The Spring Accountable Care Organization Coalition Meeting: From Finding Worth to the Future of the Affordable Care Act

A day after the House Republicans gave vote to send the American Health Care Act to the Senate, Forbes opinion editor Avik Roy put it in context: the “behemoth” that is the health system of US has grown up over a half-century and merges with the worst characteristics of delivery systems from across the world—high charges, inefficiency, and deficiency of coverage. The Spring Accountable Care Organization Coalition Meeting: From Finding Worth to the Future of the Affordable Care Act.

“We’ve all the cost inefficiencies of a highly public system without any of the real coverage gains that you would hope from a truly government system,” stated Roy, speaking in Scottsdale, Ariz., at The American Journal of Managed Care® (AJMC®)’s spring meeting of the ACO and Emerging Healthcare Delivery Coalition,® May 4-5, 2017. The Spring Accountable Care Organization Coalition Meeting: From Finding Worth to the Future of the Affordable Care Act.

The address and appearance of Roy on a panel about the future of the Affordable Care Act (ACA) gave a high point in an information-packed conference, which also depicted:

• Keynote speaker Darius Lakdawalla, PhD, of the University of Southern California, who explained the challenge of measuring what matters to sufferers as the health system shifts to value-based payment structures.


• The AJMC® 2020 Panel Discussion series, which reflected the insights from health system leaders bringing legal services to Medicaid sufferers in post-Katrina New Orleans and another tackling how to get the most out of each sufferer visit, specifically among seniors, as well as the founder of a health IT organization committed to care transformation through precision medicine.


• Insights from ACO Coalition Chair Anthony Slonim, MD, DrPH, the CEO of Renown Health, and moderator Clifford Goodman, PhD, of The Lewin Group. “The significant takeaway from this meeting is that we’re making much progress,” Goodman claimed. “We’re making much progress in comprehending what value means and how we might bridge better understanding of value into decision making.”

The next ACO Coalition meeting is set for the time period of October 26-27, 2017, in Nashville, Tenn. For information, visit the Coalition website here.

 

Good Shepherd Health seems to reduce prescription costs

Pharmacist Philip Baker launched the doors of Good Shepherd Health more than a year ago to offer free or at-cost prescriptions to uninsured people in the region of Memphis. Baker rapidly discovered that individuals covered by Medicare required the services of the nonprofit pharmacy. He founded that even individuals with insurance too often could not afford the high cost of drugs or prescription costs.

Now, he has set his sights on advancing the way self-insured employers pay for medicines of their employees. Good Shepherd plans to give its at-cost model for prescriptions to chop the drug costs of employers, competing with for-profit pharmacy benefit managers like Express Scripts Inc.

“I’ve a vision to entirely revolutionize the whole industry and that is by making PBMs, pharmacy benefit managers, obsolete,” Baker stated.

According to Baker, employers are paying the complete price for prescription costs and the mark-up on those drugs can be breathtaking.

Plavix, a drug utilized to stop blood clots and one of the most usually used, is his favorite instance.

Huge drug companies get a worse rap, and they should, for pricing brand-name drugs too high, he stated. Although, the major majority of drugs on the market are generic and he claimed for-profit pharmacies and pharmacy benefit managers are marking those up.

By eliminating the profit and giving its medication management service for employers for a fee, Baker stated “merely initial numbers we are looking at we can decrease the company’s drug costs by thirty or forty percent right off the top.”

Good Shepherd has not sold the idea yet, but is in talks with various companies, stated Baker, 40, a University of Tennessee Health Science Center College of Pharmacy graduate and former rehabilitation hospital director of pharmacy.

With a half dozen workers and headquartered in the Hickory Ridge Towne Center mall, Good Shepherd has offer $1.3 million worth of free medicines and served over 1,000 since opening in the year of September 2015, Baker claimed.

Despite nationwide attempts to assist uninsured individuals with the prescription costs drugs, charity pharmacies like Good Shepherd have sprung up to help meet the requirement in the last decade, stated Chris Palombo, chief executive of Dispensary of Hope in Nashville.

Dispensary of Hope is basically a nonprofit drug distributor that gets donated drugs from manufacturers and physician practices and supplies them to free and federally qualified clinics across the country, involving Good Shepherd, Palombo stated.

With estimates of more than thirty million uninsured persons nationwide, the requirement is massive and uninsured and low-income indivudals also suffer more chronic sicknesses, he claimed.

Help with prescriptions is falling short for millions, in spite of the Affordable Care Act, a separate federal program called as “340B” that gives steeply discounted drugs to several hospitals and federally qualified health centers, and drug manufacturers’ patient assistance programs.

Baker is crucial of the federal programs and said Good Shepherd does not participate in Medicare or any insurance program.

Huge deductibles that must be met before insurance pays under coverage available through Affordable Care Act leaves few sufferers unable to afford their drugs, he stated. And he called the 340B program “corrupted,” utilized as a profit-center for hospitals and health centers that need to treat it as one.

By giving free prescriptions to those with incomes that are eligible, at-cost drugs and tapping in to manufacturers’ patient assistance plans, Baker said Good Shepherd stitches together policies for both the uninsured and the insured. Sufferers with chronic conditions have become the major niche of agency.

Good Shepherd’s vision for providing services to employers and revolutionizing the industry also will assist to subsidize its charitable work and other ventures and will try to reduce the prescription costs.

 

CMS issues service utilization data by state and county

The Centers for Medicare and Medicaid Services issued an updated data device that produces interactive state and county maps with metrics explaining the health service utilization, like emergency, non-emergency and skilled nursing services.

Utilizing the ambulance and HHA paid claims information within CMS systems for Medicare fee-for-service beneficiaries, the maps indicate whether a place has an active moratorium in a specified geographic place. The maps also have color variations to demonstrate distribution of the metric.

The information enables comparisons of contributor services and utilization information by geographic places, enabling drilldown comparisons to the county level of states. Maps are coded to unveil which places are in particular quartiles of distribution.

Information can show the number of Medicare contributors serving a geographic region, as well as the number of Medicare beneficiaries who utilize a health service in an area.

CMS used authority given by the Affordable Care Act in the year of 2013 to enforce temporary enrollment moratoria to combat fraud, waste and abuse, in accordance to a blog post by CMS’ Center for Program Integrity Director Shantanu Agrawal. CMS has expanded the moratoria in 6 month phases since then; the most recent occurred on the day of January 29.

The moratoria implemented to the enrollment of new home health agencies and ground ambulance suppliers. Agrawal wrote that the moratoria offered “CMS the chance to observe and monitor the existing provider and supplier base, as well as further focus extra fraud prevention and detection tools in these places.”

The analysis is deployed on the paid Medicare claims data from the CMS Integrated Data Repository (IDR). Claims data are observed for a 12-month reference period, and outcomes are updated quarterly. The reference period dates back as far as the month of October 2014.

The methodology differs from other kinds of public use data in determining the geographic location of a contributor. Claims are utilized to define the geographic area served by a provider, instead of the provider’s practice address.

 

Blue Cross premium rises in Texas, Oklahoma could mean Illinois sticker surprise

Illinois residents who purchase Blue Cross and Blue Shield health care coverage through the state insurance exchange may be in for Obamacare sticker surprise, if proposed rate rises by the greatest insurers in Texas and Oklahoma are any indication.

Texas and Oklahoma are potential harbingers of Blue Cross' costs on the Illinois exchange because entire 3 health policies are owned by the similar company, Chicago-based Health Care Service Corp. Blue Cross is the most famous insurer on the Illinois exchange.

In Texas, Blue Cross and Blue Shield is finding the increases averaging 53.7% across its Affordable Care Act plans, in accordance to documents posted online by the federal government. In Oklahoma, Blue Cross and Blue Shield is seeking rate increases that average 49.2%. It is far from certain if the amount increases will hold up on review, or how much they might change.

Illinois' proposed amounts have not been made public by the state so it would be premature to discuss, stated HCSC spokesman Mark Spencer. But he cautioned against speculating on the company's prices in the year of 2017 Illinois individual market because there are differences between states and health insurance is priced regionally.

What will be the Future of Affordable Care Act?

While the Affordable Care Act has reduced the number of uninsured Americans, the future may once again show that uninsured amounts will raise if the individual mandate is struck down.

The future of the Affordable Care Act and health insurance exchanges might not be as favorable as the Obama administration had expected. Several fear that the major health insurer UnitedHealthcare leaving the state-based exchanges could lead other payers to drop out. Furthermore, the upcoming health insurance mergers between Aetna and Humana as well as Cigna and Anthem could lead to significant issues for the consumers, as premium costs of health plans could increase quickly.

With UnitedHealthcare dropping out of the Exchanges, some critics say the Affordable Care Act may not sustain all of its provisions well into the future. While the Affordable Care Act has reduced the number of uninsured Americans, the future may once again indicated that uninsured rates will rise if the individual mandate is struck down while the number of high-deductible health policies may proliferate around the country. Paul Ketchel, the Founder and CEO of MD save, provided his perspective on the future of the Affordable Care Act.

ACOs Keep Growing Across USA

The Patient Protection and Affordable Care Act led to the development of the Medicare and Medicaid Innovation Center, which suddenly brought the creation of accountable care agencies and the Medicare Shared Savings Program. Over the last various years, the number of accountable care organizations has grown tremendously around the country.

Leavitt Partners along with the Accountable Care Learning Collaborative made a study in the month of January 2016, as reported by the Health Affairs Blog that found a total of 838 accountable care organizations across all fifty states in the nation. In fact, the number of accountable care organizations has grown by 12.6% in just the last year.

In addition to these findings, there is currently more than 1,200 accountable care contracts being executed across hospitals throughout the US. The study discovered that 28.3 million sufferers are now getting medical services through an accountable care organization or ACO.

The Medicare Shared Savings Program is now on its 3^rd year and many ACOs have renewed their contracts while various have decided to forego another year performing under the accountable care contract.

13 percent of Midsize Employers offer High-Deductible Health Policies

High-deductible health policies are yet a rarity among interviewers, the report found. A mere 13% of midsize employers offer high-deductible health policies.

The health insurance industry has been changing because of the Affordable Care Act and other regulatory pressures from the Centers for Medicare and Medicaid Services (CMS). Rising healthcare prices along with the reforms taking place among payers have led to employers renovating their approach to selecting benefits and health policies. Various employers may require considering whether high-deductible health policies are the right choice for their workers.

Benefitfocus released a report called the State of Employee Benefits 2016, which describes how employers are bringing greater financial responsibility for health plans back onto the employees. Therefore, it is up to the consumers or employees to work directly with health payers in order to limit their out-of-pocket spending and utilize healthcare services in a cost-effective manner.

High-deductible health plans are yet a rarity among employers, the report discovered. A mere 13% of midsize employers provide high-deductible health plans. PPOs and HMOs still tend to be the most famous option among health plan offerings across businesses. Employers would be wise to think about other insurance options in case to decrease rising healthcare spending and the overuse of medical services within typical fee-for-service insurance policies.

Obamacare Purchasers Could Have Fewer Choices in the year 2017

With the nation's greatest health insurer exiting all but a few Affordable Care Act exchanges next year, few Americans may be left with fewer choices and few might see higher monthly premiums.

Experts say that will be the upshot of UnitedHealth Group Inc.'s recent announcement that it will pull out of most of the 34 states where it offers health plans on the public health insurance exchanges.

The public health insurance exchanges are online marketplaces where persons can shop for and enroll in a health policy. This is the 3^rd year of operation for the exchanges, a key component of the Affordable Care Act, also called as Obamacare.

Meanwhile, health insurers stung by the high price of covering public health exchange enrollees, are hoped to request sharply higher rates for the year 2017.

In Virginia alone, 9 insurers have proposed average rate hikes ranging from more than 9% to 37%, the Associated Press reported.

In the year 2016, about 12.7 million persons enrolled in a health policy through HealthCare.gov or state-based insurance exchanges, in accordance to the U.S. Department of Health and Human Services. And more than eight in 10 enrollees qualified for federal tax credits to make their monthly insurance premiums more affordable.

The country's greatest health-insurance company is almost completely quitting Obamacare

The country's greatest healthcare company is getting out of the Obamacare business.

United Healthcare, which presently covers the most Americans in the US (pending the proposed Anthem-Cigna merger), stated that in its quarterly earnings release on the day of Tuesday that it is removing its offerings from almost all Affordable Care Act exchanges by the year 2017.

"The smaller overall market size and shorter-term higher risk profile within this market segment sustain to suggest we can’t broadly serve it on an effective and sustained basis," claimed CEO Stephen Hemsley in the company's quarterly earnings conference call.

Healthcare BI Platform Market to Increase Because of Rising Demand for Technologically Advanced Healthcare Networks

A business intelligence platform is utilized by healthcare organizations to make helpful healthcare applications that help them in ensuring the provision of quality healthcare to sufferers. BI platforms help control healthcare costs and offer various benefits to healthcare organizations like analysis capability, providing information on delivery, and integration.

Healthcare BI platforms give a very useful function called financial analytics. The availability of the financial analytics function is acting as a major progress driver for the healthcare BI platform market. An increasing number of conventional healthcare systems are being replaced by BI platforms as the latter are technologically advanced, thus driving the market for healthcare BI platforms.

Healthcare BI Platform Market to Expand because of Growing Demand for Reduced Healthcare Expenditure

Government regulations like the Affordable Care Act in the U.S. in 2010 are also promoting the adoption of healthcare BI platform, leading to the market’s growth. The capability of BI platforms to offer quality healthcare to patients at a reduced cost is compelling the market’s growth. Increasing prevalence of health issues and the consequent rise in the healthcare expenditure have led to a increasing demand for advanced healthcare systems. BI platforms are thus the requirement of the hour in terms of providing technologically advanced healthcare facilities at reduced prices.

Financial Analytics Segment to Lead Healthcare BI Platform Market

The global healthcare BI platform market is segmented on the basis of function, deployment type, model and geography. On the basis of model kind, the healthcare BI platform is segmented into corporate BI and self-service BI. Of these 2 sub-segments, the segment dominating the healthcare BI platform market is the corporate BI model. Although, the self-service BI model is hoped to be the fastest growing segment during the time of 2015 to 2023 owing to the high demand for faster and diverse analytics by making utilization of decentralized data.

HEALTH CARE SYSTEM EXTENDS TO COVER UNDOCUMENTED KIDS

Starting next month, almost 200,000 kids of undocumented workers will now have approach to health care.

Changes to California's health care system will now expand coverage to undocumented kids, ages 18 and younger, who don’t have medical insurance.

The changes go into effect on May 16, and it is a relief to some parents.

"Thank God that we have it," claims Jose Hernandez, who was capable to enroll his kids into the program because they were born in the U.S.

Hernandez claims the program saved his son's life when he had his appendix removed.

"Painful," the boy claims. "But I am happy I had the coverage."

Yet others say they can’t say the same. Their kids are not covered by California's health system, and the Affordable Care Act also excludes them from getting coverage.

Greatest Health Insurer Bailing On Much Obamacare Exchanges

UnitedHealth Group, the greatest health insurer in the U.S., will pull out of most states’ Obamacare exchanges next year, the company declared on the day of Tuesday.

UnitedHealth cited about $1 billion in losses over the past 2 years for the firm’s decision to significantly scale back its business on the health insurance exchanges created by the Affordable Care Act.

UnitedHealth offers policies on the exchange marketplaces in 34 states this year, but will merely remain in a “handful” of states in the year 2017, UnitedHealth CEO Stephen Hemsley claimed during a conference call on the company’s quarterly earnings. The company cautioned in the month of November it might bail on the marketplaces nationwide.

The UnitedHealth Group announcement and warning symbols from other health insurers that Obamacare enrollees are costlier than hoped to serve as a reminder of how new and how fragile the health insurance exchange marketplaces are ahead of the open enrollment period for the year 2017 coverage, which begins this fall.

President Barack Obama’s health care overhaul may have extended health coverage to an estimated 20 million persons and brought the uninsured amount to an all-time low, but its future sustains to be uncertain as market dynamics continue to play out. No matter what UnitedHealth Group may be doing next year, it is going to take longer than that to determine whether the regulated, subsidized health insurance exchange market will be viable long period.

UnitedHealth Group to exit Obamacare exchanges in all but a ‘handful’ of states

UnitedHealth Group, the nation's greatest health insurer, stated on the day of Tuesday that in the year 2017 it will exit most of the 34 states where it offers policies on the Affordable Care Act insurance exchanges.

"We will be down to a handful of states that we will be actively engaging in the exchanges," Stephen J. Hemsley, chief executive officer of UnitedHealth Group claimed in an earnings call, noting that the small market size and greater expense of sufferers insured through the marketplaces led the insurer to make the decision.

UnitedHealth plans to withdraw from health insurance marketplaces in Arkansas, Michigan, Connecticut and parts of Georgia. The decision is a sequel to an declaration by executives late initial year that the insurer had suffered financial losses and might leave the health exchanges altogether in the year 2017. UnitedHealth reported that it hopes to lose $650 million in the exchanges in the year 2016.

New Health Insurance Clients Are Sicker. Should We Be Shocked?

Before Obamacare, health insurance companies routinely denied to sell policies straightly to sufferers who had illnesses such as AIDS, hepatitis C or heart disease.

It should be no surprise to anyone, then, that once the Affordable Care Act needed insurers to give insurance to sick persons, a lot more sick people signed up.

That is the basic conclusion of a latest report on health insurance customers from the Blue Cross and Blue Shield Association analyzing health insurance for 4.7 million Americans in 27 states and the District of Columbia. The report, which indicates that new consumers are sicker and costlier than people in the old individual insurance market, made a big splash on the day of Wednesday, because it implied that the Obamacare markets are more troubled than many had hoped.

The issue with the report, however, is that it does not really tell us how Obamacare has affected the individual insurance market. It does not say how expensive it was to pay the medical bills for the whole group of people who bought their own health insurance.

Consumer Education Key for Health Insurance Marketplace Success

It appears that those residing in the state of Texas who have bought their healthcare coverage through the health insurance marketplace do not have as much understanding of certain terms as those who have medical insurance through their employer or through Medicaid or Medicare, in accordance to a study completed by the Episcopal Health Foundation (EHF) and Rice University’s Baker Institute for Public Policy.

The outcomes from the study indicate that the number Texans who bought individual health plans through the health insurance marketplace have risen 78% from the year 2013 to 2015. When it comes to the Affordable Care Act’s federal health insurance exchange, 1.3 million Texans gained coverage through these means.

Nonetheless, the study discovered that those who bought individual health policies through the health insurance marketplace had more trouble understanding simple insurance terms such as premiums, deductibles, and co-payments. For example, only one out of  four poll takers with employer-sponsored health insurance did not understand the term “maximum out-of-pocket expenses” while more than 42% of Texans who had individual health plans had trouble understanding the concept.

More significantly, the research discovered that those who bought individual health plans through the federal or state exchanges had more difficulty understanding how to utilize their coverage plans.

If Healthcare Costs Emerge, Americans Will not Link To Quality

As the healthcare industry starts to give more ways for users to see and use price data, a new study shows Americans do not mostly link the price tag with quality.

Most Americans “did not consider that price and quality are connected,” in accordance to new research conducted by Public Agenda that is issued in the April issue of the journal Health Affairs. Relying on how the query was framed, 58 percent to 71 percent of Americans did not associate healthcare costs with quality.

It is a timely study offered some states and the federal government as well as insurance companies and employers are experimenting with latest approaches to make healthcare more transparent to users and sufferers. And the shopping experience is starting to make better somewhat, with more users using public exchanges under the Affordable Care Act or private exchanges given by employers.

The study is also significant because doctors and hospitals often complain health insurance company networks are all about cost and not offering the best medical-care providers when depicting them to health plan members in lower-priced health plans. Most insurers, involvingcluding Anthem ANTM -2.23%, Aetna AET -2.42%, UnitedHealth Group UNH -1.46%and Blue Cross and Blue Shield plans across the country, are offering more policies with narrow networks.

6 things to celebrate about the Affordable Care Act

Previous week we celebrated the 6^th anniversary of the Affordable Care Act (ACA) and depicted on historic gains in health insurance coverage. About 20 million initially uninsured Americans are now covered. In Texas, we recently saw the greatest one-year drop in Texas’ uninsured rate in decades. And this happened despite Texas’ denial to accept federal Medicaid funding to cover an additional 750,000 low-income, uninsured Texans who lack affordable options today.

With so much concentration on coverage gains under the ACA, it is convenient to forget fundamental changes to the health insurance market that the ACA delivered. Before the ACA, unfair and discriminatory practices excluded millions of people from health insurance and inflated prices for others. To honor the ACA’s 6^th anniversary, here are 6 things to which we have bid good riddance:

• Lifetime limits. 6 years ago lifetime limits were common in health insurance policies. Some seriously sick people, like those with hemophilia and transplants, could run out of insurance advantages after the cost of their care exceeded an arbitrary cap. The ACA ended lifetime limits.


• Frivolous cancellations. Prior to the ACA, few insurers utilized flimsy excuses to revoke the policies of tens of thousands of Americans shortly after they were diagnosed with costly and life-threatening conditions. The ACA now prohibits this appalling practice.


• Being “uninsurable.” Before the ACA, insurers could deny coverage, charge more, or need a waiting period before providing coverage to persons with “pre-existing conditions.” The ACA put an end to these practices in the year 2014.


• Medicare “doughnut hole.” The ACA is closing the gap in Medicare drug coverage that could need enrollees to shoulder significant out-of-pocket costs. Since the year 2010, the doughnut hole has shrunk a bit more each year, already saving Medicare recipients in Texas almost $1 billion on prescription drugs. The doughnut hole disappears in the year 2020.


• Paying more for being a woman. Prior to the ACA, insurers commonly charged women much more than males for the similar coverage. That was real even when maternity was excluded, which was standard practice in pre-ACA Texas “individual market” policies — or coverage bought straightly from an insurer, not through a job. The ACA ended gender discrimination in premiums and needs insurance policies to cover maternity.


• Missing mental health coverage. Prior to the ACA, small employer and individual market health insurance plans mostly lacked profits for mental health and substance abuse treatment. And when mental health benefits were covered, policies often capped those profits at a much lower level of coverage than for physical health services. The ACA extended mental health and substance use disorder benefits to an estimated 62 million Americans, with benefits on par with physical health profits.

Obamacare Enrollees Are ill And They are Getting Much Health Care

WASHINGTON — the landmark health care reform law called as Obamacare seems to be succeeding in its twin objevtives of extending health coverage to the uninsured and enabling persons to access life-saving treatments.

But this humanitarian victory also underscores the newness and fragility of the remade health insurance market, as a latest report issued on the day of Wednesday by the Blue Cross Blue Shield Association shows. The consumers who flocked to the exchanges are sick and are utilizing a lot of medical care, a trend that could jeopardize Obamacare’s gains by destabilizing the health insurance system.

Greater access to health care for persons with pre-existing conditions who were shut out of the old market and those whose low incomes made health insurance too expensive before the Affordable Care Act’s subsidies became available in the year 2014 was one of the core objectives of the law President Barack Obama enacted 6 years ago.

Health care data is key to better sufferer results

Healthcare is believed to be one of the greatest portions of the U.S. economy, depicting a $2.8 trillion market (PDF), in accordance to PwC. It is also a sector rife with problems, with the price of care, drugs, and insurance generally increasing above the cost of inflation per year. As politicians on the right and the left debate the merits of the Affordable Care Act, what to do about Medicare, or whether we should shift to a single payer model as in the country of Europe and Canada, 1 thing is clear: Health care in the U.S. requires a lot of fixing, and employing innovative technology effectively can be part of the solution.

In a panel on health care APIs this week, experts and entrepreneurs in health data convened to explain the state of building interoperable API based solutions for approaching health records. The accessibility of health care records across contributors and sufferers has long been a sore point.

Deficiency of Medicaid Expansion moves to Hospital Revenue Loss

Ever since various states rejected to expand their Medicaid programs and gain the majority of funding for this enterprise from the federal government, there has been a division of revenue between states that have broadened Medicaid coverage and those who have been reluctant to do so. Hospitals in states with Medicaid expansion have seen a increase in sufferer numbers and revenue.

An Urban Institute study discovered that hospitals are losing up to $400 billion in federal Medicaid funds when states do not engage in Medicaid expansion. In addition to, these same hospitals are spending $44 billion on treating sufferer who lack health insurance.

This indicates how beneficial it is for the healthcare revenue cycle when states adopt the Medicaid expansion provisions of the Affordable Care Act. When the Supreme Court governed that Medicaid expansion was optional, several states necessarily created a gap in healthcare coverage by refusing to broaden the program.

Although, the Department of Health and Human Services (HHS) is motivating these regions to consider the significance of expanding Medicaid coverage. Hospital systems would be much less likely to pay for uninsured medical care when more sufferers have Medicaid coverage.

HHS Secretary Sylvia Burwell is emphasizing states to execute the expansion and is working to grant waivers to governors to offer more flexibility. Few major problems in the healthcare revenue cycle could finally bring states to institute Medicaid expansion, as some hospitals may end up foreclosing while others struggle with the costs of treating uninsured patients.