Tag Archives: Jill Van Den Bos

The cost of inpatient death associated with acute coronary syndrome

The cost of hospitalization for acute coronary syndrome (ACS) is expensive and continues to rise. In terms of direct medical expenditures, ACS costs Americans more than $150 billion annually, with approximately 60% to 75% of these costs related to hospital admission and readmission. No prior studies have addressed the cost of inpatient mortality during an ACS admission. This article, co-authored by Milliman’s Jill Van Den Bos and Travis Gray, compares ACS-related length of stay, total admission cost, and total admission cost by day of discharge/death for patients who died during an inpatient admission with a matched cohort discharged alive following an ACS-related inpatient stay.

This article was published by PubMed.

Ten critical considerations for health insurance plans evaluating participation in public exchange markets

The Patient Protection and Affordable Care Act (PPACA) will introduce new marketplaces for individual and small group health insurance, effective January 1, 2014, in the form of public exchanges. Health insurance plans need to fully prepare for and understand the impact that the public exchanges may have on their business. Whether or not a health plan participates, the logjam that blocked reform progress for several months appears to have been cleared; PPACA is now moving forward with weekly releases of regulations and rules (most are preliminary rules and open for comments). This momentum of rule writing brings new terminology and issues to light, which are critical to understand before making decisions on whether or not to participate in the public exchanges.

This paper provides 10 critical considerations based on the preliminary rule recommendations published in the last half of November. As these rules are finalized, the considerations and market dynamics may change.

Medicaid expansion: Wyoming as microcosm

A new article in a Wyoming blog about Medicaid expansion offers a helpful view of the decision facing states. Here is an excerpt from that article:

A report for the Wyoming Department of Health prepared by Milliman, Inc., an actuarial consulting firm, forecasts the added costs of the program at $116 million to $148 million between 2014 and 2020, based on their best estimate of 28,200 new enrollees. The report said the enrollment could be as low as 17,000 and might exceed 44,000. Under the best estimate, Milliman expects about 3,700 “woodwork” cases that the federal government would reimburse at only 57 percent.

In the same report, Milliman notes potential for significant savings. Some current state health programs would be at least partially subsumed under Medicaid, enabling the state to discontinue their funding and save money. But forecasting these savings — frequently called “cost offsets” — is much more difficult than predicting the cost of enrolling new patients in Medicaid.

“Detailed data was available for the Medicaid cost analysis,” said Jill Van Den Bos, a senior consultant at Milliman and the lead author of the study. The researchers used U.S. Census data and claims-data, among other sources, to predict costs.

“But it was harder on the cost-offset side,” Van Den Bos said. Eligibility for some free services offered by the state — such as colorectal cancer screening, and breast and cervical cancer treatment — is set at 250 percent of FPL. But it is difficult to know how many participants in those programs would fall under the eligibility limit of 133 percent of FPL.

“There is no hard data,” Van Den Bos said. “Assuming uniform distribution, it’s about half.” The state might also be able to reduce its bill for funding the Wyoming State Hospital, which took $60 million from the general fund and  “generated only $1.4 million in revenue from all third party payers,” including Medicaid, the report said. But once again, the savings are hard to pin down, since it is unclear how much Medicaid will pay for the indigent — for example, how many days of care per year — until more information arrives from Washington.

“The uber-person who had access to all of the data on Earth would still have a better data for the cost side than the cost-offset side,” Van Den Bos said.

This excerpt gets at two of the complicating factors surrounding this kind of analysis:

  • First, a range is important. States want to know their full budget exposure, and thus need 100% enrollment scenario estimates, but also have to account for the behavioral vagaries of other enrollment scenarios.
  • Second, the data supporting cost estimates is clearer than the data supporting cost offsets. This is compounded with each state having a unique Medicaid situation and its own local set of programs that may be subsumed by expansion, such as the payments to the Wyoming State Hospital mentioned here.

States face a complex decision as they wrestle with whether or not to expand their Medicaid program.

Cost drivers of autoimmune inflammatory diseases

This analysis published in the Journal of Occupational and Environmental Medicine (subscription required) by Ksenia Draaghtel and Jill Van Den Bos examines the total cost burden of autoimmune inflammatory diseases. The study takes an employee and employer’s perspective by using direct and available indirect costs from a national data source. The data includes total direct medical costs, number of absence days, and indirect costs related to work absences.

Read more about the study here.

Sustainable provider payment arrangements

In the 1990s, managed care programs faced a series of difficulties. Providers who accepted risk experienced financial trouble and consumers resented and abandoned plans that placed limits on access and choice, leading to a perception of medical care rationing. These problems resulted in a widespread return to fee-for-service reimbursement and an escalation in medical utilization and costs. Now, insurers and their employer clients are looking for ways to shift some financial risk back to providers as a way to encourage the alignment of incentives to achieve better care delivery.

Jill Van Den Bos’ explores this topic in her new paper, “Sustainable provider payment arrangements: What are the key elements conceptually?” The paper takes a brief look at the shortcomings of provider payment during the 1990s and considers payment arrangements that may make provider risk sharing sustainable in the future.

CMS announces 27 new ACOs for Medicare Shared Savings Program

The Center for Medicare and Medicaid Services (CMS) recently designated 27 providers to take part in the Medicare Shared Savings Program as accountable care organizations (ACOs). Quoted in a Modern Healthcare article, CMS emphasized the mix of provider types chosen:

The mix of organization types—just over half are physician-led—was touted by CMS officials.

“There were some people who feared that the only entities that would participate would be hospital-dominated systems,” Jonathan Blum, director of the Center for Medicare at the CMS, said in a call with reporters. “That has not happened.”

The 27 ACOs join 32 Pioneer Model ACOs chosen in December of 2011 and six Physician Group Practice Transition Demonstration entities initiated in January of 2011. Counting all these entities, ACOs will serve more than a million Medicare patients. Milliman consultant Jill Van Den Bos recently wrote a paper on risk management and cost controls  targeted at Pioneer ACOs.