THIS WEEK IN U.S. DOMESTIC MEDICAL TRAVEL™
Volume 1, Issue 25
In recent years, a growing number of providers, employers and health plans have made it their mission to lead the way in the march toward payment reform.
According to Catalyst for Payment Reform (CPR), payment reform can be defined as payment methods that reflect or support provider performance, especially the quality and safety of care that providers deliver, and are designed to spur provider efficiency and reduce unnecessary spending.
Andréa E. Caballero, program director, CPR, says the nonprofit organization works with large healthcare purchasers, both public and private, in an effort to shed light on the urgency for payment reform and higher quality, more affordable healthcare.
Additionally, it didn't take very long for market leaders to begin weighing in on the CMS proposed regulations regarding bundled pricing for total joint replacement surgeries. For further information about the proposed regulations, please visit http://www.cms.gov/.
Editor's Note: I am pleased to report that the Self Insurance Institute of America has invited me to chair a panel on employer direct contracting during its annual meeting: www.siia.org/national.
Additionally, I am pleased to report that the Self Insurance Institute of America has invited me to chair a panel on employer direct contracting during its annual meeting: www.siia.org/national.
Panel: Employer Direct Contracting: Game-Changing Medical Travel Trend
Date: October 19, 2015
Time: 10:15am - 11:30am
Location: Marriott Marquis, Washington D.C.
The SIIA National Conference & Expo is the world's largest event focused exclusively on the self-insurance/alternative risk transfer marketplace, typically attracting more than 1,700 attendees from throughout the United States and from a growing number of countries around the world. The program features more than 40 educational sessions designed to help employers and their business partners identify and maximize the value of self-insurance solutions.
For additional details about SIIA and the upcoming panel, read the announcement entitled, "SIIA Panel Discussion: Employer Direct Contracting: Game-Changing Medical Travel Trend," below.
We're starting to hear from many hospitals, independent surgi-centers and provider groups that want to be better positioned to serve self-funded employers offering medical/surgical travel options. If you have a good story to tell us, please be in touch! We want to boost opportunities for Centers of Excellence nationwide.
What distinguishes your service offering in terms of cost, patient experience and satisfaction, outcomes, or other quality indicators.
Send us your descriptor, including photos or charts, and we will evaluate for publication in this newsletter.
Thank you for your interest in this exciting, growing market space. Please be in touch with your comments and editorial contributions, which can be sent directly to: editor@USDomesticMedicalTravel.com.
Editor and Publisher
SPOTLIGHT: Andréa E. Caballero, Program Director, Catalyst for Payment Reform
About Andréa E. Caballero
Andréa E. Caballero, program director for Catalyst for Payment Reform, comes to CPR with over 15 years of experience in the healthcare industry. Prior to joining CPR, she served as vice president, Enterprise and Health Services Policy for UnitedHealth Group, one of the nation's largest health and well-being companies. In that capacity, she worked on a range of healthcare policy issues at the state and federal levels. From 2002-2005, Andréa was a member of PacifiCare's Public Affairs team as the director of State Government Relations for the Western Region. Before joining PacifiCare, Andréa was with Humana serving as a Regional Legislative manager. A Wisconsin native, Andréa began her career in Madison, Wisconsin, working for the State Senate and as a Legislative liaison representing various issues before the state legislature, regulators and administration. Andréa earned B.A.s from Ripon College in Ripon, Wisconsin.
About Catalyst for Payment Reform
Catalyst for Payment Reform (CPR) is an independent, nonprofit corporation working on behalf of large employers and other healthcare purchasers to catalyze improvements in how we pay for health services and promote higher-value care in the U.S.
U.S. Domestic Medical Travel (USDMT): Give our readers some background on Catalyst for Payment Reform (CPR).
Andréa Caballero (AC): CPR is an independent, national nonprofit that works with large healthcare purchasers, both public and private. We use the collective strength of our members to strive for higher quality, more affordable healthcare.
It is very important to emphasize that we are active in both the public and private sector, as this alignment is essential to drive payment reform.
USDMT: How does CPR differ from other purchasing coalitions?
AC: We primarily focus on payment reform, whereas a number of business coalitions have a broader emphasis on many healthcare issues.
CPR focuses on giving employers and purchasers tools they can use to drive payment reform. Some examples include our model request for information and model contract language for health plans. We shed light on the urgency for payment reform through various initiatives, including our National Scorecard on Payment Reform, as well as our national summits, which spotlight payment reform-related issues, like provider competition and price transparency.
In addition to working alongside large, self-funded purchasers, CPR also works with benefit consultants who help us spread our tools and amplify our messages.
All of our information is publically available on our website, http://www.catalyzepaymentreform.org/.
USDMT: What is your perception on domestic and international medical travel?
AC: It hasn't been an area that CPR has looked at.
What we have witnessed is a number of large employers changing their benefit designs to include a medical travel benefit.
In the future, if we were to expand and entertain an international conversation, it would have to be based on the impact of local competition. In other words, do employers need an international medical travel benefit to help keep providers competitive so that care remains affordable and high quality?
Part of the reason CPR doesn't have a broad policy around a medical travel benefit is because it is a decision every employer needs to make for themselves. Employers handle different cultures, benefit design approaches and workforces. They will need to make the decision whether travel is a good fit with the rest of their benefits design and strategy.
USDMT: Does CPR disclose information on pricing transparency?
AC: Absolutely. Our members have a difficult time envisioning high-quality healthcare without sufficient transparency on price and quality. CPR has surveyed the landscape of health plan and independent vendor tools and found that these tools play a significant role in helping to synthesize transparency information for purchasers. We have also graded states based on their laws and policies-how much they help or hinder consumers' access to price information.
USDMT: In the future, will CPR address smaller or mid-sized companies if they were to aggregate purchasing power?
AC: Right now, we do have initiatives underway to help educate brokers who work with smaller or mid-sized employers.
USDMT: Is there anything else you would like to share with our readers?
AC: CPR has prepared a how-to guide on bundled payment for total joint replacements.
In the guide, we have a list of quality measures and criteria that providers should demonstrate prior to considering a joint replacement procedure.
Additionally, CPR partnered with the Pacific Business Group on Health (PBGH) to construct a how-to guide which focuses on Accountable Care Organizations (ACO).
You can find all our tools for employers and purchasers at: http://www.catalyzepaymentreform.org/how-we-catalyze/purchaser-strategy-and-tools.
Bundling Badly - The Problems with Medicare's Comprehensive Care for Joint Replacement Proposal
On July 9, the Centers for Medicare and Medicaid Services (CMS) proposed regulations to create what it described as an "episode payment" for hip and knee surgery. However, what sounds like a desirable patient-centered payment reform - "Comprehensive Care for Joint Replacement" or CCJR - turns out to be primarily a plan to penalize hospitals when patients receive higher-than-average amounts of post-acute care services after knee or hip surgery. Moreover, the plan is implemented in a way that could lead to many very problematic results, including:
- Encouraging further consolidation in the healthcare industry, fewer choices for consumers, and higher prices for private purchasers; and
- Discouraging truly innovative approaches to managing hip and knee problems and encouraging unnecessary surgeries
Most people won't have the stamina to read through 394 pages of preamble and 45 pages of regulations to figure out the complex structure CMS developed, so here's an explanation of why what sounds like a good idea turns out to be exactly the opposite.
True Episode Payment Would Be Desirable, But This Is Just P4P
Creating an episode payment for joint replacement is a good idea - a patient shouldn't have to worry about whether their surgeon, the hospital, other doctors, physical therapists, the rehabilitation facility, home health nurses, etc. are coordinating their services, and Medicare shouldn't have to pay more if patients receive services they don't really need to achieve a good outcome. In a true episode payment structure, all of those providers would work together to deliver care in a way that achieves the best outcomes at the lowest cost, and because they are working together, they can take a single, bundled payment and divide it among themselves. Moreover, under a true episode payment, the providers would have the flexibility to completely redesign the way they deliver care, including providing services that aren't paid for at all today, but they would also have accountability for ensuring that the different approach to services achieves similar outcomes at a lower cost or better outcomes at the same cost.
However, the Medicare CCJR proposal isn't a true episode payment and there isn't any requirement that all providers whose services are included in the episode work together to redesign the way they deliver care. CMS is telling every individual provider - the doctors, the home health agency, the skilled nursing facility, the hospital, and any others - that they will continue to be paid exactly the same way they are paid today for doing the same things they do today. The only difference is that at the end of the year, the hospital - and only the hospital - would get a penalty or bonus based on the grand total of the payments for all of the services billed by all of those providers. The hospital wouldn't be given any control over which services the Medicare beneficiary received (the patient could use whichever physicians, skilled nursing facilities, home health agencies, etc. they wished) and those providers would have no obligation to control how many services they provide. But if the beneficiary received "too many" of those services, the hospital would be expected to pay for the excess.
So even though the proposed regulation calls CCJR an "episode payment," it's actually just a new pay-for-performance system for hospitals based on Medicare's retrospective analysis of spending that occurred during an episode.
It May Look Like a Bundled Payment But It Isn't Really
What most people will likely find confusing is that many true episode and bundled payment systems are being implemented using a retrospective reconciliation process that looks similar to what Medicare is proposing to do. Under those systems, during the course of the time period covered by the episode payment, the providers who are involved continue to bill a payer using traditional fee-for-service billing codes. The payer then adds up all of those bills, compares them to the episode payment amount, and either sends the providers an additional payment for the difference, or tells them they need to pay back any overage. That retrospective reconciliation process is really just a convenience for the providers; it enables them to get interim payments during the episode and avoids forcing one of the providers to take on the responsibility of paying all the other providers for their individual services. As a practical matter, though, the system functions as though the providers were getting a single bundled payment of a predefined amount and then distributing it among themselves based in part on the services they delivered.
What Medicare is proposing in CCJR sounds similar, but the details differ in several key ways:
- In a true episode payment system, the providers determine how much it will cost them to deliver the complete bundle of services in the episode and the payer decides whether to pay that. In Medicare's proposed CCJR system, Medicare decides what to pay for the episode (the "spending target") based on its average spending on knee and hip surgery patients in the prior year for all hospitals, and each individual hospital is then forced to accept that amount.
- In a true episode payment system, the providers decide in advance which other providers to partner with in order to deliver a complete set of coordinated services. In Medicare's proposed CCJR system, the beneficiary decides which providers will deliver which services in the episode, regardless of whether those providers work together or even know each other.
- In a true episode payment system, the providers have the flexibility to deliver services that they could not bill for under the fee-for-service structure, knowing that they will ultimately be paid for those services when the reconciliation occurs. In Medicare's proposed CCJR system, this would only happen in the short run; over time, providers would ultimately lose money if they delivered services that are not billable under Medicare's fee-for-service payment systems.
It's a Payment Design That Penalizes Innovation Instead of Encouraging It
The last point is particularly important, but it may be very difficult to understand because there is a lot of confusion today about the difference between healthcare spending and healthcare costs. Sustainable innovation in any industry occurs when products and services can be redesigned in ways that lower their costs so they can be sold at lower prices. In contrast, simply cutting payment amounts may lead to shortages of services and other undesirable effects.
Here's an example: Suppose orthopedic surgery practices and hospitals felt that instead of discharging some knee surgery patients to a skilled nursing facility (SNF) for the kinds of rehabilitation services Medicare will pay for under the SNF payment system, the patients would recover faster and at lower cost with a new home-based rehabilitation program. This hypothetical new program is not covered by Medicare, so if a surgery practice or hospital began offering this new service to patients, they would not be able to bill or be paid for it directly. But for patients who received the service instead of going to a SNF, the total cost of services would decrease. In this scenario, however, Medicare's spending would decrease more than the actual cost of services would go down, because Medicare would be paying nothing for the new home-based service even though it clearly would cost the surgery practice or hospital something to deliver it.
Under a true episode payment structure implemented using retrospective reconciliation, the entity that's managing the payment, whether it was the hospital or the surgery practice, would ultimately receive enough revenue to cover the cost of the new service. That's because the lack of billing for SNF services would create a surplus in the "budget" defined by the episode payment; that surplus would be paid to the entity at the end of the year and it could use the surplus payment to cover the cost of the unbillable new service.
In the CCJR program Medicare has proposed, there would be a similar surplus payment in the first year in which the program was in effect. In this hypothetical example, total billings with the new home-based service would be lower than the episode spending target established by Medicare because the target was based on average billings in the prior year when SNF services were still being used more frequently. However, over time, if many providers begin offering the new service that's not directly billable instead of using SNF services that are billable, Medicare will reduce the amount of the CCJR "episode price" it pays below the cost of actually delivering the services.
That's because under the proposed CCJR regulations, CMS will base the episode spending target each year on the amount it spent on services it was billed for in the prior year, not on the costs the providers incurred for the services they actually delivered. In a true episode payment system, the providers wouldn't agree to an episode payment that low because they couldn't afford to deliver the full package of services at that price. But Medicare isn't planning to assess whether the lower spending target is adequate or not; under the proposed CCJR system, Medicare will simply reduce the target and penalize the providers if their spending is higher.
The key thing to remember is that what Medicare and health insurance plans spend on services isn't the same as what it costs providers to deliver those services, and in some cases, the services payers do pay for may not deliver as much value as the services they don't pay for. A well-designed bundled payment system sets a price and then lets providers decide which services provide the best combination of cost and quality. The providers could accept a lower price for care than what is being spent by payers today, because they'd have the flexibility to substitute a higher-value service that's not paid for today and to define an episode payment amount that's adequate to cover the new, lower costs of the new set of services. But the price has to be set based on the services the providers plan to deliver, not determined through a retrospective analysis of the payer's spending on the services it pays for. (See The Payment Reform Glossary (www.paymentreformglossary.org) for more detailed explanations and comparisons of the terms "bundled payment," "episode payment," "spending," "cost," etc.)
Instead of encouraging providers to innovate, the proposed CCJR regulations attempt to specify exactly how care should be delivered. For example, the regulations state that "a home visit of once a week to a non-homebound beneficiary who has concluded PAC and who could also receive services in the physician's office or hospital outpatient department as needed, along with telehealth visits in the home from a physician or NPP, should be sufficient to allow comprehensive assessment and management of the beneficiary throughout the LEJR episode." That's CMS defining how care should be delivered, rather than the physicians, hospitals, and other providers who know what the patients actually need.
Moreover, the most innovative approaches of all would be completely precluded by the design of the CCJR payment model:
- The CCJR only applies to patients receiving surgery during an inpatient hospital stay, even if surgery could be delivered in an outpatient setting. (The regulations say "There is little opportunity for shifting the procedures under this model to the outpatient setting," even though many providers are now beginning to use outpatient joint surgery for appropriate patients.) If some patients can be treated on an outpatient basis, the average costs for patient those who do continue to need inpatient surgery may be higher, and that could result in a financial penalty under CCJR.
- There is no reward under CCJR for helping a patient address their knee or hip problem without surgery, and there may be a financial penalty for doing so. The reason is that if lower-acuity patients are treated non-surgically, the patients who do get surgery will likely be those who need more extensive post-acute care services; that would make the hospital's average costs for surgery cases increase, causing them to be penalized under the CCJR structure.
The bottom line is that Medicare's model would discourage innovation and it could bankrupt innovative providers, whereas a true episode payment structure could encourage innovation and allow patients, providers, and Medicare to all benefit - a genuine win-win-win.
CCJR Will Likely Accelerate Provider Consolidation and Increase Prices for Private Payers
In addition to discouraging innovation, Medicare's proposal would likely encourage fewer choices for patients, more consolidation of providers, and higher prices for private payers. If you're a hospital and Medicare is going to penalize you when total episode spending is high because post-acute care providers and physicians order or deliver too many services after patients leave the hospital, what are you going to do? One logical strategy would be for the hospital to buy the post-acute providers (i.e., the nursing homes, the home health agencies, etc.) and buy the physician practices so the hospital could directly control how much those providers spend following hip and knee surgery. Smaller hospitals who don't own their own post-acute care providers may be even more nervous about the financial risks they'd face under CCJR if the post-acute care providers are owned by a competitor hospital, and so another potential result would be for smaller hospitals to get out of the business of delivering hip and knee surgeries altogether or to consolidate with the larger hospitals. The net result either way would be fewer choices of hospital and post-acute care providers who deliver care for knee and hip surgery, and that in turn could result in higher prices for private purchasers and patients who rely on competition to hold down prices.
The CMS regulations seem to assume that all of the post-acute care providers will willingly sign contracts with hospitals to share their financial responsibility, since there is a lot of detail in the regulations designed to control what those contracts would look like. But if you're a post-acute care provider, why would you want to voluntarily agree to lose revenues by delivering fewer services in order to help a hospital avoid a penalty? And if you're a hospital, why would you want to try and define a contract that CMS would approve if you could just acquire the post-acute care provider and avoid the need for the contracts altogether?
Similarly, there would be a strong incentive for hospitals to acquire orthopedic surgery practices and preclude independent practices from performing surgeries at the hospital since any extra services ordered or delivered by the physicians after discharge could turn into financial penalties for the hospital.
The problem goes beyond just the providers directly involved with hip and knee surgeries, however. The way the CCJR proposal is defined, hospitals would be accountable for essentially all of the healthcare services that beneficiaries receive after discharge from the hospital, whether they are directly related to the surgery or not. So if a Medicare beneficiary with COPD, diabetes, hypertension, etc. receives hip or knee surgery at the hospital, the hospital would then be at financial risk for how the beneficiary's primary care physician, pulmonologist, endocrinologist, cardiologist, etc. manage their care for those diseases after discharge. That means CCJR is much more than an "episode payment" for hip and knee surgery; it forces a hospital that performs hip and knee surgeries to become a mini-Accountable Care Organization during the 90 days after patients are discharged.
Poorly Designed Risk Adjustment Could Reduce Access to Care and Result in More Unnecessary Surgeries
Under the proposed regulations, CMS wouldn't adjust the episode spending targets based on differences in the kinds of care Medicare beneficiaries needed after they left the hospital. Although CMS will have different spending targets for the two different hospital DRGs used to pay for hip and knee surgeries, the current DRGs were designed to risk-adjust spending for care in the hospital, not to risk-adjust spending for both hospital and post-acute care. So the patients in the same DRG at two different hospitals could have very different needs for care after they leave the hospital. If one hospital had a higher-than-average number of patients who live alone or have other problems that require them to go to a skilled nursing facility for rehabilitation rather than return home, the average episode spending would be higher for the patients treated at that hospital (even if the cost of the care during the hospital stay was the same), and the hospital could be forced to pay for part of those additional nursing home stays. In the regulations, CMS implicitly acknowledges that differences in patient characteristics could affect episode spending more than what is accounted for by the two DRGs, but the regulations say that since there is no consensus on what the right risk adjustment system should be, no risk adjustment system at all will be used.
Two types of serious problems result from using no risk adjustment or the wrong risk adjustment system. First, it may become more difficult for patients to find a hospital to do surgery if the patient would need higher levels of post-acute care after surgery, because the hospital could be penalized if those higher-need patients caused the average episode spending to increase. Since the hospital would be accountable not just for services and complications related to the surgery, but for chronic disease care for patients with chronic disease, it might also be more difficult for patients with chronic disease to get surgery from a hospital if the patient's other physicians weren't affiliated with that hospital.
Second, CCJR would create a financial incentive for hospitals to encourage younger, healthier patients with joint osteoarthritis to undergo surgery, even if the patients could have managed with non-invasive treatments such as physical therapy, medications, and exercise. The reason is that since those patients would likely need less post-acute care, they would reduce the hospital's overall average spending per episode, helping it avoid a penalty and potentially receive a bonus. There is nothing in the CMS regulations that would penalize a hospital for doing surgeries when they could be avoided using other services, but there is plenty to penalize the hospitals for spending more than average on the surgeries that are done. The net result could be more surgeries and higher total spending, even though the average spending per surgery episode would be lower.
There's No Reward for Higher Quality, Just Smaller Bonuses If Quality is Low
The provision of the Affordable Care Act that gave CMS the authority to issue the CCJR regulations (Section 1115A of the Social Security Act) states that Congress's goal was to "reduce spending without reducing the quality of care or improve the quality of patient care without increasing spending." However, under the proposed CCJR program, there's no reward for a hospital that achieves better outcomes for its patients at the same cost, e.g., if its patients had less pain during the recovery period or less pain or discomfort with their new knee or hip after they completed rehabilitation. The CCJR includes quality measures, but they're only applicable if spending is lower, and they're only used to give a hospital a smaller bonus than it would have otherwise received if quality is lower than the standards CMS establishes. If spending is the same but quality is higher, there's no bonus. If spending is higher, the hospital is penalized the same regardless of whether quality is better, worse, or the same. So clearly savings is the primary focus, not improving quality.
A Mandatory "Test" Would Preclude Other, Better Approaches
Under the proposed regulation, in 75 regions of the country, every hospital that is paid under the DRG system would be subject to these new penalties during a five year "test" period. The regions are selected through a randomization process, and as a result, the hospitals in one of two neighboring regions might be subject to the penalties while those in the other region would be excluded.
There would be no opportunity for either the hospitals or the physicians in CCJR communities to develop and implement true episode payment models while the test was underway unless they were already doing so under the CMMI Bundled Payment for Care Improvement (BPCI) program. This is both unfortunate and surprising, since CMS is currently testing several other bundled and episode payment models as part of BPCI, and the lessons and impacts from those projects are not yet available. Moreover, in the proposed Medicare hospital payment regulations issued earlier in the year, CMS explicitly invited comments on whether and how to expand the BPCI program, but the CCJR program would appear to preclude that in the communities it requires to participate.
Going Back to the Drawing Board
The inescapable conclusion is that CMS should go back to the drawing board on this proposal. Rather than truly reforming payment systems, the proposed Comprehensive Care for Joint Replacement program would add a problematic layer of new incentives on top of the undesirable incentives in the current fee-for-service payment systems, and the undesirable consequences of those new incentives could easily outweigh any of the benefits that are intended.
Reverse Medical Tourism
by Adam J. Scheiner, M.D.
I have a practice in Laser Eyelid and Facial Plastic Surgery and have been practicing successfully for many years. In 2011, after my appearance on the Doctor Oz show, my practice changed in a substantial way.
As a result of my appearance on that show and the demonstration of a procedure to help a difficult condition to treat called eyelid festoons, many patients began contacting us from around the world.
Festoons and Malar mounds are a term to describe skin folds and swollen mounds that form on the cheek.
Lower eyelid bags usually accompany them. Both lower lid bags and festoons can make a person appear tired, sick, old and sometime drunk even when those people feel fine inside. Many people have surgery to help lower eyelid bags but when they are accompanied by festoons, and malar mounds and those festoons and malar mounds aren't treated at the same time, the result after surgery can even look worse. This is because once lower eyelid fullness is removed above the festoons, this problematic area is highlighted and becomes more obvious.
There hasn't been a great treatment for festoons until my procedure. As a result, many people travel to see me for help with their lower eyelid rejuvenation concerns. Once the large number of calls and emails began to come in, I initially didn't have the resources to deal with them.
This required hiring new staff and setting up infrastructure to manage this large increase in new patient contacts. I used technology to help with this and setup a HIPPA-compliant medical form on my website where patients could upload information that would allow me to determine if they were likely a good candidate for my procedure.
My new staff would then contact the patient and arrange the medical release, understanding of the procedure, and financial arrangements. I was fortunate that local hotels and businesses became partners in making the visit of my patients more enjoyable. Certain hotels started competing with one another to attract my patients to their hotels. One started offering transportation to my patients for airport transfers and for every visit to my office. The other hotel then hired a cab service to provide the same. The first hotel was offering breakfast and hors d'oeuvres four nights a week. The second hotel then matched this, as well.
Patients were often leaving gifts for future patients. One patient purchased a lounge chair and then signed the back of it and left it for future patients of mine. Others continued signing the back and leaving notes of encouragement and love for future patients.
I enjoyed seeing the sense of sisterhood and brotherhood my patients had for one another.
In 2012, I was featured on the Doctors TV show for my treatment of eyelid bags and eyelid festoons.
At this point, my infrastructure was in place and I was able to easily handle the volume of people contacting us after the airing of that show.
Today, 80 percent of my practice is from people travelling in to see us from many parts of this and other countries.
Recently, I've become aware that I'm a small engine for my community in Tampa because those traveling here stay in local hotels, eat at restaurants and enjoy the entertainment options available in the Tampa Bay area.
I love what I do to help my patients restore, reveal and reclaim their natural beauty, and I feel thankful that I'm able to be a resource for people from around the world.
CVS Health Announces New Clinical Affiliations with Four Leading Healthcare Organizations
CVS Health (NYSE: CVS) announced today it has entered into new clinical affiliations with Sutter Health in California, Millennium Physician Group in Florida, Bryan Health Connect in Nebraska and Mount Kisco Medical Group, PC in New York. These affiliations will help enhance access to high-quality, affordable healthcare services for patients. Through these clinical affiliations, CVS Health will provide prescription and visit information to the participating healthcare organizations by enabling communication between our secured electronic health record (EHR) systems, which will help enhance clinical care for patients served by the partnering organizations. In addition, patients will continue to have access to clinical support, medication counseling, chronic disease monitoring and wellness programs at CVS/pharmacy stores and MinuteClinic, the retail medical clinic of CVS Health.
"In this era of healthcare reform, we are pleased to work with these healthcare organizations to develop collaborative programs that enhance access to patient care, improve health outcomes and lower healthcare costs in the communities they serve," said Troyen A. Brennan, M.D., chief medical officer, CVS Health. "By allowing our electronic health records and information systems to communicate and share important information about the patients we collectively serve, we will have a more comprehensive view of our patients, which can aid in healthcare decision-making and help ensure patients adhere to important medications for chronic diseases."
CVS/pharmacy currently has more than 7,800 retail pharmacy locations across the U.S. where CVS pharmacists provide counseling to patients to help them be adherent to their chronic disease medications. In addition, MinuteClinic also plays an important role by providing patients with timely, affordable and high-quality walk-in healthcare. There are nearly 1,000 MinuteClinic walk-in medical clinics available at CVS/pharmacy retail stores. MinuteClinic locations are open seven days a week, offering evening hours with no appointment necessary, and most health insurance is accepted. The clinics are staffed by nurse practitioners and physician assistants who provide treatment for common family illnesses, and administer wellness and prevention services, including health-condition monitoring for patients with chronic diseases.
Affiliates' healthcare providers will receive data on interventions conducted by CVS pharmacists to improve medication adherence for their patients. The affiliation also encourages collaboration between the healthcare providers and MinuteClinic providers to improve coordination of care for patients seen at MinuteClinic locations. Through this collaboration, the affiliate organizations and MinuteClinic practitioners will also work together on planning strategies around chronic care and wellness. If more comprehensive care is needed, patients can follow up with their primary care provider and have access to the services at the healthcare provider as appropriate. For those patients who do not have regular access to healthcare, MinuteClinic provides information to help patients in finding a primary care physician and a greater opportunity for continuity of healthcare services.
MinuteClinic, CVS/pharmacy and the participating healthcare organizations will begin to work toward streamlining and enhancing communication through their EHR systems. This will include the electronic sharing of messages and alerts from CVS/pharmacy to the healthcare organizations' physicians regarding medication non-adherence issues. In addition, MinuteClinic will electronically share patient visit summaries with the patient's primary care physician when they are part of an affiliate organization and with the patient's consent. MinuteClinic will continue its standard practice of sending patient visit summaries to primary care providers who are not affiliated with one of these participating healthcare organizations via fax or mail, with patient consent.
The new affiliations announced here bring the total number of clinical collaborations for CVS Health and MinuteClinic to nearly 60 major health systems and healthcare providers across the country.
About CVS Health
CVS Health (NYSE: CVS) is a pharmacy-innovation company helping people on their path to better health. Through its 7,800 retail drugstores, nearly 1,000 walk-in medical clinics, a leading pharmacy benefits manager with more than 70 million plan members, and expanding specialty pharmacy services, the Company enables people, businesses and communities to manage health in more affordable, effective ways. This unique integrated model increases access to quality care, delivers better health outcomes and lowers overall healthcare costs. Find more information about how CVS Health is shaping the future of health at www.cvshealth.com.
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King v. Burwell: The Fix Was Definitely In
by Richard Amerling, M.D.
As I predicted back in March, the U.S. Supreme Court ruled for the administration in King v. Burwell. So I was not surprised by the decision, but that doesn't mean I am not deeply disappointed. I am.
Beyond the ramifications for the continuation of the abominable Obamacare, the obvious truth is that we are being ruled by a corrupt oligarchy that includes the majority of the Supreme Court. This was driven home on Friday by the discovery by Justice Anthony Kennedy of a right to same-sex marriage in the "shadows and penumbras" of the Constitution, which will certainly ignite another never-ending culture war in the country.
Further legal challenges to federal over-reaching are likely to fail. There are constitutional remedies to this tyranny, as Senator Ted Cruz points out, including action by Congress to either impeach members of the Court, or to limit the Court's jurisdiction. Neither of these options is feasible, given current lily-livered Republican leadership, and of course, a presidential veto. This leaves a constitutional amendment to overturn the decision, originating either in Congress, or in a convention of the states, as specified in Article V.
We are living, as says radio host Mark Levin, in a "post-constitutional republic," where rules and laws are concocted by a small group of elites, either unelected or elected in perpetuity by a tiny fraction of the electorate, and who are unresponsive to the will of the people.
What does this decision mean for the medical profession, and for those who depend on us for care?
We are in dire straits!
Obamacare, and more recently the Medicare Access and CHIP Reauthorization Act (MACRA), solidify bureaucratic control over the practice of medicine. We have already seen the widespread closing of private practices, with now over two-thirds of physicians working under a hospital umbrella. Those who remain private are under immense pressure, both financial and regulatory, and many will fold their tents. In addition to rigid price controls on their fees, there are never-ending requirements for documentation via the electronic health record of personal clinical details, to be used eventually to centrally direct care.
MACRA cements into place various payment schemes such as bundling, accountable care organizations (ACOs), and other forms of "payment-for-outcomes," that will be applied to the Medicare program, and ultimately to private insurance.
All of these systems create financial disincentives to caring for truly sick patients, and will have a devastating effect. Patients will be increasingly subjected to one-size-fits-all care, dictated by algorithms inserted into the electronic health record. These will be created by professional groups, such as the American Medical Association, the American College of Physicians, and the American Board of Internal Medicine, and will be labeled as "evidence-based," or "best practices."
This will lead to even greater over-prescription of statins, anti-hypertensives, and diabetes medications, based on achieving certain numerical "targets." Many individual patients will certainly be harmed by this approach.
To maximize revenue, physicians will dutifully click on boxes and comply with the central mandates. Thus will fade the Hippocratic ethic to render their best judgment on behalf of their patients. Over time, the medical profession will devolve from a science-based art into a trade requiring less training and less experience. Doctors are already being indoctrinated away from a commitment to individual patients and towards allegiance to the state, or to "society." This should be of grave concern to all of us.
To defend what is left of the private, independent practice of medicine, doctors will have to "opt out" of official, government medicine, and go back to the days when we worked for, and were paid by, our patients. This will allow the continued delivery of high quality, personalized care, and the survival of Hippocratic medicine for future generations of physicians.
And given the tyrannical nature of our government, doctors need to opt out while they still can. It is not inconceivable that the federal government would, completely without authority and violating the 10th Amendment insuring state sovereignty, federalize all state medical boards. They could then institute a federal medical license, and make licensure conditional on agreeing to accept all government insurance as full payment. We need a critical mass.
And who would stop such a move? Clearly not the Roberts Court!
About Richard Amerling, M.D.
Richard Amerling, M.D. (New York City) is an associate professor of Clinical Medicine and an academic nephrologist at Mount Sinai Beth Israel in New York. Dr. Amerling received an M.D. from the Catholic University of Louvain in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on healthcare issues and is president of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians' Declaration of Independence and is a seasoned speaker and on-air contributor.
Medical Tourism - A New Handbook Looks at the Implications for Patients and Health Systems Around the World
York.ac.uk-Patients who travel abroad for medical treatment risk returning with complications or infections that require costly treatment on the NHS is one of the issues highlighted in a new handbook exploring medical tourism.
In particular, cosmetic procedures appear to be an area of growth for medical travel by U.K. patients, but can often result in costly intervention when back home, researchers at the University of York have concluded.
It's estimated that botched cosmetic work overseas costs the NHS £8 million a year.
Medical tourism - people traveling abroad with the expressed purpose of accessing medical treatment - is a growing phenomenon associated with globalization.
This growth has been boosted by cheaper air travel and by the Internet, which allows medical providers from one country to market themselves to patients in another.
It is estimated that in 2015 globally five million people will seek medical treatment abroad.
However, little is known as to which patients choose to travel and why, when others do not.
Researchers from York's department of Social Policy and Social Work and the London School of Hygiene and Tropical Medicine brought together a global community of researchers and writers to produce the 'Handbook on Medical Tourism and Patient Mobility'. It is published by Edward Elgar.
One of the handbook's editors, Dr Neil Lunt, said: "We have been aware of a growing international group of scholars who are interested in patients who travel out of country for treatment. What we wanted to do in this handbook was really to bring together all the scholars but also to focus on places and writers that are quite often neglected. Often the focus is on the U.S. and Europe, but there's important things going on around the world in Africa, Asia, Middle East and South America."
The handbook explores the emergence of medical tourism and patient mobility and the implications this has for patients and health systems around the world.
It explores topics such as risk, law and ethics, patient experience and treatment outcomes for cosmetic, transplantation, dental, fertility and weight loss surgery.
The editors conclude that despite a number of studies focusing on U.K. patients, there needs to be further research on the potential impact and costs of medical tourism on the NHS.
Neil Lunt added: "If someone decides to go oversees for cosmetic work, that's an individual thing they do. But if when they come back there's work that needs to be done, that typically gets picked up by the NHS. People are travelling abroad without necessarily understanding that if something goes wrong they are not covered in the same way in terms of redress if they were treated by the NHS or treated privately in the U.K. People are so used to just jumping on planes."
To view the original article click here.
Aetna to Acquire Humana for $37 Billion, Combined Entity to Drive Consumer-Focused, High-Value Healthcare
- Strengthens Ability to Lead Effort to Transform Healthcare Delivery to a More Consumer-Focused Marketplace
- Establishes a Leading Medicare Advantage and Commercial Player with Enhanced Nationwide Presence that will Improve Affordability, Quality and Convenience for Consumers
- Transaction Projected to Realize $1.25 Billion in Annual Synergies in 2018
- Adds Over 14 Million Total Members, Including 3.2 Million Medicare Advantage Members
- Maintains Commitment to Louisville, Kentucky
- Projected to be Accretive to Operating EPS beginning in 2017
Aetna (NYSE: AET) and Humana Inc. (NYSE: HUM) today announced that they have entered into a definitive agreement under which Aetna will acquire all outstanding shares of Humana for a combination of cash and stock valued at $37 billion or approximately $230 per Humana share based on the closing price of Aetna common shares on July 2, 2015.
The complementary combination brings together Humana's growing Medicare Advantage business with Aetna's diversified portfolio and commercial capabilities to create a company serving the most seniors in the Medicare Advantage program and the second-largest managed care company in the United States. The combined entity will help drive better value and higher-quality healthcare by reducing administrative costs, leveraging best-in-breed practices from the two companies - including Humana's chronic-care capabilities that measurably improve health outcomes for larger populations - and enabling the company to better compete with more cost-effective products.
Under the terms of the agreement, which has been unanimously approved by the board of directors of each company, Humana stockholders will receive $125.00 in cash and 0.8375 Aetna common shares for each Humana share. As a result of the transaction, Aetna's shareholders would own approximately 74 percent of the combined company and Humana's shareholders would own approximately 26 percent. Aetna expects to finance the cash portion of the transaction with a combination of cash on hand and by issuing approximately $16 billion of new term loans, debt and commercial paper. Upon closing, which is expected to be in the second half of 2016, the company's debt-capital ratio is projected to be approximately 46 percent, and management has committed to reducing that ratio below 40 percent over the 24 months following the closing. The transaction is projected to be neutral to Aetna's 2016 Operating EPS and produce mid-single digit percentage Operating EPS accretion in 2017 and low double-digit percentage Operating EPS accretion in 2018.
The combined company will be well positioned to offer a broad choice of affordable, consumer-centric healthcare products, helping to constrain cost growth, improve health outcomes, and promote wellness. The combination will provide Aetna with an enhanced ability to work with providers and create value-based payment agreements that result in better care to consumers, and spread cutting-edge clinical practices and quality care.
The combined company would have projected 2015 operating revenue of approximately $115 billion, with approximately 56 percent from government-sponsored programs (including Medicare and Medicaid). The combined company will have over 33 million medical members, based on memberships as of March 31, 2015. The combined membership includes Humana's 3 million TRICARE members, under a program of healthcare coverage for military families and retirees administered by the U.S. Department of Defense.
After closing Aetna will make Louisville the headquarters for its Medicare, Medicaid and TRICARE businesses, and will maintain a significant corporate presence in Louisville. Founded in Louisville more than 50 years ago, Humana has a long history of contributing to the Louisville community.
"The acquisition of Humana aligns two great companies and will significantly advance our strategy of more effectively serving members in a rapidly changing healthcare industry," said Mark T. Bertolini, Aetna chairman and CEO. "This combination will allow us to continue to invest in excellent service for our members and strengthen our partnerships with providers to deliver high quality care at an affordable price. We have great respect for Humana, their talented team, their culture and their strong medical management capabilities. We look forward to working with them following the closing, as we enhance our combined portfolio of innovative healthcare offerings to provide significant benefits to consumers, employers and providers, and to continue delivering value for our shareholders."
"Aetna and Humana share a strong commitment to improving the health and well-being of consumers, whatever their needs and wherever they are on their lifelong health journey," said Bruce D. Broussard, president and CEO of Humana. "Through the use of technology and integrated services to simplify the consumer experience, the combined entity will be even more effective in meeting the health needs of many more people - especially people with chronic conditions, who will benefit from Humana's home health, pharmacy management, and data analytics programs. The transaction is a testament to the accomplishments of Humana associates and an outstanding outcome for our shareholders, who will receive an immediate premium and the opportunity to participate in the growth potential of the combined organization."
Shawn M. Guertin, Aetna's executive vice president and CFO, added, "The complementary nature of our two companies provides us with a significant synergy opportunity, furthering Aetna's efforts to increase its operating efficiency. We expect synergies from the transaction to be $1.25 billion annually in 2018. These cost efficiencies will support our efforts to drive costs out of the system and offer more affordable products."
The combination of Aetna and Humana:
- Builds on each company's respective efforts to provide innovative, technology-driven products, services and solutions to build healthier populations, promote higher quality healthcare at lower cost, and offer greater transparency and convenience for consumers.
- Increases Aetna's Medicare Advantage membership to 4.4 million and improves Aetna's ability to serve members and their providers with cutting-edge technology and best practices.
- Brings together two companies with leading percentages of membership in Medicare plans rated four Stars or higher.
- Creates a leading healthcare services and pharmacy benefit franchise, serving members who use over 600 million prescriptions annually.
- Strengthens care management capabilities by taking the best-of-breed provider solutions, including robust offerings of patient-centered provider services, clinical intelligence, value-based reimbursement models, data integration and analytics solutions from both companies.
- Brings together two companies with longstanding commitments to promoting wellness, health, and access to high-quality healthcare for everyone, while supporting the communities in which they serve.
Following the close of the transaction, Mark Bertolini will serve as chairman and CEO of the combined company. At the time of the closing, the Aetna Board of Directors will be comprised of twelve current Aetna directors and four Humana directors, for a total of 16 directors.
The transaction is subject to customary closing conditions, including the approval by Humana stockholders of the merger agreement, the approval by Aetna shareholders of the issuance of shares in the transaction, as well as the expiration of the federal Hart-Scott-Rodino antitrust waiting period and approvals of state departments of insurance and other regulators.
Aetna has received commitments from both Citi and UBS Investment Bank in connection with the financing of the transaction.
Citi and Lazard are acting as financial advisors to Aetna. Davis Polk & Wardwell LLP is acting as legal advisor to Aetna. Goldman Sachs is acting as financial advisor to Humana and Fried, Frank, Harris, Shriver & Jacobson LLP is acting as its legal advisor.
Share Repurchase Program
Prior to closing, Aetna's ability to repurchase its own shares will be limited. To meet its deleveraging plans, Aetna expects to suspend its share repurchase program for the combined company for approximately six months following the closing of the transaction. In addition, Humana will be suspending its share repurchase program.
The proposed transaction does not impact Aetna's ability and intent to continue quarterly dividend payments, including the $0.25 dividend declared on May 15, 2015, payable on July 31, 2015 to shareholders of record at the close of business on July 16, 2015. Under the merger agreement Aetna has agreed that its quarterly dividend will not exceed $0.25 per share prior to closing. Declaration and payment of future dividends is at the discretion of Aetna's board of directors and may be adjusted as business needs or market conditions change.
The proposed transaction also does not impact Humana's ability and intent to continue quarterly dividend payments prior to the closing of the transaction, including the cash dividend of $0.29 per share payable on July 31, 2015 to stockholders of record on June 30, 2015. Under the merger agreement Humana has agreed that its quarterly dividend will not exceed $0.29 per share prior to closing. Declaration and payment of future dividends is at the discretion of Humana's board of directors and may be adjusted as business needs or market conditions change.
Conference Call and Webcast
Aetna and Humana will hold a conference call to discuss the transaction at 8:30 a.m. ET on Monday, July 6, 2015. The public may access the conference call through a live audio webcast available on Aetna's Investor Information link at https://www.aetna.com/about-us/investor-information.html, and on Humana's Investor Relations link which can be accessed via www.humana.com. Information related to the conference call also will be available on Aetna's Investor Information website and Humana's Investor Relations website. Additional information regarding the transaction, including an investor presentation describing highlights of the transaction, can also be found at AetnaHumana.TransactionAnnouncement.com.
The conference call also can be accessed by dialing (877) 709-8150 or (201) 689-8354 for international callers. No access code is required. Participants should dial in approximately 10 minutes before the call. Individuals who dial in will be asked to identify themselves and their affiliations.
A replay of the call may be accessed through Aetna's and Humana's investor websites, or by dialing (877) 660-6853 or (201) 612-7415 for international callers. The access code is 13613657. Telephone replays will be available beginning at 11:00 a.m. (ET) on July 6, 2015 through 11:00 p.m. (ET) on July 20, 2015.
Aetna is one of the nation's leading diversified healthcare benefits companies, serving an estimated 46 million people with information and resources to help them make better informed decisions about their healthcare. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid healthcare management services, workers' compensation administrative services and health information technology products and services. Aetna's customers include employer groups, individuals, college students, part-time and hourly workers, health plans, healthcare providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com and learn about how Aetna is helping to build a healthier world. @AetnaNews
Humana Inc., headquartered in Louisville, Kentucky, is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. The company's strategy integrates care delivery, the member experience, and clinical and consumer insights to encourage engagement, behavior change, proactive clinical outreach and wellness for the millions of people we serve across the country. More information regarding Humana is available to investors via the Investor Relations page of the company's web site at www.humana.com.
Important Information For Investors And Stockholders
This communication does not constitute an offer to sell or the solicitation of an offer to buy any securities or a solicitation of any vote or approval. In connection with the proposed transaction between Aetna Inc. ("Aetna") and Humana Inc. ("Humana"), Aetna and Humana will file relevant materials with the Securities and Exchange Commission (the "SEC"), including an Aetna registration statement on Form S-4 that will include a joint proxy statement of Aetna and Humana that also constitutes a prospectus of Aetna, and a definitive joint proxy statement/prospectus will be mailed to stockholders of Aetna and Humana. INVESTORS AND SECURITY HOLDERS OF AETNA AND HUMANA ARE URGED TO READ THE JOINT PROXY STATEMENT/PROSPECTUS AND OTHER DOCUMENTS THAT WILL BE FILED WITH THE SEC CAREFULLY AND IN THEIR ENTIRETY WHEN THEY BECOME AVAILABLE BECAUSE THEY WILL CONTAIN IMPORTANT INFORMATION. Investors and security holders will be able to obtain free copies of the registration statement and the joint proxy statement/prospectus (when available) and other documents filed with the SEC by Aetna or Humana through the website maintained by the SEC at http://www.sec.gov. Copies of the documents filed with the SEC by Aetna will be available free of charge on Aetna's internet website at http://www.Aetna.com or by contacting Aetna's Investor Relations Department at 860-273-8204. Copies of the documents filed with the SEC by Humana will be available free of charge on Humana's internet website at http://www.Humana.com or by contacting Humana's Investor Relations Department at 502-580-3644.
Aetna, Humana, their respective directors and certain of their respective executive officers may be considered participants in the solicitation of proxies in connection with the proposed transaction. Information about the directors and executive officers of Humana is set forth in its Annual Report on Form 10-K for the year ended December 31, 2014, which was filed with the SEC on February 18, 2015, its proxy statement for its 2015 annual meeting of stockholders, which was filed with the SEC on March 6, 2015, and its Current Report on Form 8-K, which was filed with the SEC on April 17, 2015.
Information about the directors and executive officers of Aetna is set forth in its Annual Report on Form 10-K for the year ended December 31, 2014 ("Aetna's Annual Report"), which was filed with the SEC on February 27, 2015, its proxy statement for its 2015 annual meeting of shareholders, which was filed with the SEC on April 3, 2015 and its Current Reports on Form 8-K, which were filed with the SEC on May 19, 2015 and May 26, 2015. Other information regarding the participants in the proxy solicitations and a description of their direct and indirect interests, by security holdings or otherwise, will be contained in the joint proxy statement/prospectus and other relevant materials to be filed with the SEC when they become available.
Cautionary Statement Regarding Forward-Looking Statements
This news release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. You can generally identify forward-looking statements by the use of forward-looking terminology such as "anticipate," "believe," "continue," "could," "estimate," "expect," "explore," "evaluate," "intend," "may," "might," "plan," "potential," "predict," "project," "seek," "should," or "will," or the negative thereof or other variations thereon or comparable terminology. These forward-looking statements are only predictions and involve known and unknown risks and uncertainties, many of which are beyond Aetna's and Humana's control.
Statements in this news release regarding Aetna that are forward-looking, including Aetna's projections as to the anticipated benefits of the pending transaction to Aetna, increased membership as a result of the pending transaction, the impact of the pending transaction on Aetna's businesses and share of revenues from Government business, the methods Aetna will use to finance the cash portion of the transaction, the impact of the transaction on Aetna's revenue and operating earnings per share, the synergies from the pending transaction, and the closing date for the pending transaction, are based on management's estimates, assumptions and projections, and are subject to significant uncertainties and other factors, many of which are beyond Aetna's control. In particular, projected financial information for the combined businesses of Aetna and Humana Inc. is based on management's estimates, assumptions and projections and has not been prepared in conformance with the applicable accounting requirements of Regulation S-X relating to pro forma financial information, and the required pro forma adjustments have not been applied and are not reflected therein. None of this information should be considered in isolation from, or as a substitute for, the historical financial statements of Aetna or Humana Inc. Important risk factors could cause actual future results and other future events to differ materially from those currently estimated by management, including, but not limited to: the timing to consummate the proposed acquisition; the risk that a condition to closing of the proposed acquisition may not be satisfied; the risk that a regulatory approval that may be required for the proposed acquisition is delayed, is not obtained or is obtained subject to conditions that are not anticipated; Aetna's ability to achieve the synergies and value creation contemplated by the proposed acquisition; Aetna's ability to promptly and effectively integrate Humana's businesses; the diversion of management time on acquisition-related issues; unanticipated increases in medical costs (including increased intensity or medical utilization as a result of flu or otherwise; changes in membership mix to higher cost or lower-premium products or membership-adverse selection; medical cost increases resulting from unfavorable changes in contracting or re-contracting with providers (including as a result of provider consolidation and/or integration); and increased pharmacy costs (including in Aetna's health insurance exchange products)); the profitability of Aetna's public health insurance exchange products, where membership is higher than Aetna projected and may have more adverse health status and/or higher medical benefit utilization than Aetna projected; uncertainty related to Aetna's accruals for healthcare reform's reinsurance, risk adjustment and risk corridor programs ("3R's"); the implementation of healthcare reform legislation, including collection of healthcare reform fees, assessments and taxes through increased premiums; adverse legislative, regulatory and/or judicial changes to or interpretations of existing healthcare reform legislation and/or regulations (including those relating to minimum MLR rebates); the implementation of health insurance exchanges; Aetna's ability to offset Medicare Advantage and PDP rate pressures; and changes in Aetna's future cash requirements, capital requirements, results of operations, financial condition and/or cash flows. Healthcare reform will continue to significantly impact Aetna's business operations and financial results, including Aetna's pricing and medical benefit ratios. Key components of the legislation will continue to be phased in through 2018, and Aetna will be required to dedicate material resources and incur material expenses during 2015 to implement healthcare reform. Certain significant parts of the legislation, including aspects of public health insurance exchanges, Medicaid expansion, reinsurance, risk corridor and risk adjustment and the implementation of Medicare Advantage and Part D minimum medical loss ratios ("MLRs"), require further guidance and clarification at the federal level and/or in the form of regulations and actions by state legislatures to implement the law. In addition, pending efforts in the U.S. Congress to amend or restrict funding for various aspects of healthcare reform, and litigation challenging aspects of the law continue to create additional uncertainty about the ultimate impact of healthcare reform. As a result, many of the impacts of healthcare reform will not be known for the next several years. Other important risk factors include: adverse changes in healthcare reform and/or other federal or state government policies or regulations as a result of healthcare reform or otherwise (including legislative, judicial or regulatory measures that would affect Aetna's business model, restrict funding for or amend various aspects of healthcare reform, limit Aetna's ability to price for the risk it assumes and/or reflect reasonable costs or profits in its pricing, such as mandated minimum medical benefit ratios, or eliminate or reduce ERISA pre-emption of state laws (increasing Aetna's potential litigation exposure)); adverse and less predictable economic conditions in the U.S. and abroad (including unanticipated levels of, or increases in the rate of, unemployment); reputational or financial issues arising from Aetna's social media activities, data security breaches, other cybersecurity risks or other causes; Aetna's ability to diversify Aetna's sources of revenue and earnings (including by creating a consumer business and expanding Aetna's foreign operations), transform Aetna's business model, develop new products and optimize Aetna's business platforms; the success of Aetna's Healthagen® (including Accountable Care Solutions and health information technology) initiatives; adverse changes in size, product or geographic mix or medical cost experience of membership; managing executive succession and key talent retention, recruitment and development; failure to achieve and/or delays in achieving desired rate increases and/or profitable membership growth due to regulatory review or other regulatory restrictions, the difficult economy and/or significant competition, especially in key geographic areas where membership is concentrated, including successful protests of business awarded to Aetna; failure to adequately implement healthcare reform; the outcome of various litigation and regulatory matters, including audits, challenges to Aetna's minimum MLR rebate methodology and/or reports, guaranty fund assessments, intellectual property litigation and litigation concerning, and ongoing reviews by various regulatory authorities of, certain of Aetna's payment practices with respect to out-of-network providers and/or life insurance policies; Aetna's ability to integrate, simplify, and enhance Aetna's existing products, processes and information technology systems and platforms to keep pace with changing customer and regulatory needs; Aetna's ability to successfully integrate Aetna's businesses (including Humana, Coventry, bswift LLC and other businesses Aetna may acquire in the future) and implement multiple strategic and operational initiatives simultaneously; Aetna's ability to manage healthcare and other benefit costs; adverse program, pricing, funding or audit actions by federal or state government payors, including as a result of sequestration and/or curtailment or elimination of the Centers for Medicare & Medicaid Services' star rating bonus payments; Aetna's ability to reduce administrative expenses while maintaining targeted levels of service and operating performance; failure by a service provider to meet its obligations to us; Aetna's ability to develop and maintain relationships (including collaborative risk-sharing agreements) with providers while taking actions to reduce medical costs and/or expand the services Aetna offers; Aetna's ability to demonstrate that Aetna's products and processes lead to access to quality affordable care by Aetna's members; Aetna's ability to maintain Aetna's relationships with third-party brokers, consultants and agents who sell Aetna's products; increases in medical costs or Group Insurance claims resulting from any epidemics, acts of terrorism or other extreme events; changes in medical cost estimates due to the necessary extensive judgment that is used in the medical cost estimation process, the considerable variability inherent in such estimates, and the sensitivity of such estimates to changes in medical claims payment patterns and changes in medical cost trends; a downgrade in Aetna's financial ratings; and adverse impacts from any failure to raise the U.S. Federal government's debt ceiling or any sustained U.S. Federal government shut down. For more discussion of important risk factors that may materially affect Aetna, please see the risk factors contained in Aetna's 2014 Annual Report on Form 10-K ("Aetna's 2014 Annual Report") on file with the Securities and Exchange Commission ("SEC"). You should also read Aetna's 2014 Annual Report and Aetna's Quarterly Report on Form 10-Q for the quarter ended March 31, 2015, on file with the SEC, for a discussion of Aetna's historical results of operations and financial condition.
No assurances can be given that any of the events anticipated by the forward-looking statements will transpire or occur, or if any of them do occur, what impact they will have on the results of operations, financial condition or cash flows of Aetna or Humana. Neither Aetna nor Humana assumes any duty to update or revise forward-looking statements, whether as a result of new information, future events or otherwise, as of any future date.
Aetna Media Contact:
Sard Verbinnen & Co
Meghan Gavigan/Patrick Scanlan, 212-687-8080
Aetna Investor Contact:
Tom Cowhey, 860-273-2402
Humana Media Contact:
Tom Noland, 502-580-3674
Humana Investor Contact:
Regina Nethery, 502-580-3644
To view the original release click here.
SIIA Panel Discussion: Employer Direct Contracting: Game-Changing Medical Travel Trend
Panel: Employer Direct Contracting: Game-Changing Medical Travel Trend
Date: October 19th, 2015
Time: 10:15am - 11:30am
Location: Marriott Marquis, Washington D.C.
Description: With the sticker-shock of health reforms resonating in the employer community, business leaders are seeking solutions that not only lower costs, but also ensure quality. While there are a few pioneers in the large business category that have tested the waters to execute direct contracting arrangements with targeted Centers of Excellence (COEs) (e.g. Wal-Mart, Lowe's, Boeing) the vast majority of large employers are now contemplating these arrangements in the year ahead. Furthermore, virtually all of the mid-size and small employers are also receptive to this concept and may aggregate their purchasing power through coalitions and other multiple employer welfare arrangements (MEWAs). A panel of experts will discuss the latest trends in this area.
Moderator: Laura Carabello
Editor and Publisher: National and International Newsletters
U.S. Domestic Medical Travel: www.USDomesticMedicalTravel.com
Medical Travel Today: www.MedicalTravelToday.com
Cheryl DeMars, CEO, The Alliance
Trisha M. Frick-Hall, MS RN, Assistant Director, Managed Care Contracting, Office of Managed Care, John Hopkins Healthcare LLC
David LaMarche, MBA, Administrative Director, Finance, Virginia Mason Medical Center
To learn more about the upcoming panel and/or event, please visit: www.siia.org/national.
HMFA ANI 15: How Bundled Payments Can Standardize Care Quality
Value-based care will reduce variation in quality, says Harvard's Michael Chernew
by Zack Budryk
Fiercehealthfinance.com-Alternative payment models such as bundled payments could help create more consistent healthcare quality standards, Michael Chernew, Ph.D., a professor in healthcare policy at Harvard Medical School said at the Healthcare Financial Management's (HFMA) annual meeting in Orlando, Florida.
To view the original article click here.
Telemedicine May Support Flexible Work-Life Balance, Survey Finds
by Akanksha Jayanthi
Becker's Hospital Review is the original producer/publisher of this content.
Beckershospitalreview.com-More than half of physicians would be willing to conduct video consultations with patients, largely to help improve work-life balance, according to a survey conducted by telemedicine platform provider American Well.
To view the original article click here.
Price Transparency: A Look Back and Ahead
by Zack Budryk
Fiercehealthfinance.com-As the healthcare industry becomes increasingly consumer-focused, there is a movement afoot to provide patients with greater price transparency so they can make better decisions about their care and treatment.
To view the original article click here.
CMS to Transform Hip and Knee Replacement Payment Model
New proposal will hold hospitals accountable for quality and cost for entire episode of care
by Dori Zweig
Fiercehealthfinance.com - Medicare will now pay providers who perform hip and knee replacement surgeries based on their ability to deliver high-quality, low-cost care under a five-year initiative announced Thursday by the federal government.
To view the original article click here.
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MatchingDonors is a 501c3 nonprofit organization and the nation's largest online living organ donor organization finding living organ donors for people needing organ transplants. In conjunction with various health organizations throughout the United States we have created a very successful Public Service Announcement campaign to help people recognize that they can save lives by being a living organ donor, to encourage them to register as an altruistic living organ donor, and to make them realize they can help save the lives of people needing organ transplants by donating other things. This MatchingDonors Living Organ Donor Initiative program has already saved thousands of lives.
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