New Plan for Health Coverage

Indiana Governor Mike Pence’s new plan to provide health coverage for more of the state’s low-income residents is another sign that few if any of the states holding out on Obamacare’s Medicaid expansion will do it in the way the law envisioned. The proposal also will test the Obama administration’s appetite to meet its coverage goals against its reticence to approve policies, such as cost-sharing requirements, favored by some conservatives.

Not counting Indiana, 23 states have yet to move forward with some form of expansion. Like several other Republican-led states, Indiana plans to apply for a waiver that will allow it to use federal Medicaid expansion funds to purchase coverage for adults earning up to 138% of the federal poverty level.

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ACOs Challenged by Unrestricted Patient Choice

A study published online in JAMA Internal Medicine found that Medicare accountable care organizations could face challenges with controlling costs and managing patient care due to the unrestricted choice of health providers offered to most beneficiaries. About 33 of Medicare beneficiaries assigned to ACOs in 2010 or 2011 were not assigned to the same ACO in both years, and much of the specialty care they received was outside the patients’ assigned ACO. The study authors noted that among ACO-assigned beneficiaries, 8.7 percent of office visits with primary care physicians and 66.7 percent of office visits with specialists were provided outside of the assigned ACO. About 38 percent of Medicare spending on outpatient care billed by ACO physicians was devoted to assigned beneficiaries. Annual changes in patient populations of ACOs can make care management for specific patients more difficult. “Leakage of outpatient specialty care, particularly among high-cost and medically complex patients, could pose a significant care coordination challenge to ACOs and substantially limit their ability to achieve economies of scope in both patient-specific and systemic approaches to controlling spending,” the authors said.

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Contact ABISA, a consultancy specializing in solo and small group practice management. Visit us at ABISALLC.com.