Aetna and Hunterdon HealthCare Partners Forge New Accountable Care Relationship
Hunterdon Healthcare employees and Aetna members in 5 NJ counties will benefit from new ACO committed to higher quality more coordinated care
HARTFORD, Conn.–(BUSINESS WIRE)–Aetna (NYSE: AET) and Hunterdon HealthCare Partners today announced a new accountable care agreement that will improve the quality and cost of patient care, helping members and plan sponsors save money. Hunterdon Healthcare is establishing an Accountable Care Organization (ACO) to deliver a better patient experience, and aims to improve the quality of patient care while reducing the overall cost of care.
“Becoming an ACO not only supports our mission to deliver better access to primary care and specialist physicians, but will allow us to better provide integrated healthcare to improve the health of our community.”
“We are excited to bring our industry-leading technology and care management capabilities together with Hunterdon’s quality-driven team to offer highly coordinated and comprehensive care management to members in New Jersey,” said John Lawrence, president, Aetna New Jersey market. “Beginning this summer, 8,000 Hunterdon Healthcare employees and Aetna members will receive health care in this new patient-focused, accountable care model.”
An ACO is a group of health care providers who coordinate care and are accountable for cost, quality and patient satisfaction for the health care they provide.
“In the past several years, the healthcare industry has changed with the demands of health care reform. The industry trend is shifting from paying for services, regardless of patient outcomes, to paying for care that delivers better value, quality and patient satisfaction. Collaborating with Aetna will help Hunterdon Healthcare deliver better care at a better price. We think patients will see direct benefit from this approach,” explained Robert P. Wise, president and CEO, Hunterdon Healthcare.” Jeffrey Weinstein, executive director for Hunterdon HealthCare Partners added, “Becoming an ACO not only supports our mission to deliver better access to primary care and specialist physicians, but will allow us to better provide integrated healthcare to improve the health of our community.”
About the Hunterdon HealthCare Partners ACO
Under the new ACO agreement, 2,200 members in the Hunterdon Healthcare employee benefits plan, and approximately 5,700 fully insured Aetna members who live in Hunterdon, Mercer, Warren, Morris and Somerset Counties will be served by the ACO. Aetna members served by this new model are ones who primarily received care from Hunterdon Healthcare’s providers in the last 24 months, as well as those who seek care from Hunterdon Healthcare physicians following the start of the agreement.
Hunterdon Medical Center, more than 225 affiliated primary care physicians and specialists, and the affiliated ambulatory surgery, radiology, hospice, and other Hunterdon Healthcare facilities and providers will all be part of the ACO. Working together, and supported by a full suite of Aetna health information technology and care management capabilities, the providers will become part of a coordinated health care network and receive notices of any treatments and medications the patient may be receiving. As a result, the patients will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.
Aetna and Hunterdon HealthCare Partners are implementing a payment model that will change the way Hunterdon Healthcare is reimbursed for care. Under the ACO agreement, Hunterdon Healthcare will be paid based on achieving certain quality, efficiency and patient satisfaction measures, which are designed to:
improve the patient’s health care experience through greater care coordination and patient engagement;
improve the health of populations; and
reduce the cost of health care by aligning payment with quality, patient outcomes and value.
The measures include, but are not limited to:
the percentage of Aetna members who receive recommended preventive care and screenings, such as increased cancer screenings, flu shots and other vaccinations;
improved management of patients with chronic conditions such as diabetes, heart failure and asthma;
reductions in hospital readmission rates; and
reductions in Emergency Room visits by improving primary care access hours.
Aetna’s Technology Support
To support the full success of the ACO, Aetna will implement the following integrated technologies and capabilities for Hunterdon HealthCare Partners:
health information exchange technology from Medicity, a wholly-owned subsidiary of Aetna, to enable the secure, two-way exchange of health information across a patient’s entire care team, including hospitals, physicians, labs, pharmacies and other ambulatory services;
point-of-care clinical decision support services and the Active CareTeamSM desktop-based workflow tool to track, monitor, coordinate and report on patient health outcomes from ActiveHealth Management a wholly-owned subsidiary of Aetna; and,
reporting tools that will help Hunterdon Healthcare providers evaluate how they are performing against their targeted clinical and financial outcomes.
About Hunterdon HealthCare Partners
Hunterdon HealthCare Partners was created by physicians and the Hunterdon Healthcare System, the parent organization of the Hunterdon Medical Center. The partnership’s goal is to provide the residents of Hunterdon County and the surrounding areas better access to integrated care delivered through their network of primary care and specialist physicians. For more information, contact Jeffrey Weinstein at Weinstein.Jeffrey@hunterdonhealthcare.org.
About Aetna
Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 36.1 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services and health information technology services. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com.
The biggest Supreme Court Ruling in a decae is expected this Thursday before the Summer recess. Yet thats when the fun begins.Possible outcomes:
Delay hearing the legal issues associated with case for several years due to the Tax Issue.
Invalidate the Individual Mandate.
Invalidate all or part of the Medicaid Expansion requirements.
Uphold PPACA as is.
Declare the entire Act unconstitutional due to the lack of a Severability Clause if any of the key provisions such as the Individual Mandate overturned.
If individual mandate is repealed but leave other PPACA provisions in place, this outcome could greatly limit the coverage goals underpinning the Affordable Care Act and cause significant problems in the health insurance markets. For example, MIT economist Jonathan Gruber said, “Without a mandate the law is a lot less effective. The market will not collapse, but it will be a ton more expensive and cover many fewer people.”
While States such as NY may follow Massachusetts and set up their own Individual Mandate this becomes challenging with less Federal funding. Funding for the individual market place subsidy with subsidies could collapse. See subsidy calculator here.
Eliminating the mandate would increase premiums and mean that far fewer of the uninsured would be covered. This is known as adverse selection where the sick population would be willing to pay higher premiums and forcing the healthy population to opt out of exchange. States such as NY in fact have seen the Individual Market spiral out of control as they are high risk adverse group in order to supplement the preferred guaranteed non-preexisting condition group marketplace. Furthermore, NYS requires guaranteed issue for pre-existing condition for individual members with prior coverage.
If the court invalidates the individual mandate and leave rest of Act in tact it may lead to a death spiral. Popular reforms such as overage 26 dependent coverage and expected pre-existing condition waiver in 2014 would possibly be dismantled.
The decision would punt health-care reform back to Congress, which “isn’t doing anything this year” and thus create major uncertainty going into the November elections. Taxes on pharma and medical devices would remain, while managed-care and hospital companies would suffer big losses. Insurers would be forced to take on sick patients without benefitting from the healthy ones who would have been enrolled under the mandate.
In this scenario, a lot of companies would simply cut their losses and leave the individual insurance market altogether; the law would essentially “run them out of business.
Either way the lack of uncertainty has delayed hospitals and insurers from new hires and taking decisive actions. Same time next week we hope to celebrate July 4th with certainty.
Most are familiar with the AFLAC duck when it comes to supplemental benefits to primary medical plans. Today, primary medical plans are extremely valuable but in many cases the benefits paid cover only a fraction of the true cost of a major illness or injury. For instance, a person who suffers a severe heart attack can expect to experience a lengthy hospital stay, followed by a period of recuperation at home or in an extended care or rehabilitative facility. A primary medical plan will cover a significant portion of the hospital and physician costs, but the insured is likely to be responsible for some expenses. Depending on the terms of the plan, these expenses can be substantial.
Most Popular Benefits
The most in-demand voluntary benefits continue to be those that supplement core medical, life, or disability insurance coverage, according to surveys. These include dental, critical illness, specific illness, hospital supplemental, medical supplemental, disability buy-up, and supplemental life coverage. However, demographic trends are also contributing to growing interest in long-term care and financial planning products.
As more people are faced with their parents’ elder care needs, they begin to appreciate the cost of extended care and anticipate what their needs may be in a few years. And, many mid-career employees face the double crunch of saving for retirement at the same time they are financing college education for their children.
Perhaps reflecting the many demands on the time and money of today’s employees, 28 percent of participants in one survey said they wanted employers to provide a wider array of voluntary benefits. In addition, 30 percent of respondents said they were interested in having employer-provided access to financial planners to assist them in making decisions.
Furthermore, an individual experiencing a health crisis such as a heart attack can expect to be absent from work for some time. A disability plan usually replaces only 60 percent to 70 percent of wages, and not everyone has disability coverage. This disruption to an individual’s income stream, combined with the added medical expenses, can devastate a family’s financial well-being, and can even force tough decisions about treatment options.
The prospect of experiencing a severe health calamity is not as uncommon as one might think. According to a study by the National Heart Lung and Blood Institute, 1.1 million Americans have heart attacks each year. And the American Cancer Society predicts more than 1.4 million new occurrences of cancer annually in the U.S., with men accounting for a slightly higher percentage than women.
Fortunately, insurance products are available that supplement a primary medical plan. Usually available to employees on a voluntary basis and at group rates, these products can fill gaps in traditional health insurance coverage such as the indirect costs of an illness or injury. Surprisingly, the indirect costs can sometimes outweigh the direct cost of medical care.
The following provides an overview of the types and benefits of supplemental medical insurance products. Remember that different carriers may market similar products under various names, and that the specific benefits provided may vary.
Critical illness insurance usually pays a cash benefit upon diagnosis of a life-threatening disease or condition, such as cancer, heart attack, stroke, or the need for an organ transplant. The benefit can be used as the insured — or survivors — see fit. For instance, the benefit may be used to pay for health care from an out-of-network provider under the primary plan; experimental treatment not covered by the primary plan; indirect costs associated with medical treatment, such as transportation, lodging, and child care; as well as lost income.
Some carriers offer disease-specific insurance. The most well known among these products is cancer insurance. Depending on the way the policy works, specific disease insurance may pay a cash benefit upon diagnosis, and/or may provide coverage beyond the primary medical plan for treatments associated with the disease, such as radiation and chemotherapy in the case of cancer insurance. Some cancer insurance carriers provide disease management services through a health care professional with expertise in oncology.
Catastrophe medical insurance provides coverage that kicks in after the primary medical plan has run out. Although many primary medical plans have high lifetime limits, some do not. This is especially true of those purchased with economy of premium in mind. Catastrophe plans carry a high deductible, but typically all medical expenses paid both by the insured and the insured’s primary plan count toward the deductible. In light of the high cost of health care, a low-limit primary plan can be easily exhausted. Consider the medical costs associated with a premature baby or the trauma of a major automobile accident. Catastrophe insurance provides much needed benefits for all of these types of occurrences.
Hospital indemnity insurance supplements the primary medical plan if an illness or injury requires a hospital stay. Depending on the policy terms, benefits may be paid for specified hospital procedures or on a cash per diem basis.
With today’s skyrocketing costs of medical care prompting employers to study how health insurance is offered to employees, voluntary supplemental medical coverage may be an appropriate offering for your workplace. Adding supplemental medical coverage to an umbrella of voluntary benefit offerings can bring value as well as flexibility to your employee benefit package. Remember that coverages vary by carrier, and by state. Speak with your insurance agent to learn which supplemental insurance products provide the coverages that best suit your needs.
For more information on how a work-site supplemental package would help you and your company please contact us at (855)667-4621 info@medicalsolutionscorp.com today.
The NYT article – Waking Up to Major Colonoscopy Bills illustartes what our clients are increasingly running into – increased out of pocket expenses.
“Patients who undergo colonoscopy usually receive anesthesia of some sort in order to “sleep” through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap. Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. … And in both cases, the Gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple’s insurance. They billed the couple’s insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.”
Patients can go for Colonoscopies either in an outpatient medical office or in ambulatory hospital setting. Gastrointerologists cannot bill for the anesthesia unless there is an employed licensed Anesthesiologist on staff. The treating Physician cannot be the same person who administer/monitors the sedation. Generally speaking the Anesthesiologist in a hospital settings are separate entities and attempt to bill independently form the hospital charges. Now you can begin to see how patients are getting added billing.
Furthermore, we are seeing increasing out of network charges with Physicians dropping health plans in certain geographic areas as well as insurers shifting more of the costs burden.
The posting Out of Control Out of Network Charges points to examples such as – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.” Another example: “ a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.
Our clients get 3 bills with any procedure needing general anesthesia
1) A bill from the hospital
2) A bill from the surgeon
3) A bill from anesthesia
Actually, the physician bill is typically the lowest cost of the bill . On a $5,000 total bill the GI may only get 10%. Sometimes the hospital and anesthesia charges are bundled into a single bill but many times they are not. On most plans patients can negotiate with the hospital depending on pre-authorization the anesthesia bill and resubmit charges. This is probably the most common appeal we perform on behalf of our clients.
Patient on a cost sharing plan with in-network deductibles may fair better with outpatient office colonoscopies. From an insurer costs perspective the charges in an office setting are typically $2,000-$2,500. So why do it in the hospital? The procedure may require general anesthesia and financial incentives. Also, at times the procedure may be a loss to the provider. For example, Pediatricians will not perform Gardasil vaccination because the vaccine costs more than what the pediatrician will get reimbursed to give it.
The vast majority of providers make sure that patients were in-network or arranged pre-payment plan prior to the procedure. As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.
Oxford /United Healthcare has announced last week their contract termination with the Valhalla teaching hospital, Westchester Medical Center effective May 1, 2012. The NYS “cooling off period” imposes both parties to renegotiate a contract until July 1st. The hospital will be considered in-network until that time.
This marks the second time a large health insurer has terminated their contracts with Westchester medical Center. Empire had terminated their contract on Nov 10, 2010 after a similar dispute and is still not under contract. While contractual posturing is all too common in the health industry with eleventh hour agreements, we are seeing this disturbing trend playing out in other instances now.
We will monitor the situation and keep members posted. Oxford member letters explaing this are going out. Please contact us with any questions.
We are always on the lookout for highly motivated individuals with relevant industry experience and a strong interest in our industry. We are particularly interested in people with backgrounds in hospitals, web technologies and HR consulting. A bilingual skill is also desirable. If you think your skills would be a good fit for our business, please forward your resume to info@medicalsolutionscorp.com. We look forward to hearing from you.
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this as "ambulance-care" would be more fitting than "ObamaCare".
After 3 days of Health Care Reform Supreme Court Hearings, a central components debated is the constitutionality of forcing an individual to purchase health insurance. Certainly it would be costly if one could just opt out at any time and then come back in you would be left with a high risk pool.
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this alternative as “ambulance-care” would be more fitting than “ObamaCare”.
Of course there are Individual Mandate penalties. So how does the penalty work?
In 2014, the penalty for being without health insurance is $95 per adult and $47.50 per child (up to $285 for a family) or 1.0% of family income, whichever is greater.
In 2015, the penalty for being without health insurance is $325 per adult and $162.50 per child (up to $975 for a family) or 2.0% of family income, whichever is greater.
In 2016, the penalty for being without health insurance is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
As of now, there are no known method to enforcing the penalty if you don’t buy insurance and you don’t pay the penalty. In fact, the law specifically states that no criminal action or liens can be imposed on you but I am certain that will change. I would also think that if a large numbers of people continue to choose not to enroll and the cost of premiums increase, the chance to revise the low penalties and increased enforcement are inevitable.
In conclusion, the Supreme Court ruling set for June is worth watching but only for legal wonks. With average health insurance single rates costing $600/month wouldnt you pay the penalty and just opt out?
Few healthcare changes have been more impacted than the out of control out of network charges billed to patients. The health care reform bill known as PPACA has for the most part been insignificant in the Northeast, in particular, as many state laws have already addressed issues such aspre-existing conditions, contraception, coverage rescissions and maximum loss ratios (MLR).
Instead, the market forces are reshaping the medical field into significant insurance & provider consolidation, larger hospital groups and flattening provider reimbursements. The problem is pointed out in Out of Network Medical Costs Affecting NY State Across investigation report commissioned by Governor Cuomo recognizing the unexpected out-of-network claim problem. Officials say that this is now “an overwhelming amount of consumer complaints.” Some examples cited in the report An Unwelcome Surprise – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.” Another example: ” a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.
To make matters worse, Health Insurers have reduced their out of network recognized charges from private industry index UCR (usual customary and reasonable) to the Medicare Index known as RBRVS( Resource Based Relative Value Scale ). Insurers moved away from UCR after then-NYS D.A. Mario Cuomo in 2009 forced Unitedhelatcare Group (owners of Inginex) to settle $50 Million in a conflict of interest allegation. D.A. Cuomo future hopes for UCR were to that it be overseen by a non-profit entity. So much for best laid plans.
Today, 90% of SMB members have in network only benefits but the few remaining consumers are paying for eroding out of network benefits with little transparencies and necessary protection from new out of network billing practices. The NY Dept of Financial services is calling for providers in non-emergency situations to disclose whether or not all services are in-network, what out-of-network charges will be and how much insurers will cover.
In an ominous statement” “Failure to recognize this historical out-of-network avalanche will result in shocking financial disasters, as experienced by so many hospitals in 2003″
In a pleasant surprise, Empire will delay their April 2012 decision to “simplify” small group plans 1 more year from April 2012 to April 2013 instead. The Nov 4th Empire announcement to leave the NY Small Group Businesswas truly shocking after being in business for 75 years and insuring 35% of the market.
What this means for consumers is that insured members will now breath a sigh of relief and keep their contracted plan at least until their renewal. Evidentially, Empire was allowed to abruptly do a “hard shut down of their plans” for April and not allow a group to complete their 12 month contract. The negative consequence would have affected many unfairly as most members today have some kind of annual deductible and/or coinsurance on Rx plans, hospitalizations and surgeries. Example: a member signs up for a plan Oct 1 and has already met their deductible responsibilities would suddenly have to now change plans on April 2012. and start all over again.
A point needing further explanation is are they or they not exiting? Empire is stating that they are not in fact leaving but merely simplifying their offering to 6 plans but this is actually a red herring as the plans offered are not market friendly and allows Empire to stay within the market without having to really exit. Example: Their HMO monthly rate is $675/single when you can get the same plan from a leading competitor for $465/single.
So why be in the market without actually being in the market? The state’s regulation would not permit an insurer to re-enter for 3 years. With Health Care Reform changes in the subsequent years there are variables that may help NYS such as add’l federal funding. Additionally, it is an election year and with many unknown Health Care Reform variables still evolving such as Supreme Court hearing on individual mandate by June 2012 – WSJ Supreme Test for Health Law.
Either way this is welcome news to our existing clients and for the marketplace at large however short term it is.
Happy Holidays!!
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Medicare Part A insurance helps pay for medically necessary care—care for an illness or medical condition—that involves an inpatient stay in the hospital. Part A also helps pay for a stay in a skilled nursing facility as a follow-up to a hospital stay, hospice care for the terminally ill and some skilled home health care for those who cannot leave their homes. And it helps pay for some blood transfusions.
What providers can you see?
You can choose any qualified provider in the United States who has been accepted by Medicare and who is accepting new patients. Because Part A offers the same benefits throughout the United States, you are not limited to a particular state or region for your care.
Part A is free if you or your spouse made payroll contributions to Social Security for at least 10 years (40 quarters).
If you otherwise qualify for Medicare but neither you nor your spouse contributed to Social Security for at least 10 years, you’ll pay a monthly premiums of up to $450 per month in 2011.
Important: If you don’t qualify for no-premium Part A benefits, and you don’t enroll in Part A when you first become eligible for Medicare, your Part A premium could be higher.
Before Part A begins paying a share of your costs, you must first pay a deductible. In 2011, your Part A deductible is $1,132. You’ll pay this deductible for each hospital stay, subject to certain limits.
Medicare Copay
You pay a copay after you have stayed in the hospital or in a skilled nursing facility a certain number of days. Here are the Part A copays for 2011:
For hospital stays, you’ll pay $283 per day for days 61 through 90, and $566 per day for days 91 through 150.
In a skilled nursing facility, you’ll pay $141.50 for days 21 through 100 that you stay.
You’ll also pay a copay of $5 for each outpatient drug prescription you receive in hospice care.
Medicare Coinsurance
You will pay a small coinsurance payment if you use inpatient respite care for hospice patients.
An overview of Medicare Part B
Medicare Part B insurance helps pay for a variety of medically necessary care—that is, care for an illness or medical condition. This includes services like doctor’s office visits, care in hospitals and clinics when you are not admitted for an inpatient stay, laboratory tests and some diagnostic screenings, and some skilled nursing care at home if you cannot leave your home.
Part B also covers most doctor services you receive as a hospital inpatient, although other hospital services are covered by Part A. Unlike Part A, Medicare Part B is voluntary, but most people sign up when they first become eligible.
In 2011, Medicare Part B is making it easier to get preventive care. It will now cover an annual physical exam plus additional preventive screenings at no cost to you.
What providers can you see with Medicare Part B?
You can choose any provider who is eligible to participate in Medicare and who is accepting new patients.
Most people pay a monthly premium for Medicare Part B. The premium amount depends on your yearly income. If you receive Social Security, the premium will be automatically deducted from your Social Security benefits. For 2011, premiums range from $115.40 to $369.10 per month.
Important: You may pay a penalty if you don’t sign up for Part B when you are first eligible. Your cost for Medicare Part B may go up 10% for each full 12-month period that you could have had Part B but didn’t sign up for it. You’ll pay that penalty for as long as you’re enrolled in Part B.
This penalty may not apply to you if you are still working for an employer who provides group health coverage or if you have other credible coverage when you become eligible for Medicare.
