Narrow Networks


Narrow networks return with promise of cost control—and backlash.

By Jerome Connolly, PT, CAE
July 7, 2014

Provider networks are anything but a new phenomenon in the insurance industry. Payers have been engaging preferred providers for decades dating back to the managed care era. Consumers have had to factor in provider availability and coverage when selecting a health plan if they were involved in such a selection process. This process of consumer choice has been magnified by the adoption of the individual mandate included in the Affordable Care Act (ACA). Likewise, once the initial choice is made, patients must make decisions at the time a health care need emerges—do I stay in network and pay less or choose to incur higher out-of-pocket expenses by accessing an out-of-network provider? Often, this is when they discover their provider of choice is not in the insurer’s network.

Congress Does it Again


Instead of finding real solutions, the House and Senate once again offer a temporary fix.

By Jerome Connolly, PT, CAE
June 6, 2014

While it is old news now, congressional action March 31 was greeted with a sigh of relief as another 24 percent cut to Medicare payment rates was averted, again temporarily. Legislation passed only hours before a self-imposed congressional deadline maintains the current Medicare reimbursement rate through March 31, 2015. The legislation also included an extension of the Medicare therapy cap exceptions process, which means that our patients—the ones who need our services the most—are not saddled with the arbitrary annual per beneficiary Medicare cap. The approximate $20 billion cost of this temporary fix was paid for through a combination of gimmicks, including adding another year (2025) to the sequester provisions used to reach a budget agreement in December of last year.

Improving Performance


Can value-based purchasing in health care live up to the promise?

By Jerome Connolly, PT, CAE
May 5, 2014

On March 4, 2014, the RAND Corporation released a new report concluding that after a decade of experimentation with reforms that give health providers financial incentives to improve performance—so-called value-based purchasing—relatively little is known about how to best execute such strategies or to judge their success.

The report—authored by Cheryl L. Damberg, Melony E. Sorbero, Susan L. Lovejoy, Grant Martsolf, Laura Raaen, and Daniel Mandel—which was designed to assess the state of knowledge about value-based purchasing programs in health care, found that evidence thus far is mixed about whether using such payment schemes can help improve quality and lower costs.1

Growth of ACOs


Continued growth of accountable care organizations could impact private practice physical therapists.

By Jerome Connolly, PT, CAE
April 4, 2014

A December 2013 announcement1 by the Centers for Medicare and Medicaid Services (CMS) provides evidence of the growth of the so-called Accountable Care Organizations (ACOs). The 123 new ACOs bring the number of Medicare ACOs to 366. In addition, the best estimate for the total number of public and private ACOs is 606.

A list of the 123 new Medicare ACOs announced in January can be found at:

Prospects Brighten for Sustainable Growth Rate and Therapy Cap Repeal

By Jerome Connolly, PT, CAE
March 3, 2014

Congress must have been affected by the holiday spirit in December when two key committees passed separate bills that would lead to repeal of the long dysfunctional sustainable growth rate (SGR) formula used to calculate therapist and physician payments under the Medicare Physician Fee Schedule.

Congress has been providing waivers and short-term patches to the policy almost annually since 2003. And three committees of jurisdiction expressed sincere interest in early 2013 in enacting legislation that would finally repeal the arcane formula. The congressional committees got off to an early start last year in circulating concept papers, holding hearings, and seeking extensive input from stakeholders. PPS participated vigorously in that process.

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