2012 Available at httphealthaffairsorgblog20121018turning-consumers-into-shoppers-using-high-deductible-plans-wisely

September 30 2013 Measuring Provider Performance The Foundation for Network Management Provider Payment and Public Reporting Efforts Efforts on the part of health plans and employers to measure provider performance have intensified over the past decade Health plans construct measures of performance to select providers for inclusion in networks create tiered networks structure provider incentive payments and produce provider performance reports for their members These measures also can be used in public reports of provider performance The way in which performance measures are constructed and used has been a point of contention between employershealth plans and providers In this session we describe methods used by employers and health plans to measure provider performance common issues in measure construction and the use of ldquorisk-adjustmentrdquo techniques and alternatives for attributing patient to providers Learning Objectives Students should be able to

1 Describe and contrast different approaches to performance measurement 2 Discuss strengths and weaknesses of these approaches 3 Discuss the role of risk adjustment techniques in measure construction and how they are applied 4 Discuss different alternatives for attributing patients to providers for measurement purposes

Suggested Readings The Basics of Provider Performance Measurement

1 Berenson RA Pronovost PJ Krumholz HM ldquoAchieving the potential of health care performance measures Timely analysis of immediate health policy issues Robert Wood Johnson Foundation May 30 2013 Available at

8


httpwwwrwjforgenresearch-publicationsfind-rwjf-research201305achieving-the-potential-of-health-care-performance-measureshtml

2 Berenson R ldquoSeven policy recommendations to improve quality measurementrdquo Health Affairs Blog May 22 2013 Available at httphealthaffairsorgblog20130522seven-policy-recommendations-to-improve-quality-measurement

3 Miller TP Brennan TA Milstein A ldquoHow can we make more progress in measuring physiciansrsquo performance to improve the value of carerdquo Health Affairs 28(5)1429-1437 2009 Available at httpcontenthealthaffairsorgcontent2851429fullpdf+html

4 Damberg CL Sorbero ME Lovejoy SL et al An Evaluation of the Use of Performance Measures In Health Care Santa Monica CA RAND Corporation 2011 Available at httpwwwrandorgpubstechnical_reportsTR1148html

5 National Committee on Quality Assurance ldquoHEDIS measure development process Desirable attributes of HEDIS HEDIS life cyclerdquo Available at httpwwwncqaorgtabid414Defaultaspx

6 National Quality Forum ldquoThe ABCs of measurementrdquo Available at httpwwwqualityforumorgMeasuring_PerformanceABCs_of_Measurementaspx

7 Pronovost PJ Lilford R ldquoA road map for improving the performance of performance measuresrdquo Health Affairs 201130(4)569-573 Available at httpcontenthealthaffairsorgcontent304569fullpdf+html

8 National Quality Forum Mission and vision Available at httpwwwqualityforumorgAbout_NQFMission_and_Visionaspx Field of Practice

1) Consumer-Purchaser Disclosure Project Available at httpwwwhealthcaredisclosureorg Importance of Risk Adjustment in Performance Measurement

1 Draaghtel K ldquoConcurrent risk adjustmentrdquo Milliman January 2012 Available at httppublicationsmillimancomperiodicalsrsapdfsrsa-01-2012pdf

2 Martin K Rogal DL Arnold SB Health-based risk assessment Risk-adjusted payments and beyond AcademyHealth Available at httpwwwhcfoorgpdfriskadjustmentpdf

3 Schone E Brown RW Goodell S ldquoRisk adjustment What is the current state of the art and how can it be improvedrdquo Policy Brief No 25 Robert Wood Johnson Foundation Synthesis Project July 2013 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research201307risk-adjustment---what-is-the-current-state-of-the-art-and-how-chtml Field of Practice

1) Draaghtel K ldquoMilliman advanced risk adjuster MARArdquo Milliman February 2010 Available at httppublicationsmillimancomperiodicalsrsapdfscoming-soon-milliman-advancedpdf

2) Milliman Milliman Advanced Risk Adjuster (MARA) Predictive value of inpatient risk score November 2011 Available at httppublicationsmillimancomperiodicalsrsapdfsmilliman-advanced-risk-adjusterpdf

Challenges in Measuring Provider Quality 1 Conway PH Mostashari F Clancy C ldquoThe future of quality measurement for improvement and accountabilityrdquo Journal of the

American Medical Association 309(21)2215-2216 2013 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=927065ampdirection=P

2 Kupfer JM ldquoThe morality of using mortality as a financial incentive Unintended consequences and implications for acute hospital carerdquo Journal of the American Medical Association 309(21)2213-2214 2013 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=927065ampdirection=P

3 Wood DL ldquoMeasure health not carerdquo Minnesota Medicine April 2012 Available at httpwwwminnesotamedicinecomPastIssuesApril2012aspx

4 Mathias JS Baker DW ldquoDeveloping quality measures to address overuserdquo Journal of the American Medical Association 309(18)1897-1898 2013 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=926917ampdirection=P

5 Seaman AM ldquoMany medical guidelines donrsquot consider costsrdquo Reuters May 7 2013 Available at httpwwwreuterscomarticle20130507us-medical-guidelines-idUSBRE94610V20130507

6 Stefan MS Pekow PS Nsa W et al ldquoHospital performance measures and 30-day readmission ratesrdquo Journal of General Internal Medicine 28(3)377-385 2013 Available at httplinkspringercomcontentpdf1010072Fs11606-012-2229-8pdf

7 Nyweide DJ Weeks WB Gottlieb DJ ldquoRelationship of primary care physiciansrsquo patient caseload with measurement of quality and cost performancerdquo Journal of the American Medical Association 2009302(22)2444-2450 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=4491ampdirection=P

8 Berenson R A ldquoMoving payment from volume to value What role for performance measurementrdquo Washington DC Urban Institute December 2010 Available at httpwwwrwjforgfilesresearch71568fullpdf

9 Rosof B The importance of accurate data in quality ndashof-care measurement (Editorial) Annals of Internal Medicine 2012157(5)379-380 Available at httpannalsorgissueaspxjournalid=90ampissueID=24808ampdirection=P Field of Practice

1) Neuman HB Michelassi F Turner JW Bass BL ldquoSurrounded by quality metrics what do surgeons think of ACS-NSQIPrdquo Surgery 2009145(1)27-33 Available at httpswwwclinicalkeycomBrowserCtrldoBrowseTojournalIssuefacet[1-s20-S0039606008X00133]issn00396060contentTypeJournals

9


2) Cheung K ldquoAHA report Not all readmissions avoidable lsquoill-suitedrsquo quality indicatorrdquo Fierce Healthcare September 15 2011 Available at httpwwwfiercehealthcarecomstoryaha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator2011-09-15

3) Overland D Minnesota health plan releases doctor ratings despite opposition FierceHealthPayer January 20 2011 Available at httpwwwfiercehealthpayercomstoryminnesota-health-plan-releases-doctor-ratings-despite-opposition2011-01-20

Challenges in Measuring Provider Prices Costs and Efficiency 1 Romley JA Hussey PS de Vries H Wang MC Shekelle PG McGlynn EA ldquoEfficiency and its measurement what

practitioners need to knowrdquo American Journal of Managed Care 200915(11)842-845 Available at httpwwwajmccompublicationsissue20092009-11-vol15-n11AJMC_09Nov_Romley_842to845

2 Robinson RC Williams T Yanagihara D ldquoMeasurement of and reward for efficiency in Californiarsquos pay-for-performance programrdquo Health Affairs 200928(5)1438-1447 Available at httpcontenthealthaffairsorgcontent2851438fullpdf+html

3 Painter MW Chernew ME ldquoCounting change Measuring health care prices costs and spendingrdquo Robert Wood Johnson Foundation March 2012 Available at httpwwwrwjforgqualityequalityproductjspid=74078

Field of Practice 1) Alltucker K ldquoAuction website lets patients suggest pricesrdquo azcentralcom June 16 2012 Available at

httpwwwazcentralcombusinessarticles20120614medical-care-auctionhtml Challenges in Measuring Patient Experience

1 Browne K Roseman D Shaller D Edgman-Levitan S ldquoAnalysis and Commentary Measuring patient experience as a strategy for improving primary carerdquo Health Affairs 201029(5)921-925 Available at httpcontenthealthaffairsorgcontent304569fullpdf+html

Further Readings

1 Greene RA Beckman HB Mahoney T ldquoBeyond the efficiency index finding a better way to reduce overuse and increase efficiency in physician carerdquo Health Affairs 200827(4)w250-w259 (published online 20 May 2008) Available at httpcontenthealthaffairsorgcontent274w250fullpdf+htmlsid=b7a69b28-401f-4081-a781-a8eea63b91b9

2 Higgins A Zeddies T Pearson SD ldquoMeasuring the performance of individual physicians by collecting data from multiple health plans The results of a two-state testrdquo Health Affairs 201130(4)673-681 Available at httpcontenthealthaffairsorgcontent304673fullpdf+html

3 Hoefer TP Hayward RA Greenfield S Wagner EH Kaplan SH Manning WG ldquoThe unreliability of individual physician lsquoreport cardsrsquo for assessing the costs and quality of care of a chronic diseaserdquo Journal of the American Medical Association 1999281(22)2098-2105 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=4646ampdirection=P

4 Mehrotra A Adams JL Thomas JW McGlynn EA ldquoIs physician cost profiling ready for prime timerdquo RAND Research Brief 2010 Available at httpwwwrandorgpubsresearch_briefsRB9523

5 Nelson B ldquoAccurate Measuresrdquo The Hospitalist May 2011 Available at httpwwwthe-hospitalistorgdetailsarticle1056003Accurate_Measureshtml

6 Nelson EC Gentry MA Mook KH Spritzer KL Higgins JH Hays RD ldquoHow many patients are needed to provide reliable evaluations of individual cliniciansrdquo Medical Care 200442(3)259-266 Available at httpwwwjstororgstablepdfplus4640735pdfacceptTC=true

7 Romano P Hussey P Ritley D ldquoSelecting quality and resource use measures A decision guide for community quality collaborativesrdquo AHRQ Publication No 09(10)-0073 May 2010 Available at httpwwwahrqgovqualperfmeasguide

8 Scholle SH Roski J Adams JL Dunn DL Kerr EA Dugan DP Jensen RE ldquoBenchmarking physician performance reliability of individual and composite measuresrdquo American Journal of Managed Care 200814(12)829-838 Available at httpwwwajmccompublicationsissue20082008-12-vol14-n12Dec08-3781p833-838

9 Thomas JW Grazier KL Ward K ldquoEconomic profiling of primary care physicians consistency among risk-adjusted measuresrdquo HSR Health Services Research 200439(4 Part I)985-1003 Available at httponlinelibrarywileycomdoi101111j1475-6773200400268xpdf

October 7 2013 Provider Contracting and Network Management A major factor in health plansrsquo success in securing employer contracts is their ability to negotiate favorable terms when contracting with providers and to effectively ldquomanagerdquo provider networks In this session we will discuss the basics of provider contracting including the way in which health plans and providers attempt to exert leverage in the contracting process We also describe steps that health plans are taking to develop products based on subsets of ldquohigh performingrdquo providers and the reasons why this strategy has been controversial Learning Objectives Students should be able to

1 Discuss the nature of the contracting process from the health plan and provider perspectives 10


2 Describe how provider reimbursement levels are determined 3 Discuss issues pertaining to tiered provider networks

Suggested Readings Health PlanProvider Leverage in the Contracting Process

1 Ginsburg PB ldquoWide variation in hospital and physician payment rates evidence of provider market powerrdquo Research Brief No 16 November 2010 Washington DC Center for Studying Health System Change Available at httpwwwhschangecomCONTENT11621162pdf

2 Berenson RA Ginsburg PB Christianson JB Yee T ldquoThe growing power of some providers to win steep payment increases from insurers suggests policy remedies may be neededrdquo Health Affairs 201231(5)973-981 Available at httpcontenthealthaffairsorgcontent315973fullpdf+html

3 Melnick GA Shen Y-C Wu VY ldquoThe increased concentration of health plan markets can benefit consumers through lower hospital pricesrdquo Health Affairs 201130(9)1728-1733 Available at httpcontenthealthaffairsorgcontent3091728fullpdf+html

4 Kocher B Emanuel EJ Overcoming the pricing power of hospitals Journal of the American Medical Association 2012308(12)1213-1214 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=24967ampdirection=P

Field of Practice 1) Terhune C ldquoSmall surgeries huge markupsrdquo Los Angeles Times January 31 2013 Available at

httparticleslatimescom2013jan31businessla-fi-high-price-knee-20130131 2) Hancock J ldquoExpert Hospitalsrsquo lsquohumongous monopolyrsquo drives prices highrdquo Kaiser Health News March 4 2013

Available at httpcapsuleskaiserhealthnewsorgp=17379 3) Merritt G ldquoChildrenrsquos Hospital Anthem reaches agreement after two-month standoffrdquo The CT mirror June 12 2012

Available at httpwwwctmirrororgstory16625childrens-hospital-anthem-reach-multi-year-agreement 4) Terhune C ldquoMany hospitals doctors offer cash discount for medical billsrdquo Los Angeles Times online May 27 2012

Available at httparticleslatimescom2012may27businessla-fi-medical-prices-20120527 5) Lund-Muzikant Providence severs contract with Health Net just as employers consider options for 2013 The Lund

Report September 20 2012 Available at httpwwwthelundreportorgresourceprovidence_severs_contract_with_health_net_just_as_employers_consider_options_for_2013

Tiered Networks High Performance Networks and Centers of Excellence 1 Rabin RC ldquoReport faults high fees for out-of-network carerdquo The New York Times January 31 2013 Available at

httpwwwnytimescom20130201healthinsurance-industry-report-faults-high-fees-for-out-of-network-carehtml_r=0 2 Andrews M ldquoWhen a plan overpays for a service is a patient responsible for a refundrdquo Kaiser Health News December 10

2012 Available at httpwwwkaiserhealthnewsorgfeaturesinsuring-your-health2012121112-michelle-andrews-overpaymentaspx Field of Practice

1) Overland D ldquoCigna to cover telehealth doctor consultsrdquo FierceHealthPayer April 24 2013 Available at httpwwwfiercehealthpayercomstorycigna-covere-telehealth-doctor-consults2013-04-24

2) Terhune C Companies go surgery shopping Los Angeles Times November 17 2012 Available at httparticleslatimescom2012nov17businessla-fi-bargain-surgery-20121117

3) Boulton G Aurora-Anthem plan seeks exclusivity promises savings Journal Sentinel October 24 2012 Available at httpwwwjsonlinecombusinessauroraanthem-plan-seeks-exclusivity-promises-savings-0d7av36-175522981html

4) Appleby J ldquoDomestic medical travel is taking off for surgery dealsrdquo USA Today July 9 2010 Available at httpwwwusatodaycommoneyindustrieshealth2010-07-07-travelforhealth07_CV_Nhtm

5) Kowalczyk L ldquoInsurers may slash rates to hospitals some patients might have to switch MDsrdquo The Boston Globe May 24 2010 pB1 Available at httpwwwbostoncomnewshealtharticles20100524insurers_aim_to_cut_payments_to_hospitals_doctors_groups

6) Kaiser Health News ldquoSome heart care costs stay outside insurance coverage Lowersquos does national comparison shopping for employeesrsquo heart surgeryrdquo February 17 2010 Available at httpwwwkaiserhealthnewsorgdaily-reports2010february17cost-of-heart-careaspx

7) Andrews M ldquoInsurance trade-off Reducing premiums by eliminating expensive doctors hospitalsrdquo Kaiser Health News March 1 2011 Available at httpwwwkaiserhealthnewsorgfeaturesinsuring-your-healthmichlle-andrews-on-premiums-and-pricesaspxreferrer=search

8) Gonzales A ldquoCigna offering lower co-pays at its own clinics in Phoenixrdquo Phoenix Business Journal August 9 2011 Available at httpwwwbizjournalscomphoenixnews20110809cigna-offering-lower-co-pays-at-itshtmlpage=all

9) Weaver C ldquoAetna doctors face off over costsrdquo Wall Street Journal online July 4 2012 Available at httponlinewsjcomarticleSB10001424052702303933404577505182228232366html

10) Boulton G ldquoAetna Aurora to begin offering new health planrdquo Equitiescom July 27 2012 Available at httpwwwequitiescomnewsheadline-storydt=2012-07-27ampval=315527ampcat=hcare

11


11)Appleby J ldquoConsumers hit by higher out-of-network medical costsrdquo Kaiser Health News February 8 2012 Available at httpwwwkaiserhealthnewsorgstories2012february09consumers-hit-by-higher-out-of-network-medical-costsaspx

12) Crosby J ldquoMedica teams with Fairview on new planrdquo StarTribune online March 8 2012 Available at httpwwwstartribunecombusiness141693483htmlrefer=y

13) Andrews M ldquoSome insurers paying patients who agree to get cheaper carerdquo Kaiser Health News March 26 2012 Available at httpwwwkaiserhealthnewsorgfeaturesinsuring-your-health2012cash-rewards-for-cheaper-care-michelle-andrews-032712aspx

14) Toland B Highmark offers cheaper UPMC-free plan Pittsburgh Post-Gazette September 11 2012 Available at httpwwwpost-gazettecomstoriesbusinessnewshighmark-offers-cheaper-upmc-free-plan-652783

Provider Issues Concerning Contracts with Health Plans Field of Practice

1) Toland B ldquoMedical ethics focus of insurance dispute between UPMC and Highmarkrdquo Pittsburgh Post-Gazette March 8 2013 Available at httpwwwpost-gazettecomstorieslocalstatemedical-ethics-focus-of-insurance-dispute-between-upmc-and-highmark-678402

2) Miller V Feeley J ldquoUnitedHealth units to pay $24 million in hepatitis caserdquo Bloomberg April 4 2013 Available at httpwwwbloombergcomnews2013-04-04unitedhealth-units-told-to-pay-24-million-over-hepatitis-doctorhtml

3) Fuhrmans V ldquoInsurers stop paying for care linked to errors health plans say new rules improve safety and cut costs hospitals canrsquot dun patientsrdquo The Wall Street Journal January 15 2008 pD1 Available at httponlinewsjcomarticleSB120035439914089727html

4) Associated Press ldquoAMA others suing Aetna Cigna over paymentsrdquo February 10 2009 Available at httpblogclevelandcombusiness200902ama_others_suing_aetna_cigna_ohtml

5) Reuters ldquoAetna ranked tops in connection with doctorsrdquo May 25 2011 Available at httpwwwreuterscomarticle20110525idUS189606+25-May-2011+BW20110525

6) Cheung K ldquoAMA blasts insurers for costly 20 percent error ratesrdquo FierceHealthcare June 20 2011 Available at httpwwwfiercehealthcarecomstoryama-blasts-insurers-costly-20-percent-error-rate2011-06-20

7) Bernstein N ldquoInsurers alter cost formula and patients pay morerdquo New York Times online April 23 2012 Available at httpwwwnytimescom20120424nyregionhealth-insurers-switch-baseline-for-out-of-network-chargeshtmlpagewanted=all

Further Readings

1 Americarsquos Health Insurance Plans ldquoHealth plans collaborate on landmark initiative to reduce time expense for physician office practice lsquopaperworkrsquordquo Press Release February 11 2010 Available at httpwwwahiporgcontentpressreleaseaspxbc=174|29422amppf=true

2 Bebinger M ldquorsquoTieredrsquo insurance confounds consumers docs in Massrdquo Kaiser Health News January 17 2012 Available at httpwwwkaiserhealthnewsorgStories2012January17Mass-Tiered-Insuranceaspx

3 Cantlupe J Physicians insurers clash over medical necessity in CA HealthLeaders Media September 27 2012 Available at httpwwwhealthleadersmediacompage-1PHY-284876Physicians-Insurers-Clash-Over-Medical-Necessity-in-CA

4 Casalino LP Nicholson S Gans DN Hammons T Morra D Karrison T Levinson W ldquoWhat does it cost physician practices to interact with health insurance plansrdquo Health Affairs 200928(4)w533-w543 (published online 14 May 2009) Available at httpcontenthealthaffairsorgcontent284w533fullpdf+htmlsid=36420c5a-9240-4639-b71c-0cf279227dc4

5 Ellis P Sandy LG Larson AJ Stevens SL Wide variation in episode costs within a commercially insured population highlights potential to improve the efficiency of care Health Affairs 201231(9)2084-2093 Available at httpcontenthealthaffairsorgcontent3192084fullpdf+html

6 Kaiser Health News ldquoCigna agrees to end use of database to determine payments for out-of-network medical servicesrdquo February 18 2009 Available at httpwwwkaiserhealthnewsorgdaily-reports2009february18dr00057024aspxreferrer=search

7 Mathews AW ldquoOut-of-network ratesrdquo Wall Street Journal (online) June 19 2011 Available at httponlinewsjcomarticleSB10001424052702304451504576394103294050580html

8 News Release AHIP files amicus brief on impact of hospital consolidation Americarsquos Health Insurance Plans November 29 2012 Available at httpwwwahiporgNewsPress-Room2012AHIP-Files-Amicus-Brief-on-Impact-of-Hospital-Consolidationaspx

9 Terhune C Cedars-Sinai and UCLA cut from Los Angeles health plan Los Angeles Times September 21 2012 Available at httparticleslatimescom2012sep21businessla-fi-hospital-costs-20120921

October 14 2013 Fundamentals of Provider Payment Incentives and Rewards During the 1980s through the mid-1990s most provider payment arrangements employed by health plans were designed to influence

12


providers to reduce unnecessary service utilization Over the past decade health plans and purchasers have initiated a variety of new payment approaches that have broader behavioral change goals including improving quality of care implementing evidence-based medical practices effectively and supporting the restructuring of care delivery Recently health reform legislation has encouraged Medicare to institute payment reforms with similar objectives We will discuss traditional methods of provider payment as well as new payment arrangements in this session and the two sessions to follow Learning Objectives Students should be able to

1 Describe the basic reimbursement approaches used by health plans in contracts with providers including their strengths and weaknesses

2 Describe the different types of pay-for-performance initiatives being undertaken by health plans and purchasers 3 Describe how these approaches differ in their design and the challenges they pose for implementation in comparison to previous

payment arrangements between health plans and providers Suggested Readings Basics of Provider Payment

1 Robinson JC ldquoTheory and practice in the design of physician payment incentivesrdquo The Milbank Quarterly 200179(2)149-177 Available at httpwwwjstororgstablepdfplus3350546pdfacceptTC=true

2 Averill RF Goldfield NI Vertrees JC McCullough EC Fuller RL Eisenbandler J ldquoAchieving cost control care coordination and quality improvement through incremental payment system reformrdquo Journal of Ambulatory Care Management 201033(1)2-23 Available at httpovidsptxovidcomsp-381aovidwebcgiWebLinkFrameset=1ampS=PIKCFPCJGBDDLCLENCOKIDGCMIABAA00ampreturnUrl=ovidwebcgi3f26TOC3dSsh18192225257c2257c5026FORMAT3dtoc26FIELDS3dTOC26S3dPIKCFPCJGBDDLCLENCOKIDGCMIABAA00ampdirectlink=http3a2f2fgraphicstxovidcom2fovftpdfs2fFPDDNCGCIDLEGB002ffs0472fovft2flive2fgv0242f000044792f00004479-201001000-00002pdfampfilename=Achieving+Cost+Control2c+Care+Coordination2c+and+Quality+Improvement+Through+Incremental+Payment+System+Reformamplink_from=Ssh181922257c2amppdf_key=Bamppdf_index=Ssh18192225

3 Berenson RA Rich EC ldquoUS approaches to physician payment the deconstruction of primary carerdquo Journal of General Internal Medicine 201025(6)613-618 Available at httplinkspringercomcontentpdf1010072Fs11606-010-1295-zpdf

4 Reinhardt UE ldquoThe options for payment reform in US health carerdquo New York Times online February 17 2012 Available at httpeconomixblogsnytimescom20120217the-options-for-payment-reform-in-u-s-health-care

Use of Provider Payment to Encourage and Reward Quality Improvement 1 Reinhardt UE ldquoMaking surgical complications payrdquo Journal of the American Medicine Association 309(15)1634-1635 2013

Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=926822ampdirection=P 2 Christianson JB Leatherman S Sutherland K ldquoLessons from evaluations of purchaser pay-for-performance programs a

review of the evidencerdquo Medical Care Research and Review 200865(6 suppl)5S-35S Available at httpmcrsagepubcomcontent656_suppl5Sfullpdf+html

3 Rosenthal ME de Brantes FS Sinaiko AD Frankel M Robbins RD Young S ldquoBridges to excellencerecognizing high-quality care analysis of physician quality and resource userdquo American Journal of Managed Care 200814(10)670-677 Available at httpwwwajmccompublicationsissue20082008-10-vol14-n10Oct08-3648p670-677

4 Werner RM Dudley RA ldquoMaking the lsquopayrsquo matter in pay-for-performance implications for payment strategiesrdquo Health Affairs 200928(5)1498-1508 Available at httpcontenthealthaffairsorgcontent2851498fullpdf+html

5 Werner RM Kolstad JT Stuart EA Polsky D ldquoThe effect of pay-for-performance in hospitals Lessons for quality improvementrdquo Health Affairs 201130(4)690-698 Available at httpcontenthealthaffairsorgcontent2851498fullpdf+html

6 Rau J ldquoEffort to pay hospitals based on quality didnrsquot cut death rates study findsrdquo Kaiser Health News March 28 2012 Available at httpwwwkaiserhealthnewsorgstories2012march28nejm-study-hospital-quality-and-death-ratesaspx Field of Practice

1) Editorial ldquoA view from the safety netrdquo Journal of the American Medical Association 309(21)2221-2222 2013 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=927065ampdirection=P

2) Mathews AW ldquoWellPoint helps cut employersrsquo health costrdquo The Wall Street Journal June 26 2013 Available at httponlinewsjcomarticleSB10001424127887323998604578567982013011300html

3) Abelson R ldquoEmployers test plans that cap health costsrdquo The New York Times June 24 2013 Available at httpwwwnytimescom20130624healthemployers-test-plan-to-cap-medical-spendinghtmlpagewanted=allamp_r=0

4) Blue Cross Blue Shield Michigan ldquoBlue Cross Blue Shield of Michigan and Trinity Health-Michigan achieve new approach to reimbursement with landmark contractrdquo Trinity Health News Release April 2013 Available at httpwwwtrinity-healthorgbodycfmid=186ampaction=detailampref=46

5) Kennedy K ldquoHealth care providers want faster changes in paymentsrdquo USA Today April 14 2013 Available at httpwwwusatodaycomstorynewspolitics20130414health-care-providers-pushing-faster-payment-reforms2074715

13


6) Metro L ldquoCommercial Blues plans adopting the CMS do-not-pay list policyrdquo Modern Medicine April 1 2010 Available at httplicenseicopyrightnetuserviewFreeUseactfuid=OTIxMDMwMw3D3D

7) BusinessWire ldquoAnthem Blue Cross and Blue Shield launches innovative program to enhance primary care by rewarding physicians for quality and cost improvementsrdquo February 1 2012 Available at httpwwwbusinesswirecomnewshome20120201006036enAnthem-Blue-Cross-Blue-Shield-Launches-Innovative

8) BusinessWire Humanarsquos provider quality rewards program distributes more than $35 million to primary care physicians in Florida November 14 2012 Available at httpwwwbusinesswirecomnewshome20121114005577enHumanaE28099s-Provider-Quality-Rewards-Program-Distributes-35

Payment for Patient Centered Medical Home (PCMH) 1 Merrell K Berenson RA ldquoStructuring payment for medical homesrdquo Health Affairs 201029(5)852-858 Available at

httpcontenthealthaffairsorgcontent295852fullpdf+html Field of Practice

1) BusinessWire Empire announces physician practices to participate in historic public-private partnership to strengthen primary care August 23 2012 Available at httpwwwbusinesswirecomnewshome20120823006208enEmpire-Announces-Physician-Practices-Participate-Historic-Public-Private

2) Feder JL ldquoA health plan spurs transformation of primary care practices into better-paid medical homesrdquo Health Affairs 201130(3)397-399 Available at httpcontenthealthaffairsorgcontent303397fullpdf+html

Reference Pricing 1 Kanavos P Reinhardt U ldquoReference pricing for drugs Is it compatible with US Health carerdquo Health Affairs 200322(3)16-

30 Available at httpcontenthealthaffairsorgcontent22316fullpdf+html 2 Robinson JC MacPherson K ldquoPayers test reference pricing and centers of excellence to steer patients to low-price and high-

quality providersrdquo Health Affairs 31(9)2028-2036 2012 Available at httpcontenthealthaffairsorgcontent3192028fullpdf+html Field of Practice

1) Terhune C ldquoHospitals cut some surgery prices after CalPERS caps reimbursementsrdquo Los Angeles Times June 23 2013 Available at httpwwwlatimescombusinessmoneyla-fi-mo-calpers-hospital-surgery-prices-2013062306571991story

Medicare Payment Reform Initiatives 1 Guterman S Davis K Schenbaum S Shih A ldquoUsing Medicare payment policy to transform the health system a framework

for improving performancerdquo Health Affairs ndash Web Exclusive 200928(2)w238-w250 (published online 27 January 2009) Available at httpcontenthealthaffairsorgcontent282w238fullpdf+html

2 VanLare JM Conway PH ldquoValue-based purchasing ndash National programs to move from volume to valuerdquo New England Journal of Medicine 2012367(4)292-295 Available at httpwwwnejmorgdoipdf101056NEJMp1204939

3 Ryan AM Blustein J Casalino LP ldquoMedicarersquos flagship test of pay-for-performance did not spur more rapid quality improvement among low-performing hospitalsrdquo Health Affairs 201231(4)797-805 Available at httpcontenthealthaffairsorgcontent282w238fullpdf+html

4 Rau J ldquoMedicare announces plans to accelerate linking doctor pay to qualityrdquo Kaiser Health News July 22 2013 Available at httpwwwkaiserhealthnewsorgStories2013July22Medicare-value-based-pay-for-doctorsaspx

5 Kuttner R ldquoMedicare lsquocost-savingsrsquo rules pushing costs onto patientsrdquo Boston Globe July 18 2013 Available at httpwwwbostonglobecomopinion20130718medicare-disguised-form-rationingW6sF7dkTW08oGOlSekzlFIstoryhtml Field of Practice

1) Galewitz P ldquoTulsa hospital gives Medicare patients cash back for surgeryrdquo Kaiser Health News October 26 2009 Available at httpwwwkaiserhealthnewsorgstories2009october26tulsa-medicare-hospital-bundlingaspxreferrer=search

2) Rau J ldquoMedicare to begin basing hospital payments on patient-satisfaction scoresrdquo Kaiser Health News April 28 2011 Available at httpwwwkaiserhealthnewsorgStories2011April28medicare-hospital-patient-satisfactionaspx

3) Rau J ldquoMedicare announces rules for quality bonuses to hospitalsrdquo Kaiser Health News April 29 2011 Available at httpwwwkaiserhealthnewsorgStories2011April29medicare-rules-for-hospital-qualityaspx

4) Pecquet J Baker S ldquoMedicare proposal links surgical center payments to qualityrdquo The Hill July 1 2011 Available at httpthehillcomblogshealthwatchmedicare169497-medicare-proposes-linking-surgical-center-payments-to-quality

Further Readings

1 ldquoHumanarsquos new provider quality program awarding nearly $10 million in quality awards to primary care physicians across the USrdquo BusinessWire July 20 2011 Available at httpwwwbusinesswirecomnewshome20110720006098enHumanaE28099s-Provider-Quality-Rewards-Program-Awarding-10

14


2 Abelson R ldquoHospitals pay for cutting costly readmissionsrdquo The New York Times May 9 2009 pB1 Available at httpwwwnytimescom20090509business09relapsehtmlpagewanted=allamp_r=0

3 Abelson R ldquoA health insurer pays more to saverdquo New York Times June 21 2010 Available at httpwwwnytimescom20100622business22geisingerhtmlpagewanted=all

4 Adamy J ldquoWellPoint shakes up hospital paymentsrdquo Wall Street Journal online May 16 2011 Available at httponlinewsjcomarticleSB10001424052748704281504576325163218629124html

5 BlueCross BlueShield Association ldquoBlue Shield of California awards $296 million in pay-for-performance programs in 2009rdquo Press release October 5 2009 Available at httpswwwblueshieldcacomproducernewsnewslettershieldspotlightshieldspotlight_nov09_articlespsection4

6 Bridges to Excellence Available at httpwwwbridgestoexcellenceorg 7 Bury G ldquoProvider groups receive innovation award from Medicardquo Medica Press Release October 15 2008 Available at

httpnewscentermedicacompress-releasecorporate-announcementsprovider-groups-receive-innovation-award-medica 8 BusinessWire ldquoHealthPartners announces performance bonuses for providersrdquo November 10 2008 Available at

httpwwwbusinesswirecomportalsitehomepermalinkndmViewId=news_viewampnewsId=20081110006521ampnewsLang=en 9 Christianson JB Leatherman S Sutherland K ldquoPaying for quality understanding and assessing physician pay-for-

performance initiativesrdquo Robert Wood Johnson Foundation Research Synthesis Report No 13 December 2007 Available at httpwwwrwjforgprproductjspid=24373

10 Dentzer S ldquoOne payerrsquos attempt to spur primary care doctors to form new medical homesrdquo Health Affairs 201231(2)341-349 Available at httponlinewsjcomarticleSB125444082517257805html

11 Friedberg MR Safran DG Coltin K Dresser M Schneider EC ldquoPaying for performance in primary care potential impact on practices and disparitiesrdquo Health Affairs 201029(5)926-932 Available at httpcontenthealthaffairsorgcontent295926fullpdf+html

12 Kurtzman ER OrsquoLeary D Sheingold BH Devers KJ Dawson EM Johnson JE ldquoPerformance-based payment incentives increase burden and blame for hospital nursesrdquo Health Affairs 201130(2)211-218 Available at httpcontenthealthaffairsorgcontent302211fullpdf+html

13 Miller HD ldquoFrom volume to value better ways to pay for health carerdquo Health Affairs 200928(5)1418-1428 Available at httpcontenthealthaffairsorgcontent2851418fullpdf+html

14 PR Newswire ldquoHarvard Pilgrim awards close to $1 million in quality grants to 14 physician groupsrdquo May 15 2011 Available at httpwwwprnewswirecomnews-releasesharvard-pilgrim-awards-close-to-1-million-in-quality-grants-to-14-physician-groups-121313819html

15 Rosenthal MB Dudley RA ldquoPay-for-performance minus Will the last payment trend improve carerdquo Journal of the American Medicine Association 2007297(7)740-744 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=5110ampdirection=P

16 Serumaga B Ross-Degnan D Avery AJ Elliott RA Majumdar SR Zhang F Soumerai SB ldquoEffect of pay for performance on the management and outcomes of hypertension in the United Kingdom Interrupted time series studyrdquo BMJ 2011 Available at httpwwwbmjcomcontent342bmjd108fullpdfsid=b6f47b59-d8ba-4dae-9226-b4f8c2800d0f

17 UCare ldquoUcare announces details of 2011 pay for performance program that rewards providers for health improvementsrdquo May 2 2011 Available at httpwwwucareorgSiteCollectionDocumentsmediaNewsReleases201120P4P20prog20details20rel20print205-2-11pdf

October 21 2013 New Payment Arrangements BundledEpisode-Based Payment Learning Objectives Students should be able to

1 Understand the basic design features relating to bundled payment 2 Discuss the obstacles to implementing bundled payment arrangements 3 Discuss Medicare support for bundled payment

Suggested Readings Bundled Payment in Concept

1 Aligning Forces for Quality ldquoBundled payment The quest for simplicity in pricing and tying payment to qualityrdquo Robert Wood Johnson Foundation June 2013 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research201306bundled-payment--the-quest-for-simplicity-in-pricing-and-tying-phtml

2 Silversmith J ldquoFive payment models The pros the cons the potentialrdquo Minnesota Medicine February 2011 Available at httpwwwminnesotamedicinecomPastIssuesPastIssues2011February2011aspx

15


3 Rosenthal MB ldquoBeyond pay for performance emerging models of provider-payment reformrdquo New England Journal of Medicine 2008359(12)1197-1200 Available at httpwwwnejmorgdoipdf101056NEJMp0804658

4 de Brantes F DrsquoAndrea G Rosenthal MB ldquoShould health care come with a warrantyrdquo Health Affairs ndash Web Exclusive 200929(4)w678-w687 (published online 16 June 2009) Available at httpcontenthealthaffairsorgcontent284w678fullpdf+html

5 Mechanic RE Altman SH ldquoPayment reform options episode payment is a good place to startrdquo Health Affairs ndash Web Exclusive 200928(2)w262-w271 (published online 27 January 2009) Available at httpcontenthealthaffairsorgcontent282w262fullpdf+html

6 Painter MW ldquoBundled payments This way toward a challenging yet better placerdquo Health Care Incentives Issue Brief 2012 Available at httpwwwhci3orgsitesdefaultfilesfilesHCI-IssueBrief-4-2012pdf

7 Cutler DM Ghosh K ldquoThe potential for cost savings through bundled episode paymentsrdquo New England Journal of Medicine 2012366(12)1075-1077 Available at httpwwwnejmorgdoipdf101056NEJMp1201853

8 Berenson RA DeBrantes F Burton R Payment reform Bundled episodes vs global payments Urban Institute September 2012 Available at httpwwwurbanorgpublications412655html

9 Bach PB ldquoReforming the payment system for medical oncologyrdquo Journal of the American Medical Association 2013310(3)261-262 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927287ampdirection=P Field of Practice

1) Mitchell R ldquoSlow progress on efforts to pay docs hospitals for lsquovaluersquo not volumerdquo Kaiser Health News March 26 2013 Available at httpwwwkaiserhealthnewsorgstories2013march26employers-value-volume-purchasingaspx

Examples of Bundled Payment 1 Bailit M Burns M Houy M ldquoBundled payments one year later An update on the status of implementations and operational

findingsrdquo Health Care Incentives Improvement institute May 30 2013 Available at httpwwwhci3orgsitesdefaultfilesfilesIBBundledPayment-June2013-L3_0pdf

2 Hussey PS Ridgely MS Rosenthal MB ldquoThe PROMETHEUS bundled payment experiment Slow start shows problems in implementing new payment modelsrdquo Health Affairs 201130(11)2116-2124 Available at httpcontenthealthaffairsorgcontent30112116fullpdf+html Field of Practice

1) Wall Street Journal Market Watch ldquoBlueCross announces bundled payment agreement with leading orthopedic groups in Tennesseerdquo Press Release May 22 2012 Available at httpwwwmarketwatchcomstorybluecross-announces-bundled-payment-agreements-with-leading-orthopedic-groups-in-tennessee-2012-05-22

2) Klukarni SS Eyes turn to Arkansasrsquo bold effort to cut Medicaid costs add transparency Kaiser Health News October 1 2012 Available at httpwwwkaiserhealthnewsorgDaily-Reports2012October012khnstoryaspxprint=1

3) Emanuel EJ The Arkansas innovation The New York Times September 5 2012 Available at httpopinionatorblogsnytimescom20120905the-arkansas-innovation

Medicare Payment Reform Initiatives 1 Chernew M Goldman D ldquoProposal 1 Transitioning to bundled payments in Medicarerdquo Brookings The Hamilton Project 2013

Available at httpwwwbrookingsedu~mediaresearchfilespapers201302thp20budget20papersthp_15waysfedbudget_prop1pdf

2 Pecquet J ldquoMedicare to bundle dialysis payments reward facilities for training patientsrdquo The Hill July 26 2010 Available at httpthehillcomblogshealthwatchmedicare110975-medicare-to-reward-dialysis-facilities-for-training-patientstmpl=componentampprint=1amppage=

3 Komisar HL Feder J Ginsburg PB ldquorsquoBundlingrsquo payment for episodes of hospital care Issues and recommendations for the new pilot program in Medicarerdquo 2011 Washington DC Center for American Progress Available at httpwwwamericanprogressorgissues201107pdfmedicare_bundlingpdf

4 Mechanic RE ldquoOpportunities and challenges for episode-based paymentrdquo New England Journal of Medicine 2011365(9)777-779 Available at httpwwwnejmorgdoipdf101056NEJMp1105963

Field of Practice 1) Minich-Pourshadi K ldquoCMS bundled payment changes untenablerdquo HealthLeaders Media December 10 2013

Available at httpwwwhealthleadersmediacompage-1FIN-287297CMS-Bundled-Payment-Changes-Untenable 2) Walker EP ldquoCMS testing bundled payments for Medicarerdquo MedPage Today August 23 2011 Available at

httpwwwmedpagetodaycomPublicHealthPolicyMedicare28172 Further Readings

1 Abelson R ldquoIn bid for better hospital care heart surgery with a warranty health plans quality controlrdquo New York Times May 17 2007 Available at httpwwwnytimescom20070517business17qualityhtmlpagewanted=allamp_r=0

2 Adamy J ldquoWellPoint shakes up hospital paymentsrdquo Wall Street Journal (online) May 16 2011 Available at httpproquestumicompqdlinkindex=6ampdid=2348036301ampSrchMode=2ampsid=1ampFmt=3ampVInst=PRODampVType=PQDampRQT=309ampVName=PQDampTS=1314044474ampclientId=2256

16


3 Galewitz P ldquoCan bundled payments help slash health costs Effort touts efficiency critics fear drop in carerdquo USA Today October 26 2009 Available at httpusatoday30usatodaycomnewshealth2009-10-25-bundle-payments_nhtm

4 Hussey PS Sorbero ME Mehrotra A Liu H Damberg CL ldquoEpisode-based performance measurement and payment making it a realityrdquo Health Affairs 200928(5)1406-1417 Available at httpcontenthealthaffairsorgcontent2851406fullpdf+html

5 Newcomer LN ldquoChanging physician incentives for cancer care to reward better patient outcomes instead of use of more costly drugsrdquo Health Affairs 201231(4)780-785 Available at httpcontenthealthaffairsorgcontent2851406fullpdf+html

6 Reuters ldquoBundled payments a way to cut health costs studyrdquo November 11 2009 Available at httpwwwreuterscomarticleidUSTRE5AA4YV20091111

7 Reuters ldquoUS encourages bundling Medicare paymentsrdquo August 23 2011 Available at httpwwwreuterscomarticle20110823us-cms-innovation-idUSTRE77M5NR20110823

8 Struijs JN Baan CA ldquoIntegrating care through bundled payments ndash lessons from the Netherlandsrdquo New England Journal of Medicine 2011364(11)990-991 Available at httpwwwnejmorgdoipdf101056NEJMp1011849

9 TriZetto Press Release QualChoice Health Insurance chooses TriZettorsquos payment-bundling solution to help improve cost and quality of care for members August 22 2012 Available at httpwwwtrizettocomNewsEventsPressReleasesPressReleaseaspxid=4243

October 28 2013 New Payment Arrangements Comprehensive GainsharingTotal Cost of Care (TCOC) Learning Objectives Students should be able to

1 Describe the basic features of comprehensive TCOC payment arrangements between health plans and providers 2 Discuss the obstacles to implementing TCOC arrangements 3 Discuss Medicare support for TCOC payment as evidenced by Alternative Care Organizations

Suggested Readings TCOC Payment Approaches

1 Klar R ldquoSaving the shared savings program (ACOs) Specific suggestions for successmdashpart onerdquo Health Affairs Blog May 17 2011 Available at httphealthaffairsorgblog20110517saving-the-shared-savings-program-acos-specific-suggestions-for-success-part-one

2 Lieberman SM Bertko JM ldquoBuilding regulatory and operational flexibility into accountable care organizations and lsquoshared savingsrsquordquo Health Affairs 30(1)23-31 2011 Available at httpcontenthealthaffairsorgcontent30123fullpdf+html

3 Shields MC Patel PH Manning M Sacks L ldquoA model for integrating independent physicians into accountable care organizationsrdquo Health Affairs 201130(1)161-172 Available at httpcontenthealthaffairsorgcontent301161fullpdf+html

4 Berenson RA Burton RA ldquoAccountable care organization in Medicare and the private sector A status updaterdquo Robert Wood Johnson FoundationUrban Institute November 2011 Available at httpwwwrwjforgfilesresearch734705470acoreportpdf

5 Mechanic RE Santos P Landon BE Chernew ME ldquoMedical group responses to global payment Early lessons from the lsquoalternative quality contractrsquo in Massachusettsrdquo Health Affairs 201130(9)1734-1742 Available at httpcontenthealthaffairsorgcontent3091734fullpdf+html

6 Higgins A Stewart K Dawson K Bocchino C ldquoEarly lessons from accountable care models in the private sector Partnerships between health plans and providersrdquo Health Affairs 201130(9)1718-1727 Available at httpcontenthealthaffairsorgcontent3091718fullpdf+html

7 Landon BE ldquoKeeping score under a global payment systemrdquo New England Journal of Medicine 366(5)393-395 2012 8 Muhlestein D Croshaw A Merrill T Pena C ldquoGrowth and dispersion of accountable care organizations June 2012 updaterdquo

Leavitt Partners 2012 Available at httpleavittpartnerscomwp-contentuploads201206Growth-and-Dispersion-of-ACOs-June-2012-Updatepdf

9 Song Z Safran DG Landon BE Landrum MB He Y Mechanic RE Day MP Chernew ME ldquoThe lsquoalternative quality contractrsquo based on a global budget lowered medical spending and improved qualityrdquo Health Affairs 201231(8)1885-1894 Available at httpcontenthealthaffairsorgcontent3181885fullpdf+html

10 Bird J ldquoPhysician-led ACOs outnumber hospital counterpartsrdquo FierceHealthcare April 15 2013 Available at httpwwwfiercehealthcarecomstoryphysician-led-acos-outnumber-hospital-counterparts2013-04-15

11 Christensen C Flier J Vijayaraghavan V Opinion ldquoThe coming failure of lsquoaccountable carersquordquo The Wall Street Journal February 18 2013 Available at httponlinewsjcomarticleSB10001424127887324880504578296902005944398html

12 Muhlestein D ldquoContinued growth of public and private accountable care organizationsrdquo Health Affairs Blog February 19 2013 Available at httphealthaffairsorgblog20130219continued-growth-of-public-and-private-accountable-care-organizations

17


Field of Practice 1) Betbeze P ldquoIncentives motivations clash under ACOsrdquo HealthLeaders Media April 26 2013 Available at

httpwwwhealthleadersmediacomcontentLED-291569Incentives-Motivations-Clash-Under-ACOs 2) Bailit M Hughes C Burns M Freedman DH ldquoShared-savings payment arrangement in health care Six case

studiesrdquo Commonwealth Fund August 2012 Available at httpwwwcommonwealthfundorgPublicationsFund-Reports2012AugShared-Savings-Payment-Arrangementsaspx

3) McCann E ldquoBon Secours Aetna ink big ACO Dealrdquo Healthcare IT News June 25 2013 Available at httpwwwhealthcareitnewscomnewsbon-secours-aetna-ink-big-aco-deal

4) Geist RW ldquoMinnesotarsquos health care merger proposalsrdquo Star Tribune April 15 2013 Available at httpwwwstartribunecomopinioncommentaries203112301html

5) Lowrey A ldquoA health provider finds success in keeping hospital beds emptyrdquo The New York Times April 23 2013 Available at httpwwwnytimescom20130424businessaccountable-care-helping-hospitals-keep-medical-costs-downhtmlpagewanted=allamp_r=0

6) Betbeze P ldquoACO or not Fairview builds shared savings into all payer contractsrdquo HealthLeaders Media May 23 2011 Available at httpwwwhealthleadersmediacompage-1HEP-266457ACO-or-Not-Fairview-Builds-Shared-Savings-into-All-Payer-Contracts

7) HealthPartners ldquoHealthPartners among first to receive accountable care organization accreditation from NCQArdquo News Release February 14 2013 Available at httpwwwhealthpartnerscompublicnewsroomnewsroom-article-list2-14-13html

8) Crosby J ldquoUnitedHealth expands efforts to link cost qualityrdquo Star Tribune July 10 2013 Available at httpwwwstartribunecombusiness215007791html

9) UnitedHealthcare ldquoUnitedHealthcare expects to more than double industry-leading accountable care contracts to $50 billion by 2017rdquo July 10 2013 Available at httpfinanceyahoocomnewsunitedhealthcare-expects-more-double-industry-120000393html

Medicare Payment Reform Initiatives 1 Wayne A ldquoObamacare shows hospital savings as patient make gainsrdquo Bloomberg June 12 2013 Available at

httpwwwbloombergcomnews2013-06-12obamacare-shows-hospital-savings-as-patients-make-gainshtml 2 Centers of Medicare and Medicaid Services ldquoPioneer accountable care organization modelrdquo General Fact Sheet September 12

2012 Available at httpinnovationcmsgovFilesfact-sheetPioneer-ACO-General-Fact-Sheetpdf 3 Klar R ldquoOverweight and out of shape ACO regs need a major makeoverrdquo Health Affairs Blog April 7 2011 Available at

httphealthaffairsorgblog20110407overweight-and-out-of-shape-aco-regs-need-a-major-makeover 4 Lieberman S ldquoProposed CMS regulation kills ACOs softlyrdquo Health Affairs Blog April 6 2011 Available at

httphealthaffairsorgblog20110406proposed-cms-regulation-kills-acos-softly 5 Correia EW ldquoAccountable care organizations The proposed regulations and the prospects for successrdquo American Journal of

Managed Care 201117(8)560-568 Available at httpwebebscohostcomehostpdfviewerpdfviewervid=3ampsid=68ac2d73-3f7a-4fdf-890c-00fee61d722d40sessionmgr111amphid=128

6 Berwick DM ldquoMaking good on ACOsrsquo promise mdash The final rule for the Medicare shared savings programrdquo New England Journal of Medicine 2011365(19)1753-1756 Available at httpwwwnejmorgdoipdf101056NEJMp1111671

7 Berenson RA ldquoShared savings program for accountable care organizations A bridge to nowhererdquo American Journal of Managed Care 201016(10)721-726 Available at httpwwwajmccompublicationsissue20102010-10-vol16-n10AJMC_10oct_Berenson_721to726

8 McClellan M McKethan AN Lewis JL Roski J Fisher ES ldquoA national strategy to put accountable care into practicerdquo Health Affairs 201029(5)982-990 Available at httpcontenthealthaffairsorgcontent295982fullpdf+html

9 Meyer H ldquoAccountable care organization prototypes Winners and losersrdquo Health Affairs 201130(7)1227-1231 Available at httpcontenthealthaffairsorgcontent3071227fullpdf+html

10 Ginsburg PB ldquoSpending to save ndash ACOs and the Medicare shared savings programrdquo New England Journal of Medicine 2011364(22)2085-2086 Available at httpwwwnejmorgdoipdf101056NEJMp1103604

11 Klar R ldquoACO 101 The basics of accountable carerdquo Health Affairs Blog August 29 2011 Available at httphealthaffairsorgblog20110829aco-101-the-basics-of-accountable-care

12 Gold J ldquoFAQ on ACOs Accountable care organizations expandedrdquo Kaiser Health News October 21 2011 Available at httpwwwkaiserhealthnewsorgstories2011january13aco-accountable-care-organization-faqaspx

13 Binder J ldquoDoctors should be rewarded for quality care ndash not for cutting cornersrdquo Health Affairs Blog July 19 2013 Available at httphealthaffairsorgblog20130719doctors-should-be-rewarded-for-quality-care-not-for-cutting-corners Field of Practice

1) BCBS of Illinois ldquoBlue Cross and Blue Shield of Illinois and OSF HealthCare team to create accountable care organization to improve quality of care and reduce costsrdquo News Release May 17 2013 Available at httpwwwbcbsilcomcompany_infonewsroompress_releases20132013_05_17html

18


2) Torres C ldquo32 lsquopioneersrsquo selected to test new health care model for seniorsrdquo Kaiser Health News Blog December 19 2011 Available at httpcapsuleskaiserhealthnewsorgindexphp20111232-pioneers-selected-to-test-new-healthcare-model-for-seniors

Further Readings

1 BusinessWire ldquoLahey Clinic joins Blue Cross Blue Shield of Massachusetts alternative quality contractrdquo News Release May 14 2012 Available at httpwwwbusinesswirecomnewshome20120514006575enLahey-Clinic-Joins-Blue-Cross-Blue-Shield

2 Crosby J ldquoFeds reward Park Nicollet for healthy patientsrdquo StarTribune August 8 2011 Available at httpwwwstartribunecombusiness127283643html

3 Elliott J ldquoCould health plans derail ACOsrdquo HealthLeaders Media October 27 2010 Available at httpwwwhealthleadersmediacompage-1HEP-258288Could-Health-Plans-Derail-ACOs

4 Gold J ldquoACO rollout continues with 89 new networksrdquo Kaiser Health News Blog July 9 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201207aco-rollout-continues-with-89-new-networks

5 Goodnough A New medical care networks show savings The New York Times September 11 2012 Available at httpwwwnytimescom20120912healthpolicymedical-care-networks-show-savings-study-findshtml

6 Haywood TT ldquoThe ACO model ndash A three-year financial lossrdquo New England Journal of Medicine 364e27 March 23 2011 Available at httpwwwnejmorgdoipdf101056NEJMp1100950

7 NCQA Press Release NCQA releases HEDIS for ACOs September 11 2012 Available at httpwwwncqaorgNewsroom2012NewsArchiveNewsReleaseSeptember112012aspx

8 Overland D Medica launches private exchange to sell ACO projects FierceHealthPayer October 16 2012 Available at httpwwwfiercehealthpayercomstorymedica-launches-private-exchange-sell-aco-products2012-10-16

9 Parmar A Mayo Medica partner to create alternative to fee-for-service health insurance MedCity News June 14 2012 Available at httpmedcitynewscom201206mayo-clinic-cements-new-collaboration-with-minnesota-health-plan

10 Rosenthal MB Cutler DM Feder J ldquoThe ACO rules ndash Striking the balance between participation and transformative potentialrdquo New England Journal of Medicine 2011365e6 Available at httpwwwnejmorgdoipdf101056NEJMp1106012

11 Snowbeck C From HMOs to ACOs Meet the newest model in health care management TwinCitiescom September 24 2012 Available at httpwwwtwincitiescomci_21602399

12 The New York Times How insurers can help September 30 2012 Available at httpwwwnytimescom20121001opinionhow-insurers-can-helphtml

13 Weisman R Harvard Pilgrim partners agree on 4-year contract The Boston Globe October 25 2012 Available at httpwwwbostonglobecombusiness20121025partners-harvard-pilgrim-reach-new-four-year-contract-that-limits-annual-payment-increasesBpoapJk1S48xuiUo4p6QFKstoryhtml

November 4 2013 Utilization Management Reminders clinical decision-support systems predictive modeling guidelines and rules are all used by health plans to influence the amount and type of care that providers deliver to their patients Reminders prompt physicians about a patients care needs prior to or at the time of the treatment visit Clinical decision-support systems typically involve software designed to assist the physicians clinical decision-making Predictive modeling uses large claims databases to identify patients who may be at risk of specific illnesses in the future and alert clinicians prior to the patient visit Guidelines or pathways assist physicians in taking the appropriate treatment steps given a patients condition and often are applied when treating patients with chronic health problems Rules are used by health plans to intervene more directly in the care process This session will address the different ways that health plans attempt to influence the delivery of care by providers including the manner in which these techniques are being employed and evidence of their effectiveness Learning Objectives Students should be able to

1 Describe the most common practices used by health plans to support physicians in the delivery of care 2 Explain the barriers to their effective implementation 3 Assess the strength of the evidence supporting their effectiveness 4 Describe recent trends in their use in conjunction with other efforts to influence physician behavior

Suggested Readings Utilization Management Challenges Faced by Health Plans

1 The Medical Society of the State of New York ldquoSurvey reveals that doctors feel pressured by health insurers to alter the way they treat patientsrdquo September 10 2008 Available at httpwwwmssnyorgmssnyipcfmc=iampnm=Insurance_Carrier_Rules

2 Paltrow SJ ldquoInsurersrsquo black boxrdquo Center for American Progress October 23 2009 Available at httpwwwamericanprogressorgissues200910black_boxhtml

19


3 Beckman HB ldquoLost in translation Physiciansrsquo struggle with cost-reduction programsrdquo Annals of Internal Medicine 2011154(6)430-433 Available at httpannalsorgissueaspxjournalid=90ampissueID=20228ampdirection=P

4 Goldberger JJ Buston AE ldquoPersonalized medicine vs guideline-based medicinerdquo Journal of the American Medical Association 2013309(24)2559-2560 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=927181ampdirection=P Field of Practice

1) Gardner A ldquoDay of admission dictates length of stay for heart failurerdquo ABC News May 22 2010 Available at httpabcnewsgocomHealthHealthdaystoryid=4904656amppage=1

Overview of Health Plan Efforts 1 Landon BE Rosenthal MB Normand S-LT Frank RG Epstein AM ldquoQuality monitoring and management in commercial

health plansrdquo American Journal of Managed Care 200814(6)377-386 Available at httpwwwajmccompublicationsissue20082008-06-vol14-n6Jun08-3301p377-386

2 Goodell S Bodenheimer T Berry-Millet R ldquoCare management of patients with complex health care needsrdquo Policy Brief No 19 Robert Wood Johnson Foundation Synthesis Project December 2009 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research200912care-management-of-patients-with-complex-health-care-needshtml Field of Practice

1) MedeAnalytics ldquoBlue Cross Blue Shield of Vermont slects MedeAnalyticsrsquo medical management analyticsrdquo April 30 2013 Available at httpwwwmedeanalyticscomnews-eventsblue-cross-blue-shield-of-vermont-selects-medeanalytics-medical-management-analytics

2) MedSolutions ldquoMedSolutions launches comprehensive post-acute care management projectrdquo March 28 2013 Available at httpwwwmedsolutionscomnews3-28-13html

3) Keim B Paging Dr Watson Artificial intelligence as a prescription for health care Wired October 16 2012 Available at httpwwwwiredcomwiredscience201210watson-for-medicine

ProfilingFeedback of Information on Treatment Patterns 1 Bindman A ldquoCan Physician Profiles Be Trustedrdquo JAMA 1999281(22)2142-2143 Available at

httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=4646ampdirection=P 2 Greene RA Beckman H Chamberlain J Partridge G Miller M Burden D Kerr J ldquoIncreasing adherence to a

community-based guideline for acute sinusitis through education physician profiling and financial incentivesrdquo American Journal of Managed Care 200410(10)670-678 Available at httpwwwajmccompublicationsissue20042004-10-vol10-n10Oct04-1901p670-678

Practice Guidelines 1 Goldberger JJ Buxton AE ldquoPersonalized medicine vs guideline-based medicinerdquo Journal of the American Medical Association

2013309(24)2559-2560 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927181ampdirection=P 2 Lin KW Slawson DC ldquoIdentifying and using good practice guidelinesrdquo American Family Physician 200980(1)67-69 Available

at httpswwwclinicalkeycomBrowserCtrldoBrowseTojournalIssuefacet[1-s20-S0002838X09X60156]issn0002838XcontentTypeJournals

3 Editorial ldquoImproving practice guidelines with patient-specific recommendationsrdquo Annals of Internal Medicine 2011154(9)638-639 Available at httpannalsorgissueaspxjournalid=90ampissueID=20231ampdirection=P Field of Practice

1) Graham J ldquoMammogram guidelines are sparking a firestorm Critics hit suggestion that women in 40s may not need routine screeningrdquo Chicago Tribune November 17 2009 p1 Available at httparticleschicagotribunecom2009-11-17news0911160603_1_routine-mammograms-annual-mammograms-breast-cancer

2) Ando R ldquoIBM and Aetna tie up to offer clinical support servicerdquo Reuters August 5 2010 Available at httpwwwreuterscomarticleidUSTRE6740EW20100805

3) Boulton G ldquoGuidelines met with dose of skepticism Do they aid doctors or hinder themrdquo Milwaukee Journal Sentinel June 27 2010 Available at httpwwwjsonlinecombusiness97280724html

4) Nussbaum A ldquoAetna urges moms to avoid cesareans births to reduce riskrdquo Bloombergcom July 12 2012 Available at httpwwwbloombergcomnews2012-07-13aetna-urges-moms-to-avoid-cesareans-births-to-reduce-riskhtml

5) Gordon S ldquoDiabetes groups issue new guidelines on blood sugarrdquo HealthDay April 19 2012 Available at httpconsumerhealthdaycomArticleaspAID=663893

Use of Treatment Reminders 1 Derose SF Dudl JR Benson VM Contreras R Nakahira RK Ziel FH ldquoPoint-of-service reminders for prescribing

cardiovascular medicationsrdquo The American Journal of Managed Care 200511(5)298-304 Available at httpwwwajmccompublicationsissue20052005-05-vol11-n5May05-2027p298-304 Field of Practice

1) Mathews AW ldquoWellPointrsquos new hire What is Watsonrdquo Wall Street Journal online September 12 2011 Available at httponlinewsjcomarticleSB10001424053111903532804576564600781798420html

Managing Imaging Use and Costs Combining Utilization Management Tools 1 Tynan A Berenson RA Christianson JB ldquoHealth plans target advanced imaging services cost quality and safety concerns

prompt renewed oversightrdquo Center for Studying Health System Change Issue Brief No 118 February 2008 Available at

20


httpwwwhschangecomCONTENT968 2 Iglehart JK ldquoHealth insurers and medical-imaging policy ndash a work in progressrdquo New England Journal of Medicine

2009360(10)1030-1037 Available at httpwwwnejmorgdoipdf101056NEJMhpr0808703 3 Rao VM Levin DC The overuse of diagnostic imaging and the choosing wisely initiative Annals of Internal Medicine Available

at httpannalsorgarticleaspxarticleid=1355170 4 Lee DW Levy F ldquoThe sharp slowdown in growth of medical imaging An early analysis suggests combination of policies was

the causerdquo Health Affairs 201231(8)1876-1884 Available at httpcontenthealthaffairsorgcontent3181876fullpdf+html Field of Practice

1) Seaman AM ldquoMany lower back MRI scans may be unnecessaryrdquo Reuters March 25 2013 Available at httpwwwreuterscomarticle20130325us-lower-back-mri-idUSBRE92O0XV20130325

2) Mathews AW ldquoInsurers hire radiology police to vet scanning firms make doctors justify costly CTs MRIs and PETs patients stuck in the middlerdquo Wall Street Journal November 6 2008 Available at httponlinewsjcomarticleSB122591900516802409html

3) Kaiser Health News ldquoConcerns about unnecessary scans and radiation risk prompt reviews by doctorsrdquo March 2 2010 Available at httpwwwkaiserhealthnewsorgdaily-reports2010march02radiation-and-ct-scansaspxreferrer=search

4) Parashar A ldquoIn emergency rooms itrsquos getting tougher to say lsquonorsquo to CT scansrdquo Kaiser Health News November 29 2010 Available at httpwwwkaiserhealthnewsorgStories2010November29CT-scan-study-short-takeaspx

5) Galewitz P ldquoImaging at the doctorrsquos Good thing or transparent ployrdquo USAToday August 23 2010 Available at httpwwwusatodaycomyourlifehealthhealthcaredoctorsnurses2010-08-23-Imaging23_ST_Nhtm

6) Carey MA ldquoMedical imaging advocates fight proposals requiring advance authorizationrdquo Kaiser Health News October 18 2011 Available at httpcapsuleskaiserhealthnewsorgindexphp201110medical-imaging-advocates-fight-proposals-requiring-advance-authorization

7) Hancock J Pressure from insurers government cuts radiology use and spending KHN Blog September 10 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201209pressure-from-insurers-government-cuts-radiology-use-and-spending

8) Bardin J ldquoUse of imaging tests sores raising questions on radiation riskrdquo Los Angeles Times online June 20 2012 Available at httparticleslatimescom2012jun12sciencela-sci-ct-mri-growth-20120613

Medicare Utilization Initiatives 1 US Government Accountability Office ldquoMedicare per capita method can be used to profile physicians and provide feedback on

resource use Summaryrdquo September 25 2009 Available at httpwwwgaogovproductsGAO-09-802 2 Pecquet J ldquoBipartisan duo fights proposals to curb medical imagingrdquo The Hill March 31 2011 Available at

httpthehillcomblogshealthwatchmedicare163957-bipartisan-duo-fights-proposals-to-curb-medical-imaging 3 Matlock DD Groeneveld PW Sidney S et al ldquoGeographic variation in cardiovascular procedure use among Medicare fee-for-

service vs Medicare advantage beneficiariesrdquo Journal of the American Medical Association 2013310(2)155-162 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927264ampdirection=P

Field of Practice 1) Carey MA Serafini MW ldquoDoctors balk at proposal to cut Medicarersquos use of imagingrdquo Kaiser Health News June 14 2011

Available at httpwwwkaiserhealthnewsorgDaily-Reports2011June151khnstoryaspx Further Readings on Imaging

1 Allen GP ldquoCosts escalate patients suffer when waste abuse and fraud permeate diagnostic imagingrdquo May 2007 Available at httpwwwimakenewscomseropere_article000814532cfmx=b110w

2 Bogdanich W McGinty JC ldquoMedicare claims showing overuse of CT scanningrdquo New York Times June 18 2011 p A1 Available at httpwwwnytimescom20110618health18radiationhtmlpagewanted=all

3 Bogdanich W Ruiz RR ldquoFDA to increase oversight of medical radiationrdquo The New York Times February 10 2010 Available at httpwwwnytimescom20100210healthpolicy10radiationhtml

4 Franklin C ldquoBefore you get that CT scanhelliprdquo Chicago Tribune March 17 2011 p21 Available at httparticleschicagotribunecom2011-03-17opinionct-oped-0317-scanner-20110317_1_future-cancers-ct-scans-ct-colonography

5 Holcombe D ldquoOncology management programs for payers and physiciansrdquo American Journal of Managed Care 201117e182-e186 Available at httpwwwajmccompublicationsissue20112011-5-vol17-n5AJMC_11JOPmayHolcombe_e182to6

6 Iglehart JK ldquoThe new era of medical imaging progress and pitfallsrdquo The New England Journal of Medicine 2006354(26)2822-2828 Available at httpwwwnejmorgdoipdf101056NEJMhpr061219

7 Kaiser Health News ldquoFederal officials focus on radiation practices at Florida clinic medical scan makers announce new efforts to prevent mistakesrdquo February 26 2010 Available at httpwwwkaiserhealthnewsorgDaily-Reports2010February26Radiationaspx

8 Kaiser Health News ldquoLos Angeles Times examines growing popularity concerns regarding CT scansrdquo September 8 2008 Available at httpwwwkaiserhealthnewsorgdaily-reports2008september08dr00054331aspxreferrer=search

21


9 Landro L rdquoThe informed patient better ways to treat back pain insurers employers target excessive scans and surgeries to improve patient outcomesrdquo Wall Street Journal May 16 2007 Available at httponlinewsjcomarticleSB117926943880204067html

10 Marchione M ldquoBe wary of radiation overdose from medical tests doctors sayrdquo TwinCitiescom June 14 2010 Available at httpwwwtwincitiescomalllistingsci_15296869source=rss

11 Perrone M ldquoMedical scan makers to install radiation controlsrdquo Seattle Times online February 25 2010 Available at httpseattletimesnwsourcecomhtmlbusinesstechnology2011184043_apusradiationscanssafetyhtml

12 Phelps Drdquo Insurers want 2nd opinion before approving scansrdquo MPR News January 4 2007 Available at httpminnesotapublicradioorgdisplayweb20070104scans

13 PR Newswire ldquoAnthem Blue Cross and Blue Shield of Wisconsin expands transparency of diagnostic imagingrdquo October 21 2007 Available at httpwwwprnewswirecomnews-releasesanthem-blue-cross-and-blue-shield-expands-cost-disclosure-tool-to-northcentral-wisconsin-65185497html

14 Salganik MW ldquoMedical scans zapping insurersrdquo Baltimore Sun May 13 2007 Available at httparticlesbaltimoresuncom2007-05-13business0705130014_1_pet-scans-emission-tomography-positron-emission

15 Sataline S ldquoDoctors may risk overuse of CT scansrdquo Wall Street Journal November 29 2007 Available at httponlinewsjcomarticleSB119627836509306828html

16 Serafini MW Carey MG ldquoPanel urges crackdown on Medicarersquos use of imagingrdquo Kaiser Health News June 14 2011 Available at httpwwwkaiserhealthnewsorgStories2011June15Medicare-imagingaspx

17 Steenhuysen J ldquoDoctors work on radiation problem to ease fearsrdquo Reuters June 7 2010 Available at httpwwwreuterscomarticleidUSTRE6565Y820100608

18 Steenhuysen J ldquoYounger Americans overexposed to radiation riskrdquo Reuters August 27 2009 Available at httpwwwreuterscomarticleidUSTRE57P59Z20090827

19 Szabo L Cancer risks prompt doctors to try to lower imaging scan radiation USA Today Available at httpwwwusatodaycomnewshealth2010-05-05-radiation05_st_Nhtm

20 Tanner L ldquoUse of costly scans is climbing in cancer patientsrdquo April 27 2010 Available at httpwwwmsnbcmsncomid36807258nshealth-cancer

21 Bodenheimer T Berry-Millet R ldquoCare management of patients with complex health care needsrdquo Research Synthesis Report No 19 Robert Wood Johnson Foundation Synthesis Project December 2009 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research200912care-management-of-patients-with-complex-health-care-needshtml

Further Readings ndash General 1 Juster IA et al ldquoUse of administrative data to identify health plan members with unrecognized bipolar disorder a retrospective

cohort studyrdquo American Journal of Managed Care 200511(9)578-584 Available at httpwwwajmccompublicationsissue20052005-09-vol11-n9Sep05-2123p578-584

2 Neergaard L ldquoOvertreated more medical care isnrsquot always betterrdquo ABC News July 7 2010 Available at httpabcnewsgocomHealthwireStoryid=10843361

3 OrsquoConnor PJ Sperl-Hillen J Johnson PE ldquoCustomized feedback to patients and providers failed to improve safety or quality of diabetes care A randomized trialrdquo Diabetes Care 200932(7)1158-1163 Available at httpcarediabetesjournalsorgcontent3271158fullpdf+html

November 11 2013 Supporting EmployeesEnrollees in Choosing Providers Reporting of Provider Performance Providing consumers with timely useful information about the performance of providers is one way that purchasers hope to engage consumers Their intent is that consumers will use this information in combination with financial incentives to seek out lower cost higher quality providers And it is hoped that providers will improve their quality and reduce their costs when faced with public comparisons with their peers The present health care system some argue does not provide information that is truly useful to consumers in making costquality tradeoffs when choosing providers or that is credible to providers We will discuss recent efforts to publicly report information comparing providers as well as the evidence regarding the influence of this information on consumer and provider decisions Learning Objectives Students should be able to

1 Describe the recent efforts to increase the amount and quality of information available to health care consumers about providers 2 Discuss the responses of providers to these efforts 3 Assess the evidence regarding the impact of comparative provider performance data on consumer decisions quality of care and

health care costs

22


Suggested Readings Private Entities Producing Public Reports

1 Young GJ ldquoMultistakeholder regional collaboratives have been key drivers of public reporting but now face challengesrdquo Health Affairs 201231(3)578-584 Available at httpcontenthealthaffairsorgcontent313578fullpdf+html

2 Christianson JB Volmar KM Alexander J Scanlon DP ldquoA report card on provider report cards Current status of the health care transparency movementrdquo Journal of General Internal Medicine 201025(11)1235-1241 Available at httplinkspringercomcontentpdf1010072Fs11606-010-1438-2pdf

Public Reports and Their Use by Consumers 1 Kullgren JT Duey KA Werner RM ldquoA census of state health care price transparency websitesrdquo Journal of the American

Medical Association 2013309(23)2437-2438 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927128ampdirection=P

2 Reinhardt UE ldquoHealth care payers push back against costsrdquo The New York Times February 3 2012 Available at httpeconomixblogsnytimescom20120203health-care-payers-push-back-against-costs

3 Rothberg MB Morsi E Benjamin EM Pekow PS Lindenauer PK ldquoChoosing the best hospital the limitations of public quality reportingrdquo Health Affairs 200827(6)1680-1687 Available at httpcontenthealthaffairsorgcontent2761680fullpdf+html

4 Harris KM and Buntin MB ldquoChoosing a Health Care Provider The Role of Quality Informationrdquo Research Synthesis Report No 14 Princeton NJ The Synthesis Project Robert Wood Johnson Foundation May 2008 Available at httpwwwrwjforgprproductjspid=29683

5 The LeapfrogGroup ldquoTransparency should not be a luxury it is a matter of life and death what purchasers and consumers can dordquo February 2 2010 Available at httpwwwleapfroggrouporgnewsleapfrog_news4773661

6 Osborne NH Ghaferi AA Nicholas LH Dimick JB ldquoEvaluating popular media and internet-based hospital quality ratings for cancer surgeryrdquo Archives of Surgery 2011146(5)600-604 Available at httparchsurgjamanetworkcomIssueaspxjournalid=76ampissueID=5406ampdirection=P

7 Cutler D Dafney L ldquoDesigning transparency systems for medical care pricesrdquo New England Journal of Medicine 2011(10)364894-895 Available at httpwwwnejmorgdoipdf101056NEJMp1100540

8 Hibbard JH Greene J Shoshanna S Firminger K Hirsh J ldquoAn experiment shows that a well-designed report on costs and quality can help consumers choose high-value health carerdquo Health Affairs 201231(3)560-568 Available at httpcontenthealthaffairsorgcontent313560fullpdf+html

9 Sinaiko AD Eastman D Rosenthal MB ldquoHow report cards on physicians physician groups and hospitals can have greater impact on consumer choicesrdquo Health Affairs 201231(3)602-611 Available at httpcontenthealthaffairsorgcontent313602fullpdf+html

10 Friedberg MW Damberg CL ldquoA five-point checklist to help performance reports incentivize improvement and effectively guide patientsrdquo Health Affairs 201231(3)612-618 Available at httpcontenthealthaffairsorgcontent313612fullpdf+html

11 Minnesota HealthScores ldquoUnderstanding the cost of your carerdquo Available at httpwwwmnhealthscoresorgp=cost_landingampcategory=allampsf=group Field of Practice

1) Kaiser Health News ldquoRating your doctorrdquo August 3 2010 Available at httpwwwkaiserhealthnewsorgFeaturesInsuring-Your-Healthandrews-column-on-physician-ratingsaspx

2) redOrbit Blue Cross and Blue Shield of Georgia Launches ldquoZagat health survey toolrdquo September 23 2009 Available at httpwwwredorbitcomnewshealth1758420blue_cross_and_blue_shield_of_georgia_launches_zagat_healthindexhtml

3) McCann E ldquoThe price transparency argumentrdquo Healthcare Finance News May 23 2013 Available at httpwwwhealthcarepayernewscomcontentprice-transparency-argument

4) Soltas E ldquoHow to make the health-care market work betterrdquo Bloomberg March 28 2013 Available at httpwwwbloombergcomnews2013-03-28how-to-make-the-health-care-market-work-betterhtml

5) Mitchell R Employers unions jointly demand health care price transparency KHN Blog November 1 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201211employers-unions-jointly-demand-health-care-price-transparency

6) Commins J ldquoConsumer reports expands hospital ratings listrdquo HealthLeaders Media April 19 2013 Available at httpwwwhealthleadersmediacompage-1QUA-291310Consumer-Reports-Expands-Hospital-Ratings-List

7) Betbeze P ldquoManaging physicians may be impossiblerdquo HealthLeaders Media April 19 2013 Available at httpwwwhealthleadersmediacompage-1LED-291313Managing-Physicians-May-Be-Impossible

8) MN Community Measurement The Measurement Minute February 2013 Available at httpmncmorgwp-contentuploads201305February-2013-MNCM-Measurement-Minutepdf

9) Rau J ldquoHospital ratings are in the eye of the beholderrdquo Kaiser Health News March 18 2013 Available at httpwwwkaiserhealthnewsorgstories2013march18expanding-number-of-groups-offer-hospital-ratingsaspx

23


10) Bebinger M ldquoHow much for an MRI $500 $5000 A reporter struggles to find outrdquo Kaiser Health News December 9 2012 Available at httpwwwkaiserhealthnewsorgstories2012december09mri-cost-price-comparison-health-insuranceaspx

11) Betbeze P ldquoGet ready for price transparencyrdquo HealthLeaders Media November 30 2012 Available at httpwwwhealthleadersmediacompage-1LED-287017Get-Ready-for-Price-Transparency

Concerns about Public Reports 1 Williams D ldquoThe state of online doctor ratings Itrsquos still earlyrdquo KevinMDcom April 24 2013 Available at

httpwwwkevinmdcomblog201304state-online-doctor-ratings-earlyhtml 2 Ubel P ldquoHow price transparency could end up increasing health-care costsrdquo The Atlantic April 9 2013 Available at

httpwwwtheatlanticcomhealtharchive201304how-price-transparency-could-end-up-increasing-health-care-costs274534 3 Ginsburg P ldquoMost health costs data of little use Opposing viewrdquo USA Today March 5 2013 Available at

httpwwwusatodaycomstoryopinion20130305health-care-price-transparency-center-for-studying-health-system-change1966039

4 Werner R Asch D ldquoThe unintended consequences of publicly reporting quality informationrdquo Journal of the American Medical Association 2005293(10)1239-1244 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=4967ampdirection=P

5 Sinaiko AD Rosenthan MB ldquoIncreased price transparency in health care ndash challenges and potential effectsrdquo New England Journal of Medicine 2011364(10)891-894 Available at httpwwwnejmorgdoipdf101056NEJMp1100041

6 Reuters ldquoHospital ratings miss many high performers studyrdquo May 18 2011 Available at httpwwwreuterscomarticle20110518us-hospital-ratings-idUSTRE74H73F20110518

7 Mehrotra A Hussey PS Milstein A Hibbard JH ldquoConsumersrsquo and providersrsquo responses to public cost reports and how to raise the likelihood of achieving desired resultsrdquo Health Affairs 201231(4)843-851 Available at httpcontenthealthaffairsorgcontent314843fullpdf+htmlsid=90f9112a-49f3-4748-ba50-8d6ce5cf3343

Field of Practice 1) Associated Press ldquoACPE survey finds most physician leaders skeptical of online ratingsrdquo January 16 2013 Available

at httpwwwereleasescompracpe-survey-finds-physician-leaders-skeptical-online-ratings-97316 2) BusinessWire ldquoUS news best hospitals rankings may be misleading according to Comparionrdquo May 7 2013

Available at httpwwwbusinesswirecomnewshome20130507005013enUS-News-Hospitals-Rankings-Misleading-Comparion

3) Minnesota Medicine ldquoMMA finds significant errors in Medicarsquos physician ratingsrdquo February 2011 Available at httpwwwminnesotamedicinecomPastIssuesPastIssues2011February2011MMANewsFeb2011aspx

4) Mitchell R ldquo29 states get lsquoFrsquo for price transparency lawsrdquo Kaiser Health News Blog March 18 2013 Available at httpcapsuleskaiserhealthnewsorgp=17815

5) Ostrow N ldquoHospitals ranked top based on reputation more than quality study saysrdquo Bloomberg Businessweek April 19 2010 Available at httpwwwbloombergcomnews2010-04-19hospitals-ranked-top-based-on-reputation-more-than-quality-study-sayshtml

6) Lieber R ldquoThe web is awash in reviews but not for doctors Herersquos whyrdquo New York Times online March 9 2012 Available at httpwwwnytimescom20120310your-moneywhy-the-web-lacks-authoritative-reviews-of-doctorshtmlpagewanted=all

Provider Responses to Public Reporting 1 Frisch S ldquoPricing problem Hospitals and clinics struggle to tell patients what things costrdquo Minnesota Medicine April 2013

Available at httpwwwminnesotamedicinecomPortalsmnmedApril202013Pricingproblem1304pdf 2 Woo HE ldquoThe crucible of physician performance reportsrdquo Journal of General Internal Medicine 201026(2)226-227 Available

at httplinkspringercomcontentpdf1010072Fs11606-010-1498-3pdf 3 Watts LA de Bocanegra HT Darney PD Hulett D Howell M Mikanda J Zerne R Policar MS ldquoIn a California

program quality and utilization reports on reproductive health services spurred providers to changerdquo Health Affairs 201231(4)852-862 Available at httplinkspringercomcontentpdf1010072Fs11606-010-1498-3pdf

4 Smith MA Wright A Queram C Lamb GC ldquoPublic reporting helped drive quality improvement in outpatient diabetes care among Wisconsin physician groupsrdquo Health Affairs 201231(3)570-577 Available at httpcontenthealthaffairsorgcontent314843fullpdf+html

5 Teleki S Shannon M ldquoIn California quality reporting at the state level is at a crossroads after hospital group pulls outrdquo Health Affairs 201231(3)642-646 Available at httpcontenthealthaffairsorgcontent313642fullpdf+html

6 Mehrotra A Hussey PS Milstein A Hibbard JH ldquoConsumersrsquo and providersrsquo responses to public cost reports and how to raise the likelihood of achieving desired resultsrdquo Health Affairs 201231(4)843-851 Available at httpcontenthealthaffairsorgcontent314843fullpdf+html

7 Seabrook GR ldquoDoes rigorous quality process reporting guarantee superior-quality health carerdquo Journal of the American Medical Association 2013310(3)316-317 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927287ampdirection=P

24


Field of Practice 1) Associated Press ldquoDoctors dispute quality rankingsrdquo February 8 2007 Available at

httpwwwpittsburghlivecomxpittsburghtribbusinesss_492216html 2) Mathews AW ldquoCompare and contrast when doctors are given a public report card the resulting competition can

serve patients wellrdquo Wall Street Journal October 27 2009 p R4 Available at httponlinewsjcomarticleSB10001424052970204488304574431741881361528html

3) CBS News ldquoDoctors can guard reputation on rating siterdquo March 3 2011 Available at httpwwwcbccanewshealthstory20110503doctor-rating-websites-reputationhtml

4) Chen PW ldquoA report card for doctorsrdquo New York Times June 16 2011 Available at httpwellblogsnytimescom20110616a-report-card-for-doctors

Medicare Reporting 1 Hostetter M Klein S ldquoQuality matters In focus Medicare data helps fill in picture of health care performancerdquo The

Commonwealth Fund AprilMay 2013 Available at httpwwwcommonwealthfundorgNewslettersQuality-Matters2013April-MayIn-Focusaspx

2 Klein S ldquoQuality matters QampA Building an all-payer claims databasemdashThe Wisconsin modelrdquo The Commonwealth Fund AprilMay 2013 Available at httpwwwcommonwealthfundorgNewslettersQuality-Matters2013April-MayQAaspx

Further Readings

1 Andrews C ldquoEmpire BlueCross Blue Shield and Zagat to survey New Yorkers about doctor accessibility offices and communication skillsrdquo Empire BlueCross BlueShield November 18 2009 Available at httpwwwempirebluecomwpsportalehpfootercontent_path=sharednoapplicationf1s0t0pw_b139674htmamplabel=Empire20BlueCross20BlueShield20and20Zagat20To20Survey20New20Yorkers20About20Doctor20Accessibility20Offices20and20Communication20Skills

2 Auerbach AD Hilton JF Maselli J Pekow PS Rothberg MB Lindenauer PK ldquoShop for quality or volume Volume quality and outcomes of coronary artery bypass surgeryrdquo Annals of Internal Medicine 2009150(10)696-704 Available at httpannalsorgissueaspxjournalid=90ampissueID=20182ampdirection=P

3 Barr S ldquoDream of a medical lsquoprice listrsquo dies in Florida legislaturerdquo KHN Blog January 30 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201201dream-of-a-medical-price-list-dies-in-florida-legislature

4 Boulton G ldquoBill would require listing of medical procedure costsrdquo JSOnline March 4 2010 Available at httpwwwjsonlinecombusiness86466282html

5 Clark C ldquoConsumer reports rates hospital safetyrdquo HealthLeaders Media July 5 2012 Available at httpwwwhealthleadersmediacompage-1LED-281969Consumer-Reports-Rates-Hospital-Safety

6 Ferraro M ldquoMedicinersquos big mystery what does treatment costrdquo Bloomberg July 12 2011 Available at httpwwwbloombergcomnews2011-07-12medicine-s-big-mystery-what-does-treatment-cost-mimi-ferrarohtml

7 Fox M ldquoPeople like expensive health care study findsrdquo NationalJournal March 5 2012 Available at httpwwwnationaljournalcomhealthcarepeople-like-expensive-health-care-study-finds-20120305

8 Hibbard J Stockard Tusler M ldquoDoes publicizing hospital performance stimulate quality improvement effortsrdquo Health Affairs 200322(2)84-94 Available at httpcontenthealthaffairsorgcontent22284fullpdf+html

9 Hibbard JH Stockard J Tusler M ldquoHospital performance reports impact on quality market share and reputationrdquo Health Affairs 200524(4)1150-1160 Available at httpcontenthealthaffairsorgcontent2441150fullpdf+html

10 Intuit ldquoUnitedHealthcare expands availability of quicken health expense tracker to nearly 700000 consumersrdquo August 3 2009 Available at httpaboutintuitcomabout_intuitpress_roompress_releasearticles2009UNITEDHEALTHCAREEXPANDShtml

11 Kaiser Health News NY AG ldquoCigna reach agreement on physician ranking systemrdquo October 30 2007 Available at httpwwwkaiserhealthnewsorgdaily-reports2007october30dr00048525aspxreferrer=search

12 King J Henry E ldquoBill Clinton awaits heart surgery next weekrdquo CNNcom September 4 2004 Available at httpwwwcnncom2004ALLPOLITICS0903clintontestsindexhtml

13 Lansky D Findlay S ldquoPhysician compare site could be lsquogame changerrsquo but challenges remainrdquo iHealthBeat January 12 2011 Available at httpwwwihealthbeatorgperspectives2011physician-compare-site-could-be-game-changer-but-challenges-remainaspx

14 Lazar K ldquoFederal websites updated with data on hospital imaging use of antipsychotics in nursing homesrdquo Boston Globe online July 19 2012 Available at httpwwwbostoncomdailydose20120719federal-websites-updated-with-data-hospital-imaging-use-antipsychotics-nursing-homesTtjhhiM8tt0HdP16Q0XQ1Mstoryhtml

15 Levey N ldquoNew website to help patients compare doctors hospitalsrdquo Los Angeles Times June 27 2011 Available at httparticleslatimescom2011jun27newsla-heb-health-quality-20110628

16 Monegain B ldquoStudy names 100 top-performing hospitalsrdquo Healthcare IT News March 29 2010 Available at httpwwwhealthcareitnewscomnewsstudy-names-100-top-performing-hospitals

17 Norton A ldquoHospital report cards get mixed marksrdquo Reuters November 18 2009 Available at httpwwwreuterscomarticleidUSTRE5AH49920091118

25


18 Rau J ldquoLots of lsquoCrsquos as hospitals get graded for patient safetyrdquo KHN Blog June 6 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201206lots-of-cs-as-hospitals-get-graded-for-patient-safety

19 Robert Wood Johnson Foundation ldquoNavigating health care why itrsquos so hard and what can be done to make it easier for the average consumerrdquo Issue Brief 3 of 6 October 2007 Available at httpwwwrwjforgprproductjspid=23073

20 Ryan AM Nallamothu BK Dimick JB ldquoMedicarersquos public reporting initiative on hospital quality had modest or no impact on mortality from three key conditionsrdquo Health Affairs 201231(3)585-592 Available at httpcontenthealthaffairsorgcontent313585fullpdf+html

21 Sullivan K ldquoHealth care report card was flawedrdquo November 28 2010 Available at httpwwwhowtoquitsmokingfreecomquit-smokingkip-sullivan-health-care-report-card-was-flawed

22 Sun LH Johns Hopkins other major area hospitals left off top-performer list The Washington Post September 20 2012 Available at httparticleswashingtonpostcom2012-09-20national35497303_1_stroke-patients-hospitals-joint-commission

23 Weaver C ldquoWant to know what a hospital charges Good luckrdquo Kaiser Health News June 29 2010 Available at httpwwwkaiserhealthnewsorgstories2010june29hospital-pricesaspxreferrer=search

24 Whitney E ldquoAttention health care shoppers Coloradorsquos new price list for proceduresrdquo Kaiser Health News May 16 2012 Available at httpwwwkaiserhealthnewsorgStories2012May16colorado-health-care-price-list-databaseaspx


November 18 2013 Supporting EmployeesEnrollees in Choosing Treatment Options There is growing support for the need to provide consumers with information necessary to evaluate treatment options and select the option that is the best fit for their individual circumstances and preferences Consumer decision aids have been developed with this objective in mind We will discuss these decision aids evidence of their effectiveness and the roles of employers and health plans in encouraging their use We also will discuss the challenges that low health literacy can pose to informed consumer choice of providers and the use of ldquoshared decision making more generally and specifically relating to treatment options and how payers and health plans are attempting to address this issue Learning Objectives Students should be able to

1 Describe different approaches being used to support consumers in their choice of treatments 2 Discuss the problems faced by employers and health plans in implementing decision aids 3 Evaluate the evidence regarding the effectiveness of these decision aids 4 Assess the challenges that low health literacy poses for informed consumer decision making

Suggested Readings Shared Decision Making in Concept

1 RWJF Aligning Forces for Quality ldquoShared decision-making and benefit design Engaging employees and reducing costs for preference-sensitive conditionsrdquo April 2013 Available at httpwwwrwjforgenresearch-publicationsfind-rwjf-research201304shared-decision-making-and-benefit-designhtml

2 Robert Wood Johnson Foundation ldquoThe current and future role of consumers in making treatment decisionsrdquo Issue Brief 4 of 6 October 2007 Available at httpwwwrwjforgprproductjspid=23074

3 Frosch DL May SG Rendle KAS Tietbohl C Elwyn G ldquoAuthoritarian physicians and patientsrsquo fear of being labeled lsquodifficultrsquo among key obstacles to shared decision makingrdquo Health Affairs 201231(5)1030-1038 Available at httpcontenthealthaffairsorgcontent3151030fullpdf+html

4 Weinstein JN Clay K Morgan TS ldquoInformed patient choice patient-centered valuing of surgical risks and benefitsrdquo Health Affairs 200726(3)726-730 Available at httpcontenthealthaffairsorgcontent263726fullpdf+html

5 Seaman AM ldquoPatient communication has room to grow Studiesrdquo Reuters May 27 2013 Available at httpwwwreuterscomarticle20130527us-patient-communication-idUSBRE94Q0KN20130527

6 Brown E ldquoPatients who helped with medical choices had higher bills Studyrdquo Los Angeles times May 27 2013 Available at httparticleslatimescom2013may27sciencela-sci-sn-patient-decisions-higher-bills-20130528

7 Tanner L ldquoHospitals try high-tech to better inform patientsrdquo Daily Herald November 10 2010 Available at httpwwwdailyheraldcomarticle20101110entlife101119961

8 Healthwisereg ldquoPatient response Giving voice to the patientsrdquo February 21 2012 Available at httpwwwhealthwiseorgInsightsdocsPressReleasesPatient-Response--Giving-Voice-to-the-Patientsaspx

9 WiserTogether ldquoGroup Health Cooperative of Eau Claire implements WiserTogetherrsquos shared decision support platformrdquo July 20 2012 Available at httpwwwwisertogethercomnews20120720group-health-cooperative-of-eau-claire

10 Brownlee S Colucci J The cost of assuming doctors know best The Atlantic September 28 2012 Available at httpwwwtheatlanticcomhealtharchive201209the-cost-of-assuming-doctors-know-best262993

26


11 Health Dialog Health dialog makes decision aid available for national hospice and palliative care month November 15 2012 Available at httpwwwhealthdialogcomUtilityNewsPressRelease12-11-16Health_Dialog_Makes_Decision_Aid_Available_for_National_Hospice_and_Palliative_Care_Month Field of Practice

1) Landro L ldquoWeighty choices in patients handsrdquo The Wall Street Journal August 4 2009 p D2 Available at httponlinewsjcomarticleSB10001424052970203674704574328570637446770html

2) Lewis D ldquoSurvey Patient engagement important but loosely definedrdquo FierceHealthcare March 20 2012 Available at httpwwwfiercehealthcarecomstorysurvey-patient-engagement-important-loosely-defined2012-03-20

3) Kenen J ACA boosts lsquoshared decision-makingrsquo Politico November 29 2012 Available at httpwwwpoliticocomstory20121184356html

4) Weiner SJ Schwartz A Sharma G et al ldquoPatient-centered decision making and health care outcomes An observational studyrdquo Annals of Internal Medicine 2013158(8)573-579 Available at httpannalsorgissueaspxjournalid=90ampissueID=926759ampdirection=P

5) Rao A Study Decision aids show promise in reducing medical procedures KHN Blog September 5 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201209study-decision-aids-show-promise-in-reducing-medical-procedures

Issues in Shared Decision Making and the Use of Decision Aids 1 Frosch DL May SG Rendle KAS Tietbohl C Elwyn G ldquoAuthoritarian physicians and patientsrsquo fear of being labeled

lsquodifficultrsquo among key obstacles to shared decision makingrdquo Health Affairs 201231(5)1030-1038 Available at httpcontenthealthaffairsorgcontent3151030fullpdf+html

2 Mullan RJ Montori VM Shah ND Christianson TJH Bryant SC Guyatt GH LPerestelo-Perez LI Stroebel RJ Yawn BP Yapuncich V Breslin MA Pencille L Smith SA ldquoThe diabetes mellitus medication choice decision aidrdquo Archives of Internal Medicine 2009169(17)1560-1568 Available at httparchintejamanetworkcomIssueaspxjournalid=71ampissueID=5741ampdirection=P

3 Carman KL Maurer M Yegian JM Dardess P McGee J Evers M Mario KO ldquoEvidence that consumers are skeptical about evidence-based health carerdquo Health Affairs 201029(7)1400-1406 Available at httpcontenthealthaffairsorgcontent2971400fullpdf+html

4 Krumholz HM ldquoVariations in health care patient preferences and high-quality decision makingrdquo Journal of the American Medical Association 2013310(2)151-152 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927264ampdirection=P Field of Practice

1) Shaw G ldquoDoes decision support make docs look dumbrdquo Health Leader Media April 14 2011 Available at httpwwwhealthleadersmediacompage-1MAG-264919Does-Decision-Support-Make-Docs-Look-Dumb

The Importance of Health Literacy and Language Issues to Informed Choice 1 Peters E Hibbard J Slovic P Dieckmann N ldquoNumeracy skill and the communication comprehension and use of risk-

benefit informationrdquo Health Affairs 200726(3)741-748 Available at httpcontenthealthaffairsorgcontent263741fullpdf+html

3 Americarsquos Health Insurance Plans ldquoAHIP statement on HHSrsquos national action plan to improve health literacyrdquo Press Release May 27 2010 Available at httpwwwahiporgcontentpressreleaseaspxdocid=30599

Field of Practice 1) Americarsquos Health Insurance Plans ldquoNew tool available for health care companies to assess their organizationsrsquo health

literacy programsrdquo Press Release March 15 2010 Available at httpwwwahiporgcontentpressreleaseaspxbc=174|29744

2) Boodman SG ldquoHelping patients understand their medical treatmentrdquo Kaiser Health News March 1 2011 Available at httpwwwkaiserhealthnewsorgStories2011March01Health-Literacy-Understanding-Medical-Treatmentaspx

Further Readings

1 Barclay E ldquoSpeaking the same language Medical providers struggle to communicate with immigrant patientsrdquo The Washington Post April 21 2009 p F1 Available at httpwwwwashingtonpostcomwp-dyncontentarticle20090420AR2009042002466html

2 Bavley A ldquoHealth literacy is touted to improve patient rolesrdquo June 3 2010 Available at httpwwwcomputerizedscreeningcomaboutnews06-07-2010health-literacy-is-touted-to-improve-patient-roles

3 Brownlee S ldquoGiving patients a larger voice more doctors welcome dialogue about tests and proceduresrdquo The Washington Post October 23 2007 Available at httpwwwwashingtonpostcomwp-dyncontentarticle20071019AR2007101902620html

4 Brownlee S Collins ED ldquoLet women decide on medical testsrdquo Kaiser Health News December 15 2009 Available at httpwwwkaiserhealthnewsorgColumns2009December121509BrownleeandCollinsaspx

5 Foubister V ldquoIssue of the month health literacy ndash a quality and patient safety imperativerdquo The Commonwealth Fund Newsletter November 16 2006 Volume 21 Available at httpwwwcommonwealthfundorgContentNewslettersQuality-Matters2006November-DecemberIssue-of-the-Month-Health-Literacy-A-Quality-and-Patient-Safety-Imperativeaspx

27


6 Health Dialog ldquoHealth Dialog releases testimony on health literacyrdquo Press Release July 7 2010 Available at httpwwwhealthdialogcomUtilityNewsPressRelease10-07-07Health_Dialog_Releases_Testimony_on_Health_Literacy

7 Katz SJ Howley ST ldquoFrom policy to patients and back surgical treatment decision making for patients with breast cancerrdquo Health Affairs 200726(3)761-769 Available at httpcontenthealthaffairsorgcontent263761fullpdf+html

8 Landro L ldquoThe informed patient the importance of trying to be a good patientrdquo Wall Street Journal April 29 2009 9 Ling BS Trauth JM Fine MJ Mor MK Resnick A Braddock CH Bereknyei S Weissfeld JL Schoen RE Ricci

EM Whittle J ldquoInformed decision-making and colorectal cancer screening Is it occurring in primary carerdquo Medical Care 200846(9 Suppl 1)S23-S29 Available at httpovidsptxovidcomsp-381aovidwebcgiWebLinkFrameset=1ampS=MEIDFPGIPFDDEEFINCOKEGMCIOAEAA00ampreturnUrl=ovidwebcgi3f26TOC3dSsh18192327257c5257c5026FORMAT3dtoc26FIELDS3dTOC26S3dMEIDFPGIPFDDEEFINCOKEGMCIOAEAA00ampdirectlink=http3a2f2fgraphicstxovidcom2fovftpdfs2fFPDDNCMCEGFIPF002ffs0472fovft2flive2fgv0242f000056502f00005650-200809001-00005pdfampfilename=Informed+Decision-Making+and+Colorectal+Cancer+Screening3a+Is+it+Occurring+in+Primary+Care3famplink_from=Ssh181923277c5amppdf_key=Bamppdf_index=Ssh18192327

10 OrsquoConnor AM Wennberg JE Legare F Liewellyn-Thomas HA Moulton BW Sepucha KR Sodano AG King JS ldquoToward the lsquotipping pointrsquo decision aids and informed patient choicerdquo Health Affairs 200726(3)716-725 Available at httpcontenthealthaffairsorgcontent263716fullpdf+html

11 Olson J ldquoElective surgery rates all over maprdquo Star Tribune February 25 2011 p B3 Available at httpwwwstartribunecomlifestylehealth116782593html

12 PR Newswire ldquoLimited health literacy increased safety risk for patients with diabetesrdquo May 19 2012 Available at httpwwwprnewswirecomnews-releaseslimited-health-literacy-increases-safety-risks-for-patients-with-diabetes-94230884html

13 Robert Wood Johnson Foundation ldquoChoice in medical care when should the consumer deciderdquo Issue Brief 5 of 6 October 2007 Available at httpwwwrwjforgprproductjspid=23075

November 25 2013 Supporting EmployeesEnrollees in Maintaining and Improving Their Health Increasingly employers are instituting programs and financial incentives that support employees in maintaining and improving their health The expectation is that these efforts will reduce the rate of increase in health care costs overtime by reducing or delaying the onset of chronic illnesses Employers also hope that they will reduce absenteeism and increase worker productivity Payersrsquo efforts rely both on rewards and negative incentives to encourage healthy behaviors Employers depend on both health plans and independent vendors for delivering program content Learning Objectives Students should be able to

1 Describe the rationale for employerhealth plan support for healthy lifestyle programs 2 Assess the strengths and weaknesses of different program designs 3 Evaluate the evidence that these programs have been successful in achieving their goals 4 Discuss the impediments to the successful implementation of these programs

Suggested Readings Design of Healthy Lifestyle Programs

1 Volpp KG Asch DA Galvin R Loewenstein G ldquoRedesigning employee health incentives mdash Lessons from behavioral economicsrdquo New England Journal of Medicine 2011365(5)388-390 Available at httpwwwnejmorgdoipdf101056NEJMp1107285

2 Draper DA Tynan A Christianson JB ldquoHealth and wellness the shift from managing illness to promoting healthrdquo Center for Studying Health System Change Issue Brief No 121 June 2008 Available at httpwwwhschangecomCONTENT989

3 Jauhar S ldquoNo matter what we pay for others bad habitsrdquo New York Times March 30 2010 Available at httpwwwnytimescom20100330health30riskhtml_r=0

4 Wall Street Journal ldquoSurvey employers fret over workersrsquo poor health habitsrdquo February 22 2010 Available at httpblogswsjcomhealth20100222survey-employers-fret-over-with-workers-poor-health-habits

5 Appleby J Workersrsquo poor health costs employers $344 billion study finds KHN Blog September 14 2012 Available at httpcapsuleskaiserhealthnewsorgindexphp201209workers-poor-health-costs-employers-344-billion-study-finds

6 National Business Group on Health ldquoAnnual wellness study finds significant jump in incentive dollars as employers report improved employee participationrdquo February 8 2011 Available at httpwwwbusinessgrouphealthorgpressreleasecfmprintPage=1ampID=170

7 Bernstein L ldquoKeeping employees bottom lines in shaperdquo The Washington Post July 5 2011 p A1 (posted on Moodle) 28


Field of Practice 1) Health Net ldquoHealth Net urges men to be proactive when it comes to their healthrdquo News Release June 4 2013

Available at httpnewsroomhealthnetcompress-releasehealth-net-urges-men-be-proactive-when-it-comes-their-health

2) Midwest Business Group on Health ldquoNew employer survey finds growing use of outcomes-based incentives majority using either carrot or stick to motivate healthy employee behaviorsrdquo PRNewswire May 7 2013 Available at httpwwwprnewswirecomnews-releasesnew-employer-survey-finds-growing-use-of-outcomes-based-incentives-majority-using-either-carrot-or-stick-to-motivate-healthy-employee-behaviors-206394381html

3) Cigna ldquoCigna says health assessment and coaching are key to reducing health risks extends exclusive license with University of Michiganrdquo August 16 2011 Available at httpnewsroomcignacomNewsReleasescigna-says-health-assessment-and-coaching-are-key-to-reducing-health-risks--extends-exclusive-license-with-university-of-michiganhtm

4) Press Release ldquoDean Health Plan Healthways partner to introduce comprehensive integrated total population health programsrdquo Reuters February 21 2012 Available at httpwwwreuterscomarticle20120221idUS203818+21-Feb-2012+BW20120221

5) HealthPartners ldquoHealthPartners first in regional market to introduce health and well-being web portal customized to employersrdquo Press Release March 19 2012 Available at httpwwwhealthpartnerscompublicnewsroomnewsroom-article-list03-19-12html

6) Medica ldquoMedica introduces group health and wellness coaching programrdquo Corporate Announcement April 19 2012 Available at httpnewscentermedicacompress-releaseproducts-servicesmedica-introduces-group-health-and-wellness-coaching-program

Evidence of Program Effectiveness 1 Minnesota Medicine ldquoThe healthy workplacerdquo September 2007 Available at

httpwwwminnesotamedicinecomPastIssuesPastIssues2007September2007PulseYogaSeptember2007aspx 2 Horwitz JR Kelly BD DiNardo JE ldquoWellness incentives in the workplace Cost savings through cost shifting to unhealthy

workersrdquo Health Affairs 201332(3)468-476 Available at httpcontenthealthaffairsorgcontent323468fullpdf+html 3 Mattke S Serxner SA Zakowski SL Jain AK Gold DB ldquoImpact of 2 employer-sponsored population health management

programs on medical care cost and utilizationrdquo American Journal of Managed Care 200915(2)113-120 Available at httpwwwajmccompublicationsissue20092009-02-vol15-n2Feb09-3916p113-120

4 Russell LB ldquoPreventing chronic disease an important investment but donrsquot count on cost savingsrdquo Health Affairs 200928(1)42-45 Available at httpcontenthealthaffairsorgcontent28142fullpdf+html

5 Huskamp HA Rosenthal MB ldquoHealth risk appraisals how much do they influence employeesrsquo health behaviorrdquo Health Affairs 200928(5)1532-1540 Available at httpcontenthealthaffairsorgcontent2851532fullpdf+html

6 Goetzel RZ ldquoDo prevention or treatment services save money The wrong debaterdquo Health Affairs 200928(1)37-41 Available at httpcontenthealthaffairsorgcontent2851532fullpdf+html

7) Goodell S Cohen J Neumann P ldquoCost savings and cost-effectiveness of clinical preventive carerdquo Policy Brief No 18 Robert Wood Johnson Foundation Synthesis Project September 2009 Available at httpwwwrwjforgcontentdamfarmreportsissue_briefs2009rwjf46045 Field of Practice

1) Thomas K ldquoCompanies get strict on health of workersrdquo The New York Times March 25 2013 Available at httpwwwnytimescom20130326businesscompanies-offer-workers-more-incentives-for-health-changeshtml_r=0

2) PR Newswire ldquoStudy Preventive services can save lives billions of dollars at little or no costrdquo September 7 2011 Available at httpwwwprnewswirecomnews-releasesstudy-preventive-services-can-saves-lives-billions-of-dollars-at-little-or-no-cost-102351314html

3) Henke RM Goetzel RZ McHugh J Isaac F ldquoRecent experience in health promotion at Johnson amp Johnson Lower health spending strong return on investmentrdquo Health Affairs 201130(3)490-499 Available at httpcontenthealthaffairsorgcontent303490fullpdf+html

4) Medica ldquoMedica health and wellness coaching program improves health reduces costrdquo January 3 2012 Available at httpnewscentermedicacompress-releaseproducts-servicesmedica-health-and-wellness-coaching-program-improves-health-reduces-

Concerns about Program Incentives 1 Pearson SD Lieber SR ldquoFinancial penalties for the unhealthy Ethical guidelines for holding employees responsible for their

healthrdquo Health Affairs 200928(3)845-852 Available at httpcontenthealthaffairsorgcontent283845fullpdf+html Field of Practice

1) Kwoh L ldquoWhen your boss makes you pay for being fatrdquo The Wall Street Journal April 5 2013 Available at httponlinewsjcomarticleSB10001424127887324600704578402784123334550html

2) Lerner M ldquoMedica wants to put health coach between you and your bad habits but critics say the voluntary no-cost program is like health care big brotherrdquo Star Tribune October 1 2008 Available at httpwwwstartribunecomlifestyle29981699html

3) Knight VE ldquoTreading carefully with wellness programsrdquo The Wall Street Journal July 28 2009 Available at

29


httponlinewsjcomarticleSB124880470938287485html 4) Tuna C ldquoTheory and practice wellness efforts face hurdle --- asking workers about family health history can clash with

US genetics lawrdquo Wall Street Journal February 1 2010 p B2 Available at httponlinewsjcomarticleSB10001424052748703822404575019790731232312html

5) Mincer J ldquoInsight Firms to charge smokers obese more for healthcarerdquo Reuters October 30 2011 Available at httpwwwreuterscomarticle20111030us-penalties-idUSTRE79T2S220111030

6) USA Today ldquoNot hiring smokers crosses privacy linerdquo Editorial January 29 2012 Available at httpwwwusatodaycomnewsopinioneditorialsstory2012-01-29not-hiring-smokers-privacy528743481

7) Koch W ldquoWorkplaces ban not only smoking but smokersrdquo USA Today January 6 2012 Available at httpwwwusatodaycommoneyindustrieshealthstory2012-01-03health-care-jobs-no-smoking523947821

Health Reform and Wellness 1 Lewis A Khanna V ldquoHere comes ObamaCarersquos lsquoworkplace wellnessrsquordquo The Wall Street Journal June 20 2013 Available at

httponlinewsjcomarticleSB10001424127887323501004578389673547444046html 2 Jost T ldquoImplementing health reform Workplace wellness programsrdquo Health Affairs Blog May 29 2013 Available at

httphealthaffairsorgblog20130529implementing-health-reform-workplace-wellness-programs 3 Madison K Schmidt H Volpp KG ldquoSmoking obesity health insurance and health incentives in the Affordable Care Actrdquo

Journal of the American Medical Association 2013310(2)143-144 Available at httpjamajamanetworkcomissueaspxjournalid=67ampissueid=927264ampdirection=P

4 Lewis A Khanna V ldquoThe million-dollar workplace wellness heart attack screenrdquo Health Affairs Blog April 29 2013 Available at httphealthaffairsorgblog20130429the-million-dollar-workplace-wellness-heart-attack-screen

Further Readings 1 Appleby J ldquoFirms offer bigger incentives for healthy livingrdquo USA Today January 20 2009 Available at

httpwwwusatodaycomnewshealth2009-01-19-diabetes_Nhtm 2 Businesswire ldquoAetna introduces resources for living a new approach to engaging members in their emotional and physical

healthrdquo June 28 2011 Available at httpwwwbioportfoliocomnewsarticle726997Aetna-Introduces-Resources-For-Living-A-New-Approach-To-Engaging-Members-Inhtml

3 CIGNA Corporation ldquoCIGNA Launches Worksite Wellness Program to Help Combat Top Health Risks Facing Americansrdquo News Release February 22 2010 Available at httpnewsroomcignacomarticle_displaycfmarticle_id=1175

4 Cohen J Neuman P ldquoCost savings and cost-effectiveness of clinical preventive carerdquo Robert Wood Johnson Foundation The Synthesis Project Policy Brief No 18 September 2009 Available at httpwwwrwjforgprproductjspid=48508

5 Editors ldquoShould people be paid to stay healthyrdquo New York Times June 14 2010 Available at httproomfordebateblogsnytimescom20100614should-people-be-paid-to-stay-healthy

6 Gold J ldquoCorporate wellness programs healthier employees lower costsrdquo Kaiser Health News October 30 2009 Available at httpwwwkaiserhealthnewsorgChecking-In-Withfikry-wellness-q-and-aaspx

7 Johnson A ldquoCashing in on healthful lifestyles State paying its workers to take charge live wellrdquo Columbus Dispatch January 17 2008 Available at httpwwwdispatchcomcontentstorieslocal20080117PAID_TO_BE_HEALTHYART_ART_01-17-08_B1_EI9342Rhtml

8 National Institute for Health Care Management ldquoBuilding a stronger evidence base for employee wellness programsrdquo Meeting Brief May 2011 Available at httpnihcmorgimagesstoriesWellness_FINAL_electonic_versionpdf

9 PR Newswire ldquoKnow your numbers campaign a healthy successrdquo July 21 2011 Available at httpwwwprnewswirecomnews-releasesknow-your-numbers-campaign-a-healthy-success-125946673html

10 PR Newswire ldquoMedical Mutual of Ohio partners with Linkwell Health to bring can-do wellness program to its membersrdquo May 5 2011 Available at httpwwwprnewswirecomnews-releasesmedical-mutual-of-ohio-partners-with-linkwell-health-to-bring-can-do-wellness-program-to-its-members-121340073html

11 Slitt M ldquoCIGNA earns new accreditation for wellness and health promotion programs from the National Committee for Quality Assurance (NCQA)rdquo News Release November 9 2009 Available at httpnewsroomcignacomarticle_displaycfmarticle_id=1126

12 Stobbe M ldquoDieting for dollars More US employees trying itrdquo The Register Citizen May 28 2010 Available at httpwwwregistercitizencomarticles20100528businessdoc4bff41797e90c027843010txt

13 Sutherland K Christianson JB Leatherman S ldquoImpact of targeted financial incentives on personal health behavior A review of the literaturerdquo Medical Care Research and Review 200865(Suppl to 6)36S-78S Available at httpmcrsagepubcomcontent656_suppl36Sfullpdf+html

14 Cohen JT Neumann PJ ldquoThe cost savings and cost-effectiveness of clinical preventive carerdquo Research Synthesis Report No 18 Robert Wood Johnson Foundation September 2009 Available at httpwwwrwjforgcontentdamfarmreportsissue_briefs2009rwjf46045subassetsrwjf46045_1

30


December 2 2013 Supporting EmployeesEnrollees in Managing Chronic Illnesses Employers are strong supporters of programs that help employees ldquoself-managerdquo care for chronic illnesses The general idea is to place the consumer in a much more central role in medical care treatment By educating consumers in appropriate treatment methods for their illnesses and supporting their efforts to manage their illnesses payers and health plans hope that the progression of chronic illnesses can be delayed and the number of acute flare-ups of chronic illnesses can be minimized This in turn would improve the quality of life for employees reduce emergency room and hospital use and restrain growth in costs We will discuss efforts of payers and health plans to support consumers in chronic care management and the contexts in which they have been successful Learning Objectives Students should be able to

1 Explain the concepts of patient self-management and disease management in their different forms 2 Discuss the various ways in which employers and health plans are supporting employees and plan enrollees in chronic illness

management 3 Assess the evidence of their effectiveness in various settings 4 Describe the obstacles to the effective implementation by payers and health plans of programs to support chronic illness

management by consumers Suggested Readings Importance of Developing Effective Approaches to Chronic Illness Management

1 Steenhuysen J ldquoUS diabetes cases to double costs triple by 2034rdquo Reuters November 27 2009 Available at httpwwwreuterscomarticleidUSTRE5AQ0C220091127

2 Terhune C Weintraub A ldquoTake your meds exerciseand spend billionsrdquo BusinessWeek February 4 2010 Available at httpwwwbusinessweekcommagazinecontent10_07b4166046292556htm

3 Sklaroff S ldquoOn our own Why we who struggle to live with diabetes could use a helping handrdquo Health Affairs 31(1)236-239 2012 Available at httpcontenthealthaffairsorgcontent311236fullpdf+html

4 Grens K ldquoHalf of heart patients donrsquot stick to their medsrdquo Reuters July 25 2012 Available at httpwwwreuterscomarticle20120725us-heart-patients-meds-idUSBRE86O16M20120725

Self-Management of Illnesses 1 Health Affairs Patient engagement People actively involved in their health and health care tend to have better outcomesmdashand

some evidence suggests lower costs Health Policy Brief February 14 2013 Available at httphealthaffairsorghealthpolicybriefsbrief_pdfshealthpolicybrief_86pdf

2 Bodenheimer T Lorig K Holman H Grumbach K ldquoPatient self-management of chronic disease in primary carerdquoJAMA 2002288(19)2469-2475 Available at httpjamajamanetworkcomIssueaspxjournalid=67ampissueID=4856ampdirection=P

3 Jerant A Moore-Hill M Franks P ldquoHome-based peer-led chronic illness self-management training findings from a 1-year randomized controlled trialrdquo Annals of Family Medicine 20097(4)319-327 Available at httpswwwclinicalkeycomBrowserCtrldoBrowseTojournalIssuefacet[1-s20-S1544170909X6004X]issn15441709contentTypeJournals

Disease Management Programs ndash Structure and Effectiveness 1 PR Web ldquoNew study shows coaching to patient activation levels improves disease management outcomesrdquo June 10 2009

Available at httpwwwprwebcomreleasesInsignia_HealthLifeMastersprweb2510184htm 2 Lin WC Chien HL Willis G et al ldquoThe effect of a telephone-based health coaching disease management program on

Medicaid members with chronic conditionsrdquo Medical Care 201250(1)91-98 Available at httpovidsptxovidcomsp-381aovidwebcgiWebLinkFrameset=1ampS=KIAOFPEMJODDDCAANCOKIHJCIEPOAA00ampreturnUrl=ovidwebcgi3f26TOC3dSsh18192327257c12257c5026FORMAT3dtoc26FIELDS3dTOC26S3dKIAOFPEMJODDDCAANCOKIHJCIEPOAA00ampdirectlink=http3a2f2fgraphicstxovidcom2fovftpdfs2fFPDDNCJCIHAAJO002ffs0472fovft2flive2fgv0312f000056502f00005650-201201000-00012pdfampfilename=The+Effect+of+a+Telephone-based+Health+Coaching+Disease+Management+Program+on+Medicaid+Members+With+Chronic+Conditionsamplink_from=Ssh181923277c12amppdf_key=Bamppdf_index=Ssh18192327

3 Bernstein J Chollet D Peterson GG ldquoDisease management does it workrdquo Mathematica Policy Research Inc Issue Brief No 4 May 2010 httpwwwmathematica-mprcompublicationsPDFshealthreformhealthcare_IB4pdf

4 Vojta D De Sa J Prospect T Stevens S ldquoEffective interventions for stemming the growing crisis of diabetes and prediabetes A national payerrsquos perspective Health Affairs 31(1)20-26 2012 Available at httpcontenthealthaffairsorgcontent31120fullpdf+html

5 Joelving F Drop in hospital visits seen with lower drug copay Reuters October 3 2012 Available at httpwwwreuterscomarticle20121003us-drop-drug-idUSBRE8921AP20121003

6 Mullainathan S ldquoWhen a co-pay gets in the way of healthrdquo The New York Times August 10 2013 Available at httpwwwnytimescom20130811businesswhen-a-co-pay-gets-in-the-way-of-healthhtmlpagewanted=allamp_r=0

31


Field of Practice 1) Andrews M ldquoGroup appointments with doctors When three isnrsquot a crowdrdquo Kaiser Health News March 19 2013

Available at httpwwwkaiserhealthnewsorgfeaturesinsuring-your-health2013031913-michelle-andrews-on-group-patient-appointmentsaspx

2) Calandra R ldquoThe doctor will see you now ndash in a grouprdquo The Inquirer May 13 2013 Available at httparticlesphillycom2013-05-13news39231077_1_dietary-fiber-group-appointments-family-physicians

3) Independence Blue Cross ldquoIndependence Blue Crossrsquos nurse coaches are just a phone call awayrdquo Press Release May 16 2013 Available at httpwwwibxcomcompany_infonewspress_releases201305_16_IBCs_nurse_coaches_are_jhtml

4) Ramsey M ldquoFord adopts health management programrdquo The Wall Street Journal June 24 2013 Available at httponlinewsjcomarticleSB10001424127887324183204578565503660688878html

5) McQueen MP ldquoLook whos watching your health expenses employers increasingly turn to care managers to control medical costs but some wonder if patients always benefitrdquo Wall Street Journal September 25 2007 p D1 Available at httponlinewsjcomarticleSB119067896298438111html

6) Feder JL ldquoPredictive modeling and team care for high-need patients at HealthCare Partnersrdquo Health Affairs 201130(3)416-418 Available at httpcontenthealthaffairsorgcontent303416fullpdf+html

7) Draaghtel K Predicting participation and savings Using predictive modeling to identify patients for disease management Milliman White Paper Available at httppublicationsmillimancomperiodicalsrsapdfspredicting-participation-and-savingspdf

Further Readings

1 Agency for Healthcare Research and Quality USDHHS ldquoAsthma Return-on-Investment Calculator Userrsquos Guiderdquo Available at httpstatesnapshotsahrqgovasthmaUserGuidejsp

2 Conklin A Nolte E ldquoDisease management evaluation A comprehensive review of current state of the artrdquo RAND Technical Report December 2010 Available at httpwwwrandorgcontentdamrandpubstechnical_reports2011RAND_TR894pdf

3 Draaghtel K Hit or miss Using risk scores to decide Milliman March 7 2011 Available at httppublicationsmillimancomperiodicalsrsapdfshit-or-miss-using-riskpdf

4 Healthways well-being improvement solution Available at httpwwwhealthwayscomsolutiondefaultaspxid=91 5 Mattke S ldquoIs there a disease management backlashrdquo American Journal of Managed Care 200814(6)349-350 Available at

httpwwwajmccompublicationsissue20082008-06-vol14-n6Jun08-3297p349-350 6 Motheral BR ldquoTelephone-based disease management Why it does not save moneyrdquo American Journal of Managed Care

201117(1)e10-e16 Available at httpwwwajmccompublicationsissue20112011-1-vol17-n1AJMC_11jan_Motheral_WebX_e10

7 Nakashima E ldquoPrescription data used to assess consumersrdquo The Washington Post August 4 2008 p A1 Available at httparticleswashingtonpostcom2008-08-04business36810357_1_prescription-drug-federal-health-ingenix

8 Paez KA Zhao L Hwang W ldquoRising out-of-pocket spending for chronic conditions a ten-year trendrdquo Health Affairs 200928(1)15-25 Available at httpcontenthealthaffairsorgcontent28115fullpdf+html

9 PR Newswire ldquoCapital BlueCross receives inaugural national award for developing oncology case management programrdquo July 12 2011 Available at httpwwwprnewswirecomnews-releasescapital-bluecross-receives-inaugural-national-award-for-developing-oncology-case-management-program-125428503html

10 Preidt R ldquoSimple case management cuts pulmonary disease admissionsrdquo ABC News May 22 2008 Available at httpabcnewsgocomHealthHealthdaystoryid=4901415amppage=1

11 Reuters ldquoIncentives and pharmacist coaches lead to improved health and lower health care costs for diabetic patientsrdquo May 7 2009 Available at httpwwwreuterscomarticle20090507idUS158325+07-May-2009+PRN20090507

December 9 2013 Whatrsquos on the Horizon for Purchasers and Health Plans Employers and health plans are introducing comprehensive approaches including new benefit designs that they hope will encourage and reward consumers for healthy living effective self-management of their chronic illnesses and choice of cost effective treatments and providers Some of these strategies especially as they pertain to obesity reduction move employers and health plans into what has historically been the purview of ldquopublic healthrdquo while others appear to provide a basis for scaling down employer involvement in health care These strategies are in the early stages of implementation and evidence on their impact to date is limited Learning Objectives Students should be able to

1 Describe value-based benefit strategies and how they are being implemented 2 Assess the strengths and weaknesses of these strategies from the perspectives of employers and consumers 3 Describe recent collaborative approaches to control community health care costs and improve health

32


Suggested Readings Collaborative Initiatives

1 Blackmore CC Mecklenburg RS Kaplan GS ldquoAt Virginia Mason collaboration among providers employers and health plans to transform care cut costs and improved qualityrdquo Health Affairs 201130(9)1680-1687 Available at httpcontenthealthaffairsorgcontent3091680fullpdf+html 2 Tomek IM Sabel AL Froimson MI Muschler G Jevsevar DS Koenig KM Lewallen DG Naessens JM Savitz

LA Westrich JL Weeks WB Weinstein JN ldquoA collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value Health Affairs 201231(6)1329-1338 Available at httpcontenthealthaffairsorgcontent3161329fullpdf+html Field of Practice

1) Center for Value-Based Insurance Design ldquoThe state innovation models initiative An opportunity to align payer and consumer incentivesrdquo V-BID Center Brief May 2013 Available at httpwwwsphumicheduvbidcenterpublicationspdfsV-BID20Brief20SIMS20May13pdf

2) Aetna News Hub ldquoAetna Carolinas HealthCare System advance more collaborative care in Charlotterdquo April 25 2013 Available at httpnewshubaetnacompress-releasehealth-care-professionals-and-networksaetna-carolinas-healthcare-system-advance-more-

3) Meyer H ldquoCollaborative efforts can save money and improve carerdquo Kaiser Health News January 5 2012 Available at httpwwwkaiserhealthnewsorgstories2012january06collaborative-efforts-can-save-money-and-improve-careaspx

Value-Based Benefit Designs 1 Availity Research Study ldquoHealth plan readiness to operationalize value-based payment modelsrdquo April 2013 Available at

httpwwwnbchorgnbchfilesccLibraryFilesFilename000000002854Availity_Study_on_Plan_Readiness_to_Operationalize_New_Payt_Modelspdf

2 Thomson S Schang L Chernew ME ldquoValue-based cost sharing in the United States and elsewhere can increase patientsrsquo use of high-value goods and servicesrdquo Health Affairs 201332(4)704-712 Available at httpcontenthealthaffairsorgcontent324704fullpdf+html

3 Hibbard JH Greene J Tusler M ldquoPlan design and active involvement of consumers in their own health and healthcarerdquo American Journal of Managed Care 200814(11)729-736 Available at httpwebebscohostcomehostpdfviewerpdfviewervid=3ampsid=305e43bb-34cc-45e0-b3b0-f8d8288d48fa40sessionmgr111amphid=127

4 Fendrick AM Chernew ME ldquoValue based insurance design maintaining a focus on health in an era of cost containmentrdquo American Journal of Managed Care 200915(6)338-343 Available at httpwebebscohostcomehostpdfviewerpdfviewervid=3ampsid=305e43bb-34cc-45e0-b3b0- f8d8288d48fa40sessionmgr111amphid=127 5 Health Care Financing amp Organization ldquoMaking the value proposition in benefit designrdquo HCFO June 2010 Available at

httpwwwhcfoorgpublicationsmaking-value-proposition-benefit-design 6 Neumann PJ Auerbach HR Cohen JT Greenberg D ldquoLow-value services in value-based insurance designrdquo American

Journal of Managed Care 201016(4)280-286 Available at httpwebebscohostcomehostpdfviewerpdfviewervid=3ampsid=305e43bb-34cc-45e0-b3b0-f8d8288d48fa40sessionmgr111amphid=127

7 Gibson TB Wang S Kelly E Brown C Turner C Frech-Tamas F Doyle J Mauceri E ldquoA value-based insurance design program at a large company boosted medication adherence for employees with chronic illnessesrdquo Health Affairs 201130(1)109-117 Available at httpcontenthealthaffairsorgcontent301109fullpdf+html Field of Practice

1) Appleby J ldquoCarrot-and-stick health plans aim to cut costsrdquo USA TodayKaiser Health News March 11 2010 Available at httpwwwkaiserhealthnewsorgstories2010march11value-based-health-insuranceaspxreferrer=search

2) Chernew ME Shah MR Wegh A Rosenberg SN Juster IA Rosen AB Sokol MC Yu-Isenberg K Fendrick AM ldquoImpact of decreasing copayments on medication adherence within a disease management environmentrdquo Health Affairs 200827(1)103-112 Available at httpcontenthealthaffairsorgcontent271103fullpdf+html

3) The Free Library ldquoCenter for Health Value Innovation releases white paper value-based design manages costs improves health for public sector employersrdquo September 21 2009 Available at httpwwwthefreelibrarycomCenter+for+Health+Value+Innovation+Releases+White+Paper3A+Value-Based+-a0208090928

Private Health Insurance Exchanges Field of Practice

1) Mercer ldquoMercer signs first group of insurance carriers to Mercer marketplace private exchangerdquo Press Release April 33


15 2013 Available at httpwwwmercercompress-releases1521295 2) Japsen B ldquoInsurers flock to private exchanges while states grapple with Obamacare marketplacerdquo Forbes April 15

2013 Available at httpwwwforbescomsitesbrucejapsen20130415insurers-flock-to-private-exchanges-while-states-grapple-with-obamacare-marketplace

3) Overland D ldquoWill private exchanges become the new Travelocityrdquo FierceHealthPayer May 29 2012 Available at httpwwwfiercehealthpayercomstorywill-private-exchanges-become-new-travelocity2012-05-29

4) Overland D ldquoUnitedHealth Cigna HCSC to sell plans on Aon Hewitt exchangerdquo FierceHealthPayer September 27 2012 Available at httpwwwfiercehealthpayercomstoryunitedhealth-cigna-hcsc-sell-plans-aon-hewitt-exchange2012-09-27

5) Overland D ldquoMedica launches private exchange to sell ACO productsrdquo FierceHealthPayer October 16 2012 Available at httpwwwfiercehealthpayercomstorymedica-launches-private-exchange-sell-aco-products2012-10-16

6) Overland D ldquo10 insurers to sell plans on Mercerrsquos private exchangerdquo FierceHealthPayer April 17 2013 Available at httpwwwfiercehealthpayercomstoryaetna-cigna-unitedhealth-sell-plans-mercers-private-exchange2013-04-17

Supporting Customized Care Field of Practice

1) Dishman E ldquoHow big data can revolutionize health carerdquo Politico June 26 2013 Available at httpwwwpoliticocomstory201306how-big-data-can-revolutionize-health-care-93449html

Addressing Public Health Problems The Case of Obesity 1 Weiner JP Goodwin SM Chang H-Y et al ldquoImpact of bariatric surgery on health care costs of obese personsrdquo JAMA

Surgery 2013148(6)555-561 Available at httparchsurgjamanetworkcomarticleaspxarticleid=1653574 2 Ignagni K ldquoHealth plan innovations in delivery system reformsrdquo American Journal of Managed Care 201319(4)260-262

Available at httpwwwajmccompublicationsissue20132013-1-vol19-n4Health-Plan-Innovations-in-Delivery-System-Reforms

3 Alliance for a Healthier Generation ldquoAnthem Blue Cross and Blue Shield in Virginia teams with the Alliance for a Healthier Generation to offer comprehensive health benefits to combat childhood obesityrdquo Press Release May 18 2010 Available at httpwwwhealthiergenerationorgmediaaspxid=4583

4 Finkelstein EA Trogdon JG Cohen JW Dietz W ldquoAnnual medical spending attributable to obesity payer-and service-specific estimatesrdquo Health Affairs 200928(5)w822-w831 (published online 27 July 2009) Available at httpcontenthealthaffairsorgcontent285w822fullpdf+html Field of Practice

1) Americarsquos Health Insurance Plans ldquoHealth plans leading efforts to reduce and prevent obesityrdquo June 19 2013 Available at httpwwwahipcoveragecom20130619health-plans-leading-efforts-to-reduce-and-prevent-obesity

2) Varney S ldquoObamacare insurance wonrsquot cover weight-loss surgery in many statesrdquo Kaiser Health News May 27 2013 Available at httpwwwkaiserhealthnewsorgstories2013may27bariatric-surgery-obesity-exchange-marketplace-mississippiaspx

3) Alliance for a Healthier Generation ldquoAnthem Blue Cross and Blue Shield in Virginia teams with the Alliance for a Healthier Generation to offer comprehensive health benefits to combat childhood obesityrdquo Press Release May 18 2010 Available at httpwwwhealthiergenerationorgmediaaspxid=4583

4) Steenhuysen J ldquoHospital label no guarantee of better weight surgeryrdquo Reuters April 20 2009 Available at httpwwwreuterscomarticleidUSTRE53J5WL20090421

5) Pollack A ldquoFDA studies band surgery for less obeserdquo New York Times December 2 2010 p A1 Available at httpwwwnytimescom20101202business02obesehtmlpagewanted=allamp_r=0

6) Gardner A ldquoGastric bypass best for weight loss study findsrdquo Healthcom February 21 2011 Available at httpnewshealthcom20110221gastric-bypass-best-for-weight-loss-study-finds

7) Pittman G ldquoBariatric surgery doesnrsquot reduce long-term costsrdquo Reuters Health Information July 16 2012 Available at httpwwwnlmnihgovmedlineplusnewsfullstory_127291html

8) Graham J ldquoDoctors and Insurers are key to fighting obesityrdquo Kaiser Health News May 12 2012 Available at httpwwwkaiserhealthnewsorgstories2012may13obesity-and-doctorsaspx

9) Rundle RL ldquoObesity surgery is called cost-effectiverdquo The Wall Street Journal September 8 2008 Available at httponlinewsjcomarticleSB122082794026608293html

Further Readings

1 Kane D ldquoOverweight NC workers may pay a pricerdquo News amp Observer February 20 2009 Available at httpwwwnewsobservercom2009022094051overweight-nc-workers-may-payhtmlstorylink=misearch

2 IBM ldquoIBM to provide employees with 100 primary health care coverage new wellness rebaterdquo Press Release October 29 2009 Available at httpwww-03ibmcompressusenpressrelease28728wss

3 National Business Coalition on Health ldquoValue-based benefit design a purchaser guiderdquo 2009 Available at httpwwwnbchorgNBCHfilesccLibraryFilesFilename000000000222VBBD20Purchaser20Guidepdf

4 PR Newswire ldquoHarvard Pilgrim launches social networking e-community to inspire people to be wellrdquo November 23 2009 34


Available at httpwwwprnewswirecomnews-releasesharvard-pilgrim-launches-social-networking-e-community-to-inspire-people-to-be-well-71527682html

5 Johnson A ldquoHealth amp wellness -- Heart beat the do-it-yourself house call --- insurer-endorsed remote-monitoring technology leads heart patients to take their readings at homerdquo Wall Street Journal July 27 2010 p D2 Available at httponlinewsjcomarticleSB10001424052748704700404575391262635170370html

6 Intel ldquoAetna Intel effort signals importance of early intervention remote health managementrdquo News Release June 10 2010 Available at httpwwwintelcompressroomarchivereleases20100610corphtm

7 Nucci C ldquoInsurers curbing hospital admissions remotelyrdquo HealthLeaders Media January 13 2011 Available at httpwwwhealthleadersmediacompage-1MAG-260996Insurers-Curbing-Hospital-Admissions-Remotely

8 Galewitz P ldquoInsurers embrace lsquovirtualrsquo doctor visitsrdquo Kaiser Health News May 6 2012 Available at httpwwwkaiserhealthnewsorgstories2012may07telemedicineaspx

VII Evaluation and Grading

Grades will be determined based on two group assignments (total of 25 points) and five individual assignments (total 75 points) The student will receive a grade of zero if an assignment is not submitted as scheduled unless prior arrangements have been made for late submission Grading Scale An AF letter grade will be determined based on the following

A=93-100 Represents outstanding achievement relative to the level necessary to meet course requirements

A- = 90-9299

B+ = 87-8999

B = 83-8699 Represents achievement that is significantly above the level necessary to meet course requirements

B- = 80-8299

C+ = 77-7999

C = 73-7699 Represents achievement that meets the minimum course requirements

C- = 70-7299

D+ = 65-6999

D = 60-6499

F = lt 5999 No credit Signifies work was below level of achievement that represents minimum threshold to obtain credit or work was not completed and there was no agreement between instructor and student that the student would be awarded an I

The instructor reserves the right to adjust final grades ldquoupwardrdquo based on the overall distribution of points for the class That is students may receive a higher grade than expected based on their overall point total but not a lower grade Course Evaluation Beginning in fall 2008 the SPH will collect student course evaluations electronically using a software system called CoursEval wwwsphumneducourseval The system will send email notifications to students when they can access and complete their course evaluations Students who complete their course evaluations promptly will be able to access their final grades just as soon as the faculty member renders the grade in SPHGrades wwwsphumnedugrades All students will have access to their final grades through OneStop two weeks after the last day of the semester regardless of whether they completed their course evaluation or not Student feedback on course content and faculty teaching skills are an important means for improving our work Please take the time to complete a course evaluation for each of the courses for which you are

35


registered

Incomplete Contracts A grade of incomplete ldquoIrdquo shall be assigned at the discretion of the instructor when due to extraordinary circumstances (eg documented illness or hospitalization death in family etc) the student was prevented from completing the work of the course on time The assignment of an ldquoIrdquo requires that a contract be initiated and completed by the student before the last official day of class and signed by both the student and instructor If an incomplete is deemed appropriate by the instructor the student in consultation with the instructor will specify the time and manner in which the student will complete course requirements Extension for completion of the work will not exceed one year (or earlier if designated by the studentrsquos college) For more information and to initiate an incomplete contract students should go to SPHGrades at wwwsphumnedugrades University of Minnesota Uniform Grading and Transcript Policy - A link to the policy can be found at onestopumnedu

VIII Other Course Information and Policies

Grade Option Change (if applicable) For full-semester courses students may change their grade option if applicable through the second week of the semester Grade option change deadlines for other terms (ie summer and half-semester courses) can be found at onestopumnedu Course Withdrawal Students should refer to the Refund and DropAdd Deadlines for the particular term at onestopumnedu for information and deadlines for withdrawing from a course As a courtesy students should notify their instructor and if applicable advisor of their intent to withdraw Students wishing to withdraw from a course after the noted final deadline for a particular term must contact the School of Public Health Office of Admissions and Student Resources at sph-sscumnedu for further information Student Conduct Code The University seeks an environment that promotes academic achievement and integrity that is protective of free inquiry and that serves the educational mission of the University Similarly the University seeks a community that is free from violence threats and intimidation that is respectful of the rights opportunities and welfare of students faculty staff and guests of the University and that does not threaten the physical or mental health or safety of members of the University community As a student at the University you are expected adhere to Board of Regents Policy Student Conduct Code To review the Student Conduct Code please see httpregentsumnedusitesdefaultfilespoliciesStudent_Conduct_Codepdf Note that the conduct code specifically addresses disruptive classroom conduct which means engaging in behavior that substantially or repeatedly interrupts either the instructors ability to teach or student learning The classroom extends to any setting where a student is engaged in work toward academic credit or satisfaction of program-based requirements or related activities Use of Personal Electronic Devices in the Classroom Using personal electronic devices in the classroom setting can hinder instruction and learning not only for the student using the device but also for other students in the class To this end the University establishes the right of each faculty member to determine if and how personal electronic devices are allowed to be used in the classroom For complete information please reference httppolicyumneduPoliciesEducationEducationSTUDENTRESPhtml Scholastic Dishonesty You are expected to do your own academic work and cite sources as necessary Failing to do so is scholastic dishonesty Scholastic dishonesty means plagiarizing cheating on assignments or examinations engaging in unauthorized collaboration on academic work taking acquiring or using test materials without faculty permission submitting false or incomplete records of academic achievement acting alone or in cooperation with another to falsify records or to obtain dishonestly grades honors awards or professional

36


endorsement altering forging or misusing a University academic record or fabricating or falsifying data research procedures or data analysis (Student Conduct Code httpregentsumnedusitesdefaultfilespoliciesStudent_Conduct_Codepdf) If it is determined that a student has cheated he or she may be given an F or an N for the course and may face additional sanctions from the University For additional information please see httppolicyumneduPoliciesEducationEducationINSTRUCTORRESPhtml The Office for Student Conduct and Academic Integrity has compiled a useful list of Frequently Asked Questions pertaining to scholastic dishonesty httpwww1umneduoscaiintegritystudentindexhtml If you have additional questions please clarify with your instructor for the course Your instructor can respond to your specific questions regarding what would constitute scholastic dishonesty in the context of a particular class-eg whether collaboration on assignments is permitted requirements and methods for citing sources if electronic aids are permitted or prohibited during an exam Makeup Work for Legitimate Absences Students will not be penalized for absence during the semester due to unavoidable or legitimate circumstances Such circumstances include verified illness participation in intercollegiate athletic events subpoenas jury duty military service bereavement and religious observances Such circumstances do not include voting in local state or national elections For complete information please see httppolicyumneduPoliciesEducationEducationMAKEUPWORKhtml Appropriate Student Use of Class Notes and Course Materials Taking notes is a means of recording information but more importantly of personally absorbing and integrating the educational experience However broadly disseminating class notes beyond the classroom community or accepting compensation for taking and distributing classroom notes undermines instructor interests in their intellectual work product while not substantially furthering instructor and student interests in effective learning Such actions violate shared norms and standards of the academic community For additional information please see httppolicyumneduPoliciesEducationEducationSTUDENTRESPhtml Sexual Harassment Sexual harassment means unwelcome sexual advances requests for sexual favors andor other verbal or physical conduct of a sexual nature Such conduct has the purpose or effect of unreasonably interfering with an individuals work or academic performance or creating an intimidating hostile or offensive working or academic environment in any University activity or program Such behavior is not acceptable in the University setting For additional information please consult Board of Regents Policy httpregentsumnedusitesdefaultfilespoliciesSexHarassmentpdf Equity Diversity Equal Opportunity and Affirmative Action The University will provide equal access to and opportunity in its programs and facilities without regard to race color creed religion national origin gender age marital status disability public assistance status veteran status sexual orientation gender identity or gender expression For more information please consult Board of Regents Policy httpregentsumnedusitesdefaultfilespoliciesEquity_Diversity_EO_AApdf Disability Accommodations The University of Minnesota is committed to providing equitable access to learning opportunities for all students Disability Services (DS) is the campus office that collaborates with students who have disabilities to provide andor arrange reasonable accommodations If you have or think you may have a disability (eg mental health attentional learning chronic health sensory or physical) please contact DS at 612-626-1333 to arrange a confidential discussion regarding equitable access and reasonable accommodations If you are registered with DS and have a current letter requesting reasonable accommodations please contact your instructor as early in the semester as possible to discuss how the accommodations will be applied in the course For more information please see the DS website httpsdiversityumnedudisability

37


Mental Health and Stress Management As a student you may experience a range of issues that can cause barriers to learning such as strained relationships increased anxiety alcoholdrug problems feeling down difficulty concentrating andor lack of motivation These mental health concerns or stressful events may lead to diminished academic performance and may reduce your ability to participate in daily activities University of Minnesota services are available to assist you You can learn more about the broad range of confidential mental health services available on campus via the Student Mental Health Website httpwwwmentalhealthumnedu Academic Freedom and Responsibility for courses that do not involve students in research Academic freedom is a cornerstone of the University Within the scope and content of the course as defined by the instructor it includes the freedom to discuss relevant matters in the classroom Along with this freedom comes responsibility Students are encouraged to develop the capacity for critical judgment and to engage in a sustained and independent search for truth Students are free to take reasoned exception to the views offered in any course of study and to reserve judgment about matters of opinion but they are responsible for learning the content of any course of study for which they are enrolled Reports of concerns about academic freedom are taken seriously and there are individuals and offices available for help Contact the instructor the Department Chair your adviser the associate dean of the college or the Vice Provost for Faculty and Academic Affairs in the Office of the Provost [Customize with names and contact information as appropriate for the coursecollegecampus]

Language adapted from the American Association of University Professors Joint Statement on Rights and Freedoms of Students Template update 92013

38


II Course Prerequisites

III Course Goals and Objectives

IV Methods of Instruction and Work Expectations




Grading Scale


Student Conduct Code

The University seeks an environment that promotes academic achievement and integrity that is protective of free inquiry and that serves the educational mission of the University Similarly the University seeks a community that is free from violence

Use of Personal Electronic Devices in the Classroom

Scholastic Dishonesty

Makeup Work for Legitimate Absences

Appropriate Student Use of Class Notes and Course Materials

Sexual Harassment

Equity Diversity Equal Opportunity and Affirmative Action

Mental Health and Stress Management

Academic Freedom and Responsibility for courses that do not involve students in research


IV Methods of Instruction and Work Expectations Each class will include a didactic presentation on the part of the instructor significant issues will be identified and discussed referencing the readings for the class period There are no ldquorequiredrdquo readings for the course The amount that students learn in this course and their performance on assignments will depend to a large degree on the time and effort they devote to the readings for each topic In most class periods students will present results from individual or group assignments Students will be expected to prepare for each class by engaging with the readings prior to class participating in the discussion during class and completing group and individual assignments as scheduled ldquoFurtherrdquo readings are provided as starting points for students who wish to explore specific topics in greater depth and to assist in the completion of individual and group assignments


1 To access readings click on link immediately following cite If you have any problems accessing assigned readings online contact Jane Raasch at raasc001umnedu If you do not have a University of Minnesota Internet ID and password call 301-HELP and support staff will help you set up an account (or set up your own account at wwwumneduinitiate and follow the directions)

2 Optional background reading for this course 1) PowerPoint lecture on the basics of health insurance posted on Moodle 2) Kongstvedt Peter Essentials of Managed Care Aspen Publishers Gaithersburg MD This book is the most frequently used reference in the field It covers most of the ldquobasicsrdquo but may not be current on all topics

3 For each class session overheadsPowerPoint slides andor audio will be posted on the Moodle website for downloading and viewing To learn more about Moodle watch Moodle Online Orientation for Students andor visit the Moodle support website at httpwww1umnedumoodle which has a link for ldquoStudent supportrdquo with user guides help and FAQs


Date Module Topics Background

September 9 Employer Goals for the Health Care System and Their Strategies for Achieving Them

September 16 23 Present State of Americarsquos Health Insurance Industry bull Presentation of Group Assignment 1 (10 pts) ndash September 16

Health PlanProvider Relationships September 30 Measuring Provider Performance The Foundation of Purchaser Strategies to Reform Americarsquos

Health Care System October 7 Provider Contracting and Network Management

bull Discussion of Individual Assignment 1 (15 pts) October 14 Fundamentals of Provider Payment Incentives and Rewards October 21 New Payment Arrangements BundledEpisode-Based Payment

bull Discussion of Individual Assignment 2 (15 pts) October 28 New Payment Arrangements Total Cost of Care (TCOC)

bull Guest Lecture November 4 Utilization Management

bull Discussion of Individual Assignment 3 (15 pts) Health PlanEnrollee Relationships

November 11 Supporting EmployeesEnrollees in Choosing Providers Reporting of Provider Performance November 18 Supporting EmployeesEnrollees in Choosing Treatment Options

bull Discussion of Individual Assignment 4 (15 pts) November 25 Supporting EmployeesEnrollees in Maintaining and Improving Their Health

2


















3




















Further Readings







4





















5




























6




























7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment





















3




















Further Readings







4





















5




























6




























7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment























Further Readings







4





















5




























6




























7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment
























5




























6




























7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment































6




























7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment































7























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment


























8



























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






























9











Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment














Further Readings






































11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






























11














Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment

















Further Readings











12






















13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment

























13























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment


























Further Readings


14























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment


























15


























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment





























16
























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment



























17



























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






























18



Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






Further Readings



















19




























20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment































20




























21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment































21





















health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment
























health care costs

22


























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment





























23



























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






























24










Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment













Further Readings


















25























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment


























26




















Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment























Further Readings






27













































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment
















































29



























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment






























30





















31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment
























31










Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment













Further Readings














32












































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment















































Further Readings














A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment













A- = 90-9299

B+ = 87-8999


B- = 80-8299

C+ = 77-7999


C- = 70-7299

D+ = 65-6999

D = 60-6499



35


registered




36



37




38








Grading Scale








Sexual Harassment





registered




36



37




38








Grading Scale








Sexual Harassment






37




38








Grading Scale








Sexual Harassment







38








Grading Scale








Sexual Harassment




PubH 6564 Private Purchasers of Health Care: Roles of Employers...

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Transcript of PubH 6564 Private Purchasers of Health Care: Roles of Employers...