Health Care Systems and HMOs

A recent study by former Centers for Medicare and Medicaid Services administrator Donald M. Berwick and RAND Corporation analyst Andrew D. Hackbarth estimated that waste may constitute a third of US health spending. This policy brief examines waste in health care that may result from poor delivery of care, failed care coordination, overtreatment, administrative complexity, and uncompetitive pricing. The author concludes with presenting opportunities and challenges associated with efforts to eliminate waste in health care without harming consumers or reducing the quality of care provided.

Much of the success of the Affordable Care Act (ACA) will hinge on issues surrounding access to care, particularly as millions of individuals become newly-insured and strain the capacity of provider systems. New service delivery reforms in state Medicaid programs and the private sector, as well as provisions in the ACA focused on increasing primary care reimbursement and provider supply, and increasing funding for Community Health Centers, hold promise to improve access to quality care. Drawing on the experiences of ten study states participating in the Robert Wood Johnson Foundation’s health reform monitoring and implementation project, this brief examines how states are addressing the complex issues of provider capacity and access to care.

This report is the first of a series of reports that will be prepared during a three-year evaluation of the statewide implementation of risk-based managed care in Kentucky's Medicaid program. The evaluation will assess the short- and medium-term effects of risk-based managed care implementation on the major partners- beneficiaries, providers, plans, and the Cabinet- with an eye toward understanding the impacts on costs and on the provision of care. In this report, we provide an overview of managed care implementation in Kentucky as of mid-2012 based on our case study analysis, conducted about eight months after the state began enrolling Medicaid beneficiaries in risk-based managed care state-wide.

The term care transition describes a continuous process in which a patient's care shifts from being provided in one setting to another, such as from a hospital to a patient's home. Poorly managed transitions can diminish health and lead to hospital readmissions, thus driving up costs for Medicare and other payers. This Health Affairs brief examines the factors contributing to poor care transitions, describes effective care delivery models aimed at improving care transitions, describes initiatives in the recent health reform law aimed at incentivizing greater attention to care transitions, and explores policy issues surrounding payment reform in this area.

There is widespread agreement that the current fee-for-service approach to paying for health care is problematic, but there is a lack of consensus on what should replace it. Medicare is pursuing bundled episode payments, and proponents like Francois de Brantes of the Health Care Incentives Improvement Institute have been laying the groundwork for implementation. But other experts, such as the Urban Institute's Robert Berenson, worry that the current interest in bundled payments will distract policy-makers from moving more decisively away from fee-for-service. In this Robert Wood Johnson Foundation-funded paper, de Brantes and Berenson debate the benefits and drawbacks of bundled payments and global capitation.