Tufts Health Plan and Harvard Pilgrim announced a planned merger, which would make the new as-yet-to-be-named organization a rising competitor to the Partners Health Group, a dominant player in the area. CMS will display the 5-star rating next to plans on the Affordable Care website, a move to make the data more visible to potential policy purchasers and others. These and other top stories are in this week’s Innovation Partners BioBlog.
Canada plots response to U.S. import plan after meeting with stakeholders
The plan released by the Department of Health and Human Services last month to create a pilot project for states, wholesalers and pharmacists to import drugs from Canada offered at a cheaper price than in the U.S. has set in motion meetings between Canadian health officials and their U.S. counterparts. Canadian officials are concerned that the plan will exacerbate drug shortages in Canada. The Canadian healthcare industry has opposed the plan. Canada does not have a large pharmaceutical manufacturing capability and typically imports many drugs for their own citizens.
Tufts and Harvard Pilgrim to merge, creating large nonprofit insurer
Harvard Pilgrim Health Care and Tufts Health Plan announced their intention to combine organizations. The new organization will become one of the largest nonprofit healthcare organizations in Massachusetts and the surrounding New England region. It will serve approximately 2.4 million people in Massachusetts, Maine, Connecticut, New Hampshire and Rhode Island, and offer employer-sponsored plans, Medicare and Medicaid plans, Qualified Health Plans and plans for those who are dually eligible for Medicare and Medicaid. The Partners HealthCare system, which includes Massachusetts General and Brigham and Women’s, currently dominates the area.
CMS to display the star ratings for Affordable Care Act exchange plans
The Centers for Medicare and Medicaid Services will now require the display of five-star ratings for health plans offered on the Affordable Care Act exchanges, beginning with the 2020 open enrollment season. The star ratings will compare prices and plan quality. The star ratings data for the 2020 plan year will be released by November. Last year, data was available to researchers and the public in a public use file but not posted to each listing on the site.
Payers face higher rates due to provider billing fights, new survey finds
Nonpayment of patient bills is at least partially included into the typical rates, according to a new survey conducted by HIMSS of patients and providers and sponsored by billing management startup OODA health. The survey found that 67% of 39 hospitals and health systems use patient collection as justification for rate increases in payer negotiations. 21% use it prominently. The study was completed just as the Trump administration calls for greater transparency in hospital and health system pricing. Payers actually design plans around what patients owe, rather than what they pay.
CMS rejects Utah’s request for Medicaid enrollment caps with full federal funding
The Trump administration formally denied Utah’s request to expand Medicaid funding while receiving a federal match. The Centers for Medicare & Medicaid Services (CMS) said last month that it would not pay out the full amount allowed under the Affordable Care Act if the state continued with a partial Medicaid expansion. While CMS supports state flexibility in Medicaid, it would reject plans that do not fully expand Medicaid while seeking full government funding. The group also said it would reject full payments under an enrollment cap in Utah for similar reasons.
Healthcare revenue cycle management market projected to be worth $104 billion by 2025
The healthcare revenue cycle management market is estimated to be worth $104 billion by 2025. What is fueling growth? Rising healthcare spending and technological advancement are key factors propelling industry growth. Factors affecting revenue management generally include medical claims processing, especially with the need to uphold quality insurance billing to achieve the desired financial outcomes. Approximately 25.5% of U.S. hospitals lack revenue cycle management services, mostly due to lack of awareness that such technology exists.