A collection of bylines

For The New York Times (published Nov, 7, 2020; updated Oct. 30, 2021): Check in on Health Insurance Open Enrollment. Amid uncertainty during a pandemic and a U.S. Supreme Court challenge, open enrollment in health insurance marketplaces began on Nov. 1. In all 50 states, individuals and families who lack insurance or want better coverage can enroll in plans that comply with the Affordable Care Act through Dec. 15, although enrollment ends later in 10 states and the District of Columbia.

For Fortune Well (Aug. 31, 2023): Medicare Savings Programs can help cover your out-of-pocket costs. Here’s who qualifies. While Medicare covers most health care costs for more than 65 million Americans, it does not cover all of them and the remaining bills can add up quickly. For Medicare beneficiaries who qualify based on having low-income and limited assets, the Medicare Savings Programs (MSP) will cover some of those costs.

For Fortune Well (Oct. 29, 2023): Does Medicare pay for nursing home care? An expert helps make sense of the rules.  As seniors age, the need for long-term care increases, particularly when they cannot do the activities of daily living (ADL), such as getting dressed, bathing, or preparing meals. For these older adults, care in a nursing home or skilled-nursing facility (SNF) may be appropriate. But it’s one of the biggest expenses Medicare beneficiaries are likely to face. Medicare will not pay for nursing-home care—except for some stays under specific (and limited) conditions.

Cover Story: Orphan Drugs: Way Too Many, Way Too Expensive. Sales hit the billion-dollar mark as pharmaceutical companies have used the Orphan Drug Act to their advantage. In response, health insurers are beginning to push back by taking steps to get more out of their investments in these medications.

Cover story: Can Separate Be Equal? Ending the Segregation of Mental Health. Even at their best, state and federal mental health parity laws sometimes appear to make behavioral care into the health system’s unwanted step child. Integrating cognitive care into primary care so that it’s a full part the health care system should be the goal—one that some insurers struggle to achieve.

Beyond Camden: Health Plans, Hospitals Test the Brenner Model. The Robert Wood Johnson Foundation highlights the work of Jeffrey Brenner, MD, whose hotspotting initiative in Camden, N.J., identifies high users of the health system and develops ways to give them appropriate and timely care. Now health systems and insurers in Ohio, Pennsylvania, and Massachusetts are adopting Brenner’s methods.

• In Ohio, Will Providing More Care to High Utilizers Save Money?
• Treating High Utilizers in Rural Pennsylvania
• Avoiding ER Visits in Massachusetts

Cover story: High Utilizing Patients: Where Are the Savings? If 1% of patients account for 21% of total health care spending, why is there so little proof of a return on the investment from giving them appropriate care? Also:  North Caroline Blues plan uses predictive modeling to identify high utilizers.

Bundled Payment: Hospitals See the Advantages, But Face Challenges, Too. While most hospital leaders see the advantages of moving to bundled payments for episodes of care, many are unprepared either for the mindset or the mechanics required to implement the emerging reimbursement model. Here are the concerns and possible strategies hospitals should consider.

Video Preview: Is Bundled Payment a Gift or Pandora’s Box? Editors at H&HN summarized my cover story on how hospitals are preparing for bundled payment.

Cover story: Dangling Dollars. Health plans are using financial incentives to encourage members to pick lower-cost providers. Some worry that cutting checks will crowd out quality.

Cover story: Confronting the World’s Most Pressing Public Health Threat.  Antibiotic resistance, which the CDC calls the world’s most pressing public health threat, requires collaborative action from physicians, hospitals, and health plans.

Cover story: Do We Overspend on Health Care, But Underspend on Social Needs? Until recently, health plans have all but ignored the social determinants of health, which may explain why the United States ranks near the bottom in terms of health outcomes while leading the world in per capita spending on health care. But now the role of the social determinants of health, and the business case for addressing them, is becoming clear as health plans seek to house the homeless and provide the social services patients need.

Cover story: Contrarians Have Long Been Managed Care’s Best Innovators. We might not agree with them, but contrarians can’t be ignored. Why? Because the history of health care–and managed care in particular– is filled with those who identified the system’s failings and offered new, unproven ideas. A. Mark Fendrick, MD, for example, asks: Can we change the conversation from how much we spend to how well we spend? Ray Drasga, MD, asks: Is it time for a single-payer system? Jay Sultan asks: Are accountable care organizations unworkable?

Feature: How Will Health Insurers React to New Mental Health Parity Rules? Will insurers raise premium rates because they are restricted under the medical loss ratio rules to spending no less than 80% of premiums on patient care? Will they argue that some mental health treatments are not medically necessary? Will they limit care? Advocates for those with mental illness say its impossible to predict.

Cover story: Hospital-Acquired Infections. Rates are far too high, and health plans are big losers. Hospitals could cut in half the number of infections that patients contract each year in health care facilities, but we lack the will or have failed to install the proper financial incentives to do so, experts say.

Cover story: Will More Transparency Finally Force Physicians and Hospitals To Compete for Patients? Health plans have more incentives than ever to foster competition, but efforts in the past have failed

Cover story: Countdown to ICD-10. Follow these 10 steps to avoid the looming cash crunch.

Cover story: Twilight for Fee for Service? Most health plans recognize how financial incentives under fee for service drive up health care costs. Although for years, health insurers have tinkered with FFS with varying degrees of success, they have yet to eliminate FFS payment. Now they recognize now that they may not be able to do so entirely or quickly, in part because FFS is inextricably linked to the nation’s Current Procedural Terminology (CPT) system.

Feature article: Bay State Blues Combine Global Payment With Quality Metrics. Under Its Alternative Quality Contract, Blue Cross Blue Shield of Massachusetts aims to make global budgets work by having physicians and hospitals cut costs and pursue meaningful quality targets.

Cover story: Renewed Interest In Shared Decision Making. Twenty years after the introduction of shared decision making, health plans are seizing on this strategy to help patients choose among treatment options.  Seeking to counterbalance physicians’ preferences, health plans are increasing their efforts to get more patients involved in decision making. Electronic medical record systems alert physicians to offer tools to help patients decide what’s best. Often, patients choose less risky and less unpleasant options, sometimes lowering costs. Federal regulations promote these methods to engage patients more fully care decisions.

Cover Story: This Year’s Model: Are We on the Way to a Real ‘Learning Health Care System’? In a report published in September 2012, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, the Institute of Medicine said the U.S. health care system wastes $750 billion each year on unnecessary services and excessive administrative costs and by failing to eliminate fraud. But here’s perhaps a more astonishing fact: We know how to eliminate this waste, says Brent C. James, MD, of the Institute for Health Care Delivery Research at Intermountain Healthcare in Salt Lake City.

Feature Article: Medical Homeless: Ophthalmology and the PCMH. The patient-centered medical home is evolving, but specialists are still looking for their place.

Feature Article: Medicare Advantage Loses Its Advantage. Seeking to increase competition among plans, CMS is eliminating extra payments of $1,200 per member per year.

Feature Article: What Works Best for Patients? PCORI Hopes to Provide Answers. Even today, studies show, only half of treatments are truly based on evidence. Here’s an organization looking to better that share, and it may behoove health plans to help.

Q&A: A Conversation With François de Brantes: Bundled Payment’s Many Challenges. Health plans are taking steps to implement this promising payment system, but so far it has not been easy.

Cover story: Is Bundled Payment an Idea Whose Time Has Come? For decades, managed care plans have sought to stop making fee for service payments. Now they’re trying bundled payments for episodes of care.

Cover story: The Next Move in Physician Compensation. Here’s how practices have tweaked their salary and benefits schemes in response to healthcare reform.

Feature Article: HPV Vaccine Goes Underused. Only about 35 percent of girls get the full three doses of the vaccine for the human papillomavirus, which causes most cervical cancers

Report on Process Improvement: Mayo’s Clinical Laboratory Science Program Uses Lean/Six Sigma to Speed Applicant Reviews and Rolling Admissions

Cover story: For Health Insurers, Retail Space Available. Under health reform, consumers will be the new buyers in public and private exchanges, meaning care management programs will need a sharper focus on return on investment

Cover story: The Next Frontier: Patient Engagement. Seeking the best return on shared-savings programs such as PCMHs and ACOs, health plans are investing cash and other resources to attract and hold patients’ attention.

Cover story: Reform Forces Health Insurers to Reinvent Themselves
To paraphrase Mark Twain, the death of the health insurance industry has been greatly exaggerated. Plans simply have to develop new business models.

• Herzlinger Predicts ACOs, PCMHs Will Fail
• Virtual vs. Actual Networks
• CEO Contends That Eliminating Financial Risk Allows Medicaid Plans To Focus On Management
• AHIP’s Karen Ignagni: Health Insurers Will Continue to Innovate
• Wendell Potter: Insurers Will Be Radically Different

Cover story: Narrow Networks Found To Yield Substantial Savings
An early managed care idea that the marketplace once rejected is now being embraced by employers and offered by health plans.

Cover story: Decision Support’s New Advocates

Health Plans and Medicare Step Up To Eliminate Costly Variation

Insurers Move Toward More Equitable Care For LGBT Population

At Long Last… Pay for Outcomes Starts to Replace Pay for Performance

Cover story: Health Plans Seek Leverage When Physicians Submit Extremely High Bills

 What Can Be Done to Counteract Growing Power of Providers?