Trust, Money, and Power: Life Cycle Dynamics in Alliances Between Management Partners and Accountable Care Organizations.

Policy Points Accountable care organizations (ACOs) form alliances with management partners to access financial, technical, and managerial support. Alliances between ACOs and management partners are subject to destabilizing tension around decision-making authority, distribution of shared savings, and conflicting goals and values. Management partners may serve either as trainers, ultimately breaking off from the ACO, or as central drivers of the ACO. Management partner participation in ACOs is currently unregulated, and management partners may receive a significant portion (in some cases, majority) of shared savings. CONTEXT: Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. METHODS: We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. FINDINGS: Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. CONCLUSIONS: The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.

Policy Options to Reduce Fragmentation in the Pooling of Health Insurance Funds in Iran.

There are fragmentations in Iran's health insurance system. Multiple health insurance funds exist, without adequate provisions for transfer or redistribution of cross subsidy among them. Multiple risk pools, including several private secondary insurance schemes, have resulted in a tiered health insurance system with inequitable benefit packages for different segments of the population. Also fragmentation might have contributed to inefficiency in the health insurance systems, a low financial protection against healthcare expenditures for the insured persons, high coinsurance rates, a notable rate of insurance coverage duplication, low contribution of well-funded institutes with generous benefit package to the public health insurance schemes, underfunding and severe financial shortages for the public funds, and a lack of transparency and reliable data and statistics for policy-making. We have conducted a policy analysis study, including qualitative interviews of key informants and document analysis. As a result we introduce three policy options: keeping the existing structural fragmentations of social health insurance (SHI)schemes but implementing a comprehensive "policy integration" strategy; consolidation of existing health insurance funds and creating a single national health insurance scheme; and reducing fragmentation by merging minor well-resourced funds together and creating two or three large insurance funds under the umbrella of the existing organizations. These policy options with their advantages and disadvantages are explained in the paper.

Evolución de la accesibilidad a los centros sanitarios en España. Seguimiento de los últimos setenta años / Evolution of the accessibility of health centers in spain. monitoring of the last seventy years

Introducción. La accesibilidad de la población a los centros sanitarios españoles ha ido evolucionando en las últimas décadas, ligada al estado de bienestar y a los cambios en las competencias en materia de salud. El objetivo de esta revisión es describir la evolución de la accesibilidad y su impacto en la población. Metodología. Se han utilizado bases bibliográficas para buscar los artículos relacionados con el objetivo de la revisión y comprendidos entre 1940 y 2013. Se han seleccionado aquellos artículos con mayor calidad y que ayudaban a construir la revisión del tema propuesto. Resultados. La accesibilidad a los centros sanitarios españoles está ligada a la evolución de la atención pública en los últimos setenta años. Por un lado, la aparición del Seguro Obligatorio de Enfermedad (SOE) y la creación de la Seguridad Social hicieron que casi el total de la población española tuviera cobertura sanitaria. Por otro lado, la aplicación de principios como los de justicia y equidad hicieron aflorar numerosos centros hospitalarios con la finalidad de acercar al máximo la asistencia a la población. En los inicios del siglo xxi, con un crecimiento desmesurado de centros hospitalarios y una crisis económica mundial, se constata la necesidad de ubicar los centros asistenciales de acuerdo con el principio de eficiencia económico-espacial o de racionalidad económica. Conclusiones. En un entorno actual de crisis se analizan las consecuencias de la hiperaccesibilidad (sistema sanitario insostenible, polimedicación de la población, etc.) y se busca un sistema sanitario más eficiente. También es necesario plantearse la relación existente entre la hiperaccesibilidad y la hiperfrecuentación de la población a los servicios sanitarios, así como la relación entre la hiperaccesibilidad y la polimedicación (AU)

Introduction: the accessibility of the population to health centers in Spain has evolved to over the past decades, linked to the welfare state and changes in the health skills. The aim of this review is to describe the evolution of accessibility and its impact on the population. Methodology: we used bibliographic databases to search for articles related to the purpose of reviewing and between 1940 and 2013. We have selected those items with higher quality and that helped to build the review of the proposed topic. Results: the accessibility to health centers in Spain is linked to the performance of public attention in the last seventy years. On the one hand, the appearance of Compulsory Health Insurance (SOE) and the creation of Social Security made almost all of the Spanish population had health coverage. On the other hand, the application of principles such as justice and equity brought to the surface many hospitals with the aim of bringing the most assistance to the population. In the early twenty-first century, with an enormous growth of hospitals and a global economic crisis, we see the need to locate health facilities under the principle of spatial economic efficiency or economic rationality. Conclusions: in a current environment of crisis, the consequences of hyperaccessibility are analyzed (unsustainable health system, population polypharmacy, etc. ) and a more efficient healthcare system is searched. It is also necessary to consider the relationship between the hyperaccessibility and the frequent attendance of population to the health services, and the relationship between hyperaccessibility and polypharmacy

How to evaluate a potential merger or acquisition.

Economic imperatives in health care financing are compelling a variety of mergers, acquisitions, integrations, and other forms of amalgamation. As hospitals merge, their pathology practices are merging. Physicians are forming clinically integrated groups, both with and without hospitals. Universities, commercial laboratories, and even insurance companies are acquiring laboratories and pathology practices. There are few standards or guidelines to help the practicing pathologist respond to such new undertakings. In the present study, we present a "how-to" guide or template to assist pathologists in evaluating proposals to amalgamate and in managing the alliance. The procedure begins with an articulation of the cons and pros, followed by a series of assessments of the cultures, the market, the organization, and operations, as well as a legal and financial assessment and human resources appraisal of each of the entities. We then outline the method for developing an organizational and operational model for the new merged entity and for performing the feasibility analysis, making a final decision, drafting a contract, and developing the business plan for the new venture.

State-based coverage solutions: the California Health Benefit Exchange.

California was the first state to create its own health insurance exchange after the passage of the Affordable Care Act. Because of its front-runner status and the sheer size of its coverage expansion, California's choices will have implications for other states as they address difficult issues, including minimizing adverse selection, promoting cost-conscious consumer choice, and seamlessly coordinating with public programs. California took advantage of the flexibility in the federal health reform law to create an exchange that will function as an active purchaser in the marketplace; take significant steps to combat adverse selection both against and within the exchange, including requiring all insurers to sell all tiers of products and making exchange participation a condition of selling catastrophic plans; and allow community-based health plans to develop commercial offerings for the exchange. This brief examines these decisions, which will provide a roadmap for other states as they set up their exchanges.

State high-risk pools: an update on the Minnesota Comprehensive Health Association.

State health insurance high-risk pools are a key component of the US health care system's safety net, because they provide health insurance to the "uninsurable." In 2007, 34 states had individual high-risk pools, which covered more than 200 000 people at a total cost of $1.8 billion. We examine the experience of the largest and oldest pool in the nation, the Minnesota Comprehensive Health Association, to document key issues facing state high-risk pools in enrollment and financing. We also considered the role and future of high-risk pools in light of national health care finance reform.

High-risk pools for the sick and uninsured under health reform: too little and thus too late.

Democrats and Republicans have turned to the concept of "high-risk pools" to provide health care for those Americans who face the dual challenge of uninsurance and serious health difficulties. Under the Patient Protection and Affordable Care Act (PPACA), these "high-risk" individuals will receive extensive help and regulatory protections, in concert with a new system of health insurance exchanges. However, these federal provisions do not become operational until 2014. As an interim measure, PPACA provides $5 billion for temporary, federally funded high-risk pools, now known as the Pre-Existing Condition Insurance Plan (PCIP). This analysis explores the adequacy of such funding. Using 2005/06 data from the National Health and Nutrition Examination Survey (NHANES), we find that approximately 4 million uninsured Americans have been diagnosed with emphysema, diabetes, stroke, cancer, congestive heart failure, angina, or a heart attack. To provide adequate health care for uninsured individuals with chronic diseases, the federal PCIP appropriations would need to be many times higher than either Democrats or Republicans have proposed.

How temporary insurance for high-risk individuals may play out under health reform.

The Patient Protection and Affordable Care Act guarantees that people with health problems will be able to buy private health insurance as of 2014. In the interim, a new federal high-risk program will accept those who are denied private insurance and have not found coverage from any other source. Such sources include a state high-risk pool or, in a handful of states, a designated carrier of last resort. However, restricted eligibility for the federal program suggests that state high-risk pools, in particular, will continue to be critical yet problematic sources of coverage for the next few years.

New roles for states in health reform implementation.

State policies and implementation practices will largely determine whether the new federal health reform law translates into more affordable coverage and access to health care services. States will play particularly important roles with respect to Medicaid expansion, the creation of insurance exchanges, and the new market rules for insurance. The decision of whether or not to create an exchange looms as the most important and consequential one for states. To achieve effective implementation, each state will need a coherent vision to guide its work. States will need help from the federal government and stakeholders and must learn from each other during implementation.

The long shadow of the past: risk pooling and the political development of health care reform in the States.

Why do the states seem to be pursuing different types of policy innovation in their health reform? Why so some seem to follow a "solidarity principle," while others seem guided by a commitment to "actuarial fairness"? Our analysis highlights the reciprocal influence of stakeholder mobilization and public policy over time. We find that early policy choices about how to achieve cost containment led the states down different paths of reform. In the 1970s and 1980s, states that featured oligopolistic or near-monopolistic markets for private insurance (usually dominated by Blue Cross) and strong urban-academic hospitals tended to adopt regulatory strategies for cost containment that led to broader forms of pooling and financing the costs of health risks--which subsequently positioned them to pursue major, solidaristic reform on favorable terms. On the other hand, states with competitive markets for private insurance and weak, decentralized hospitals tended to adopt market-based strategies for cost containment that led to the hypersegmentation of risk and the uneven financing of costs--thereby encouraging the proliferation of incremental policies that reinforce the principle of actuarial fairness. We illustrate our analysis with a brief comparison of Massachusetts and California, and we conclude with some thoughts on what our findings imply for the federal role in catalyzing health reform.

Alliance for pediatric quality: creating a community of practice to improve health care for America's children.

On any given day, hundreds of physicians, nurses, informaticists, health information management directors, and other health care providers are collaborating on how to improve health information technology systems for use in child health care. Many work in small communities of practice to share ideas, to find solutions, and to build innovations that support the goal of making electronic health record systems accessible by 2014. Together, they are a formidable virtual community aligned around a common strategy, to ensure that health information technology works for children. Each member in the community represents a children's hospital or pediatric practice affiliated with one of the 4 major national pediatric organizations that constitute the Alliance for Pediatric Quality. The alliance works with the pediatric health information technology community to speed the adoption of pediatric data standards and to define data collection and reporting systems that would work for both quality improvement and electronic health record systems. With this foundation, hospitals and physicians should be better positioned to improve the quality of health care for US children by implementing technology equipped to care for children, actively participating in improvement initiatives, conducting meaningful measurement of care, and appropriately reporting for accountability.

Coordinating eye and primary medical care in a low-income and uninsured population: the experience of the Vision of Hope Health Alliance.

PURPOSE: The Vision of Hope Health Alliance (VOHHA) was developed to provide an integrated system of eye and primary medical services to low-income and uninsured patients who were referred from nonmedical and medical agencies. METHODS: Partnerships were formed to facilitate patient referrals. Eye examinations and ophthalmic materials were provided at no cost to patients. Interpretation services and follow-up care were provided as needed. If applicable, patients were scheduled with a primary care physician at a Federally Qualified Health Center. Findings were documented by VOHHA team members or obtained through retrospective record review. RESULTS: Over a 2-year period, 1,753 patients were examined. About half (52.5%) were women. Most (80%) were black or Hispanic. Average age was 49.4 years (range, 18 to 83). Of those with diabetes mellitus (DM), 30.9% reported a last eye examination within 15 months. Of those without DM, 23.6% reported last eye examination within 15 months. Most (60%) reported last medical examination to be within 1 year. Most (85.7%) received spectacle prescriptions. Follow-up eye care appointments were kept by 367. Appointments with primary care physicians were scheduled for 165. Of those, 121 kept appointments. CONCLUSIONS: VOHHA demonstrated a model program that provided eye care and referral for primary medical care to individuals without the means to otherwise obtain care.

Does high-risk pool coverage meet the needs of people at risk for disability?

State high-risk insurance pools serve people denied coverage because of pre-existing conditions. With benefit plans modeled on the individual market, these pools generally require higher out-of-pocket expenditures and provide fewer benefits than employer-sponsored plans, while their beneficiaries have very intensive needs. We profile 416 working adults enrolled in a state high-risk pool and document their health conditions and health care utilization. High-risk pool and federal employee benefits are compared to assess insurance structure and implications for health and disability outcomes.