Tag: Managed Care

Federal rules could streamline prior authorization decisions…but not for drugs

Jason Shafrin

A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…

White vs. Brown vs. Clear Bagging

Jason Shafrin

In 2020, spending on specialty drugs was $265 billion; this constituted 49.6% of total prescription drug expenditure. To combat rising costs, payers have turned to white, brown and clear bagging as well as approaches to restrict the site of care where patients receive specialty drugs. What are these “bagging” policies, what are the pros and…

Do narrow networks save money?

Jason Shafrin

According to a recent paper by Wallace (2023), the answer is ‘yes’, but it does so in a highly inefficient manner. Using 2008-2012 Medicaid data from the New York State Department of Health, the author find that: Leveraging the random assignment of over 50,000 Medicaid enrollees in New York, I present causal evidence that narrower…

Medicaid Managed Care and Drug Utilization for Patients with Serious Mental Illness

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How will Medicaid expansions affect patient access to pharamceuticals? This question is particularly relevant for patients with serious mental illness. The answer is complicated by the increasing presence of Medicaid managed care plans. Increasingly, states have turned to contracts with Medicaid managed care plans in order to better control costs and reduce budgetary uncertainty. However, in…

Does your doc want to be in an ACO?

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The answer is likely “It depends.”  To see why this is the case, let us consider the case of some proposed health reforms in Switzerland to force physicians into managed care (MC) networks.  As described in Rischatsch (2015): In 2012, Switzerland held a referendum…aimed at encouraging the nationwide development of MC networks. Among other changes…the legal…

Who uses out-of-network providers?

Jason Shafrin1 Comment

According to a recent paper by Kyanko, Curry and Busch (2003), 8 percent of insured individuals used an out-of-network physician. Why are people using out-of-network services? The authors give the following breakdown. Approximately 40 percent of individuals using out-of-network physicians experienced involuntary out-of-network care. Whereas fifteen percent of outpatient out-of-network contacts were involuntary, almost 60…

California: Mandatory Enrollment of Seniors and the Disabled into Managed Care

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In 2010, CMS approved California’s “Bridge to Reform” waiver request that authorized the state to expand its mandatory managed care to seniors and people with disabilities covered by Medi-Cal.  Authorized under a Section 1115 waiver, the policy affected nearly 400,000 Medi-Cal enrollees, including 240,000 who were moved from fee-for-service into managed care between June 2011…

Early Medical Cooperatives

Jason Shafrin2 Comments

In the days before health reform’s pasage, many reform proponents argued for the advent of co-operative healthcare systems or “co-ops”.  Co-ops, however, have been around for a long time before that. “In the late forties, over a hundred small rural health cooperatives were founded.  Nearly all of these were in the Southwest, fifty in Texas…