INSIDE
T h e R i c a r d o G r o u p, I n c . Volume 6 Issue 1
Health Care Management News
INSIDE THIS ISSUE: TRENDS TO W A T C H I N 2006
CHANGES DEVELOPING IN HEALTH CARE
Individual Health Insurance
Plans 1 Changes for 2006 are already occurring
on every front in health care. Access to informa-
Mobile Electric Medical
2
tion and data sharing is driving the evolution of
Records systems and operations.
ePrescribing Further Pushes Paper is out and the digital age is rapidly
2
eHealth
advancing into the practice of medicine. Remem-
ber prescription pads, medical charts, lab slips,
Physician Pay for sign-in sheets, and Explanation of Benefit State-
3
Performance ments (EOBs)? In 2006 watch for advances in
ePrescribing, Mobile Electronic Medical Records,
Medicaid Fraud and Abuse Regional Health Information Organizations
Enforcement 3 (RHIOs), Data Sharing and Data Mining.
Look for exploding growth in Individual
About Us 4
Health Insurance coverage and Health Savings
Accounts. Increased attention on Physician Pay
for Performance Programs and Medicaid Fraud
and Abuse enforcement. In medicine, Complementary Medicine is being increasingly
Special points of interest: accepted by health plans and the medical community, Employers and Insurance Plans
• Demand is increasing for
continuing a strong push for nutrition, health, and preventative care.
Individual Health Plans. Various flavors of Prescription Drug Plans offered will be seen as the biggest
thing since sliced bread. Big getting bigger with more mergers and acquisition activity
• Patients want personal health expected in the insurance market. Disease Management Programs continuing to rise
records. and HMO enrollment further dropping.
This edition of “Inside” summarizes some of the expectations to come and what
• Medicare Part D plans lead- promises to catch the headlines as we move into 2006.
ing the eHealth push.
• Pay for Performance pro-
grams gaining popularity.
I N D I V I D UA L H E A L T H I N S U R A N C E P L A N S
INCREASING DEMAND MEANS MORE PLAN OPTIONS
• The government is focusing
more on fraud. Due to the slowdown in of working uninsured, POS, and Fee-for-
the issuance of group self-employed, students, Service plans.
insurance policies the recent college graduates, Most of these individ-
Insurance companies are early retirees, and people ual plans had only basic
investigating additional between jobs. coverage. However, ex-
coverage they can offer. The U.S. Census Bu- pect with growth in small
Insurance Companies are reau reported that 9.3% businesses, part-time
finding there is an in- of the total insured are employees, layoffs and
creasing market demand covered by plans pur- slowdowns, these plans
for individual medical in- chased directly by an in- will rise in 2006. Watch
surance coverage. dividual. The plans var- for a variety of options on
These Individual plans ied and included the the horizon.
target the escalating pool range of HMOs, PPOs,
Page 2 Volume 6 Issue 1
MOBILE ELECTRONIC MEDICAL RECORDS
PATIENTS WANT PERSONAL HEALTH RECORDS
We live in an increas- In the case of emer- $60 a year for a personal
ingly mobile society gencies, patients are of- EMR solution.
where as Americans we ten times treated without Several companies,
readily crisscross the vital information. At such including FollowMe, Red-
globe, effortlessly send- times, the risk of medical Medic, MedicAlert and
ing information by email, error spikes dangerously. CapMed already let cus-
mail or telephone. We Even though chip- tomers manage their
share data seamlessly for embedded smart cards m edic al i nf or m ation
business or pleasure. have not lived up to their online. Most charge ap-
Research any topic with a promise, a variety of new proximately $30 a year.
few keystrokes. We store products is emerging— Some charge more and
and carry data using from USB-enabled key provide other services,
IPODs, MP3 players, chains containing health such as specialized flash
Cruzers, and Flash records to Web-based drives. W hatever the
Cards. When it comes to solutions. Among the method, patients are de-
health care, our data is simplest solutions--are manding access. Expect
virtually unavailable and portable CD-ROM disks this push to continue.
definitely not portable. that give patients control
Tucked away in our phy- of their records.
sicians’ offices or stored According to a recent
in the records department Web survey, released
at our local hospital. Of- this week by the IT and
ten patient records are Research group Accen-
not centralized or com- ture, consumers are will-
More than three billion plete at any one location. ing to pay as much as
prescriptions are written
EPRESCRIBING FURTHER PUSHES EHEALTH
and 65% of the MEDICARE PART D PLAN CHANGING THE HORIZON
population use Electronic communi- ticipants of the Medicare dards are predicted to be
prescription medications cation continues to be Part D drug program to the first program to impact
in the United States
pushed to the forefront by comply with the ePre- our health care system dra-
the Department of Health scribing standards. matically.
each year.
and Human Services MMA is even requir- National standards for
(HHS). ing the Secretary of HHS ePrescribing are an impor-
In early 2005, the to promulgate an anti- tant step in that process,
HHS sought input into the kickback statute safe har- and stakeholders in the
development of a national bor and an exception un- ePrescribing process, in-
health information net- der the Stark legislation cluding pharmacy benefit
work. for certain non-monetary managers, pharmaceutical
In April 2005 the remuneration relating to manufacturers and ven-
Health Insurance Port- ePrescribing information dors, physicians, pharma-
ability and Accountability technology items and cies and pharmacists,
Act’s (HIPAA) Security services! should monitor the MMA
Rule became enforce- The HHS also re- ePrescribing rules and re-
able. cently awarded four con- lated state legislation.
HHS is now pushing tracts for development of All Health Care provid-
eHealth through the prototype national health ers should actively advo-
adoption of standards for information networks. cate for rules that will pro-
electronic prescriptions or The department expects mote an efficient and effec-
“ePrescribing” under the the prototypes to be de- tive eHealth infrastructure.
Improvement and Mod- livered in the fall, then Ready or not, eHealth
ernization Act of 2003 scaled up in 2007 is embraced by the govern-
(MMA), requiring all par- ePrescribing stan- ment and is here to stay.
Inside Page 3
PHYSICIAN PAY FOR PERFORMANCE
THEORY THAT OUTCOMES INFLUENCE COST
Physician Pay for - The Centers for Medicare providers and other
Performance (PFP) pro- and Medicaid Service stakeholders to ensure
grams are incentive pro- (CMS) that there are reasonable
grams being offered to In 2006 watch for more and fair standards used.
providers by health plans, Medicare initiatives to en- That providers aren’t be-
coalitions, insurance courage improved quality of ing pulled in conflicting
companies, and employ- care in all health care set- directions, and that pro-
ers. These PFP pro- tings where Medicare bene- viders have support for
grams provide additional achieving improvements.
compensation to physi- Consequently, to
cians who achieve, or develop and implement
make progress toward a these initiatives, CMS is
defined benchmark or collaborating with a wide
measurement. range of other public
The underlying theory agencies and private or-
is that as quality in- ganizations who have a
creases, the nation's common goal of improv-
health improves and ing quality and avoiding
health care costs de- ficiaries receive their health unnecessary health care
crease. care services, including costs. CMS is also pro-
Two organizations physician offices, ambula- viding technical assis-
that have evaluated and tory care facilities, hospi- tance to a wide range of
proposed the guidelines tals, nursing homes, home health care providers
and implementation proc- health care agencies and through its Quality Im-
ess for the PFP programs dialysis facilities. provement Organizations Health care providers
need in place an effective
are: The foundation of effec- (QIOs). Expect more at-
- American Medical Asso- tive PFP initiatives is en-
compliance Program,
tention on this subject in
ciation (AMA) couraging cooperation with 2006.
and remain vigilant in
MEDICAID FRAUD AND ABUSE ENFORCEMENT identifying and correcting
GOVERNMENT REPORT DETAILS OIG FOCUS
potential Medicaid
According to a recent tions of Medicaid fraud compliance problems.
government report and and abuse. The report
proposed federal legisla- also details that funds are
tion, expect an increase allocated to Centers for
in Medicaid Fraud and Medicare and Medicaid
Abuse enforcement in Services (CMS) specifi-
2006. cally to combat fraud in
Health care savings Medicaid and the State
and recoveries from Children’s Health Insur- laws more broadly. In addi-
Medicaid fraud were at ance Program (SCHIP). tion, the legislation would
the highest in 2005 and In addition, a bill was increase spending for
the push is on for more. proposed that would give Medicaid fraud and abuse
The funds are reportedly states a direct financial control activities. This in-
from settlements, judg- incentive to enact state cludes an additional $25
ments, and administrative false claims statutes and million each year begin-
penalties. The Office of to pursue state false ning in 2006 through 2010
Inspector General (OIG) claims cases. This bill for Medicaid activities of
has been recovering sub- also provides that the the OIG. The bill would
stantial sums of money state false claims laws do also establish a Medicaid
from both large and small not have to be limited to Integrity Program, much
health care providers Medicaid fraud, so states like the Medicare Integrity
based typically on allega- may choose to apply the Program.
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T H E R I CA R D O G RO U P, I N C .
Editorial Staff
Ralph C. Wolf
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Ralph@RicardoGroup.com
Maryann (Ricardo) Wolf
MsWolf@RicardoGroup.com TRG Services include:
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