Population Health and Movement to Management of Personal Healthcare

There are a number of new innovations in the market that helps put the management of personal healthcare literally in the hands of each person.  It isn’t necessarily new technology, but a push to get consumers educated and engaged as the real driving force behind this popularity. 

In 2010, the US Department of Health & Human Services (HHS) outlined its findings for Healthy People based on the relationship between changes in mortality and morbidity.  In addition, health planning and health-related policy decisions utilize healthy life expectancy as a useful tool.  “Years of active life” are now included among national and international health goals as an indication of healthy life expectancy. One of the two primary national health goals identified for Healthy People 2010 is to increase the quality and years of healthy life.  These goals and objectives outlined for the decade in Healthy People have become central to both monitoring the Nation’s health and planning an agenda to promote health and prevent ill-health. Monitoring the goals and objectives will, in part, be achieved through Leading Health Indicators which provide a way of understanding health in the future.

Individual researchers and international groups have done significant work in defining both the measurements of health and clarifying the process of population health change. This research has shown that diseases, conditions, and impairments (e.g., heart disease, arthritis, and visual impairment) occurs before there is a loss in functioning or one's ability to perform certain actions such as walking a block, climbing a specific number of stairs, or sitting for an allotted time. Functioning loss can then result in disability or an inability to perform an expected social role.  

The Division of Population Health is under the Centers for Disease Control (CDC), and is charged with managing programs that provide chronic disease and health promotion expertise.   The CDC launched an updated Community Health Status Indicators (CHSI) online tool that produces public health profiles each county in the United States (visit  http://wwwn.cdc.gov/communityhealth). The Summary Comparison Report provides a dashboard look of how a selected county compares with peer counties as better, moderate, or worse on Primary Indicators. Primary Indicators include various attributes within mortality (Alzheimer's, motor vehicle deaths), morbidity (HIV, cancer), access to health care (cost, PCP access), health behaviors (such as teen births), social factors (violent crimes, unemployment), and physician environment (drinking water, housing stress, access to health food).

The CDC has identified a number of program factors that have the potential to influence health outcomes, such as quality, health behaviors, and social factors.

Alcohol and Public Health ( http://www.cdc.gov/alcohol ) - Excessive alcohol use can lead to increased risk of health problems such as injuries, violence, liver diseases, and cancer.

 Arthritis ( http://www.cdc.gov/arthritis ) - Arthritis affects more than 1 in 5 adults; the nation’s most common cause of disability.

Chronic Obstructive Pulmonary Disease (http://www.cdc.gov/copd ) - COPD refers to a group of diseases that cause airflow blockage and breathing-related problems that includes emphysema, chronic bronchitis, and in some cases asthma.  Tobacco smoke is a key factor in the development and progression of COPD, as well as exposure to air pollutants in the home and workplace.

Epilepsy (http://www.cdc.gov/epilepsy/index.html) - A general term for conditions with recurring seizures, there are many kinds of seizures but all involve abnormal electrical activity in the brain that causes an involuntary change in body movement or function, sensation, awareness, or behavior. 

Health Related Quality of Life ( http://www.cdc.gov/hrqol ) - The concept of health-related quality of life (HRQOL) and its determinants have evolved since the 1980s to encompass those aspects of overall quality of life that can be clearly shown to affect health—either physical or mental. 

Healthy Brain Initiative (http://www.cdc.gov/aging/healthybrain/index.htm) Public health's role in maintaining cognitive health, a vital part of healthy aging and quality of life, is emerging  given the dramatic aging of the U.S. population, scientific advancements in knowledge about risk behaviors (e.g., lack of physical activity, uncontrolled high blood pressure) related to cognitive decline, and the growing awareness of the significant health, social, and economic burdens associated with cognitive decline.

Inflammatory Bowel Disease (http://www.cdc.gov/ibd/index.htm) - A broad term that describes conditions with chronic or recurring immune response and inflammation of the gastrointestinal tract characterized by an abnormal response to the body’s immune system.

School Health ( http://www.cdc.gov/HealthyYouth ) - CDC promotes the health and well-being of children and adolescents to enable them to become healthy and productive adults.

Sleep and Sleep Disorders ( http://www.cdc.gov/sleep ) - Insufficient sleep is associated with a number of chronic diseases and conditions—such as diabetes, cardiovascular disease, obesity, and depression—which threaten our nation’s health. 

The goals identified by the HHS and CDC are a driving force behind corporate America’s initiatives to educated.  Based on some of the programs they have identified, it’s a wonder why we have so many apps and tools that provide individuals with nutrition information for what we’ve eaten today, a goal to reach 10,000 daily steps, monitor our heart and blood pressure, and our sleep activity.  As we move steadier to population health management, the question is how will our providers embrace the partnership?


Deborah Sieradzki, PhD is a partner with LMC specializing in the organization and leadership of healthcare financial management.

Market Trends 2014/15

HFMA Eastern Michigan Chapter presented Brett Hickman, Merger & Acquisition partner with PWC to speak on market trends for 2014/15.  Highlights included:

 - Walmart will be the #1 primary care provider in 2 years as they move from testing six in-store clinics to 600.

- Half of the Fortune 50 companies are new entrants to healthcare.  Considering that 60% of US stocks are bought by foreigners, what is this trend telling us?

- CVS is going after Walmart with their decision to stop sale of tobacco.

- Three types of costs: waste, the way care is delivered, and self-inflicted (i.e. results from smoking).  We are currently addressing waste through errors and infection control.  Finance, operations, and clinical areas are working together to look at opportunities to deliver care differently at lower costs with better results.  New programs are focused on reducing self-inflicted.  Could we see payers not paying for the after effects for those that do not comply as they do in other countries?

- Hospitals would have to reduce cost by 50% for status quo sustainability (provide same care).  This is pushing for a drastic change in not only eliminating cost from waste, but more on how care is delivered.

- Kaiser wants to move clinic visits to homes; clinic sites too expensive. Only physician visits should be to see a specialist.  Keep an eye on Kaiser to see how they propose to accomplish this.

- Detroit is #1 over bedded in the country with 2,500 beds.  This resulted from a “perfect storm” of downturn of economy, out migration, and decrease in hospital use rates.  We will see hospitals starting to close.  It is happening now in New York.

- Hospital systems are taking control of premiums (becoming payers) to control the distribution of dollars, undercutting traditional payers in market with large employers and narrow networks.

- Physicians are beginning to move towards the theory that they hold the power. Monarch in CA was IPA; now is a 7,000 physician ACO.  The ACO owns the contracts and pays hospitals for use.

- Tenet latest acquisitions will basically have control of Connecticut by end of this year managing 3.5M lives.  Connecticut’s population is about 4M. 

- IBM "Watson" computer collects oncology data and successfully does predictive analysis.  Are we moving into an environment where whoever holds the data will have power to control healthcare? Will this be IBM?

- Predictive analysis is an attempt to be able to project when and what illness a person may acquire.  There is belief we could be moving towards predictive analysis in less than 20 years where a doctor will call the patient to address findings. If the patient doesn't comply, insurance will not pay and it becomes self-pay.  We are seeing that now in P4P.


Compiled by Deborah Sieradzki

How Prepared are you for Healthy MI Plan?

At the May 16th HFMA-EMC Member Meeting, Jackie Prokop, Director Program Policy Division for the MDCH, presented an update on the Healthy Michigan Plan (HMP) which received approval from the Centers for Medicare and Medicaid Services on December 30, 2013 and was launched April 1, 2014.   The Healthy Michigan Plan is a new category of eligibility authorized under the Patient Protection and Affordable Care Act and Michigan Public Act 107 of 2013 that makes health care benefits available to low-income Michigan residents at a low cost while promoting the adoption of healthy behaviors.  How prepared is your organization for Healthy MI Plan?  Below are some highlights and key takeaways from Jackie’s presentation that all providers should be aware of.

HMP Overview

The HMP is aimed at improving the health and wellbeing of Michigan residents by providing affordable health care coverage to residents who are age 19 to 64 years of age and have a Modified Adjusted Gross Income (MAGI) at or below 133 percent of the federal poverty level.  The HMP covers essential health benefits including inpatient hospitalization, outpatient and emergency services, maternity care,  behavioral health and substance abuse services, prescription drugs, rehabilitative services and devices, laboratory and x-ray services, preventive and wellness services, chronic disease management, dental services, pediatric care, and family planning.  Behavioral Health Services will be provided through the current Prepaid Inpatient Health Plan (PIHP) system.  All currently enrolled Medicaid providers are automatically providers for the Healthy Michigan Plan.  As of May, over 250,000 Michigan residents have enrolled with HMP, with another 250,000 anticipated eligible statewide.

Application is Fast and Easy

Michigan residents can apply for HMP online, via telephone, or in person.   A single, streamlined application process has been implemented (all states utilize the same application process) that relies on electronic data matching to the greatest extent possible and standardizes the calculation of income using a consistent formula.  Through streamlining and standardizing the process, the result is an application process that is fast, averaging 15 minutes to complete and receive immediate eligibility determination, and requires no asset test.  Upon completion of the enrollment process, beneficiaries will receive their HMP card in the mail within 2-3 days, with coverage retroactive to the 1st day of the month.  Enrollees may request up to 90 days retroactive coverage by completing an additional form; however retroactive coverage cannot precede the April 1, 2014 launch of HMP.

Eligibility Determination

Eligibility for HMP will be determined using the new MAGI eligibility methodology required under the ACA.  All criteria for MAGI eligibility, including citizen/alien status, social security numbers, child support, and spousal support, must be met for an individual to be eligible for the HMP.  To apply, individuals must be between the ages of 19 and 64 years, have a MAGI at or below 133% of the FPL, not qualify for or be enrolled in Medicare or other Medicaid programs, and may not be pregnant at the time of application.  Eligibility is based on annual income (approximately $16,000 per individual or $33,000 per family of four).  HMP beneficiaries will be required to enroll in a Medicaid health plan as well as contact their primary care physician within 60 days of enrollment to schedule an appointment.

Beneficiaries will receive a mihealth card through the mail when they become eligible for the Healthy Michigan Plan as well as an additional health plan identification card when they enroll in a health plan. The mihealth card does not contain eligibility information and does not guarantee eligibility.   Prior to rendering services, providers must verify beneficiary HMP coverage using the mihealth card to access a beneficiary's eligibility information using the Community Health Automated Medicaid Processing System (CHAMPS) eligibility inquiry. The following new benefit plans have been established to identify beneficiaries with HMP coverage:

 • MA-HMP (Healthy Michigan Plan)

• MA-HMP-MC (Healthy Michigan Plan Managed Care)

• MA-HMP-ESO (Healthy Michigan Plan Emergency Services Only)

• MA-HMP-INC (Healthy Michigan Plan Incarceration)

 Individuals will be enrolled in health plans for one year, after which there will be a yearly open enrollment period.  Providers need be aware that should an HMP enrollee be pregnant at the time of re-application they no longer meet the eligibility requirements of HMP and will revert to Medicaid FFS coverage.

Beneficiary Cost Sharing Requirements

Healthy Michigan Plan enrollees will have some cost-sharing responsibilities.   Individuals earning between 100 - 133% of the federal poverty level will be required to pay 2% of their annual income toward their HMP coverage.   Co-pays will also be utilized for all HMP participants.  Total cost sharing requirements, including co-pays, cannot exceed 5% of the annual household income and will be paid through the use of a dedicated health account called the MI Health Account. Cost sharing requirements will begin after the beneficiary has been enrolled in a health plan for six months and will be monitored through the MI Health Account by the health plan.   While beneficiaries have an obligation to contribute to their MI Health Account, they are not obligated to fully fund the account in order to receive needed healthcare services.  Should beneficiaries default on their payment of co-pays and cost sharing requirements they will not lose their HMP coverage, however the State is considering use of a garnishment tax process via the Federal Government to recoup unpaid amounts.

 Providers do not need to collect copays at the time of service as long as the provided service is covered by the health plan. These costs will be tracked and collected from the beneficiary by the health plan on a monthly basis and applied to the beneficiary’s MI Health Account. The total co-pay experience for the initial six months of services will be calculated and the average amount will be the beneficiary’s monthly payment obligation. Average co-pay amount will be recalculated every six months. If the amount contributed by the beneficiary is less than the amount due for a rendered service, the provider will still be paid in full for the services provided. Providers may want to review and revise their participation agreements with HMP health plans as necessary to ensure language indicates that collection of copays for HMP enrollees is the plan’s responsibility and providers will receive full payment for services rendered.    Services not covered by the beneficiary’s health plan will be subject to the following co-pays and must be collected at the point of service. 

Similar to programs implemented by HMOs and other managed care plans, HMP enrollees will have the opportunity to reduce and/or eliminate their cost sharing responsibilities by engaging in various healthy behavior activities.  Such activities include completing the annual health risk assessment and changing unhealthy activities, i.e. smoking cessation.  The more health behaviors a beneficiary engages in, the greater the opportunity to reduce cost-sharing responsibility, up to and including 100% elimination of cost sharing.

Transition of Current Adult Benefits Waiver Beneficiaries into the Healthy Michigan Plan

Current Adult Benefits Waiver (ABW) beneficiaries were automatically transitioned into the Healthy Michigan Plan effective April 1, 2014.  A key change for these patients is that inpatient care will now be a covered benefit under their HMP coverage where it was not a benefit under ABW.

 New cost report requirements

Did you know that for FYEs after March 31, 2014 providers must separately identify Healthy Michigan Plan on cost reports?  It’s true, according to information shared by Brian Keisling & Jason Jorkasky of the MDCH at the May 16th HFMA-EMC Member Meeting.  It was also stated that the MDCH surveyed Michigan Medicaid plans and while most indicated they have not yet finalized plans for identifying a traditional Medicaid fee-for-service patient from a HMP patient, they acknowledge additional work on this is needed.  What does this mean for providers?  Providers will need to have a means to capture and track HMP patient data separate from traditional Medicaid FFS and Medicaid Managed Care.  While the health plans may not yet have finalized a means of identifying HMP enrollees, providers are encouraged to begin implementing policies and procedures for capturing and tracking HMP patient data for cost reporting purposes, whether that is through the creation of separate insurance plan codes for each HMP health plan or some other means.  Providers will be able to access the Community Health Automated Medicaid Processing System (CHAMPS) to verify beneficiary HMP coverage and identify which health plan beneficiaries are enrolled in. Providers must also ensure Patient Access and Eligibility/Verficiation staffs are educated in the need to separately capture/track HMP patient data. 


For more information on the Healthy Plan Michigan visit michigan.gov

Written by Cheryl Comeau

Healthcare in Transition: Retail Opportunities Abound

Healthcare costs are approaching 20 percent of GDP, outstripping inflation and economic growth with significantly more services provided to the aging baby boom generation. While health care is an important contributor to the economy, many feel 20 percent of GDP is not sustainable.

Healthcare spending in the United States was $2.6 trillion in 2010. By 2021, healthcare expenditures will reach $4.8 trillion or about one-fifth of the economy.1 For American families in 2012, healthcare costs exceeded $20,000 for the first time.2 For many families, this easily exceeds the cost of a mortgage premium and property taxes. For those employees whose healthcare premiums are paid by their employers, more costs are being passed on to employees making them consumers.

The Patient Protection and Affordable Care Act implemented in 2010, has created more consumers by embedding in law the concept of high deductible health plans. Although new federal tax subsidies will help reduce health insurance rates for many consumers, many individuals and families do not qualify. For those individuals and families that do qualify, others make up this subsidy in the form of higher taxes or some other cost transfer. These first-dollar-no-coverage policies make these people into consumers.

This creates an expanding market opportunity. With more patients in control to manage their own health care dollars it is in a consumer’s best interest to shop around, compare prices and providers to select the medical services that are best fit their needs. Therefore, providers are encouraged to repackage and re-price their services, competing for patients based on price and quality.

The healthcare market is ripe for market encroachment by other industries eager to tap this large GDP healthcare segment. For example, Walmart, Costco, Target, CVS and others have expanded into the prescription drug business by offering low cost generic drugs and significant marketing influence. Other sectors of the healthcare sector will follow.

A case in point is Walgreen. Walgreen is the largest drugstore chain with fiscal 2013 sales of $72 billion and provides six million customers cost-effective pharmacy, health and wellness services and advice each day. The company operates 8,209 drugstores in 50 states, the District of Columbia, Puerto Rico 


Written by Steve Fehlinger