Managed Care Business Models 101 – Digital Therapeutics & Health Technology

The video titled “Managed Care Business Models 101 – Digital Therapeutics & Health Technology” on the channel Carenodes provides an in-depth discussion on healthcare business models, focusing on managed care, and is aimed at healthcare entrepreneurs, especially those new to the sector. Here’s a summary of key points covered in the transcribed part of the video:

The video titled “Managed Care Business Models 101 – Digital Therapeutics & Health Technology” on the channel Carenodes provides an in-depth discussion on healthcare business models, focusing on managed care, and is aimed at healthcare entrepreneurs, especially those new to the sector. Here’s a summary of key points covered in the transcribed part of the video:

Introduction to Healthcare Business:
- The video begins with an overview of healthcare business, emphasizing the importance of understanding where healthcare money comes from and one’s role within the healthcare ecosystem.
- It’s specifically designed for healthcare entrepreneurs, including those with varied backgrounds, highlighting the steep learning curve and business side of healthcare that is often overlooked by clinicians.
Speaker’s Background:
- The speaker shares their extensive background in healthcare administration, including managing clinics, overseeing hospital networks, and working with health plans. This diverse experience underpins the insights shared in the presentation.
Key Concepts Discussed:
- Healthcare as a Personal and Nuanced Field: The importance of hands-on, job-based learning over theoretical knowledge.
- Navigating the Healthcare Ecosystem: For newcomers, understanding the ecosystem’s complexity and finding one’s place within it is crucial.
- Importance of Demystifying Healthcare: Emphasizes the need for transparency and understanding in healthcare, drawing an analogy with a cave that becomes illuminated the moment a match is struck.
Ethical Considerations:
- A significant portion of the video is dedicated to ethical considerations, urging participants to take healthcare seriously, understand their roles, and always prioritize patient well-being.
Managed Care and Its Components:
- Managed care is defined, and its components are outlined, including payer-provider contracting, credentialing, and network development.
- The video explains the managed care department’s role in ensuring that healthcare providers are credentialed and contracted with health plans.
The Business Side of Healthcare:
- The speaker dives into the financial aspects of healthcare, explaining managed care’s focus on cost control and the shift towards value-based care.
- Various healthcare financing mechanisms are discussed, with an emphasis on understanding the flow of funds within the healthcare system.

This summary covers the first part of the video. There are more pages available, indicating additional content not included here. If you’re interested in more detailed information or specific parts of the video, please let me know!

Watch the video here.

Decoding Healthcare Options: A Comparative Guide to ACOs, HMOs, and PPOs

This comprehensive guide offers an in-depth comparison of Accountable Care Organizations (ACOs), Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs), three prominent healthcare models in the United States. It breaks down the fundamental differences and similarities across various dimensions, including network structure, patient choice and access to care, payment models, and their overall focus. Whether you’re a healthcare professional seeking clarity on these models or a patient navigating your healthcare options, this guide provides essential insights to understand how each model impacts care delivery, cost, and patient experience. By elucidating the complex landscape of healthcare options, this article empowers readers to make informed decisions about their healthcare needs, contributing to better health outcomes and satisfaction. Perfect for individuals looking to demystify healthcare terminologies and structures, our guide simplifies the decision-making process in choosing the right healthcare plan.

Given the popularity of this topic, we are publishing a table below presenting a comparison between ACOs, HMOs, and PPOs in a table format that can help readers quickly grasp the differences and similarities.

Navigating the landscape of healthcare options can be a daunting task for patients and providers alike. Among the plethora of models available, Accountable Care Organizations (ACOs), Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs) stand out as prominent frameworks designed to streamline care delivery, manage costs, and improve patient outcomes. Each model boasts its unique structure and operational philosophy, catering to diverse healthcare needs and preferences. This blog post delves into the core characteristics of ACOs, HMOs, and PPOs, shedding light on their network structures, patient choice, access to care, and payment models.

At the heart of ACOs is a commitment to coordinated care, aiming to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. Unlike ACOs, HMOs emphasize preventive care within a closed network of providers, requiring patients to choose a primary care physician who oversees their health journey and referrals. On the other hand, PPOs offer a balance between flexibility and cost, providing patients the freedom to visit any healthcare provider, albeit at varying costs based on network status.

Understanding these differences is crucial for making informed healthcare decisions. Whether you’re a patient evaluating your healthcare plan options, a provider considering joining a healthcare network, or a policymaker analyzing healthcare system improvements, grasping the nuances of ACOs, HMOs, and PPOs can empower you to navigate the healthcare ecosystem more effectively. This comparison aims to illuminate the paths available for achieving high-quality, cost-effective care tailored to individual health needs.

Feature	ACO (Accountable Care Organization)	HMO (Health Maintenance Organization)	PPO (Preferred Provider Organization)
Network Structure	Self-defined network of clinicians.	Network defined by the health plan. Patients choose a primary care physician who acts as a gatekeeper.	Network defined by the health plan. More flexibility to see specialists without a referral.
Patient Choice and Access to Care	Patients cannot be limited to using only ACO clinicians. Freedom to see any clinician.	Requires seeing clinicians within the HMO network. Primary care physician referral needed for specialists.	Can use clinicians inside and outside the network. No referral needed for specialists, but higher cost for out-of-network services.
Payment Model	Fee-for-service payments, with potential for shared savings. No change to underlying fee-for-service structure for clinicians.	Capitation model where a clinician group receives a set amount per patient, incentivizing efficient care within the budget.	Fee-for-service basis within the network. Different rates for out-of-network services, without primarily using capitation.
Focus	Improving care coordination and quality while controlling costs.	Cost control, preventive care, and efficiency within a closed network.	Flexibility in provider choice with a broader network, offering a balance between cost and access to care.

Navigating New Paths in Healthcare: Understanding Kentucky’s ‘Any Willing Provider’ Statutes

In an ambitious move to reshape healthcare access, Kentucky has enacted the ‘Any Willing Provider’ (AWP) statutes, challenging the traditional exclusivity of health maintenance organizations (HMOs) and their provider networks. At the heart of these statutes lies a simple yet powerful principle: preventing discrimination against healthcare providers ready to adhere to an insurer’s terms and conditions.

Introduction

In many areas of the U.S., health maintenance organizations (HMOs) have established exclusive relationships with certain doctors, hospitals, and other health-care providers. These collaborations form what is known as “provider networks”. For patients within an HMO, seeking services outside these networks often means higher out-of-pocket expenses or no coverage at all. Kentucky, however, has made strides in challenging this exclusivity through the enactment of two “Any Willing Provider” (AWP) statutes.

What Are the “Any Willing Provider” Statutes?

The essence of Kentucky’s AWP laws is clear: prohibit discrimination by health insurers against providers who are ready and willing to meet the terms and conditions set by the insurer. Specifically, these laws dictate:

A health insurer cannot discriminate against any provider who is willing to comply with the insurer’s terms and conditions for participation.
Any health benefit plan offering chiropractic benefits must permit any licensed chiropractor who agrees to the plan’s terms and conditions to serve as a primary chiropractic provider.

Implications for HMOs

Increased Provider Options for Patients: AWP laws may lead to a broader range of healthcare providers for patients. This can particularly be beneficial in rural areas where there might be a limited number of providers within an exclusive network.
Potential for Increased Costs: While the AWP statutes may increase accessibility, they could also potentially increase costs. If a larger number of providers participate in the HMO networks, the negotiated rates may rise, leading to higher premiums or out-of-pocket expenses.
Quality Control Concerns: One of the reasons HMOs create exclusive networks is to ensure a standard of care. With the introduction of AWP laws, there might be concerns about maintaining consistent care quality if any provider willing to meet the basic terms can join.
Administrative Burdens: Managing a larger pool of providers might introduce administrative challenges for HMOs. Ensuring that all providers adhere to the same regulations, billing practices, and standards might require additional resources.
Empowerment of Chiropractors: The specific mention of chiropractors in the AWP statutes underscores the growing recognition of chiropractic care in the medical community. This provision ensures that chiropractors are not left out of HMO networks, further integrating them into mainstream healthcare.

Conclusion

Kentucky’s “Any Willing Provider” statutes represent an effort to democratize the healthcare landscape, ensuring that patients have access to a wide range of providers and that providers are not unjustly excluded from networks. While the intent is commendable, it remains to be seen how these laws will play out in the broader context of healthcare economics and quality control.

As with any major change in the healthcare system, there will be a period of adjustment and recalibration. Stakeholders, from patients to providers to insurers, will need to collaborate to ensure that the benefits of these laws are realized without compromising on the quality and affordability of care.

Financial Benefits of Doulas for Hospitals with Capitated Contracts

Doulas, with their specialized training in providing emotional, physical, and educational support during childbirth, are becoming increasingly integral in modern maternity care. For hospitals navigating the intricacies of capitated contracts—where fixed payments are made irrespective of services rendered—the role of a doula presents a compelling financial argument. Evidence suggests that doula-assisted births may lead to fewer medical interventions, shorter labor durations, and reduced postpartum complications. These reductions not only enhance the childbirth experience for mothers but also translate into tangible cost savings for hospitals. In an era where patient satisfaction is paramount and efficiency is sought, the integration of doulas in the childbirth process is both a qualitative and quantitative win for healthcare.

Reduced Interventions
Shorter Labor Duration
Improved Patient Satisfaction
Fewer NICU Admissions
Reduction in Postpartum Complications

The following is based on an article published in Becker’s Hospital Review: The Financial Benefits of Doulas for Hospitals with Capitated Contracts.

Doulas: Doulas are non-medical professionals trained to provide emotional, physical, and educational support to mothers before, during, and shortly after childbirth. They complement the medical care provided by doctors and nurses.

Capitated Contracts: In the healthcare setting, a capitated contract is a payment agreement where providers (like hospitals or doctors) receive a set amount (a “capitation”) for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount is pre-determined and is meant to cover all the standard services the patient might need during that time frame.

Financial Benefits of Doulas for Hospitals with Capitated Contracts:

Reduced Interventions: Studies have shown that the presence of a doula during childbirth can reduce the need for certain medical interventions, such as cesarean sections, forceps, and vacuum deliveries. Since these procedures can be costly, a reduction in their frequency can lead to financial savings for hospitals.
Shorter Labor Duration: Some research indicates that doula-supported births might be associated with shorter labor durations. Shorter labors can reduce costs associated with prolonged hospital stays or additional medical care.
Improved Patient Satisfaction: Doulas can enhance the birthing experience for mothers, leading to higher patient satisfaction scores. Hospitals with higher patient satisfaction might attract more patients and potentially negotiate better rates with insurers.
Fewer NICU Admissions: There’s some evidence suggesting that doula support can reduce the likelihood of newborns being admitted to the Neonatal Intensive Care Unit (NICU). NICU care is expensive, so any reduction in admissions can translate to considerable cost savings.
Reduction in Postpartum Complications: Doulas can also support mothers postpartum, potentially reducing the risk of certain complications that would necessitate additional medical care or readmission to the hospital.

For hospitals under capitated contracts, the financial incentive is to provide care efficiently while maintaining quality. Since the payment is pre-determined and not based on the number or type of services rendered, reducing unnecessary interventions or complications can directly translate to cost savings.

It’s worth noting that while the financial benefits are a positive outcome, the primary goal of integrating doulas into maternity care is to enhance the childbirth experience and outcomes for mothers and babies. Improved patient well-being and satisfaction, combined with cost savings, make a compelling case for more widespread inclusion of doulas in maternity care settings.

35 States with Any Willing Provider laws

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

Any Willing Provider and Freedom of Choice laws restrict the ability of managed care
entities, including pharmacy benefit managers, to selectively contract with providers. The
managed care entities argue this limits their ability to generate cost savings, while proponents of
the laws suggest that such selective contracts limit competition, leading to an increase in
aggregate costs.

These laws generally require health insurance companies to allow any qualified healthcare provider who is willing to meet the terms and conditions of the insurer’s contract to participate in their networks.

States listed below have some form of Any Willing Provider laws:

Alabama:

Section 27-1-19: The agreement providing coverage to an insured may not exclude assignment of benefits to any provider at the same benefit paid to a contract provider.

Section 27-45-3: Plan Beneficiaries may choose the licensed pharmacist or pharmacy of their choice. Health insurance policies and employee benefit plans may not deny licensed pharmacies or pharmacists the right to participate.

Arkansas:

Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, 23-209 : Benefit differentials are prohibited. Insurers must give qualified health care providers the opportunity to participate if providers are willing to accept the plan’s terms and conditions.

Colorado:

Section 10-16-122: Any PBM/intermediary whose contract with a carrier includes an open network must allow all area pharmacy providers to participate if they agree to the terms and conditions of the contract. PBms/Intermediaries may contract with exclusive pharmacy networks if a 60-day notice is given before the termination or the effective date of such contract by publication in a newspaper of general circulation.

Connecticut:

Section 38a-471: A prescription program administrator shall allow a pharmacy to enroll in a program absent cause for excluding it.

Delaware:

Sections 18-7301, 18-7302, 18-7303: Beneficiaries may choose any pharmacy that has agreed to participate according to the terms. Benefit differentials are prohibited.

Florida:

Section 110.12315: The state employees’ prescription drug program requires the Department of Management services to allow prescriptions to be filled by any licensed pharmacy pursuant to contractual claims processing provisions.

Section 440.13(3) (j): The worker’s compensation statute allows for a sick or injured employee to have free, full and absolute choice in the selection of the pharmacy.

Georgia:

Section 26-2-144(a)(9): That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies.

Section 33-30-25: Insurers may impose “reasonable limits” on the number/classes of preferred providers that meet the insurers’ standards. Insurers must give all licensed and qualified providers within a defined service are the opportunity to become a preferred provider.

Section 33-30-4.3: Beneficiaries who do not use mail-order shall not be penalized if the provider used by the insured has agreed to the same terms and conditions applicable to mail-order and has agreed to accept payment or reimbursement at no more than the same amount that would be paid for the same mail-order services.

Hawai’i:

Section 451 R-1: It shall be a violation of this section for a prescription drug benefit plan, health benefits plan under chapter 87A, or pharmacy benefit manager to refuse to accept an otherwise qualified retail community pharmacy as part of a pharmacy benefit manager’s retail pharmacy network.

Idaho:

Sections 41-2872 & 41-3927: Any insurance company or health maintenance organization issuing benefits must be willing to contract with qualified providers who meet the terms of the organization. Organizations issuing benefits must be willing to contract with qualified providers who meet the terms of the organization

Illinois:

Section 215-5/370h: Insurers/administrators must be willing to enter into agreements with any non- institutional providers who meet the established terms and conditions. The terms and conditions may not discriminate unreasonably against or among non-institutional providers.

Section 215-134/72(a) : A plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the plan.

Indiana:

Section 27-8-11-3 : Pharmacists who agree to comply with established terms and conditions

are entitled to enter into contracts with insurers. Terms and conditions established by insurers may not discriminate unreasonably against or among providers.

Iowa:

Section 514C.5: Policies or contracts providing for third-party payment may not require a beneficiary to order prescriptions by mail if the pharmacy chosen by the beneficiary agrees to comply with the same terms and conditions as the mail-order pharmacy.

Kentucky:

Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships.

Section 304.17A-505: …if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for

participation, the provider has the right to become a provider for the insurer.

Louisiana:

Section: 22:1964: Policies/plans must allow beneficiaries to select the pharmacy/pharmacist of their choice as long as the chosen pharmacy agrees to meet the terms and conditions of the plan.

Pharmacies that agree to meet the established terms and conditions have the right to participate as contract providers. Renamed from Section 22:1214(15).

Section 22:2181: The Louisiana State University Health Sciences Center Health Maintenance Organization shall enter into a contract with any willing provider licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Dental Examiners to provide primary care services delivered in an outpatient setting including medical and surgical services.

Maine:

24-A M.R.S.A. § 4317: insurance carriers offering health plans subject to the Maine Health Plan Improvement Act that provide prescription drug benefits through a network of participating pharmacies may not refuse to contract with a pharmacy that is willing to meet the terms and conditions for participation in the health plan’s pharmacy network. If the network is a tiered network, Maine pharmacies must be offered the opportunity to participate in each tier. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy benefits manager.

Massachusetts:

Section 176D(3B): Carriers who offer restricted pharmacy networks must follow certain requirements in contracting. Carriers must neither exclude nor favor individual pharmacies and must not impose greater restrictions on non-network pharmacies than those required on in-network pharmacies.

Mississippi:

Section 83-9-6: Beneficiaries may choose any pharmacy that has agreed to participate in the plan according to the insurer’s terms. Pharmacies that accept those terms are entitled to participate.

Benefit differentials are prohibited. Plans that restrict pharmacy participation shall give 60 days notice of offer to participate to all pharmacies in the geographic area.

Missouri:

Section 354.535: Every Health maintenance organization has to apply the same coinsurance, co- payment and deductible factors to all prescriptions filled by a pharmacy provider who participates in the network if the provider meets the contact’s product cost determination. Also HMOs may not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription unless such limit is applied uniformly to all pharmacy providers in the network.

Montana:

Section 33-22-1704: A preferred provider agreement must provide all providers with the opportunity to participate on the basis of a competitive bid.

Nebraska:

Section 44-513.02: Beneficiaries shall not be required to obtain pharmaceutical services from mail- order in order to obtain reimbursement.

Section 44-313(2) :…an insurer may contract with a licensed pharmacist for pharmacist professional

services. Nothing in this section shall prohibit an insurer from contracting with a licensed pharmacist who is not employed or associated with a pharmacy. Nothing in this section shall require a licensed pharmacist to contract with an insurer for pharmacist professional services.

New Hampshire:

Section 420-B:12(V): HMOs seeking bids from pharmacies for agreements to be preferred providers must admit and list all pharmacies that meet the bid.

New Jersey:

Sections 17:48-6j & 26:2J-4.7: An enrollee/subscriber shall be permitted to select a pharmacy/pharmacist provided the pharmacist or pharmacy is registered. Pharmacies/pharmacists shall have the right to participate as preferred providers if the agreement provides for coverage by preferred providers, so long as the pharmacy/pharmacist complies with the terms of the agreement. Benefit differentials shall not be imposed. Enrollees/subscribers shall not be required to use a mail- order pharmacy.

New Mexico:

Section16.19.6.7(f): “Point of care vendor” means an entity contracted with a prescriber to generate or transmit electronic prescriptions authorized by a practitioner directly to a pharmacy or to a “contracted” intermediary or “network vendor”, who will ultimately transmit the prescription order to a patient’s pharmacy of choice. Vendor must provide an unbiased listing of provider pharmacies and not use

pop-ups or other paid advertisements to influence the prescriber’s choice of therapy or to interfere with patient’s freedom of choice of pharmacy. Presentation of drug formulary information, including preferred and non-preferred drugs and co-pay information if available, is allowed.

North Carolina:

Section 58-51-37: Beneficiaries may choose any pharmacy that has agreed to participate according to the insurer’s terms. Pharmacies that accept such terms are entitled to participate and must participate if offered the opportunity. Benefit differentials are prohibited. Plans that limit pharmacy participation shall give 60 days notice of an offer to participate to all pharmacies in the geographic area.

North Dakota:

Section 26.1-36-12.2: Beneficiaries may choose any licensed pharmacy/pharmacist to provide services. Benefit differentials are prohibited. Licensed pharmacists who accept the terms may participate in the plan.

Oklahoma:

Section 36-3634.3 & 36-4511: Pharmacies must be provided the right to bid on a periodic basis on any pharmacy contract to provider pharmacy services. Employers may not require employees to obtain drugs from a mail-order pharmacy as a condition for reimbursement. Employers may not impose benefit differentials if they do not use mail-order.

Title 15 § 15-788(c): No third party prescription program administrator shall deny any pharmacy the opportunity to participate in any third party prescription program offered in this state in a manner which will restrain the right of a consumer to select a pharmacy.

Rhode Island:

Sections 27-18-33, 27-19-26, 27-20-23, 27-41-38: Insurers may not require covered persons to obtain prescriptions from a mail-order pharmacy as a condition of obtaining benefits.

RI Gen. Laws 27-29-1: Unfair competition and practices.

South Carolina:

Section 38-71-147: No individual or group accident and health or health insurance policy or HMO may prohibit a participant/beneficiary from selecting pharmacies/pharmacists that agreed to participate in the plan according to the terms of the insurer, or may deny pharmacies/pharmacists the right to participate as contract providers if they agree to insurer’s terms and conditions.

South Dakota:

Section 58-18-37: Group health insurance policies may not refuse to accept licensed pharmacies/pharmacists as participating providers if they agree to the same terms and conditions offered to other providers of pharmacy services under the policy.

Tennessee:

Section 56-7-117: Group medical benefit contracts covering prescriptions may not require a covered person to obtain prescriptions from mail-order, or to pay an additional fee, or be subjected to a penalty for declining to use a designated mail-order pharmacy.

Section 56-7-2359: Licensed pharmacies may not be denied right to participate on the same terms and conditions offered other participants; benefit differentials are prohibited.

Texas:

Section 21.52B 2(a) (2): A pharmacy/pharmacist may not be denied the right to participate as a contract provider under the plan if the pharmacy/pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies/pharmacists that have been designated as providers under plan.

Utah:

Section 31A-22-617: Insurers must allow providers to apply for and be designated as preferred providers if they agree to meet established terms and conditions. “Reasonable limitations” may be placed on the number of designated preferred providers.

Virginia:

Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such health care providers and cannot exclude any provider willing to meet the terms and conditions.

Section 38.2-3407.7: Insurers shall not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice.

Section 38.2-4209: Providers who are willing to accept established terms and conditions may qualify for payment under preferred provider contracts.

Section 38.2-4209.1: Corporations must allow beneficiaries to select the pharmacy of their choice if pharmacies that are non-preferred providers have previously notified the corporation of their agreement to accept reimbursement at rates applicable to preferred providers.

Section 38.2-4312.1: No Health maintenance organization shall prohibit any person receiving pharmaceutical benefits from selecting, without limitation, the pharmacy of his choice. No monetary penalty which would affect or influence any person’s choice of pharmacy shall be imposed.

Wisconsin:

Section 628.36 (2m): An annual 30-day open enrollment period during which any pharmacist may elect to participate is required.

Wyoming:

Section 26-22-503: Any provider willing to meet the established requirements has the right to enter into contracts relating to health care services.

Section 26-34-134: Providers willing to meet an HMO’s established terms shall not be denied the right to contract. An HMO may not discriminate against a provider on the basis of the provider’s academic degree.

Please note that laws can change over time, so it’s always a good idea to verify the current status of AWP laws in specific states if you need the most up-to-date information.

State Policies on Provider Market Power

The Source is a comprehensive platform that monitors and documents various state-level activities related to healthcare prices and competition. It provides valuable resources in the form of legislation and litigation databases, which are searchable and easily accessible.

The Database of State Laws Impacting Healthcare Cost and Quality focuses on legislative measures that have an impact on the cost and quality of healthcare. This database allows stakeholders at the state level to gain insights into their legal and regulatory environment. By understanding the laws in place, these stakeholders can make informed decisions and take necessary actions to enhance access, quality, and efficiency in healthcare while also striving to reduce costs.

Additionally, The Source includes a collection of maps that offer a visual representation of notable legislation and initiatives in health policy and reform across all 50 states. These maps provide a convenient way to explore the different approaches taken by each state and the progress made in addressing healthcare challenges.

If users have specific laws or cases they are interested in, they can utilize the search functionality within the database. This feature enables targeted exploration of laws and cases pertaining to a particular state, making it easier to find relevant information.

Overall, The Source serves as a valuable tool for stakeholders involved in healthcare, providing them with the necessary information to navigate the complex landscape of healthcare legislation and policy across the United States.

Through a review of state laws, CPR found a short list of states – California, Massachusetts, Montana, New Hampshire, North Carolina, Oregon, and Rhode Island – that are particularly active in their policy efforts regarding healthcare provider consolidation and market power.

Click to access State-Policies-on-Provider-Market-Power-1.pdf

State Policies on Provider Market Power Report

The Database of State Laws Impacting Healthcare Cost and Quality (SLIHCQ)

The Source on Healthcare Price & Competition

The Source tracks state activities impacting healthcare price and competition in both legislation (The Database of State Laws Impacting Healthcare Cost and Quality) and litigation in a searchable database to help stakeholders at the state level understand their legal and regulatory environment as they make efforts to improve access, quality, and efficiency, and reduce costs in healthcare.

Browse through the maps below to find out more about notable legislation and initiatives in health policy and reform across 50 states or search the database for specific laws and cases of a particular state.

ARTICLES & REPORT

Sutter Health Attempting to Complete Cross-Market Merger with Allina Health
April 8, 2026 by Bruce Allain, Managing Editor
In mid-March 2026, Sutter Health and Allina Health announced the signing of a Letter of Intent to merge the healthcare systems. Sacramento-based Sutter Health has more than 600 locations and 27 hospitals, and reported $19.8 billion in total revenue and $509 million in operating income in 2025. Sutter Health has come under fire in recent […]
New Mexico Enacts HB 306 – Threading the Needle on Facility Fees
April 7, 2026 by Anna Chau
On March 6, 2026, New Mexico enacted HB306, the “Fair Pricing for Routine Medical Care Act”, to prohibit charging of healthcare facility fees for certain services, to require the disclosure of facility fees to patients, and to require the reporting of facility fees to the all-payer claims database. The bill prohibits hospitals and clinics from […]
The Source Roundup: April 2026 Edition
April 1, 2026 by Leelah Klauber
Antitrust and Market Competition Playing Favorites — State Protection of Academic Medical Centers from Antitrust Oversight New England Journal of Medicine Jaime S. King, Katherine L. Gudiksen, Anna D. Sinaiko The authors explore a new trend with U.S. academic medical centers (AMCs) merging with nonacademic hospitals and health care systems. These mergers pose risks of […]
Department of Justice Suit Against New York Presbyterian May Be Part of a Larger Antitrust Enforcement Trend
March 31, 2026 by Bruce Allain, Managing Editor
On March 26, 2026, the Department of Justice (DOJ) sued New York-Presbyterian Hospital (NYP), claiming NYP used illegal anticompetitive terms in their contracts with payors. In the related press release, the DOJ stated that “New York-Presbyterian uses its market power to protect its margins, impede competition from rival hospitals, and prevent employers and unions from […]
The Source Staff Co-Author New Research on the State Protection of Academic Medical Centers from Antitrust Oversight
March 25, 2026 by Bruce Allain, Managing Editor
The Source’s founder Jaime S. King, and executive editor Katherine L. Gudiksen, working with Harvard’s Anna D. Sinaiko, have authored a report on state antitrust exemptions for academic medical centers (AMCs) published recently by the New England Journal of Medicine. There is a recent history of AMCs merging with nonacademic systems, with states creating "carve-outs" to exempt AMCs from antitrust oversight. The research […]
California’s Antitrust Reform Recommendation Reaches the Legislature as AB 1776
March 23, 2026 by Kassie Williams
Background In August of last year, The Source shared information about the California Law Revision Committee's (CLRC) antitrust study, spurred by the 2022 Assembly Concurrent Resolution No. 95. At its outset, the study aimed to address the U.S. monopoly problem and the "threat of market concentration" in California. The legislature tasked the CLRC with determining […]

Minnesota

California

Florida

Mindfulness-Based Interventions: Enhancing Resilience in Healthcare Settings

Mindfulness-based meditation has emerged as a recommended intervention to address these challenges. By cultivating resilience and providing tools to cope with stress, mindfulness interventions can help healthcare professionals navigate the demanding and vulnerable nature of their work.

Within the healthcare sector, a collective sense of cognitive dissonance, burnout, and distress can have detrimental effects on both the well-being of healthcare professionals and the quality of patient care. Mindfulness-based meditation has emerged as a recommended intervention to address these challenges. By cultivating resilience and providing tools to cope with stress, mindfulness interventions can help healthcare professionals navigate the demanding and vulnerable nature of their work. This article explores the impact of low staff morale in healthcare, proposes a plan of action to address the issue, and highlights the potential benefits of implementing mindfulness-based interventions.

Establishing the Problem/Situation

Low staff morale within healthcare environments undermines the essence of “care” in healthcare, resulting in adverse consequences for both the institution and its stakeholders. The prevalence of medical errors, high turnover rates, compliance concerns, and safety implications are just some of the outcomes associated with low staff morale. To mitigate these issues, an enterprise-wide program aimed at enhancing resilience, stress management, and empathy among healthcare professionals presents a promising solution. Strengthening these constructs can yield significant clinical, financial, and operational benefits.

Proposed Plan of Action

To address the problem effectively, management should take the following steps:

Define and identify moral distress: Clearly articulate the concept of moral distress and recognize its impact on healthcare professionals’ well-being and job performance.
Assess stakeholder impact: Consider the effects of low staff morale on patients, internal staff, external stakeholders, and the overall reputation of the healthcare institution.
Evaluate the bottom-line impact: Quantify the financial repercussions of low staff morale, such as increased malpractice costs, turnover expenses, reduced patient volume, and fines/penalties from regulatory authorities.
Formulate a strategy: Develop a comprehensive strategy that targets employees’ intrinsic constructs and promotes resilience. This strategy should provide cognitive tools, such as mindfulness-based interventions, to help employees cope with stress in their work environment.

Mindfulness-based meditation interventions have demonstrated effectiveness in promoting physician well-being, resilience, and personal achievement. However, it is crucial to tailor these interventions to the unique culture and management commitment of each healthcare organization.

By implementing mindfulness-based interventions, healthcare institutions can expect the following outcomes:

Improved well-being and resilience among healthcare professionals
Enhanced quality of life and increased positive affect for employees
Development of intrinsic coping mechanisms and stress reduction
Positive spill-over effects into employees’ personal lives

Conclusions and Recommendations

In healthcare delivery settings, collective cognitive dissonance, burnout, and distress undermine the quality of patient care and the well-being of healthcare professionals. Mindfulness-based interventions offer a promising approach to address these challenges comprehensively. The neurological mechanisms underlying mindfulness meditation promote resilience, improve quality of life, increase positive affect, and develop intrinsic coping mechanisms. By providing evidence-based workplace wellness interventions, rooted in mindfulness, healthcare institutions can not only foster a positive work environment but also improve employees’ personal lives.

Implementing mindfulness-based interventions requires commitment from management and a willingness to challenge the status quo. By prioritizing employee well-being and providing the necessary resources, healthcare institutions can create a culture that supports resilience, reduces stress, and enhances the delivery of compassionate care.

References

Baer, R. (2015). Ethics, Values, Virtues, and Character Strengths in Mindfulness-Based Interventions: a Psychological Science Perspective. Mindfulness, 6(4), 956-969.

De Clercq, D., Bouckenooghe, D., Raja, U., & Matsyborska, G. (2014). Unpacking the Goal Congruence–Organizational Deviance Relationship: The Roles of Work Engagement and Emotional Intelligence. Journal of Business Ethics, 124(4), 695-711.

Robbins, A. (2015). Doctors Throwing Fits. Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2017/05/willie_parker_helped_me_find_the_moral_language_i_was_missing.html

Schroeder, D. A., Stephens, E., Colgan, D., Hunsinger, M., Rubin, D., & Christopher, M. S. (2016). A Brief Mindfulness-Based Intervention for Primary Care Physicians: A Pilot Randomized Controlled Trial. American Journal of Lifestyle Medicine.

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management, 12(2), 164-176.

Introducing Alex Yarijanian: A Visionary Leader Shaping the Future of Healthcare

Alex Yarijanian, CEO of Carenodes, has expertise in the healthcare industry, particularly in the areas of customer building, senior care, managed care, and value-based care. Here are some general steps you can take to build your own customer based on these topics:

1. Understand your target audience: Identify the specific demographic or market segment you want to target, such as seniors or healthcare entrepreneurs. Research their needs, preferences, pain points, and behaviors to better understand how to tailor your offerings to meet their demands.

2. Develop a value proposition: Clearly articulate the unique value your product or service offers to your target audience. Highlight how it solves their problems, improves outcomes, or enhances their experience compared to existing solutions. Align your value proposition with the principles of value-based care and biopsychosocial models of well-being.

3. Build relationships: Cultivate relationships with key stakeholders in the healthcare industry, including patients, caregivers, healthcare providers, payers, and policymakers. Attend conferences, industry events, and networking opportunities to establish connections and raise awareness about your offerings. Consider collaborating with other organizations or thought leaders in the field to expand your reach.

4. Leverage technology and innovation: Embrace digital solutions, ambient assisted living technologies, and cognitive health tools to enhance the quality and accessibility of your products or services. Stay informed about the latest advancements in the healthcare industry and adopt relevant technologies that can improve outcomes for your customers.

5. Provide exceptional customer experience: Focus on delivering a seamless and personalized experience for your customers. Consider implementing concierge services or managed care approaches to ensure their needs are met comprehensively. Strive for high customer satisfaction by addressing their concerns, providing timely support, and continuously improving your offerings based on their feedback.

6. Demonstrate outcomes and value: Collect and analyze data to showcase the positive impact of your products or services. Emphasize how your solutions align with value-based care principles by highlighting improved patient outcomes, reduced costs, and enhanced patient experience. Use case studies, testimonials, and real-world evidence to demonstrate the value you bring to your customers.

7. Stay updated and adaptable: Continuously educate yourself about the evolving healthcare landscape, regulatory changes, and industry trends. Adapt your strategies and offerings accordingly to remain competitive and address emerging needs in the market.

Remember that these steps are general guidelines, and it’s important to customize your approach based on your specific business model, target audience, and industry regulations. Alex Yarijanian’s keynotes, podcast episodes, and live training sessions can provide further insights into these topics and help you develop a more comprehensive understanding of customer building in the healthcare industry.

Unleashing the Power of Healthcare Data: Exploring HRSA’s Data Portal

Discover the power of the HRSA Data Portal in revolutionizing healthcare research and planning. Developed by the Health Resources and Services Administration (HRSA), this web-based platform provides access to a vast array of comprehensive healthcare data. From primary care facilities to health workforce information, the HRSA Data Portal serves as a centralized repository for diverse datasets. Explore its key features, including interactive data visualization tools that enable users to gain insights and identify trends. Customizable reports and dashboards allow for tailored analysis, while the data download capability empowers researchers to perform in-depth analysis and integrate HRSA data into their own workflows. With its potential to inform evidence-based decision-making, the HRSA Data Portal can contribute to improved healthcare delivery, reduced disparities, and targeted interventions. Unlock the potential of data-driven solutions and work towards equitable access to healthcare resources with the HRSA Data Portal. Access it now to drive positive change.

Introduction:

In today’s data-driven world, information has become a valuable asset, particularly in the healthcare industry. Access to accurate and comprehensive healthcare data can drive research, inform policy decisions, and ultimately improve patient outcomes. Fortunately, the Health Resources and Services Administration (HRSA) understands the significance of data transparency and has developed a powerful tool: the HRSA Data Portal. In this blog post, we will delve into the depths of this invaluable resource and explore its potential to revolutionize healthcare research and planning.

What is the HRSA Data Portal?

The HRSA Data Portal is a web-based platform that provides access to a wealth of healthcare data collected by the Health Resources and Services Administration. HRSA is an agency of the U.S. Department of Health and Human Services, tasked with improving access to healthcare services for underserved populations. The Data Portal serves as a centralized repository for various datasets, enabling users to analyze, visualize, and download information relevant to health resources, health workforce, and other critical healthcare domains.

Exploring the Key Features:

Comprehensive Data Collection: The HRSA Data Portal offers an extensive collection of datasets covering diverse aspects of healthcare, including but not limited to primary care facilities, healthcare workforce, medically underserved areas, and health disparities. This wide-ranging data facilitates a holistic understanding of the healthcare landscape and enables researchers, policymakers, and healthcare professionals to identify gaps and target interventions more effectively.
Interactive Data Visualization: The Data Portal incorporates interactive data visualization tools that empower users to explore healthcare data visually. From dynamic charts and graphs to geospatial mapping, these visualization features provide a user-friendly interface for gaining insights and identifying trends, patterns, and disparities across different regions and demographics. This functionality enhances data comprehension and assists in evidence-based decision-making.
Customizable Reports and Dashboards: Users can create custom reports and dashboards using the available datasets within the HRSA Data Portal. This flexibility allows individuals to tailor their analysis and focus on specific areas of interest. Whether one is conducting research on healthcare access in rural communities or examining workforce distribution in underserved regions, the ability to customize reports streamlines the data exploration process and promotes targeted investigations.
Data Download Capability: The Data Portal provides direct access to downloadable datasets in various formats, allowing researchers and analysts to integrate the HRSA data into their own analytical tools and workflows. This feature empowers users to perform in-depth analysis, conduct advanced statistical modeling, or combine HRSA data with other sources to gain a comprehensive understanding of healthcare dynamics.

The Potential Impact:

The HRSA Data Portal has the potential to revolutionize healthcare research, planning, and policy development. By fostering transparency and access to valuable information, the platform can facilitate evidence-based decision-making, leading to more effective resource allocation, improved healthcare delivery, and reduced health disparities. Researchers can leverage the data to identify gaps in healthcare access, evaluate the impact of interventions, and propose targeted solutions. Policymakers can utilize the insights gained from the data to shape healthcare policies that address the needs of underserved populations, ultimately enhancing the overall health of communities.

Conclusion:

The HRSA Data Portal stands as a testament to the power of data in transforming the healthcare landscape. Its robust collection of datasets, interactive visualization capabilities, customizable reports, and data download functionality provide a comprehensive toolkit for healthcare researchers, policymakers, and professionals. By leveraging this platform, stakeholders can gain valuable insights, make informed decisions, and work towards a future where healthcare resources are equitably distributed and accessible to all. The HRSA Data Portal serves as a beacon of hope, empowering us to unlock the potential of data-driven solutions in improving healthcare outcomes for communities across the nation.

Area Health Resources Files

BHW Clinician Dashboards

BHW Program Applicant and Award Data

Grants

Health Center Service Delivery and Look–Alike Sites

Health Professions Training Programs

Maternal and Child Health Bureau

National Health Service Corps (NHSC), Nurse Corps, and Substance Use Disorder Treatment and Recovery (STAR) and other Programs

National Practitioner Data Bank

Nursing Workforce Survey Data

Organ Donation and Transplantation

Ryan White HIV/AIDS Program

Shortage Areas

Uniform Data System

Workforce Projections

HRSA Data Portal Access

California Primary Care Clinic Annual Utilization Data

California Primary Care Clinic Annual Utilization Data. Access the complete data set of annual utilization data reported by primary care clinics contains basic clinic identification information.

Introduction

In today’s data-driven world, the ability to collect, analyze, and leverage information is crucial for making informed decisions. This holds true in the healthcare industry as well, where data plays a pivotal role in understanding patient needs, improving healthcare delivery, and optimizing resource allocation. One valuable source of information is the annual utilization data reported by primary care clinics. In this blog post, we will explore the wealth of insights that can be derived from this comprehensive dataset, including clinic identification information, financial data, and utilization trends.

Clinic Identification and Staffing Data

The complete data set of annual utilization data reported by primary care clinics contains basic clinic identification information. This includes details about the community services provided, enabling policymakers and researchers to assess the availability of healthcare resources in specific areas. Additionally, the dataset includes clinic staffing data, which sheds light on the number and types of healthcare professionals working in these clinics. This information is vital for understanding the distribution of primary care providers and identifying potential gaps in staffing.

Patient and Staff Language Data

Understanding the language preferences of both patients and staff is essential for effective communication and ensuring culturally competent care. The utilization dataset includes valuable information on the languages spoken by patients and staff members. By analyzing this data, healthcare organizations can identify linguistic needs within their patient population and make informed decisions about language assistance services and staff training programs.

Financial Information

The utilization dataset also incorporates financial information, providing insights into the financial health of primary care clinics. This includes gross revenue, itemized write-offs by program, and an income statement. By examining these financial metrics, healthcare administrators and policymakers can assess the financial viability of clinics, identify areas of potential improvement, and allocate resources more effectively. Moreover, selected capital project items are included in the dataset, enabling stakeholders to evaluate investments in infrastructure and technology.

Encounters, Diagnoses, and Procedures

A significant component of the utilization dataset is information on encounters, diagnoses, and procedures. This is captured through principal diagnosis and procedure codes, such as CPT codes. By analyzing this data, researchers and healthcare professionals can gain insights into the types of services provided, prevalent health conditions, and procedures performed within primary care clinics. These findings can guide clinical decision-making, resource allocation, and health promotion efforts.

Utilization Trends and Insights

One of the most valuable aspects of the primary care clinic utilization dataset is the ability to derive trends and insights. The dataset provides information on the number of clinics by type, allowing stakeholders to assess the distribution of primary care facilities across different regions or communities. It also includes data on the number of patients by race, ethnicity, gender, and age, enabling the identification of health disparities and the development of targeted interventions.

Furthermore, the dataset provides information on encounters by payer source, shedding light on the financial landscape of primary care clinics. This data can help policymakers evaluate the effectiveness of healthcare financing models and their impact on access to primary care services. Additionally, revenues by payer source, including the average revenue per encounter, offer valuable insights into the financial dynamics of primary care clinics and can inform reimbursement strategies.

Conclusion

The complete data set of annual utilization data reported by primary care clinics is a treasure trove of information that holds immense potential for improving healthcare delivery. From clinic identification and staffing data to financial information and utilization trends, this dataset empowers healthcare administrators, policymakers, and researchers to make data-informed decisions, enhance resource allocation, and promote equitable and patient-centered care. By harnessing the power of this comprehensive dataset, we can strive towards a future where primary care is optimized, accessible, and tailored to meet the diverse needs of communities.

California Primary Care Clinic Annual Utilization Data

The complete data set of annual utilization data reported by primary care clinics contains basic clinic identification information including community services, clinic staffing data, and patient and staff language data; financial information including gross revenue, itemized write-offs by program, an income statement, and selected capital project items; and information on encounters by service, principal diagnosis, and procedure codes (CPT codes). These products provide trend utilization information for primary care clinics in the form of tables and pivot tables. The primary care clinic trends resource includes information on the number of clinics by type, the number of patients (by race, ethnicity, gender and age), the number of encounters by payer source; and revenues by payer source including the average revenue per encounter.

Access Dataset