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PubMed1993

Blue Cross Blue Shield CEO Tresnowski calls for insurance reform. Interview by Richard L. Clarke.

The Blue Cross Blue Shield Association is the coordinating organization for the 70 independent Blue Cross Blue Shield plans across the United States. In an interview with Richard L. Clarke, FHFMA, president, Healthcare Financial Management Association, Bernard R. Tresnowski, Blue Cross Blue Shield's president and chief executive officer, addresses the issue of healthcare reform, some of which he believes may be implemented as early as next summer. In addition, Tresnowski discusses the need for insurance reform, offers reasons why some Blue Cross plans have failed, reinforces his belief in the benefits of administrative simplification, and emphasizes the strengths of linking financing and delivery.

Blue Cross Blue Shield Insurance Plans↗
PubMed1994

New developments in 'any willing provider' laws.

As the debate over healthcare reform continues, the controversy concerning "any willing provider" laws also continues. "Any willing provider" laws require a healthcare insurer (or managed care organization) to establish criteria that a provider must meet in order to participate as a network provider. Such laws prohibit an insurer from denying any provider willing to meet those criteria from participating as a network provider. Proponents of any willing provider laws cite the recent decision by the U.S. Supreme Court not to review a lower court ruling finding in favor of a hospital as validation of such laws.

Contract Services↗
PubMed1994

Offsetting unexpected healthcare costs with futures contracts.

Group health insurance futures contracts will be traded at the Chicago Board of Trade in the near future. These contracts may be useful devices for capitated systems, such as health maintenance organizations (HMOs), to hedge unanticipated increases in the costs of providing health care. This article discusses how futures contracts may be used by an HMO to prevent financial losses that arise from unexpected increases in inpatient utilization.

Chicago↗
PubMed1995

Managed care liability and the capitated provider.

While there have been no reported cases as yet on the subject of ERISA preemption of claims arising from utilization review decisions by providers, it will unquestionably be a significant issue facing providers that participate in capitated arrangements. If preemption is determined not to be available, providers will be exposed to risks from which health plans are currently shielded. Providers conducting utilization review should be following this issue as it develops, but should also be obtaining insurance for this risk to the extent it is available (e.g., it will not be available for punitive damages). Providers should also consider negotiating provisions in their contracts with health plans to the effect that any utilization review conducted by the provider is on behalf of the health plan and that the provider's utilization review activities will be covered under the health plan's liability insurance.

Capitation Fee↗
PubMed1995

1995 in the states: refinement of reform.

With the exception of Kentucky, all state legislatures met in regular session in 1995. By mid-September, all but 10 had adjourned for the year. Not surprisingly, health care reform continued to be a priority for lawmakers. However, in sharp contrast with reform activity in past years, state lawmakers chose refinement over sweeping reform as their preferred approach to health care issues. The year was not without its significant legislative initiatives, including the roll-back of far-reaching reform plans in Minnesota and Washington. However, the fine tuning of insurance market reforms, Medicaid reform, continued growth of medical savings account (MSA) legislation, and making managed care more consumer-friendly were the mainstream activities of this legislative year.

Cost Sharing↗
PubMed1996

Developing an incentive system for PHO physicians.

To succeed in a capitated market, a physician-hospital organization (PHO) must deliver high-quality health care in the most cost-effective manner possible. Integral to the provision of cost-effective care for patients covered by capitated contracts is the development of a sound physician incentive program. Such a system is essential to align the incentives of all the key players and enable them to share in the rewards and risks associated with capitation. Following specific guidelines for establishing physician incentive programs in a PHO can ensure the success of such programs.

Capitation Fee↗
PubMed1996

The tripartite regulation of America's health services.

The Republican takeover of Congress suggests that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of our nation's health services. These "voluntary" alliances, frequently as an amalgamation of health providers and health insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies. The authors anticipate, as a result, the formation of state health services commissions that will regulate market share, the scope of health services, reimbursement rates and allowable profits. State departments of public health and insurance will have their own regulatory duties. Complex relationships will result as these groups will often have conflicting, politically-charged goals.

Antitrust Laws↗