Social Determinants of Health (SDoH) and Artificial Intelligence (AI) in Healthcare

Social determinants of health (SDoH) are conditions in the environments in which people are born, live, learn, work, play, and age that impacts a wide range of health, functioning, and quality of life trajectories. Individual and community behaviors can influence health costs and outcomes regardless of being outside the control of the health system. Understanding social determinants of health is imperative for strengthening health and minimizing longstanding disparities in healthcare. More specifically, focusing on the health care system concerns of health coverage, quality of care, and medical bills is where Artificial Intelligence (AI) can step in. Focusing on the use of AI to model and understand social determinants of health will accelerate us towards a value-based care model while improving and maintaining health instead of treating illness.

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The growth of Medicaid Managed Care Organizations (MCOs) in the United States

Enrollment in Medicaid and Managed Care Organization (MCO) plans in the United States has reached an all-time high of 74 million recipients. According to Health Affairs, “an estimated 71 percent of Medicaid recipients are receiving their care via private health plans, both investor-owned and nonprofit.” In 2016, research behind the shift showed that managed care plans can provide services that state Medicaid agencies cannot fulfill. For example, network contracting, information technology, and use of management systems to display low-value care can vastly improve the health of beneficiaries. 

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Bipartisan Senators Unveil Proposal Aimed at ‘Surprise’ Medical Bills

On Tuesday, a bipartisan group of senators unveiled a draft bill targeting surprise medical bills in an effort to protect patients from unexpected and exorbitant charges. If approved, the bill will establish several measures intended to warn patients about additional costs at out-of-network facilities and prevent out-of-network health care providers from charging additional costs for emergency services.

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CMS eliminates barrier to ACA Individual Mandate Exemption

Consumers who abandoned the Obamacare exchanges this year are entitled to a “hardship” exemption to the individual mandate penalty, CMS publicized Wednesday. This will directly affect people who chose to go uninsured or who enrolled in coverage that doesn’t comply with Obamacare protocols. This follows the agency’s April guidance that expanded the exemption to people who live in rural counties or have claims going back to 2016, but applicants still had to give a written explanation for why they required the exemption.

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Texas ACA lawsuit to begin: What you need to know

Today, a Texas lawsuit will be heard determining pivotal laws and regulations concerning the Affordable Care Act. Republican attorney generals, led by Texas’ Attorney General Ken Paxton, will go against the Democratic party, led by California’s Attorney General Xavier Becerra, to debate the fate of the ACA. U.S District Judge Reed O’Connor will hear both sides and determine whether the health law should be put on hold while the case is being contested. GOP Plaintiffs are looking for a “preliminary injunction” on the law.

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NPAG 2018 Recap

Excellus Blue Cross Blue Shield was pleased to host the 2018 National Plan Automation Group (NPAG) Conference in picturesque Lake Placid, NY. The event showcased 4 days of interactive sessions exploring opportunities in EDI, electronic payments, health records, “HEDIS,” and the past, present, and future of authorization transactions. While NPAG sponsored a progressive networking retreat, attendees took advantage of Lake Placid Golf Club, Ausable Chasm, and an adventurous BobSled Experience.

In case you were not able to attend, here’s our recap of what was discussed:

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CMS to accelerate Medicaid waiver process and allocate $8.6 million in funding to states to steady health insurance markets

The Centers of Medicare and Medicaid Services (CMS) revealed on August 16th, 2018 changes to the Medicaid Review Process, unveiling substantial reduction in approval times. The new updates will generate faster processing of state requests to streamline changes to their Medicaid program through the state plan amendment and section 1915 waiver review process. Less than 1 week following this move, CMS announced $8.6 million in funding to 30 states and the District of Columbia to help reinforce and stabilize corresponding health insurance markets under the Affordable Care Act (ACA).  

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MESC 2018 Recap

The annual Medicaid Enterprise Systems Conference (MESC) showcased 4 days of interactive sessions discussing health information technology, MMIS implementations, and Medicaid innovations. Set in the picturesque city of Portland, Oregon, the conference welcomed industry experts from all over the country. Day 1 set the tone by asking the audience: “What’s your next big idea in Medicaid?” All sessions to follow explored that overarching question.  

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MESC 2018 Recap: Day 2

The annual Medicaid Enterprise Systems Conference (MESC) began day 2 with a deep dive into Machine Learning for Medicaid Payers and Providers, followed by sessions on successful modular MMIS implementations and best practices from state reuse initiatives, including that of New Jersey and Pennsylvania.

If you weren’t able to attend, check out our MESC recap of key takeaways.

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