PubH 6564 Private Purchasers of Health Care: Roles of Employers …€¦ · employer contributions towards employee health care expenses (considered to be part of employee compensation)

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PubH 6564

Private Purchasers of Health Care: Roles of Employers and Health Plans in the Care System

Fall 2014

Credits: 2

Meeting Days: Mondays. September 8 – December 8, 2014

Meeting Time: 1:25 – 3:20 PM

Meeting Place: W2-120 Weaver-Densford Hall

Instructor: Jon B. Christianson

Office Address: 15-225 Phillips Wangensteen Building

Office Phone: 612-625-3849

Fax: 612-624-2196

E-mail: [email protected]

Office Hours: By Appointment

I. Course Description

Payments received from private insurance companies, with these funds coming for the most part from employer contributions towards employee health care expenses (considered to be part of employee compensation) are critical to the financial survival of most health care providers. The purpose of this course is to help future health care managers understand the goals of their “best customers” and how health plans and employers pursue these goals. The course examines the role of employers and health plans in the health care system and, specifically, how the “payers of the bills” for health care develop and implement strategies to achieve their organizational and health care system goals. Topics covered include measurement of provider performance, health benefit design, provider network management, utilization management, payment strategies, and efforts directed at supporting consumers in their health care decisions (choice of treatment options and providers, management of chronic illnesses, and engagement in health promotion activities).

II. Course Prerequisites

Students must be admitted to the University of Minnesota’s Master in Healthcare Administration Program or have consent of the instructor.

III. Course Goals and Objectives

Specific goals and learning objectives are listed in for each class period.

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IV. Methods of Instruction and Work Expectations

Each class will include a didactic presentation on the part of the instructor; significant issues will be identified and discussed, referencing the readings for the class period. There are no “required” readings for the course. The “starred” readings are a good starting point for students to begin exploring each topic. The amount that students learn in this course, and their performance on assignments, will depend to a large degree on the time and effort they devote to the readings for each topic. In most class periods, students will present or discuss results from individual or group assignments. Students will be expected to prepare for each class by engaging with the readings prior to class, participating in the discussion during class, and completing group and individual assignments as scheduled. “Further” readings are provided as starting points for students who wish to explore specific topics in greater depth and to assist in the completion of individual and group assignments.

V. Course Text and Readings

1. To access readings click on link immediately following cite. If you have any problems accessing assigned readings online, contact Jane Raasch at [email protected]. If you do not have a University of Minnesota Internet ID and password, call 301-HELP and support staff will help you set up an account (or set up your own account at www.umn.edu/initiate and follow the directions.)

2. A PowerPoint lecture on the basics of health insurance is posted on the Moodle class website.

3. For each class session, overheads/PowerPoint slides and/or audio are posted on the Moodle class website for downloading and viewing. To learn more about Moodle, watch Moodle: Online Orientation for Students and/or visit the Moodle support website at http://www1.umn.edu/moodle/, which has a link for “Student support” with user guides, help and FAQs.

VI. Course Outline/Weekly Schedule

Date Module / Topics

Background

September 8 Employer Goals for the Health Care System and Their Strategies for Achieving Them

September 15, 22

Present State of America’s Health Insurance Industry

Presentation of Group Assignment 1 (10 pts.) – September 15

September 29 Measuring Provider Performance: The Foundation of Purchaser Strategies to Reform America’s Health Care System

Health Plans/Provider Relationships

October 6 Provider Contracting and Network Management

Discussion of Individual Assignment 1 (15 pts.)

October 13 Fundamentals of Provider Payment: Incentives and Rewards

October 20 New Payment Arrangements: Bundled/Episode-Based Payment


October 27 New Payment Arrangements: Global Contracts

November 3 Utilization Management and Cost Control


Health Plan/Enrollee Relationships

November 10 Supporting Employees/Enrollees in Choosing Providers: Reporting Provider Performance

November 17 Supporting Employees/Enrollees in Choosing Treatment Options


November 24 Supporting Employees/Enrollees in Maintaining and Improving Their Health

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Date Module / Topics

December 1 Supporting Employees/Enrollees in Managing Chronic Illnesses


December 8 What is on the Horizon for Purchasers and Health Plans?

Presentation of Group Assignment 2 (15 pts.)

BACKGROUND

September 8, 2014 Employer Goals for the Health Care System and Their Strategies for Achieving Them The two-decade period from the mid-1970s through the mid-1990s marked the ascendancy of a particular type of

health plan – the managed care organization in the private health care marketplace and also as a contractor to Medicare and Medicaid. Responding to pressures from employers and government to control health care costs, these organizations (in collaboration with risk-bearing provider systems) instituted a variety of "supply-side" mechanisms, financial and non-financial, to influence provider behavior. Accompanying steps were taken to manage access to care on the part of plan enrollees. The result, eventually, was "managed care backlash" on the part of consumers and providers, precipitated in part by a redefinition by employers of their health benefits’ objectives. In this first session, we will describe the transition over the past 15 years to a new paradigm of “managed” or “facilitated” consumerism, one that has much broader support among significant actors in the health care arena than traditional managed care. We will discuss how employers conceptualize this new, consumer-centric approach and the demands it places on health plans and consumers. Learning Objectives Students should be able to:

1. Describe the origins and evolution of managed care organizations. 2. Explain the origins and nature of the "managed care backlash" of the 1990s, and its influence on the

ongoing development of the new facilitated consumerism. 3. Explain the factors influencing present employer demands on the health care system, and the impact of

these demands on health plans, consumers, and America’s health care system as a whole.

Suggested Readings Employer Involvement in Health Care

1*. Christianson, J.B. “Managed care.” Encyclopedia of Health Economics, Elsevier, United Kingdom, forthcoming. (posted on Moodle).

2*. Galvin, R., Milstein, A. “Large employers’ new strategies in health care.” The New England Journal of Medicine 347(12):939-942, 2002. Available at: http://www.nejm.org/toc/nejm/347/12

3. Galvin, R.S. “Still in the game — Harnessing employer inventiveness in U.S. health care reform.” The New England Journal of Medicine 359(14):1421-1423, 2008. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp0805021

4. Reinhardt, U.E. “The illogic of employer-sponsored health insurance.” The New York Times, July 1, 2014. Available at: http://www.nytimes.com/2014/07/03/upshot/the-illogic-of-employer-sponsored-health-insurance.html?_r=0

Employer Strategies for the Health Care System 1*. Christianson, J.B., Ginsburg, P.B., Draper D.A. “The transition from managed care to consumerism: a

community-level status report.” Health Affairs 2008;27(5):1362-1370. Available at: http://content.healthaffairs.org/content/27/5/1362.full.pdf+html

2*. Millenson, M.L. “Paradigm, not pill: The new role of patient-centered care.” NIHCM Foundation, February 2014. Available at: http://www.nihcm.org/expert-voices-paradigm-not-pill-the-new-role-of-patient-centered-care

3. RAND Corporation. “Expanding consumer-directed health plans could help cut overall health care spending.” May 7, 2012. Available at: http://www.rand.org/news/press/2012/05/07/index1.html

http://www.nejm.org/toc/nejm/347/12http://www.nejm.org/doi/pdf/10.1056/NEJMp0805021http://www.nytimes.com/2014/07/03/upshot/the-illogic-of-employer-sponsored-health-insurance.html?_r=0http://www.nytimes.com/2014/07/03/upshot/the-illogic-of-employer-sponsored-health-insurance.html?_r=0http://content.healthaffairs.org/content/27/5/1362.full.pdf+htmlhttp://www.nihcm.org/expert-voices-paradigm-not-pill-the-new-role-of-patient-centered-carehttp://www.nihcm.org/expert-voices-paradigm-not-pill-the-new-role-of-patient-centered-carehttp://www.rand.org/news/press/2012/05/07/index1.html

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4. Robert Wood Johnson Foundation and Aligning Forces for Quality. “How employers can improve value and quality in health care.” January 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/how-employers-can-improve-value-and-quality-in-health-care.html

5. Thomas, S., O’Kane, M. “Value-based purchasing.” American Journal of Managed Care 18(11):750-752, 2012. Available at: http://web.b.ebscohost.com/ehost/results?sid=1da13801-2137-4624-a77e-4215ebf746de%40sessionmgr112&vid=2&hid=128&bquery=JN+%22American+Journal+of+Managed+Care%22+AND+DT+20121101&bdata=JmRiPWFwaCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZl

6. Goodell, S., Swartz, K. “Cost-sharing: Effects on spending and outcomes.” Policy Brief No. 20. Robert Wood Johnson Foundation Synthesis Project, December 2010. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf402103 Applications:

1) Murphy, T. “Humana CEO preaches power of health care consumer.” Seattle News online, February 24, 2011. Available at: http://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.html

2) Baker, S. “Employers shifting toward high-deductible healthcare plans.” The Hill, July 25, 2012. Available at: http://thehill.com/blogs/healthwatch/health-insurance/240089-employers-shifting-toward-high-deductible-healthcare-plans

3) Mathews, A.W. Big firms overhaul health coverage. The Wall Street Journal, September 26, 2012. Available at: http://search.proquest.com/docview/1080539311/fulltext/B955B17B662E4B74PQ/1?accountid=14586

4) Los Angeles Times. “CalPERS picks four new HMO plans for 5-year contracts” Los Angeles Times, April 17, 2013. Available at: http://articles.latimes.com/2013/apr/17/business/la-fi-calpers-hmo-changes-20130418

5) The New York Times. “Health care where you work.” September 2, 2012. Available at: http://www.nytimes.com/2012/09/03/opinion/health-care-where-you-work.html?_r=0

The Role of Self-Insurance 1*. Weaver, C., Methews, A.W. “One strategy for health-law costs: self insure.” The Wall Street Journal, May

27, 2013. Available at: http://online.wsj.com/article/SB10001424127887323336104578503130037072460.html

2. Lucia, K., Monahan, C., Corlette, S. “Cross-cutting issues: Factors affecting self-funding by small employers: Views from the market.” Princeton, NJ: Robert Wood Johnson Foundation, April 2013. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf405372 Applications:

1) Pear, R. “Some employers could opt out of insurance market, raising others’ costs.” The New York Times, February 17, 2013. Available at: http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-over-costs.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20130218&

2) Viebeck, E. Study: Self-insured health plans on the rise for private-sector employers. The Hill, November 28, 2012. Available at: http://thehill.com/blogs/healthwatch/health-insurance/269827-self-insured-health-plans-on-the-rise-study-finds

Employer Perspectives on Health Care Reform 1. Darling, H. “Health care reform: perspectives from large employers.” Health Affairs 2010;29(6):1220-1224.

Available at: http://content.healthaffairs.org/content/29/6/1220.full.pdf+html 2. Kliff, S. “Obamacare requires employers to offer insurance. What if it’s too expensive?” The Washington

Post, March 4, 2013. Available at: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/04/obamacare-requires-employers-to-offer-insurance-what-if-its-too-expensive/

3. Irwin, N. “Envisioning the end of employer-provided health plans.” The New York Times, May 1, 2014. Available at: http://www.nytimes.com/2014/05/01/upshot/employer-sponsored-health-insurance-may-be-on-the-way-out.html

4. Japsen, B. “Obamacare less threatening to private employer hiring.” Forbes, May 30, 2014. Available at: http://www.forbes.com/sites/brucejapsen/2014/05/30/obamacare-less-threatening-to-private-employer-hiring/

5. Hancock, J. “Employers eye moving sickest workers to insurance exchanges.” Kaiser Health News, May 7, 2014. Available at: http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx

http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/how-employers-can-improve-value-and-quality-in-health-care.htmlhttp://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/how-employers-can-improve-value-and-quality-in-health-care.htmlhttp://web.b.ebscohost.com/ehost/results?sid=1da13801-2137-4624-a77e-4215ebf746de%40sessionmgr112&vid=2&hid=128&bquery=JN+%22American+Journal+of+Managed+Care%22+AND+DT+20121101&bdata=JmRiPWFwaCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZlhttp://web.b.ebscohost.com/ehost/results?sid=1da13801-2137-4624-a77e-4215ebf746de%40sessionmgr112&vid=2&hid=128&bquery=JN+%22American+Journal+of+Managed+Care%22+AND+DT+20121101&bdata=JmRiPWFwaCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZlhttp://web.b.ebscohost.com/ehost/results?sid=1da13801-2137-4624-a77e-4215ebf746de%40sessionmgr112&vid=2&hid=128&bquery=JN+%22American+Journal+of+Managed+Care%22+AND+DT+20121101&bdata=JmRiPWFwaCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZlhttp://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf402103http://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.htmlhttp://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.htmlhttp://thehill.com/blogs/healthwatch/health-insurance/240089-employers-shifting-toward-high-deductible-healthcare-planshttp://thehill.com/blogs/healthwatch/health-insurance/240089-employers-shifting-toward-high-deductible-healthcare-planshttp://search.proquest.com/docview/1080539311/fulltext/B955B17B662E4B74PQ/1?accountid=14586http://search.proquest.com/docview/1080539311/fulltext/B955B17B662E4B74PQ/1?accountid=14586http://articles.latimes.com/2013/apr/17/business/la-fi-calpers-hmo-changes-20130418http://articles.latimes.com/2013/apr/17/business/la-fi-calpers-hmo-changes-20130418http://www.nytimes.com/2012/09/03/opinion/health-care-where-you-work.html?_r=0http://online.wsj.com/article/SB10001424127887323336104578503130037072460.htmlhttp://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf405372http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-over-costs.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20130218&http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-over-costs.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20130218&http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-over-costs.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20130218&http://thehill.com/blogs/healthwatch/health-insurance/269827-self-insured-health-plans-on-the-rise-study-findshttp://thehill.com/blogs/healthwatch/health-insurance/269827-self-insured-health-plans-on-the-rise-study-findshttp://content.healthaffairs.org/content/29/6/1220.full.pdf+htmlhttp://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/04/obamacare-requires-employers-to-offer-insurance-what-if-its-too-expensive/http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/04/obamacare-requires-employers-to-offer-insurance-what-if-its-too-expensive/http://www.nytimes.com/2014/05/01/upshot/employer-sponsored-health-insurance-may-be-on-the-way-out.htmlhttp://www.nytimes.com/2014/05/01/upshot/employer-sponsored-health-insurance-may-be-on-the-way-out.htmlhttp://www.forbes.com/sites/brucejapsen/2014/05/30/obamacare-less-threatening-to-private-employer-hiring/http://www.forbes.com/sites/brucejapsen/2014/05/30/obamacare-less-threatening-to-private-employer-hiring/http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspxhttp://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx

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Applications: 1) Hall, S.D. Survey: Most employers won’t drop health coverage. FierceHealthPayer, August 29,

2012. Available at: http://www.fiercehealthpayer.com/story/survey-most-employers-wont-drop-health-coverage/2012-08-29

Further Readings 1. Blumenthal, D. “Employer-sponsored health insurance in the United States – Origins and implications,”

New England Journal of Medicine 355(1):82-88, 2006. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060703

2. Blumenthal, D. “Employer-sponsored insurance – riding the health care tiger.” New England Journal of Medicine 355(2):195-202, 2006. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060704

3. Draper, D.A., Hurley, R.E., Lesser, C.S., Strunk, B.C. “The changing face of managed care.” Health Affairs 2002;21(1):11-23. Available at: http://content.healthaffairs.org/content/21/1/11.full.pdf+html

4. Hartocollis, A. “Insurer steps up fight to control health care cost.” The New York Times, January 25, 2010, p.A.1. Available at: http://www.nytimes.com/2010/01/25/health/policy/25insure.html?pagewanted=all&_r=0

5. Izlar, A.C. “The corporate role in reducing disparities: Initiatives under way at Verizon.” Health Affairs 30(10):1992-1996, 2011. Available at: http://content.healthaffairs.org/content/30/10/1992.full.pdf+html

6. PR Newswire. “New study shows lower costs, increased consumer engagement in account-based health plans.” Available at: http://www.prnewswire.com/news-releases/new-study-shows-lower-costs-increased-consumer-engagement-in-account-based-health-plans-58789467.html

7. Robinson, J.C., Ginsburg, P.B. “Consumer-driven health care: promise and performance.” Health Affairs 28(2):w272-w281 (published online 27 January 2009). Available at: http://content.healthaffairs.org/content/28/2/w272.full.pdf+html

8. Abraham, J.M., Graven, P., Feldman, R. “Employer-sponsored insurance and health reform: Doing the math.” National institute for Health Care Reform Research Issue Brief 11, December 2012. Available at: http://www.nihcr.org/ESI-and-Health-Reform

9. Buettgens, M., Blumberg, L.J. “Small firm self-insurance under the Affordable Care Act.” The Commonwealth Issue Brief, November 2012. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Nov/1647_Buettgens_small_firm_self_insurance_under_ACA_ib.pdf

September 15, 22, 2014 Present State of the Health Insurance Industry Health plans represent employer interests in the health care system, competing for contracts with employers. They structure their products and actions to gain and retain the business of employer clients, which is critical to their own financial success. In doing so, they provide a wide range of products and services in addition to traditional health insurance. In these two sessions, we trace the development of the health insurance industry and describe its current state. We discuss market concentration, premium setting, and differences among health plan products; describe how plans are evaluated by employers and consumers; and discuss public perceptions of the health insurance industry.

Learning Objectives Students should be able to:

1. Describe the structure of the health insurance industry 2. Distinguish among different types of health plans and health plan products. 3. Explain how employers assess health plan performance and choose among health plans. 4. Identify major current issues relating to health plan performance from the perspective of employers and

the public.

Suggested Readings Overview of the Private Health Insurance Market

1*. Austin, D.A., Hungerford, T.L. “The market structure of the health insurance industry.” Congressional Research Service Report #R40834, April 8, 2010. Available at: http://www.fas.org/sgp/crs/misc/R40834.pdf

2*. Fleming, C. “Employer-sponsored family health premiums rise a modest 4 percent in 2013.” Health Affairs Blog posted August 20, 2013. Available at: http://healthaffairs.org/blog/2013/08/20/employer-sponsored-family-health-premiums-rise-a-modest-4-percent-in-2013/

http://www.fiercehealthpayer.com/story/survey-most-employers-wont-drop-health-coverage/2012-08-29http://www.fiercehealthpayer.com/story/survey-most-employers-wont-drop-health-coverage/2012-08-29http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060703http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060704http://content.healthaffairs.org/content/21/1/11.full.pdf+htmlhttp://www.nytimes.com/2010/01/25/health/policy/25insure.html?pagewanted=all&_r=0http://content.healthaffairs.org/content/30/10/1992.full.pdf+htmlhttp://www.prnewswire.com/news-releases/new-study-shows-lower-costs-increased-consumer-engagement-in-account-based-health-plans-58789467.htmlhttp://www.prnewswire.com/news-releases/new-study-shows-lower-costs-increased-consumer-engagement-in-account-based-health-plans-58789467.htmlhttp://content.healthaffairs.org/content/28/2/w272.full.pdf+htmlhttp://www.nihcr.org/ESI-and-Health-Reformhttp://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Nov/1647_Buettgens_small_firm_self_insurance_under_ACA_ib.pdfhttp://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Nov/1647_Buettgens_small_firm_self_insurance_under_ACA_ib.pdfhttp://www.fas.org/sgp/crs/misc/R40834.pdfhttp://healthaffairs.org/blog/2013/08/20/employer-sponsored-family-health-premiums-rise-a-modest-4-percent-in-2013/http://healthaffairs.org/blog/2013/08/20/employer-sponsored-family-health-premiums-rise-a-modest-4-percent-in-2013/

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3*. American Medical Association. “New AMA study finds lack of competition among health insurers.” February 1, 2011. Available at: http://www.ama-assn.org/ama/pub/news/news/competition-health-insurers.page

4. Archer, D. “Private insurance is bankrupting Americans: Is Congress paying attention?” Health Affairs Blog, June 26, 2012. Available at: http://healthaffairs.org/blog/2012/06/26/private-insurance-is-bankrupting-americans-is-congress-paying-attention/

5. America’s Health Insurance Plans. “Medical loss ratio – What you need to know.” December 5, 2012. Available at: http://www.ahipcoverage.com/2012/12/05/medical-loss-ratio-what-you-need-to-know-2/

6. Editorial. “Mixed signals on employee health insurance.” The New York Times, August 25, 2013. Available at: http://search.proquest.com/docview/1427733086/fulltext/E96531C3A8F14A87PQ/1?accountid=14586

7. Mattke, S., VanBusum, K.R., Martsolf, G. “Final report: Evaluation of tools and metrics to support employer selection of health plans.” Santa Monica, CA: The RAND Corporation, 2014. Available at: http://www.rand.org/pubs/research_reports/RR327.html

Applications: 1) Manos, D. “Humana ranked top payer in 2013.” Healthcare IT News, June 26, 2013. Available at:

http://www.healthcareitnews.com/news/humana-ranked-top-payer-2013 2) Fellows, J. “Providers grade health plans. Guess who still stinks.” HealthLeaders Media, May 1,

2013. Available at: http://www.healthleadersmedia.com/page-1/HEP-291713/Providers-Grade-Health-Plans-Guess-Who-Still-Stinks

3) Wisenberg Brin, D. Blue Cross plans feeling pressure to consolidate; competition, high costs lead more to weigh for-profit conversions.” The Wall Street Journal, August 25, 2008, p.B.7. Available at: http://online.wsj.com/article/SB121963099177268101.html

4) Appleby, J. “Health insurance from both sides: KHN interview of Aetna CEO Bertolini.” Kaiser Health News, April 7, 2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/08/bertolini-aetna-q-and-a.aspx

5) Kliff, S. “Businesses think the growth of health insurance premiums is slowing. Yes, really.” Washington Post online, August 6,2012. Available at: http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/06/the-growth-of-health-insurance-premiums-is-slowing-yes-really/

6) Rabin, R.C., Some hospital networks also become insurers. The Washington Post, August 25, 2012. Available at: http://articles.washingtonpost.com/2012-08-25/business/35491800_1_private-insurers-insurance-product-hospital-systems

Products Offered by Health Plans 1.* Kulkarni, S.S. “FAQ on HSAs: The basics of health savings accounts.” Kaiser Health News, November

9, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/november/04/frequently-asked-questions-on-health-savings-accounts.aspx

2. Warner, J.P. “High deductible health plans with HSAs or HRAs.” August 25, 2010. Available at: http://www.warnerbenefits.com/file/forms/High_Deductible_Health_Plans_Explained.pdf

3. Sood, N., Wagner, Z., Huckfeldt, P., Haviland, A.M. “Price shopping in consumer-directed health plans.” Forum for Health Economics and Policy 16(1):35-53, 2013. Available at: http://www.degruyter.com/view/j/fhep.2013.16.issue-1/issue-files/fhep.2013.16.issue-1.xml

Applications: 1) Abelson, R. “High-end health plans scale back to avoid “cadillac tax.” The New York Times, May

27, 2013. Available at: http://www.nytimes.com/2013/05/28/business/cadillac-tax-health-insurance.html?pagewanted=all&_r=0

2) Weaver, C., Mathews, A.W. “Employers eye bare-bones health plans under new law.” The Wall Street Journal, May 19, 2013. Available at: http://online.wsj.com/public/resources/documents/Reprint_Samples.pdf

3) Andrews, M. “Some individual policies offer a way to shrink deductibles.” Kaiser Health News, May 21, 2013. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2013/052113-michelle-andrews-on-shrinking-deductibles.aspx

4) Blue Cross Blue Shield Minnesota. “No more one size fits all in choosing health care coverage.” March 22, 2012. Available at: http://www.bluecrossmn.com/bc/wcs/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=Latest&dDocName=POST71A_170724

Competitive Strategies of Health Plans 1.* Johnson, A. “Reforms prod insurers to diversify.” Wall Street Journal, May 12, 2011, p. B.1. Available at:

http://online.wsj.com/article/SB10001424052748703643104576291022457851278.html

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2. Brugh II, V,M., McCarthy, M. “Employer-sponsored medical clinics: much more than convenience care.” BenefitsLink.com, February 28, 2014. Available at: http://benefitslink.com/links/20140228-112098.html

3. Weaver, C. “Health insurers opening their own clinics to trim costs.” Kaiser Health News, May 4, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/may/04/insurers-turn-to-clinics-for-cost-control.aspx?referrer=search

Applications: 1) Miliard, M. “Aetna to cite Leapfrog safety scores.” Aetna News Hub, June 5, 2013. Available at:

http://newshub.aetna.com/press-release/health-care-professionals-and-networks/aetna-highlight-leapfrog-groups-hospital-safety

2) Health Care Service Corporation. “Health care consumers realize significant cost savings through benefits value advisor program.” The Wall Street Journal, April 18, 2013. Available at: http://online.wsj.com/article/PR-CO-20130418-906054.html

3) UCare Media Release. “UCare honors high-performing health care providers at June 18 salute to excellence! event.” June 19, 2013. Available at: http://www.ucare.org/SiteCollectionDocuments/Media/20130618_UCare-P4P-event.pdf

4) Irwin, G. Topdjian, J., Kaura, A. “Putting an I in healthcare.” Strategy+Business, February 18, 2013. Available at: http://www.strategy-business.com/article/00167?gko=80904

5) Von Bergen, J.M. “Independence Blue Cross and Michigan insurer to expand into Medicaid market.” Philly.com, August 10, 2011. Available at: http://articles.philly.com/2011-08-10/business/29872468_1_medicaid-market-medicaid-business-independence-blue-cross

6) Weaver, C. “Managed care enters the exam room as insurers buy doctor groups.” Kaiser Health News, July 1, 2011. Available at: http://www.kaiserhealthnews.org/daily-reports/2011/july/05/1khn-story.aspx?referrer=search

7) Daily Finance. Cigna’s gains on health plan quality report card reflect improved health and well-being of customers. October 30, 2012. Available at: http://www.dailyfinance.com/2012/10/30/cignas-gains-on-health-plan-quality-report-card-re/

8) Reuters. Health insurers begin to provide user-friendly plan guides. September 24, 2012. Available at: http://www.reuters.com/article/2012/09/24/us-usa-healthcare-insurance-idUSBRE88N0Y620120924

9) Wall, J.K. WellPoint spends $50M to burnish brand. Indianapolis Business News, September 17, 2012. Available at: http://www.ibj.com/wellpoint-spends--50m-to-burnish-brand/PARAMS/article/36730

10) Blue Cross Blue Shield of Michigan. “Blue Cross Blue Shield of Michigan saves an estimated $155 million over three years from patient-centered medical home program.” Press Release, July 8, 2013. Available at: http://www.bcbsm.com/content/microsites/blue-cross-blue-shield-of-michigan-news/en/index/news-releases/2013/july-2013/bcbsm-saves-155-million-pcmh.html

11) Nussbaum, A. “WellPoint to acquire Amerigroup for $4.9 billion. Bloomberg, July 9, 2012. Available at: http://www.bloomberg.com/news/2012-07-09/wellpoint-to-buy-amerigroup-for-4-9-billion-in-cash.html

12) De La Merced, M.J. “Aetna agrees to buy Coventry in $5.7 billion deal.” New York Times online, August 20, 2012. Available at: http://dealbook.nytimes.com/2012/08/20/aetna-is-said-to-strike-deal-for-coventry-health-for-5-7-billion/

13) Business Wire. “Priority Health opens one-stop insurance shops throughout Michigan to better serve residents.” October 11, 2013. Available at: http://www.priorityhealth.com/about-us/press-room/releases/2013/information-centers-open

14) BusinessWire. “Anthem Blue Cross and Blue Shield in Indiana committed more than $8 million to health improvement causes in 2013.” March 10, 2014. Available at: http://www.businesswire.com/news/home/20140310006246/en/Anthem-Blue-Cross-Blue-Shield-Indiana-Committed

15) Walgreens. “All Take Care health employer-based worksite health centers accredited as patient-centered medical homes from the Accreditation Association for Ambulatory Health Care (AAAHC).” February 19, 2014. Available at: http://news.walgreens.com/article_display.cfm?article_id=5853

16) BusinessWire. “Humana announces new corporate social responsibility goals and issues report on recent progress.” April 17, 2014. Available at: http://humana.newshq.businesswire.com/press-release/current-releases/humana-announces-new-corporate-social-responsibility-goals-and-issues

17) Aetna. “Aetna to acquire the InterGlobal Group.” November 25, 2013. Available at: http://www.aetnainternational.com/ai/en/news/2013/11-2013-interglobal

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18) Abelson, R. “UnitedHealth, an insurer switching roles, helps hospitals on Medicare billing.” The New York Times, June 30, 2014. Available at: http://search.proquest.com/docview/1541595410/fulltext/2FB1BB299321491CPQ/1?accountid=14586

19) PR Newswire. “Blue Cross Blue Shield of Michigan continues providing funding for free clinics to help strengthen Michigan’s health care safety net.” June 12, 2013. Available at: http://www.prnewswire.com/news-releases/blue-cross-blue-shield-of-michigan-continues-providing-funding-for-free-clinics-to-help-strengthen-michigans-health-care-safety-net-211270581.html

20) Business Wire. “Cigna and the Cigna Foundation provide weekend meals to Hamilton Elementary School students as part of Blessings in a Backpack program.” March 12, 2014. Available at: http://newsroom.cigna.com/NewsReleases/cigna-and-the-cigna-foundation-provide-weekend-meals-to-hamilton-elementary-school-students-as-part-of-blessings-in-a-backpack-program.htm

Issues Relating to Health Plan Behavior and Performance 1*. Cohn, J. “How Blue Cross became part of a dysfunctional health care system.” Kaiser Health News,

March 8, 2010. Available at: http://www.kaiserhealthnews.org/columns/2010/march/030810cohn.aspx?referrer=search

2*. Drew, L.W. “Finding a path through the health insurance market ‘gobbledygook’” Kaiser Health News, April 21, 2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/22/insurance-black-hole.aspx

3*. United Press International. “Consumers give healthcare plans low marks.” February 20, 2012. Available at: http://www.upi.com/Health_News/2012/02/20/Consumers-give-healthcare-plans-low-marks/UPI-17301329785602/

4. Cantlupe, J. “More employers unhappy with health insurers, says PWC study.” HealthLeaders Media, January 19, 2010. Available at: http://healthplans.hcpro.com/content.cfm?topic=HEP&content_id=245127

5. Andrews, M. “Some plans skew drug benefits to drive away patients, advocates warn.” Kaiser Health News, July 8, 2014. Available at: http://www.kaiserhealthnews.org/stories/2014/july/08/some-plans-skew-drug-benefits-to-drive-away-patients-advocates-warn.aspx

6. Appleby, J. “Lawsuit accuses Anthem Blue Cross of ‘fraudulent’ enrollment practices.” Kaiser Health News, July 9, 2014. Available at: http://www.kaiserhealthnews.org/stories/2014/july/09/anthem-lawsuit-over-enrollment-practices.aspx?referrer=search

7. Hancock, J. “Who really pays for health care might surprise you.” Kaiser Health News, April 30, 2014. Available at: http://www.kaiserhealthnews.org/stories/2014/april/30/five-misconceptions.aspx?referrer=search

8. J.D. Power. “Concerns about not having enough health coverage drive down member satisfaction.” March 10, 2014. Available at: http://www.jdpower.com/press-releases/2014-member-health-plan-study Applications:

1)* Terhune, C. “Kaiser’s rising premiums spark employer backlash.” Los Angeles Times, July 25, 2013. Available at: http://articles.latimes.com/2013/jul/25/business/la-fi-kaiser-cost-backlash-20130725

2)* Appleby, J. “Analyst: Nonprofit Blues have huge reserves.” Kaiser Health News, June 29, 2011. Available at: http://capsules.kaiserhealthnews.org/index.php/2011/06/analyst-nonprofit-blues-have-huge-reserves/?referrer=search

3) Terhune, C. “Blue Shield, Anthem owe small firms millions of dollars in rebates.” Los Angeles Times, June 4, 2013. Available at: Overland, D. “Blue Cross $991M surplus draws criticism, fear of monopoly. FierceHealthPayer, August 10, 2012. Available at: http://www.fiercehealthpayer.com/story/blue-cross-991m-surplus-draws-criticism-fear-monopoly/2012-08-10

4) Scolforo. M. “Pa. regulators probe health insurers’ practices.” The Associated Press, 2010. Available at: http://www.boston.com/business/healthcare/articles/2010/06/09/pa_regulators_probe_health_insurers_practices/

5) Mathews, A.W. “Insurer sets earnings cap” Wall Street Journal, June 8, 2011, p. B.1. Available at: http://online.wsj.com/article/SB10001424052702304906004576371902333544990.html

6) Snowbeck, C. “HMO cash cushions at issue in Minnesota legislature.” TwinCities.com, March 10, 2012. Available at: http://www.twincities.com/localnews/ci_20141316/minnesota-health-care-hmo-cash-cushions-at-issue

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7) Lee, D. “Worries grow as healthcare firms send jobs overseas.” Los Angeles Times online, July 25, 2012, Available at: http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725

8) Murphy, T. “Aetna chairman, CEO compensation climbs 26 pct.” The Big Story, April 8, 2013. Available at: http://bigstory.ap.org/article/aetna-chairman-ceo-compensation-climbs-26-pct

9) Terhune, C. BlueShield of California will return $50 million to customers. Los Angeles Times, October 31, 2012. Available at: http://articles.latimes.com/2012/oct/31/business/la-fi-blue-shield-credits-20121031

10) Reuters. LA doctors, patients sue Health Net for denying claims. September 13, 2012. Available at: http://www.reuters.com/article/2012/09/13/us-healthnet-lawsuit-idUSBRE88C19T20120913

11) Lazarus, D. “When health insurers play games, patients lose.” Los Angeles Times, April 17, 2014. Available at: http://www.latimes.com/business/la-fi-lazarus-20140418-column.html

The Health Insurance Industry and Health Reform 1*. Emanuel E.J., Liebman, J.F. “The end of health insurance companies.” New York Times online, January

30, 2012. Available at: http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/

2*. Cohn, J. “Obamacare is working, but some insurers are behaving badly.” New Republic, July 10, 2014. Available at: http://www.newrepublic.com/article/118638/obamacare-reduces-uninsured-some-insurers-behaving-badly

3*. Tribble S.J. “Temporary fee on big businesses funds Obamacare.” Kaiser Health News, May 22, 2014. Available at: http://www.kaiserhealthnews.org/Stories/2014/May/22/fee-on-big-business-funds-Obamacare.aspx

4*. Cunningham, P.W., Cheney, K. “Why liberals are abandoning the Obamacare employer mandate.” Politico, July 6, 2014. Available at: http://www.politico.com/story/2014/07/obamacare-employer-mandate-108578.html

5. Pear, T. “Obama and insurers join to cut health care fraud.” New York Times online, July 25, 2012. Available at: http://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.html

6. Zamosky, L. Healthcare reform law to usher in new age of consumerism. Los Angeles Times, September 8, 2012. Available at: http://articles.latimes.com/2012/sep/08/business/la-fi-future-of-health-insurance-20120908

7. Cunningham, P.W. “Mandate delay a ‘full-time’ headache for employers.” Politico, July 15, 2013. Available at: http://www.politico.com/story/2013/07/obamacare-mandate-delay-muddles-workweek-94131.html

8. Weaver, C. “Health insurers respond to reform by snapping up less-regulated businesses.” Kaiser Health News, March 19, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/march/20/health-insurers-reform-business.aspx

9. Harrington, S.E., Weiner, J. “Deciphering the data: Health insurance rates and rate review.” Robert Wood Johnson Foundation, June 2014. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414107

10. Abelson, R. “Insurers once on the fence plan to join health exchanges in ’15.” The New York Times, May 25, 2014. Available at: http://search.proquest.com/docview/1528455998/fulltext/5BC44DD634994309PQ/1?accountid=14586 ‘

11. Hancock, J. “Can employers dump workers to health exchanges? Yes, for a price.” Kaiser Health News Blog, May 28, 2014. Available at: http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)

12. Wayne, A. “Insurers joining more Obamacare exchanges for new year.” Bloomberg, May 17, 2014. Available at: http://www.bloomberg.com/news/2014-05-16/insurers-joining-more-obamacare-exchanges-for-next-year.html

13. Khimm, S. “The bigger question behind Hobby Lobby.” msnbc.com, July 7, 2014. Available at: http://www.msnbc.com/msnbc/the-bigger-question-behind-hobby-lobby

14. Wharam, J.F., Ross-Degnan, D., Rosenthal, M.B. “The ACA and high-deductible insurance — Strategies for sharpening a blunt instrument.” New England Journal of Medicine 2013;369(16):1481-1484 . Available at: http://www.nejm.org/toc/nejm/369/16

http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725http://bigstory.ap.org/article/aetna-chairman-ceo-compensation-climbs-26-pcthttp://articles.latimes.com/2012/oct/31/business/la-fi-blue-shield-credits-20121031http://articles.latimes.com/2012/oct/31/business/la-fi-blue-shield-credits-20121031http://www.reuters.com/article/2012/09/13/us-healthnet-lawsuit-idUSBRE88C19T20120913http://www.latimes.com/business/la-fi-lazarus-20140418-column.htmlhttp://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/http://www.newrepublic.com/article/118638/obamacare-reduces-uninsured-some-insurers-behaving-badlyhttp://www.newrepublic.com/article/118638/obamacare-reduces-uninsured-some-insurers-behaving-badlyhttp://www.kaiserhealthnews.org/Stories/2014/May/22/fee-on-big-business-funds-Obamacare.aspxhttp://www.kaiserhealthnews.org/Stories/2014/May/22/fee-on-big-business-funds-Obamacare.aspxhttp://www.politico.com/story/2014/07/obamacare-employer-mandate-108578.htmlhttp://www.politico.com/story/2014/07/obamacare-employer-mandate-108578.htmlhttp://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.htmlhttp://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.htmlhttp://articles.latimes.com/2012/sep/08/business/la-fi-future-of-health-insurance-20120908http://articles.latimes.com/2012/sep/08/business/la-fi-future-of-health-insurance-20120908http://www.politico.com/story/2013/07/obamacare-mandate-delay-muddles-workweek-94131.htmlhttp://www.politico.com/story/2013/07/obamacare-mandate-delay-muddles-workweek-94131.htmlhttp://www.kaiserhealthnews.org/stories/2011/march/20/health-insurers-reform-business.aspxhttp://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414107http://search.proquest.com/docview/1528455998/fulltext/5BC44DD634994309PQ/1?accountid=14586http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)http://www.bloomberg.com/news/2014-05-16/insurers-joining-more-obamacare-exchanges-for-next-year.htmlhttp://www.bloomberg.com/news/2014-05-16/insurers-joining-more-obamacare-exchanges-for-next-year.htmlhttp://www.msnbc.com/msnbc/the-bigger-question-behind-hobby-lobbyhttp://www.nejm.org/toc/nejm/369/16

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Applications: 1) Hancock, J. “Blue Cross-Blue Shield bets big on Obamacare exchanges.” Kaiser Health News,

June 21, 2013. Available at: http://www.kaiserhealthnews.org/stories/2013/june/21/obama-administration-blue-cross-blue-shield-insurance-exchanges-marketplaces.aspx

2) Overland, D. “Cigna opts out of Connecticut insurance exchange.” FierceHealthPayer, March 6, 2013. Available at: http://www.fiercehealthpayer.com/story/cigna-opts-out-connecticut-health-insurance-exchange/2013-03-06

3) Terhune, C. “Blue Shield and Aetna to raise healthcare rates over state objections.” Los Angeles Times, March 6, 2013. Available at: http://articles.latimes.com/2013/mar/06/business/la-fi-health-insure-rates-20130307

4) Bernard-Kuhn, L. “Businesses tackle the Obamacare equation.” USA Today, June 30, 2014. Available at: http://www.usatoday.com/story/money/business/2014/06/30/businesses-obamacare-costs/11822841/

Further Readings

1. Andrews, M. “Appealing an insurer’s denial is often a good strategy.” Kaiser Health News, June 20, 2011. Available at: http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspx

2. Draaghtel, K. “Maximizing your competitive advantage with predictive modeling and consumer data.” Milliman, April 6, 2012. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/rsa-03-2012.pdf

3. eValue8 Health Care. “eValue8 2009: Measuring progress toward value-based purchasing.” Available at: http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000640/Evalue8%202009%20Annual%20Report.pdf

4. Girion, L. “Health insurer tied bonuses to dropping sick policyholders.” The Los Angeles Times, November 9, 2007, p.A.1. Available at: http://www.latimes.com/business/la-fi-insure9nov09,0,3065397,full.story?coll=la-home-center

5. Haviland, A.M., Marquis, M.S., McDevitt, R.D., Sood, N. “Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually.” Health Affairs 31(5):1009-1015, 2012. Available at: http://content.healthaffairs.org/content/31/5/1009.full.pdf+html

6. Jaffe, S. “Consumers may be unaware of their right to a review of health plan decisions.” Kaiser Health News, June 10, 2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/June/10/external-appeals.aspx

7. Mathews, A.W., Kamp, J. Humana brings doctors in-house. The Wall Street Journal, November 5, 2012. Available at: http://online.wsj.com/article/SB10001424052970203347104578100774135846646.html

8. Overland, D. “Excellus defends proposed rate hikes despite big case reserves.” FierceHealthPayer, July 22, 2012. Available at: http://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22

9. Redig, A.J. “Adventures in (health-insurance-claim) wonderland.” Health Affairs 2009;28(5):1515-1520. Available at: http://content.healthaffairs.org/content/28/5/1515.full.pdf+html

10. Robinson, J.C. “Consolidation and the transformation of competition in health insurance.” Health Affairs 2004;23(6):11-24. Available at: http://content.healthaffairs.org/content/23/6/11.full.pdf+html

11. Shannon, M. Turning consumers into shoppers: Using high-deductible plans wisely. Health Affairs Blog, October 18, 2012. Available at: http://healthaffairs.org/blog/2012/10/18/turning-consumers-into-shoppers-using-high-deductible-plans-wisely/

September 29, 2014 Measuring Provider Performance: The Foundation for Network Management, Provider Payment and Public Reporting Efforts Efforts on the part of health plans and employers to measure provider performance have intensified over the past decade, with performance measurement assuming a key role in almost all private sector health care strategies. Health plans construct or employ measures of performance to: select providers for inclusion in networks; create tiered networks; structure provider incentive payments; and produce provider performance reports for their members. These measures also can be used in disease management and wellness programs. The way in which performance measures are constructed and used has been a point of contention between employers/health plans and providers. Consumers also have criticized these measures as lacking in relevance for their decision making.

http://www.kaiserhealthnews.org/stories/2013/june/21/obama-administration-blue-cross-blue-shield-insurance-exchanges-marketplaces.aspxhttp://www.kaiserhealthnews.org/stories/2013/june/21/obama-administration-blue-cross-blue-shield-insurance-exchanges-marketplaces.aspxhttp://www.fiercehealthpayer.com/story/cigna-opts-out-connecticut-health-insurance-exchange/2013-03-06http://www.fiercehealthpayer.com/story/cigna-opts-out-connecticut-health-insurance-exchange/2013-03-06http://articles.latimes.com/2013/mar/06/business/la-fi-health-insure-rates-20130307http://articles.latimes.com/2013/mar/06/business/la-fi-health-insure-rates-20130307http://www.usatoday.com/story/money/business/2014/06/30/businesses-obamacare-costs/11822841/http://www.usatoday.com/story/money/business/2014/06/30/businesses-obamacare-costs/11822841/http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspxhttp://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspxhttp://publications.milliman.com/periodicals/rsa/pdfs/rsa-03-2012.pdfhttp://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000640/Evalue8%202009%20Annual%20Report.pdfhttp://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000640/Evalue8%202009%20Annual%20Report.pdfhttp://www.latimes.com/business/la-fi-insure9nov09,0,3065397,full.story?coll=la-home-centerhttp://www.latimes.com/business/la-fi-insure9nov09,0,3065397,full.story?coll=la-home-centerhttp://content.healthaffairs.org/content/31/5/1009.full.pdf+htmlhttp://www.kaiserhealthnews.org/Stories/2011/June/10/external-appeals.aspxhttp://www.kaiserhealthnews.org/Stories/2011/June/10/external-appeals.aspxhttp://online.wsj.com/article/SB10001424052970203347104578100774135846646.htmlhttp://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22http://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22http://content.healthaffairs.org/content/28/5/1515.full.pdf+htmlhttp://content.healthaffairs.org/content/23/6/11.full.pdf+htmlhttp://healthaffairs.org/blog/2012/10/18/turning-consumers-into-shoppers-using-high-deductible-plans-wisely/http://healthaffairs.org/blog/2012/10/18/turning-consumers-into-shoppers-using-high-deductible-plans-wisely/

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In this session, we describe attempts by employers and health plans to measure provider performance, common issues in measure construction, the use of “risk-adjustment” techniques, and alternatives for attributing patients to providers.


1. Describe and contrast different approaches to performance measurement. 2. Discuss strengths and weaknesses of these approaches. 3. Discuss the role of risk adjustment techniques in measure construction and how they are applied. 4. Discuss different alternatives for attributing patients to providers for measurement purposes. 5. Contrast how measurement challenges differ for quality vs. cost/efficiency measures.

Suggested Readings The Basics of Provider Performance Measurement

1*. Berenson, R.A., Pronovost, P.J., Krumholz, H.M. “Achieving the potential of health care performance measures. Timely analysis of immediate health policy issues.” Robert Wood Johnson Foundation, May 30, 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-the-potential-of-health-care-performance-measures.html

2*. Berenson, R. “Seven policy recommendations to improve quality measurement.” Health Affairs Blog, May 22, 2013. Available at: http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/

3*. National Quality Forum. “The ABCs of measurement.” Available at: http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx

4. Damberg, C.L., Sorbero, M.E., Lovejoy, S.L., et al. An Evaluation of the Use of Performance Measures In Health Care. Santa Monica, CA: RAND Corporation, 2011. Available at: http://www.rand.org/pubs/technical_reports/TR1148.html

5. Pronovost, P.J., Lilford, R. “A road map for improving the performance of performance measures.” Health Affairs 2011;30(4):569-573. Available at: http://content.healthaffairs.org/content/30/4/569.full.pdf+html

6. National Quality Forum. Mission and vision. Available at: http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx

Importance of Risk Adjustment in Performance Measurement 1*. Schone, E., Brown, R.W., Goodell, S. “Risk adjustment: What is the current state of the art, and how can

it be improved.” Policy Brief No. 25, Robert Wood Johnson Foundation Synthesis Project, July 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/07/risk-adjustment---what-is-the-current-state-of-the-art-and-how-c.html

1. Draaghtel, K. “Concurrent risk adjustment.” Milliman, January, 2012. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/rsa-01-2012.pdf

2. Martin, K., Rogal, D.L., Arnold, S.B. Health-based risk assessment: Risk-adjusted payments and beyond. AcademyHealth. Available at: http://www.hcfo.org/pdf/riskadjustment.pdf Applications:

1. Draaghtel, K. “Milliman advanced risk adjuster, MARA.” Milliman, February 2010. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/coming-soon-milliman-advanced.pdf

2. Milliman. Milliman Advanced Risk Adjuster (MARA): Predictive value of inpatient risk score. November 2011. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/milliman-advanced-risk-adjuster.pdf

Challenges in Measuring Provider Quality 1*. Mathias, J.S., Baker, D.W. “Developing quality measures to address overuse.” Journal of the American

Medical Association 309(18):1897-1898, 2013. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926917&direction=P

2*. Berenson, R. A. “Moving payment from volume to value: What role for performance measurement?” Washington, DC: Urban Institute, December 2010. Available at: http://www.rwjf.org/files/research/71568full.pdf

3. Conway, P.H. Mostashari, F., Clancy, C. “The future of quality measurement for improvement and accountability.” Journal of the American Medical Association 309(21):2215-2216, 2013. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P

4. Kupfer, J.M. “The morality of using mortality as a financial incentive. Unintended consequences and implications for acute hospital care.” Journal of the American Medical Association 309(21):2213-2214, 2013. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P

http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-the-potential-of-health-care-performance-measures.htmlhttp://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-the-potential-of-health-care-performance-measures.htmlhttp://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspxhttp://www.rand.org/pubs/technical_reports/TR1148.htmlhttp://content.healthaffairs.org/content/30/4/569.full.pdf+htmlhttp://www.qualityforum.org/About_NQF/Mission_and_Vision.aspxhttp://www.rwjf.org/en/research-publications/find-rwjf-research/2013/07/risk-adjustment---what-is-the-current-state-of-the-art-and-how-c.htmlhttp://www.rwjf.org/en/research-publications/find-rwjf-research/2013/07/risk-adjustment---what-is-the-current-state-of-the-art-and-how-c.htmlhttp://publications.milliman.com/periodicals/rsa/pdfs/rsa-01-2012.pdfhttp://www.hcfo.org/pdf/riskadjustment.pdfhttp://publications.milliman.com/periodicals/rsa/pdfs/coming-soon-milliman-advanced.pdfhttp://publications.milliman.com/periodicals/rsa/pdfs/milliman-advanced-risk-adjuster.pdfhttp://publications.milliman.com/periodicals/rsa/pdfs/milliman-advanced-risk-adjuster.pdfhttp://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926917&direction=Phttp://www.rwjf.org/files/research/71568full.pdfhttp://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=Phttp://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P

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5. Wood, D.L. “Measure health, not care.” Minnesota Medicine, April 2012. Available at: http://www.minnesotamedicine.com/PastIssues/April2012.aspx

6. Stefan, M.S., Pekow, P.S., Nsa, W., et al. “Hospital performance measures and 30-day readmission rates.” Journal of General Internal Medicine 28(3):377-385, 2013. Available at: http://link.springer.com/content/pdf/10.1007%2Fs11606-012-2229-8.pdf

7. Nyweide, D.J., Weeks, W.B., Gottlieb, D.J. “Relationship of primary care physicians’ patient caseload with measurement of quality and cost performance.” Journal of the American Medical Association 2009;302(22)2444-2450. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4491&direction=P

8. Rosof, B. The importance of accurate data in quality –of-care measurement (Editorial). Annals of Internal Medicine 2012;157(5):379-380. Available at: http://annals.org/issue.aspx?journalid=90&issueID=24808&direction=P

9. Higgins, A., Veselovskiy, G., McKown, L. “Provider performance measures in private and public programs: Achieving meaningful alignment with flexibility to innovate.” Health Affairs 2013;32(8):1453-1461. Available at: http://content.healthaffairs.org/content/32/8/1453.full.pdf+html

10. McGinnis, T., Newman, J. “Advances in multi-payer alignment: State approaches to aligning performance metrics across public and private payers.” Milbank Memorial Fund, July 2014. Available at: http://www.milbank.org/uploads/documents/MultiPayerHealthCare_WhitePaper_071014.pdf Applications:

1) Neuman, H.B., Michelassi, F., Turner, J.W., Bass, B.L. “Surrounded by quality metrics: what do surgeons think of ACS-NSQIP?” Surgery 2009;149(1):27-33. Available at: https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0-S0039606008X00133"],"issn":"00396060","contentType":"Journals"}

2) Cheung, K. “AHA report: Not all readmissions avoidable, ‘ill-suited’ quality indicator.” Fierce Healthcare, September 15, 2011. Available at: http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator/2011-09-15

3) Overland, D. Minnesota health plan releases doctor ratings despite opposition. FierceHealthPayer, January 20, 2011. Available at: http://www.fiercehealthpayer.com/story/minnesota-health-plan-releases-doctor-ratings-despite-opposition/2011-01-20

Challenges in Measuring Provider Prices, Costs and Efficiency 1*. Robinson, R.C., Williams, T., Yanagihara, D. “Measurement of and reward for efficiency in California’s

pay-for-performance program.” Health Affairs 2009;28(5):1438-1447. Available at: http://content.healthaffairs.org/content/28/5/1438.full.pdf+html

2*. Painter, M.W., Chernew, M.E. “Counting change: Measuring health care prices, costs, and spending.” Robert Wood Johnson Foundation, March 2012. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=74078

3. Romley, J.A., Hussey, P.S., de Vries, H., Wang, M.C., Shekelle, P.G., McGlynn, E.A. “Efficiency and its measurement: what practitioners need to know.” American Journal of Managed Care 2009;15(11):842-845. Available at: http://www.ajmc.com/publications/issue/2009/2009-11-vol15-n11/AJMC_09Nov_Romley_842to845/

4. McIntyre, A. “Solving the mystery of health-care prices could save $100 billion.” Vox, May 21, 2014. Available at: http://www.vox.com/2014/5/21/5723452/could-more-price-transparency-in-health-care-really-save-100-billion

Applications: 1) Alltucker, K. “Auction website lets patients suggest prices.” azcentral.com, June 16, 2012.

Available at: http://www.azcentral.com/business/articles/20120614medical-care-auction.html Challenges in Measuring Patient Experience

1*. Browne, K., Roseman, D., Shaller, D., Edgman-Levitan, S. “Analysis and Commentary. Measuring patient experience as a strategy for improving primary care.” Health Affairs 2010;29(5):921-925. Available at: http://content.healthaffairs.org/content/29/5.toc

Further Readings 1. Higgins, A., Zeddies, T., Pearson, S.D. “Measuring the performance of individual physicians by collecting

data from multiple health plans: The results of a two-state test.” Health Affairs 2011;30(4):673-681. Available at: http://content.healthaffairs.org/content/30/4/673.full.pdf+html

2. Hoefer, T.P., Hayward, R.A., Greenfield, S., Wagner, E.H., Kaplan, S.H., Manning, W.G. “The unreliability of individual physician ‘report cards’ for assessing the costs and quality of care of a chronic disease.”

http://www.minnesotamedicine.com/PastIssues/April2012.aspxhttp://link.springer.com/content/pdf/10.1007%2Fs11606-012-2229-8.pdfhttp://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4491&direction=Phttp://annals.org/issue.aspx?journalid=90&issueID=24808&direction=Phttp://content.healthaffairs.org/content/32/8/1453.full.pdf+htmlhttp://www.milbank.org/uploads/documents/MultiPayerHealthCare_WhitePaper_071014.pdfhttps://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0-S0039606008X00133"],"issn":"00396060","contentType":"Journals"}https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0-S0039606008X00133"],"issn":"00396060","contentType":"Journals"}http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator/2011-09-15http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator/2011-09-15http://www.fiercehealthpayer.com/story/minnesota-health-plan-releases-doctor-ratings-despite-opposition/2011-01-20http://www.fiercehealthpayer.com/story/minnesota-health-plan-releases-doctor-ratings-despite-opposition/2011-01-20http://content.healthaffairs.org/content/28/5/1438.full.pdf+htmlhttp://www.rwjf.org/qualityequality/product.jsp?id=74078http://www.ajmc.com/publications/issue/2009/2009-11-vol15-n11/AJMC_09Nov_Romley_842to845/http://www.ajmc.com/publications/issue/2009/2009-11-vol15-n11/AJMC_09Nov_Romley_842to845/http://www.vox.com/2014/5/21/5723452/could-more-price-transparency-in-health-care-really-save-100-billionhttp://www.vox.com/2014/5/21/5723452/could-more-price-transparency-in-health-care-really-save-100-billionhttp://www.azcentral.com/business/articles/20120614medical-care-auction.htmlhttp://content.healthaffairs.org/content/29/5.tochttp://content.healthaffairs.org/content/30/4/673.full.pdf+html

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Journal of the American Medical Association 1999;281(22):2098-2105. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=P

3. Mehrotra, A., Adams, J.L., Thomas, J.W., McGlynn, E.A. “Is physician cost profiling ready for prime time?” RAND Research Brief, 2010. Available at: http://www.rand.org/pubs/research_briefs/RB9523/

4. Nelson, B. “Accurate Measures?” The Hospitalist, May 2011. Available at: http://www.the-hospitalist.org/details/article/1056003/Accurate_Measures.html

5. Nelson, E.C., Gentry, M.A., Mook, K.H., Spritzer, K.L., Higgins, J.H., Hays, R.D. “How many patients are needed to provide reliable evaluations of individual clinicians?” Medical Care 2004;42(3):259-266. Available at: http://www.jstor.org/stable/pdfplus/4640735.pdf?acceptTC=true

6. Romano, P., Hussey, P., Ritley, D. “Selecting quality and resource use measures: A decision guide for community quality collaboratives.” AHRQ Publication No. 09(10)-0073, May 2010. Available at: http://www.ahrq.gov/qual/perfmeasguide/

7. Scholle, S.H., Roski, J., Adams, J.L., Dunn, D.L., Kerr, E.A., Dugan, D.P., Jensen, R.E. “Benchmarking physician performance: reliability of individual and composite measures.” American Journal of Managed Care 2008;14(12):829-838. Available at: http://www.ajmc.com/publications/issue/2008/2008-12-vol14-n12/Dec08-3781p833-838/

8. Thomas, J.W., Grazier, K.L., Ward, K. “Economic profiling of primary care physicians: consistency among risk-adjusted measures.” HSR: Health Services Research 2004;39(4, Part I):985-1003. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2004.00268.x/pdf

9. Miller, T.P., Brennan, T.A., Milstein A. “How can we make more progress in measuring physicians’ performance to improve the value of care?” Health Affairs 28(5):1429-1437, 2009. Available at: http://content.healthaffairs.org/content/28/5/1429.full.pdf+html

10. National Committee on Quality Assurance. “HEDIS measure development process. Desirable attributes of HEDIS. HEDIS life cycle.” Available at: http://www.ncqa.org/tabid/414/Default.aspx

11. Dimick, J.B., Birkmeyer, N.J., Finks, J.F., et al. “Composite measures for profiling hospitals on bariatric surgery performance.” JAMA Surgery 149(1):10-16, 2014. Available at: http://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929681&direction=P

HEALTH PLAN/PROVIDER RELATIONSHIPS

October 6, 2014 Provider Contracting and Network Management A major factor in health plans’ success in securing employer contracts is their ability to negotiate favorable terms when contracting with providers and to effectively “manage” provider networks in ways that do not provoke enrollee “backlash”. In this session, we discuss the basics of provider contracting, including the way in which health plans and providers attempt to exert leverage in the contracting process. We also describe steps that health plans are taking to develop products based on subsets of “high performing” providers, and the reasons why this strategy has been controversial.


1. Discuss the nature of the contracting process from the health plan and provider perspectives. 2. Describe areas of friction between providers and plans that arise during the contracting process. 3. Discuss issues pertaining to tiered provider networks, narrow networks, and Centers of Excellence.

Suggested Readings Contents of Contracts Between Providers and Health Plans

1. CIGNA (posted on Moodle) Health Plan/Provider Leverage in the Contracting Process 1*. Berenson, R.A., Ginsburg, P.B., Christianson, J.B., Yee, T. “The growing power of some providers to win

steep payment increases from insurers suggests policy remedies may be needed.” Health Affairs 2012;31(5):973-981. Available at: http://content.healthaffairs.org/content/31/5/973.full.pdf+html

2*. Kocher, B., Emanuel E.J. Overcoming the pricing power of hospitals. Journal of the American Medical Association 2012;308(12):1213-1214. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=24967&direction=P

http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=Phttp://www.rand.org/pubs/research_briefs/RB9523/http://www.the-hospitalist.org/details/article/1056003/Accurate_Measures.htmlhttp://www.the-hospitalist.org/details/article/1056003/Accurate_Measures.htmlhttp://www.jstor.org/stable/pdfplus/4640735.pdf?acceptTC=truehttp://www.ahrq.gov/qual/perfmeasguide/http://www.ajmc.com/publications/issue/2008/2008-12-vol14-n12/Dec08-3781p833-838/http://www.ajmc.com/publications/issue/2008/2008-12-vol14-n12/Dec08-3781p833-838/http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2004.00268.x/pdfhttp://content.healthaffairs.org/content/28/5/1429.full.pdf+htmlhttp://www.ncqa.org/tabid/414/Default.aspxhttp://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929681&direction=Phttp://content.healthaffairs.org/content/31/5/973.full.pdf+htmlhttp://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=24967&direction=P

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3*. Ginsburg, P.B., Pawlson, L.G. “Seeking lower prices where providers are consolidated: An examination of market and policy strategies.” Health Affairs 33(6):1067-1075, 2014. Available at: http://content.healthaffairs.org/content/33/6.toc

4. Ginsburg, P.B. “Wide variation in hospital and physician payment rates evidence of provider market power.” Research Brief No. 16, November 2010. Washington, DC: Center for Studying Health System Change. Available at: http://www.hschange.com/CONTENT/1162/1162.pdf

5. Melnick, G.A., Shen, Y-C., Wu, V.Y. “The increased concentration of health plan markets can benefit consumers through lower hospital prices.” Health Affairs 2011;30(9):1728-1733. Available at: http://content.healthaffairs.org/content/30/9/1728.full.pdf+html

6. Baker, L., Bundorf, M.K., Royalty, A. “Private insurers’ payments for routine physician office visits vary substantially across the United States.” Health Affairs 2013;32(9):1583-1590. Available at: http://content.healthaffairs.org/content/32/9/1583.full.pdf+html

7. Vladeck, B.C. “Paradigm lost: Provider concentration and the failure of market theory.” Health Affairs 33(6):1083-1087, 2014. Available at: http://content.healthaffairs.org/content/33/6.toc

8. Seipel, T. “California doctors, insurers face off over reimbursement rates.” San Jose Mercury News, February 24, 2014. Available at: http://www.mercurynews.com/health/ci_25212839/doctors-insurers-face-off-over-reimbursement-rates

9. Frakt, A. “The future of health care costs: Hospital-insurer balance of power.” NIHCM Foundation, November 2010. Available at: http://www.nihcm.org/component/content/article/407

Applications: 1) Terhune, C. “Small surgeries, huge markups.” Los Angeles Times, January 31, 2013. Available

at: http://articles.latimes.com/2013/jan/31/business/la-fi-high-price-knee-20130131 2) Hancock, J. “Expert: Hospitals’ ‘humongous monopoly’ drives prices high.” Kaiser Health News,

March 4, 2013. Available at: http://capsules.kaiserhealthnews.org/?p=17379 3) Merritt, G. “Children’s Hospital, Anthem reach agreement after two-month standoff.” The CT

mirror, June 12, 2012. Available at: http://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreement

4) Terhune, C. “Many hospitals, doctors offer cash discount for medical bills.” Los Angeles Times online, May 27, 2012. Available at: http://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527

5) Lund-Muzikant. Providence severs contract with Health Net just as employers consider options for 2013. The Lund Report, September 20, 2012. Available at: http://www.thelundreport.org/resource/providence_severs_contract_with_health_net_just_as_employers_consider_options_for_2013

6) Editorial Board. “The risks of hospital mergers.” The New York Times, July 6, 2014. Available at: http://www.nytimes.com/2014/07/07/opinion/the-risks-of-hospital-mergers.html?_r=0

Tiered Networks, High Performance Networks, Narrow Networks, and Centers of Excellence 1*. Rabin, R.C. “Report faults high fees for out-of-network care.” The New York Times, January 31, 2013.

Available at: http://www.nytimes.com/2013/02/01/health/insurance-industry-report-faults-high-fees-for-out-of-network-care.html?_r=0

2*. Corlette, S., Volk, J., Berenson, R., Feder, J. “Changing provider networks in marketplace health plans: Balancing affordability and access to quality care.” Health Affairs Blog, June 11, 2014. Available at: http://healthaffairs.org/blog/2014/06/11/changing-provider-networks-in-marketplace-health-plans-balancing-affordability-and-access-to-quality-care/

3. Andrews, M. “When a plan overpays for a service, is a patient responsible for a refund.” Kaiser Health News, December 10, 2012. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2012/121112-michelle-andrews-overpayment.aspx

4. White, C., Reschovsky, J.D., Bond, A.M. “Understanding differences between high- and low-price hospitals: Implications for efforts to rein in costs.” Health Affairs 33(2):324-331, 2014. Available at: http://content.healthaffairs.org/content/33/2.toc

5. Abelson, R. “More insured, but the choices are narrowing.” The New York Times, May 12, 2014. Available at: http://search.proquest.com/docview/1523785309/fulltext/CA07C834B3AA4587PQ/1?accountid=14586

6. The Incidental Economist. “If plans are only offering narrow networks, blame information asymmetry.” May 29, 2014. Available at: http://theincidentaleconomist.com/wordpress/if-plans-are-only-offering-narrow-networks-blame-information-asymmetry/

7. Pacific Business Group on Health. Employers Centers of Excellence Network Program Summary. Available at: http://www.pbgh.org/storage/documents/ECEN_Program__Summary_314.pdf

8. Cheny, C. “Narrow provider networks set to spread.” HealthLeaders Media, July 15, 2014. Available at: http://www.healthleadersmedia.com/page-1/HEP-306360/Narrow-Provider-Networks-Set-to-Spread##

http://content.healthaffairs.org/content/33/6.tochttp://www.hschange.com/CONTENT/1162/1162.pdfhttp://content.healthaffairs.org/content/30/9/1728.full.pdf+htmlhttp://content.healthaffairs.org/content/32/9/1583.full.pdf+htmlhttp://content.healthaffairs.org/content/33/6.tochttp://www.mercurynews.com/health/ci_25212839/doctors-insurers-face-off-over-reimbursement-rateshttp://www.mercurynews.com/health/ci_25212839/doctors-insurers-face-off-over-reimbursement-rateshttp://www.nihcm.org/component/content/article/407http://articles.latimes.com/2013/jan/31/business/la-fi-high-price-knee-20130131http://capsules.kaiserhealthnews.org/?p=17379http://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreementhttp://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreementhttp://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527http://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527http://www.thelundreport.org/resource/providence_severs_contract_with_health_net_just_as_employers_consider_options_for_2013http://www.thelundreport.org/resource/providence_severs_contract_with_health_net_just_as_employers_consider_options_for_2013http://www.nytimes.com/2014/07/07/opinion/the-risks-of-hospital-mergers.html?_r=0http://www.nytimes.com/2013/02/01/health/insurance-industry-report-faults-high-fees-for-out-of-network-care.html?_r=0http://www.nytimes.com/2013/02/01/health/insurance-industry-report-faults-high-fees-for-out-of-network-care.html?_r=0http://healthaffairs.org/blog/2014/06/11/changing-provider-networks-in-marketplace-health-plans-balancing-affordability-and-access-to-quality-care/http://healthaffairs.org/blog/2014/06/11/changing-provider-networks-in-marketplace-health-plans-balancing-affordability-and-access-to-quality-care/http://www.kaiserhealthnews.org/features/insuring-your-health/2012/121112-michelle-andrews-overpayment.aspxhttp://www.kaiserhealthnews.org/features/insuring-your-health/2012/121112-michelle-andrews-overpayment.aspxhttp://content.healthaffairs.org/content/33/2.tochttp://search.proquest.com/docview/1523785309/fulltext/CA07C834B3AA4587PQ/1?accountid=14586http://theincidentaleconomist.com/wordpress/if-plans-are-only-offering-narrow-networks-blame-information-asymmetry/http://theincidentaleconomist.com/wordpress/if-plans-are-only-offering-narrow-networks-blame-information-asymmetry/http://www.pbgh.org/storage/documents/ECEN_Program__Summary_314.pdfhttp://www.healthleadersmedia.com/page-1/HEP-306360/Narrow-Provider-Networks-Set-to-Spread

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9. Andrews, M. “Warning: Opting out of your insurance plan’s provider network is risky.” Kaiser Health News, March 18, 2014. Available at: http://www.kaiserhealthnews.org/stories/2014/march/18/michelle-andrews-opting-out-insurer-provider-network-risky.aspx

10. Brino, A. “The trouble with narrow networks.” Healthcare Payer News, May 30, 2014. Available at: http://www.healthcarepayernews.com/content/trouble-narrow-networks

11. Pear, R. “To prevent surprise bills, new health law rules could widen insurer networks.” The New York Times, July 19, 2014. Available at: http://search.proquest.com/docview/1546075553/fulltext/1A54B8895F904963PQ/1?accountid=14586

Applications: 1)* Kaiser Health News. “Some heart care costs stay outside insurance coverage, Lowe’s does

national comparison shopping for employees’ heart surgery.” February 17, 2010. Available at: http://www.kaiserhealthnews.org/daily-reports/2010/february/17/cost-of-heart-care.aspx

2)* Andrews, M. “Insurance trade-off: Reducing premiums by eliminating expensive doctors, hospitals.” Kaiser Health News, March 1, 2011. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/michlle-andrews-on-premiums-and-prices.aspx?referrer=search

3)* Appleby, J. “Consumers hit by higher out-of-network medical costs.” Kaiser Health News, February 8, 2012. Available at: http://www.kaiserhealthnews.org/stories/2012/february/09/consumers-hit-by-higher-out-of-network-medical-costs.aspx

4) Terhune, C. Companies go surgery shopping. Los Angeles Times, November 17, 2012. Available at: http://articles.latimes.com/2012/nov/17/business/la-fi-bargain-surgery-20121117

5) Boulton, G. Aurora-Anthem plan seeks exclusivity, promises savings. Journal Sentinel, October 24, 2012. Available at: http://www.jsonline.com/business/auroraanthem-plan-seeks-exclusivity-promises-savings-0d7av36-175522981.html

6) Appleby, J. “Domestic medical travel is taking off for surgery deals.” USA Today, July 9, 2010. Available at: http://www.usatoday.com/money/industries/health/2010-07-07-travelforhealth07_CV_N.htm

7) Gonzales, A. “Cigna offering lower co-pays at its own clinics in Phoenix.” Phoenix Business Journal, August 9, 2011. Available at: http://www.bizjournals.com/phoenix/news/2011/08/09/cigna-offering-lower-co-pays-at-its.html?page=all

8) Weaver, C. “Aetna, doctors face off over costs.” Wall Street Journal online, J