Speaking of finances, Kaiser Health News reports that Medicare reversed a decision to deny a beneficiary’s prescription for the expensive Hepatitis C cure, Sovaldi. A recent Wharton School of Business blog discusses the factors behind Gilead’s pricing of that drug.
Speaking of healthcare literacy, Insurancenewsnet.com reports that United Healthcare received a health care literacy award for its Happiness Counts kits provided to Medicare beneficiaries. “The brightly colored kit includes daily journals, postcards and other information to help seniors take actions and create a stronger mind-set for staying upbeat even in the face of illness.” The award illustrates how insurers do try to work cooperatively with members to improve health care literacy.
Turning to the core claims administration side of the business, Healthdata Management reports that Aetna is seeking to transition all of its network doctors from paper to electronic benefits statements / remittance advice and payments.
Aetna in recent years has been increasingly offering EFT payments but with Medicare’s recent move to mandate EFT, Aetna knew the time was right to make its own move. Employees routinely are electronically paid these days and personal electronic banking is common, [Jay] Eisenstock [Aetna’s head of provider e-solutions] notes. While payers are required to offer EFT and ERA and benefit from it, the bulk of benefits come when providers take advantage of it. For now, Aetna’s plan for EFT and ERA includes no penalties for non-compliance, Eisenstock says. But the insurer is changing its payment policy and at some point providers not going electronic will have to decide whether to keep their relationship with Aetna.
The new strategy works like this:
Your health insurance plan slaps a dollar limit on what it will pay for certain procedures, for example, hospital charges associated with knee and hip replacement operations. That’s called the reference price.
Say the limit is $30,000. The plan offers you a choice of hospitals within its provider network. If you pick one that charges $40,000, you would owe $10,000 to the hospital plus your regular cost-sharing for the $30,000 that your plan covers.
The extra $10,000 is treated like an out-of-network expense, and it doesn’t count toward your plan’s annual limit on out-of-pocket costs.
That’s crucial because under the health care law, most plans have to pick up the entire cost of care after a patient hits the annual out-of-pocket limit, currently $6,350 for single coverage and $12,700 for a family plan. Before the May 2 administration ruling, it was unclear whether reference pricing violated this key financial protection for consumers.
The strategy also works with prescription drug benefits. The article goes on to discuss the critics but the FEHBlog likes this upside.
Forbes writes about the increasing connections between hospital systems and pharmacies / PBMs, especially to support the pharmacies’ in-house clinics.
Finally, Congress is in session this week according to the Hill’s Floor Watch blog. The Senate may confirm the HHS Secretary nominees Sylvia Mathews Burwell.