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Tag Archives: PPACA
California Screws Emergency Physicians (again) with Health Exchange Rules
Recently, the Board of the California Health Benefits Exchange decided to approve the recommendations of the Exchange staff to establish a benefit standard for out-of-network services for Exchange health care policies, based on the 50th percentile of usual and customary charges using the FAIR Health database. This was an attempt to protect Exchange enrollees from having to make large out-of-pocket payments if the plan was allowed to establish inappropriately low benefit coverage for these services. … Continue reading
The Iron Triangle of Health Care – Implications for the PPACA
I was recently working on a consultation gig and came across a report from the FTC and the DOJ entitled ‘Improving Health Care: a Dose of Competition’, which included a reference to the so-called Iron Triangle of Health Care. William Kissick initially proposed this concept in 1994 when he described medicine’s dilemma of infinite needs versus finite resources. The three vertices of the triangle are cost, quality, and access. As I read the description of … Continue reading
Health Plan Benefits for Emergency Care – Pick a Number
One of the provisions of the Patient Protection and Affordable Care Act that has not gotten much play, outside of the world of emergency medicine, was designed to prevent health plans that fall under this act from sticking it to patients who have a medical or traumatic emergency and are treated by an out of network provider. There are two elements to this protection: 1) a requirement that the plan set a benefit that is … Continue reading
PPACA, Medical Loss Ratios, and Capitation – a Loop Hole Big Enough to Drive an Armored Truck Through
One of the new health reform provisions in the PPACA regulations is a requirement for health insurers to spend a certain proportion of health insurance premiums on actual medical care, thus limiting to some extent the proportion of these premiums that can be allocated to administrative expenses and profits. This proportion is called the medical loss ratio (MLR), and in the regs the proportion that must be spent on care is 85% or higher in … Continue reading