In his WSJ article today, Doctor Perfesser Ezekiel Emanuel (sorry, subscription required) presents a breathless,
“time is running out” advocacy for not giving up on ACO’s.
He acknowledges that
no evidence exists to show ACO’s have reduced costs substantially. He goes on to
assert that if only ACO’s will implement something he calls “bundles for hospitals”,
$50 billion would be saved over the next 10 years.
Hey, $5 billion a year is not chump change, but is that what Dr. Zeke means by “substantial”?
Will it bend down the cost curve? Will it actually prevent the recession-driven
slowdown in medical spending, from bending back up?
CDC says the level of US healthcare spending has reached roughly $2.9 trillion annually.
That means Dr. Zeke’s $5 billion annual ACO hospital-bundling savings would be worth
0.001724 of our present spending. In words, that’s seventeen one-hundredths of ONE percent.
In other words, if your family medical insurance premium is $2,500 per month, Dr. Zeke’s
solution would save you $4.31. Which won’t buy you a latte grande.
Maybe the perfesser lost track of a couple decimal places along the way. Or maybe I lost
track of them. But if not, why is Dr. Zeke so worked up that time is running out; that President
Obama is missing a historic opportunity; and that the medical cost curve will again bend
upward – – if we fail to do this ACO bundling thingy that he thinks will save all of seventeen one-hundredths
of one percent?
Showing posts sorted by relevance for query ACO. Sort by date Show all posts
Showing posts sorted by relevance for query ACO. Sort by date Show all posts
Wednesday, July 08, 2015
Monday, October 24, 2011
ACO's: Regulations Cometh
The government came out with its final regulations for ACO’s, or Accountable Care Organizations, all 696 pages of information. As a medical practice manager, my main concern is still “How do I get paid?” The original scheme was a capitation plan, similar to the HMO’s of the 1980’s. In this plan a physician receives a set amount of money to care for the patient, medical care, labs, imaging, etc. If the physician spends less than the insurance company paid him, then the doctor keeps the left-over. If the treatment plan goes over what was paid then the doctor not only is not paid for his treatment, he may owe the insurance carrier. Running the word capitation through the legislation I came across this paragraph.
Response: We would like to clarify that consistent with section 1899(d)(1)(A)of the Act, fee-for-service providers will continue to receive payments "under the original Medicare fee-for-service program under Parts A and B in the same manner as they would otherwise be made" regardless of whether they participate in the Shared Savings Program. Also, as indicated previously, we do not plan to adopt partial capitation (or other such payment methodologies) at this time, but may do so in the future through appropriate rule-making, depending on lessons learned through demonstrations.”
The reason for ACO’s is to deliver quality healthcare for fewer dollars. It is thought that if the provider is in charge of the money then he will be more judicious on how it is spent. The only problem with this mindset, and why capitation models do not work, is that human beings are not mind readers and all people have different health care needs. A set amount of money per person per year is assuming that the person will not have any life threatening injuries or illnesses. It assumes that diseases that are expensive to treat will not be diagnosed. It assumes that the worst health care issue the individual will encounter is a cold.
Fee for Service plans assumes that each medical patient is unique, that care and treatment will be based on the need of that individual and payments will be made for appropriate services rendered, regardless of cost.
The first paragraph of the 696 page document speaks to new payment methods for Medicare patients. “Value-based purchasing is a concept that links payment directly to the quality of care provided and is a strategy that can help transform the current payment system by rewarding providers for delivering high quality, efficient clinical care.” This is an unneeded process because providers are rewarded right now for delivering high quality, efficient clinical care through the legal system and malpractice suits. If a physician practices poor medicine, then he risks having a malpractice suit brought against him and in some cases, criminal charges. The legal system already has in place safeguards against poor medical practice.
The concept of an ACO is a way to enable the government control over healthcare treatment by pre-setting how much your medical care should cost. In our current system, even with heavy government control, your medical care is still your decision.
Friday, October 29, 2010
ACO's Revisited: Connecting the Dots, Part 1
And so the end-game is revealed:
■ Data Point 1:
"A new survey demonstrates that very few doctors believe that government reform plans for the health care system will improve patient care .... 500 general practitioners and 500 hospital doctors ... found that only 22% believed the health service will be able to keep improving efficiency while implementing the planned changes ... only a quarter of those polled believed that the new health care practices would make it easier to tackle public health issues."
Given the topic of this post, it would have been even more helpful to know the breakdown of how many "regular" doc's feel that way vs how many "hospital" doc's concur. Alas and alack, we'll have to make do.
■ Data Point 2:
"The health care overhaul law closes the door on future physician-owned hospitals, requiring new ones to be open and certified by Medicare by Dec. 31. Otherwise, they'll be barred from taking part in Medicare, the health program for the elderly, as well as other federal health programs ... The facilities' rivals — non-profit community hospitals and for-profit institutions without physician investors — have long pressed Congress to curb physician facilities."
Starting to see the pattern?
■ Data Point 3:
"The idea of accountable care organizations ... is starting to attract a lot of national attention. One reason for the interest is that CMS plans to start a shared-savings program involving ACOs in 2012 ... ACOs must include primary-care physicians and must coordinate care across all care settings. But they need not include a hospital."
That last is, at best, disingenuous.
Why?
I am fortunate to have a number of physician clients, one of whom was willing to discuss the issue with me at some length. Bill (not his or her real name) and I spoke for almost an hour on this subject, and he was quite candid about what he's seeing. It helps to know that he practices in a town with just one local hospital, and we discussed the implications of that, as well:
IB: What can you tell us about ACO's [Accountable Care Organizations]?
Bill: First, this is a major hot-button issue with physicians; hospitals have become quite predatory, because they're in the driver's seat. The model for this is Medicare's "capitation" system, which is in place around the country. Basically, Medicare cuts one check, to the hospital, which then "divvies it up" to the various providers involved. So the hospital keeps some for the OR, the anesthesiologist gets a cut, the surgeon gets one, etc. Right now, the hospital can pay an outside physician, but the ACO model changes that.
IB: What do you mean?
Bill: With ACO's, the hospital can only pay physicians who are credentialed and the model encourages economic credentialing [ed: more on that in a moment]. So if I have a patient who needs, say, an earectomy, and I do that at XYZ Memorial Hospital, I can't get paid for that or, if I fight it, it's a major hassle.
IB: Well, some would say that this isn't necessarily a bad idea; after all, we've been trying for a while to get global billing on the table.
Bill: There's that, but this is different. The idea behind global billing is that the patient gets one bill, and everything's disclosed. This is different, because the hospital gets a check, and it's got to disburse the money to the various doctors and other providers. And then there's a major catch called "economic credentialing" [EC]. What EC does is look for which doctor does a given procedure the cheapest. Now, there's a counter-balance to that, because outcomes are also part of that equation: if he's doing it cheap but has a lot of follow-up care because of complications and the like, that counts against him.
In Part 2 [now posted], we discuss some implications of this practice, and then finish connecting the dots.
[Hat Tip for Doc Survey: FoIB Bob D. Hat Tip for Trendspotter post: FoIB Kelley B]
■ Data Point 1:
"A new survey demonstrates that very few doctors believe that government reform plans for the health care system will improve patient care .... 500 general practitioners and 500 hospital doctors ... found that only 22% believed the health service will be able to keep improving efficiency while implementing the planned changes ... only a quarter of those polled believed that the new health care practices would make it easier to tackle public health issues."
Given the topic of this post, it would have been even more helpful to know the breakdown of how many "regular" doc's feel that way vs how many "hospital" doc's concur. Alas and alack, we'll have to make do.
■ Data Point 2:
"The health care overhaul law closes the door on future physician-owned hospitals, requiring new ones to be open and certified by Medicare by Dec. 31. Otherwise, they'll be barred from taking part in Medicare, the health program for the elderly, as well as other federal health programs ... The facilities' rivals — non-profit community hospitals and for-profit institutions without physician investors — have long pressed Congress to curb physician facilities."
Starting to see the pattern?
■ Data Point 3:
"The idea of accountable care organizations ... is starting to attract a lot of national attention. One reason for the interest is that CMS plans to start a shared-savings program involving ACOs in 2012 ... ACOs must include primary-care physicians and must coordinate care across all care settings. But they need not include a hospital."
That last is, at best, disingenuous.
Why?
I am fortunate to have a number of physician clients, one of whom was willing to discuss the issue with me at some length. Bill (not his or her real name) and I spoke for almost an hour on this subject, and he was quite candid about what he's seeing. It helps to know that he practices in a town with just one local hospital, and we discussed the implications of that, as well:
IB: What can you tell us about ACO's [Accountable Care Organizations]?
Bill: First, this is a major hot-button issue with physicians; hospitals have become quite predatory, because they're in the driver's seat. The model for this is Medicare's "capitation" system, which is in place around the country. Basically, Medicare cuts one check, to the hospital, which then "divvies it up" to the various providers involved. So the hospital keeps some for the OR, the anesthesiologist gets a cut, the surgeon gets one, etc. Right now, the hospital can pay an outside physician, but the ACO model changes that.
IB: What do you mean?
Bill: With ACO's, the hospital can only pay physicians who are credentialed and the model encourages economic credentialing [ed: more on that in a moment]. So if I have a patient who needs, say, an earectomy, and I do that at XYZ Memorial Hospital, I can't get paid for that or, if I fight it, it's a major hassle.
IB: Well, some would say that this isn't necessarily a bad idea; after all, we've been trying for a while to get global billing on the table.
Bill: There's that, but this is different. The idea behind global billing is that the patient gets one bill, and everything's disclosed. This is different, because the hospital gets a check, and it's got to disburse the money to the various doctors and other providers. And then there's a major catch called "economic credentialing" [EC]. What EC does is look for which doctor does a given procedure the cheapest. Now, there's a counter-balance to that, because outcomes are also part of that equation: if he's doing it cheap but has a lot of follow-up care because of complications and the like, that counts against him.
In Part 2 [now posted], we discuss some implications of this practice, and then finish connecting the dots.
[Hat Tip for Doc Survey: FoIB Bob D. Hat Tip for Trendspotter post: FoIB Kelley B]
Monday, November 29, 2010
The (True) Cost of Health Care
An overarching theme here at IB has been that health care costs drive health insurance costs. While this may seem obvious to us, it bears repeating.
Why, you ask?
Well, a fundamental precept of ObamaCare© is that by controlling health insurance costs, health care costs can be better controlled. This is patently and (more important) demonstrably untrue:
"What Anderson might not know, however, is how Sutter's battle for market share in her corner of suburbia is affecting her bottom line. Hospital prices in the Sacramento region are among the highest in California, driven in large part by the negotiating clout of the hospital chain Sutter Health."
The Anderson family lives in a suburb of Sacramento, California, but their plight is far from unique or geo-specific. As hospital "chains" grow, competition is reduced, and prices increase. That's basic economics, of course, but a lesson lost on many folks who continue to believe that "reforming" health insurance will have any impact on the cost of care. In fact, the opposite is true. As we've previously discussed, ACO's (Accountable Care Organizations) threaten to dramatically change how health care is delivered, and the price we pay for that delivery. Bob sent me an interesting link, from an outfit called American Medical News, which underscores just how insidious these new entities really are. Here's what they want us to see and believe:
"Accountable care organizations ... generally involve a combination of physicians and hospitals taking responsibility for a defined population, working together to improve care and cutting costs."
Can you see the problem in that very short statement? A "combination" implies a partnership of co-equals. But that's laughable on its face. In any such "relationship," the hospital (and more likely, the chain of hospitals) is going to be the Big Dog, and is going to determine how the organization behaves. The doc is simply another vendor in this equation, with precious little say-so in how (and how much) health care is delivered.
And there's this little tidbit:
"Though ACOs are primarily defined as cooperative agreements between hospitals and physicians, health plans are keenly interested in the model and need to keep on top of developments because they will be the ones to reimburse the new entities for care."
Once again, what they want you to see and what's really happening are two very different things. The primary problem is that there's still that pesky third-party (the insurer) sandwiched betwixt the provider and the patient. Let's ignore for a moment the lack of consumer participation in this equation; if consumer-centric health care is predicated on choice (and it is), then it's DOA when it comes to ACO's. That is, what choice does one have when, as in the Anderson's case, there are only one or two plans that include the biggest ACO, er, hospital chain in the area?
And then apply that to the whole country.
This is a recipe for economic disaster: less choice (competition) means higher health care prices, which means higher health insurance premiums. And, as Bob's pointed out, this is exacerbated by the looming shortage of carriers.
Talk about your death spiral.
[Hat Tip for NPR item: FoIB Holly R]
Why, you ask?
Well, a fundamental precept of ObamaCare© is that by controlling health insurance costs, health care costs can be better controlled. This is patently and (more important) demonstrably untrue:
"What Anderson might not know, however, is how Sutter's battle for market share in her corner of suburbia is affecting her bottom line. Hospital prices in the Sacramento region are among the highest in California, driven in large part by the negotiating clout of the hospital chain Sutter Health."
The Anderson family lives in a suburb of Sacramento, California, but their plight is far from unique or geo-specific. As hospital "chains" grow, competition is reduced, and prices increase. That's basic economics, of course, but a lesson lost on many folks who continue to believe that "reforming" health insurance will have any impact on the cost of care. In fact, the opposite is true. As we've previously discussed, ACO's (Accountable Care Organizations) threaten to dramatically change how health care is delivered, and the price we pay for that delivery. Bob sent me an interesting link, from an outfit called American Medical News, which underscores just how insidious these new entities really are. Here's what they want us to see and believe:
"Accountable care organizations ... generally involve a combination of physicians and hospitals taking responsibility for a defined population, working together to improve care and cutting costs."
Can you see the problem in that very short statement? A "combination" implies a partnership of co-equals. But that's laughable on its face. In any such "relationship," the hospital (and more likely, the chain of hospitals) is going to be the Big Dog, and is going to determine how the organization behaves. The doc is simply another vendor in this equation, with precious little say-so in how (and how much) health care is delivered.
And there's this little tidbit:
"Though ACOs are primarily defined as cooperative agreements between hospitals and physicians, health plans are keenly interested in the model and need to keep on top of developments because they will be the ones to reimburse the new entities for care."
Once again, what they want you to see and what's really happening are two very different things. The primary problem is that there's still that pesky third-party (the insurer) sandwiched betwixt the provider and the patient. Let's ignore for a moment the lack of consumer participation in this equation; if consumer-centric health care is predicated on choice (and it is), then it's DOA when it comes to ACO's. That is, what choice does one have when, as in the Anderson's case, there are only one or two plans that include the biggest ACO, er, hospital chain in the area?
And then apply that to the whole country.
This is a recipe for economic disaster: less choice (competition) means higher health care prices, which means higher health insurance premiums. And, as Bob's pointed out, this is exacerbated by the looming shortage of carriers.
Talk about your death spiral.
[Hat Tip for NPR item: FoIB Holly R]
Thursday, October 04, 2012
Musings: An Interview with Dr Rob
Dr Rob Lamberts, one of my very favorite med-bloggers, is making a major career change. He'll still be doctorin', of course, but in a new practice, based on a cutting-edge model of health care delivery. If you've never read any of his work, I heartily recommend that you do so.
After his residency at Indiana University in 1994, Dr Rob went into private practice with another physician (who subsequently went to Africa to do missions work). Their practice was initially owned by a hospital, but by 1996 they'd decided that it was better to leave and do "their own thing."
InsureBlog: What made you decide to chuck it all and re-boot?
Dr Lamberts: I had been frustrated as the other doctors in the practice grew more and more resistant to change. The more partners we had, the more inertia we gained. Since I am not a person to sit still when I think there are solutions to problems, I found it increasingly difficult to stay put because of others' personalities. This created conflict, which led to me looking at my options. Going solo in a practice that dealt with the insurance game and had the same limitations as the old practice was not a good solution for me, so when I found the Direct Primary Care (DPC) model it really appealed to me. In the end, my (now former) partners and I saw this as an irreparable split between us and the decision to split was mutual. They have worked it out so I don't have to draw a paycheck for up to 6 months, which gives me time to build my new practice right. They also gave me access to my patients to tell them about the new practice, which is a really generous thing on their part.
IB: You've mentioned that you may have patients that can't (or won't) follow you to your new practice, can you expand on that?
RL: The DPC model is one in which the patient pays the doctor directly for their care, usually in the form of a monthly "subscription," plus or minus a fee for visits. DPC usually limits the size of the patient pool as well, so I will only be able to take 1/3 of my total patient population even if all wanted to come (I had between 3 and 4 thousand patients in my old practice and will limit it to around 1000). Plus there is the fact that some patients are not going to be willing to pay what they see as an extra fee for care they already could get. Since nobody else in the area is doing this, the only way I can show that the value of the service will be worth the cost is to make it work. Some people will trust me in this, while others won't.
IB: I know a lot of practices are being gobbled up by hospitals eager to grow their ACO's [ed: Accountable Care Organizations]. Was this ever an option for you?
RL: Not really. If we were able to work out our differences in the old practice I would have been part of a primary care ACO that is being formed by a local IPA (group of independent primary care physicians who have allied together to do this). Primary care is quite independent in Augusta, and has recently done quite well in organizing and working together for their best interest (without risking collusion, despite what the hospitals may say). I could be part of an ACO in that setting if I wanted. In truth, however, I have grown less and less enamored with these models, as they are more driven by data and processes built around meeting care standards than they are built around good patient care.
We had been working on "Patient Centered Medical Home" in our practice, and I found that it was anything but patient-centered; it was data-centered, and took my attention away from the patients. Finally, I simply don't think the hospitals are the means to truly affect meaningful change in health care. They are the businesses that have been built on over-spending on health care, on unnecessary procedures, and on consumption of medical resources. The goal of most hospitals for my patients is 180 degrees from mine: their financial gain is built on people getting procedures, going to the ER, and being hospitalized, while mine is to help them avoid all of the above. [Continued below the fold]
After his residency at Indiana University in 1994, Dr Rob went into private practice with another physician (who subsequently went to Africa to do missions work). Their practice was initially owned by a hospital, but by 1996 they'd decided that it was better to leave and do "their own thing."
InsureBlog: What made you decide to chuck it all and re-boot?
Dr Lamberts: I had been frustrated as the other doctors in the practice grew more and more resistant to change. The more partners we had, the more inertia we gained. Since I am not a person to sit still when I think there are solutions to problems, I found it increasingly difficult to stay put because of others' personalities. This created conflict, which led to me looking at my options. Going solo in a practice that dealt with the insurance game and had the same limitations as the old practice was not a good solution for me, so when I found the Direct Primary Care (DPC) model it really appealed to me. In the end, my (now former) partners and I saw this as an irreparable split between us and the decision to split was mutual. They have worked it out so I don't have to draw a paycheck for up to 6 months, which gives me time to build my new practice right. They also gave me access to my patients to tell them about the new practice, which is a really generous thing on their part.
IB: You've mentioned that you may have patients that can't (or won't) follow you to your new practice, can you expand on that?
RL: The DPC model is one in which the patient pays the doctor directly for their care, usually in the form of a monthly "subscription," plus or minus a fee for visits. DPC usually limits the size of the patient pool as well, so I will only be able to take 1/3 of my total patient population even if all wanted to come (I had between 3 and 4 thousand patients in my old practice and will limit it to around 1000). Plus there is the fact that some patients are not going to be willing to pay what they see as an extra fee for care they already could get. Since nobody else in the area is doing this, the only way I can show that the value of the service will be worth the cost is to make it work. Some people will trust me in this, while others won't.
IB: I know a lot of practices are being gobbled up by hospitals eager to grow their ACO's [ed: Accountable Care Organizations]. Was this ever an option for you?
RL: Not really. If we were able to work out our differences in the old practice I would have been part of a primary care ACO that is being formed by a local IPA (group of independent primary care physicians who have allied together to do this). Primary care is quite independent in Augusta, and has recently done quite well in organizing and working together for their best interest (without risking collusion, despite what the hospitals may say). I could be part of an ACO in that setting if I wanted. In truth, however, I have grown less and less enamored with these models, as they are more driven by data and processes built around meeting care standards than they are built around good patient care.
We had been working on "Patient Centered Medical Home" in our practice, and I found that it was anything but patient-centered; it was data-centered, and took my attention away from the patients. Finally, I simply don't think the hospitals are the means to truly affect meaningful change in health care. They are the businesses that have been built on over-spending on health care, on unnecessary procedures, and on consumption of medical resources. The goal of most hospitals for my patients is 180 degrees from mine: their financial gain is built on people getting procedures, going to the ER, and being hospitalized, while mine is to help them avoid all of the above. [Continued below the fold]
Monday, January 10, 2011
The Benefits Package: New Year's Edition
Welcome to the first Benefits Package of the new year (and, indeed, of the new decade). We're grateful to Evan for the opportunity to be the first "non-Evan" hosts, and to this week's participants for sharing their insights and ideas.
I'm also pleased to help launch a new "niche carnival;" that is, one with a more narrowly defined focus. It seems to me that these smaller versions are less intimidating for hosts and readers alike. Certainly, it's a lot easier to edit and post a carnival with 8 or 10 (or a dozen!) entries than some of the "big boys." So if you're even remotely interested in hosting a future edition, please drop Evan a note: I guarantee you you'll find it a simple, yet rewarding, experience.
And now, on with the show:
■ David Kerrigan looks under the hood at what, exactly, drives the decision to keep or change group insurance carriers. You may be surprised at the role played by network size.
■ The Cato Institute's Michael Cannon wonders if the administration is perhaps playing fast and lose with their numbers-crunching, at least regarding how it deals with expenditures and the private sector. Great food for thought.
■ Anne Freedman combines some (scary) statistics with good old-fashioned common sense as she explores the growing problem of an aging work-force. Specifically, older workers may be playing an outsized role in keeping out "new blood." This doesn't bode well for our current unemployment situation.
■ Only David Williams could combine coupons, bullets and FuzzBusters and come up with an intriguing post on why it's bad policy for drug companies to make your co-payment for you.
■ Benefits Package founder (and uber-wonk blogger) Evan Falchuk shares some important lessons he learned from a group of Longhorn business folks. He's careful to point out that it's less prediction than recognition.
■ Another great health policy wonk, David Harlow, takes aim at Jeff Goldsmith's recent article on Accountable Care Organizations (ACO's). While acknowledging that Mr G makes some valid points, David's convinced that the basic ACO model is still salvageable.
■ Jennifer Benz and Ed Bray provide us with a handy two-minute overview of PPACA (known around these parts as ObamaCare©); just the ticket when the boss asks "what's this all about?" It's handy, brief and timely.
■ There's no question that prescription drug prices play a key role in how much we pay for health benefits. George Van Antwerp lays out the case for efficient innovation in how PBM's (Pharmacy Benefits Managers) market themselves to demonstrate the value they bring to the table.
■ Just as pharmacy benefits impact the cost of health care, so may improved utilization of Information Technology (IT). Blogging at Action for Better Healthcare, Kester Freeman reports on a new IT initiative currently underway by IBM and Premier Health Alliance that hopes to effectively address the issue.
■ As Keith McMurdy explains, pension benefits are also affected by the current economic downturn, and could lead to a "withdrawal liability" problem.
■ In our own contribution, we discuss how some employers are going mental over mandates.
And that wraps up the Benefits Package, Third Edition. Be sure to stop by Jennifer Benz's place on the 24th for the next exciting installment!
Tuesday, November 01, 2011
Grand Rounds: ACO edition
David Williams hosts this week's interesting collection of medblog posts, focusing on the timely topic of Accountable Care Organizations (ACO's).
Monday, November 22, 2010
ACO: Told ya so!
ACO's (Accountable Care Organizations) are an ObamaCare© invention purportedly designed to increase access to, and affordability of, health care. As we've seen, of course, they do neither. But why take just our word for it? Writing in the New York Times (hardly a bastion of right-wing thinking), Robert Pear notes:
"Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses."
Gee, ya think?
On the other hand, if you're Donald Berwick, this is a feature , not a bug:
"Judith A. Stein, director of the nonprofit Center for Medicare Advocacy, said she was concerned that some care organizations would try to hold down costs by “cherry-picking healthier patients and denying care when it’s needed.” [emphasis added]
And since over a quarter of Medicare beneficiaries exhibit multiple conditions, the system is ripe for rationing, not to mention financial abuse:
"Hospitals and doctors have also asked the administration to waive laws intended to prevent fraud and abuse in Medicare."
Wonder why that is.
On second though, no, I don't.
And by the way, be sure to check out Mike’s take on this, as well.
"Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses."
Gee, ya think?
On the other hand, if you're Donald Berwick, this is a feature , not a bug:
"Judith A. Stein, director of the nonprofit Center for Medicare Advocacy, said she was concerned that some care organizations would try to hold down costs by “cherry-picking healthier patients and denying care when it’s needed.” [emphasis added]
And since over a quarter of Medicare beneficiaries exhibit multiple conditions, the system is ripe for rationing, not to mention financial abuse:
"Hospitals and doctors have also asked the administration to waive laws intended to prevent fraud and abuse in Medicare."
Wonder why that is.
On second though, no, I don't.
And by the way, be sure to check out Mike’s take on this, as well.
Wednesday, February 15, 2012
United Healthcare Drinks the Kool Aid
“UnitedHealth Will Tie Doctors’ Payments to Quality of Care in U.S. Shift” was the headline I saw during my morning review of medical news. The article describes in glowing terms how United Healthcare will save money because people will be healthier.
“UnitedHealth expects to save twice as much as it would spend on incentive payments for doctors because patients will be healthier, according to company documents ... The nationwide expansion of the program follows similar efforts by the U.S. government and rival insurers to trim medical costs by shifting away from paying based on the amount of services provided.”
The age-old argument of quality over quantity. Currently, the payment system in place is quantity. Providers are paid per CPT code billed, which defines either an office visit or a procedure performed. Medical notes, referred to as SOAP(S=Subjective, O=Objective, A=Assessment, and P=Plan) notes do not mention quality of care, only that care was delivered and the plan (if any) for continued care. The current guidelines to writing a SOAP define the exam, the chief complaint, what was examined, diagnosis and treatment. In situations of a chronic condition the provider can note if the patient is getting better or worse in terms of recovery, but this does not relate to the quality of care.
The argument to move away from quantity in terms of payment is that physicians are over-worked (a physician needs to see a minimum of 28 patients a day to make enough revenue to simply maintain a business) and patients are not receiving good care. Concierge medicine attempts to deal with this issue by limiting the number of patients a physician has by charging each patient a retainer to be their personal physician. A limited number of physicians have moved to this model, but it cannot be implemented with Medicare Patients: Medicare prohibits charging a patient more than the Medicare Fee Schedule for medical treatment. So, two solutions have emerged, ACO’s and payment for quality. ACO’s are a capitation plan which failed under HMO’s and will fail again, but quality is a new concept. The theory is that if a physician knows that he/she will only be paid if their care is high quality, then the physician will take the time to truly treat the patient. As with all theories, only practical application will prove their viability, but I do have some thoughts on the theory itself based on common sense and my experience.
Thought 1: People do not always do what is in their best interests. The Darwin Awards are a testimony to this thought. In medicine the physician is only as successful as his patient. If his patient is 200 lbs overweight, smokes, and has a steak for dinner every night, there is a high probability of heart disease or stroke. The physician puts the patient on a diet, enrolls him in smoking cessation classes and gets him a life time subscription to Veggies International. The physician provided quality care. But the patient ignores the diet, blows off the classes and sic’s his dog on the nice lady from the Veggie group. He has a stroke and is admitted to the hospital. Who is to blame for this situation, the physician or the patient? Under the quality mandate it would be the physician because his treatment did not prevent the stroke.
Thought 2: Pre existing conditions or genetic time bombs. Science has demonstrated that each of us have genetic markers that can become a myriad of diseases. The federal government takes this so seriously that as an employer I cannot discriminate against someone who has had a genetic test and came back positive for some chronic and life threatening disease. Even though that disease will cause my health care insurance premiums to sky-rocket, I cannot take that into consideration when hiring an individual. What if a physician takes on a patient that is unlucky enough to get one of those chronic, expensive diseases that have death as the only outcome? Will he not be paid because his treatment could not keep his patient alive? After all isn’t that the true outcome of quality care, staying alive?
Thought 3: Who defines "quality care?" In the 1980’s the argument revolved around the best care for a child, home with a parent or in a daycare setting. It was the same argument: the stay at home parent offered quantity time, while the child in daycare received quality time from one’s parent. That argument was not resolved because we all have our own definition of quality. In terms of medical care, is the fact that you did not die during your appointment prove quality care or is it keeping the person from ever getting sick or injured or suffering any bad thing from ever happening, (remember, even bad things happen to good people)? It cannot be answered, and if it cannot be answered then a payment system cannot be linked to it.
Thought 4: If the insurance company and/or government define quality and their definition determines if the provider gets paid, will the provider ever get paid? In medicine right now providers and insurance companies are competitors; competitors for the patient’s dollars. The insurance companies are a business and it is in their best interest to keep the money. The providers did the work and thus the money is owed to them. It is getting harder for a provider to be paid for treatment rendered simply based on the objective parameter of delivering treatment. How much harder will it be to get paid with the parameter as subjective as quality?
Based on these thoughts, it is my hypothesis that payment for quality care will fail because of one simple fact: We are mortal and no amount of medical treatment will alter that reality.
“UnitedHealth expects to save twice as much as it would spend on incentive payments for doctors because patients will be healthier, according to company documents ... The nationwide expansion of the program follows similar efforts by the U.S. government and rival insurers to trim medical costs by shifting away from paying based on the amount of services provided.”
The age-old argument of quality over quantity. Currently, the payment system in place is quantity. Providers are paid per CPT code billed, which defines either an office visit or a procedure performed. Medical notes, referred to as SOAP(S=Subjective, O=Objective, A=Assessment, and P=Plan) notes do not mention quality of care, only that care was delivered and the plan (if any) for continued care. The current guidelines to writing a SOAP define the exam, the chief complaint, what was examined, diagnosis and treatment. In situations of a chronic condition the provider can note if the patient is getting better or worse in terms of recovery, but this does not relate to the quality of care.
The argument to move away from quantity in terms of payment is that physicians are over-worked (a physician needs to see a minimum of 28 patients a day to make enough revenue to simply maintain a business) and patients are not receiving good care. Concierge medicine attempts to deal with this issue by limiting the number of patients a physician has by charging each patient a retainer to be their personal physician. A limited number of physicians have moved to this model, but it cannot be implemented with Medicare Patients: Medicare prohibits charging a patient more than the Medicare Fee Schedule for medical treatment. So, two solutions have emerged, ACO’s and payment for quality. ACO’s are a capitation plan which failed under HMO’s and will fail again, but quality is a new concept. The theory is that if a physician knows that he/she will only be paid if their care is high quality, then the physician will take the time to truly treat the patient. As with all theories, only practical application will prove their viability, but I do have some thoughts on the theory itself based on common sense and my experience.
Thought 1: People do not always do what is in their best interests. The Darwin Awards are a testimony to this thought. In medicine the physician is only as successful as his patient. If his patient is 200 lbs overweight, smokes, and has a steak for dinner every night, there is a high probability of heart disease or stroke. The physician puts the patient on a diet, enrolls him in smoking cessation classes and gets him a life time subscription to Veggies International. The physician provided quality care. But the patient ignores the diet, blows off the classes and sic’s his dog on the nice lady from the Veggie group. He has a stroke and is admitted to the hospital. Who is to blame for this situation, the physician or the patient? Under the quality mandate it would be the physician because his treatment did not prevent the stroke.
Thought 2: Pre existing conditions or genetic time bombs. Science has demonstrated that each of us have genetic markers that can become a myriad of diseases. The federal government takes this so seriously that as an employer I cannot discriminate against someone who has had a genetic test and came back positive for some chronic and life threatening disease. Even though that disease will cause my health care insurance premiums to sky-rocket, I cannot take that into consideration when hiring an individual. What if a physician takes on a patient that is unlucky enough to get one of those chronic, expensive diseases that have death as the only outcome? Will he not be paid because his treatment could not keep his patient alive? After all isn’t that the true outcome of quality care, staying alive?
Thought 3: Who defines "quality care?" In the 1980’s the argument revolved around the best care for a child, home with a parent or in a daycare setting. It was the same argument: the stay at home parent offered quantity time, while the child in daycare received quality time from one’s parent. That argument was not resolved because we all have our own definition of quality. In terms of medical care, is the fact that you did not die during your appointment prove quality care or is it keeping the person from ever getting sick or injured or suffering any bad thing from ever happening, (remember, even bad things happen to good people)? It cannot be answered, and if it cannot be answered then a payment system cannot be linked to it.
Thought 4: If the insurance company and/or government define quality and their definition determines if the provider gets paid, will the provider ever get paid? In medicine right now providers and insurance companies are competitors; competitors for the patient’s dollars. The insurance companies are a business and it is in their best interest to keep the money. The providers did the work and thus the money is owed to them. It is getting harder for a provider to be paid for treatment rendered simply based on the objective parameter of delivering treatment. How much harder will it be to get paid with the parameter as subjective as quality?
Based on these thoughts, it is my hypothesis that payment for quality care will fail because of one simple fact: We are mortal and no amount of medical treatment will alter that reality.
Monday, November 01, 2010
ACO's Revisited: Connecting the Dots, Part 2 (Conclusion)
In Part 1, we posited several data points, and began our interview with "Dr Bill." Let's now wrap up that interview, and draw some conclusions:
IB: Okay, then in what way are hospitals becoming "predatory?"
Bill: Here's the catch for the hospitals: they want access to certain kinds of ancillary services, and want control those services in the community. So they look at, say, cardiologists that have EKG machines and cardiac imaging or the like, and say "well, we can lease up Dr So-and-so's practice, and make his practice a hospital outpatient department (HOPD) and increase Dr XYZ's earnings because now the hospital is billing services at hospital higher rates," part of which the hospital shares with Dr XYZ. The Hospital buys and owns the practices ancillary equipment which gets us the staff and the equipment." And then, of course, they don't really need all that staff...
IB: Okay, we get that. But how would that work from the physician's perspective?
Bill: Think of it as leasing the practice, with an option to buy. The hospital can then bill Medicare at its own, usually higher rates, and reimburse the doc at somewhat lower rates, pocketing the difference. But it's really a one-way street: the hospital gets paid more, but doesn't necessarily pay the doctor more, and the doctor has no idea what that differential is. As part of the agreement, the doctor has to disclose all his reimbursement info to the hospital, but the hospital doesn't have to reciprocate.
IB: A kind of "reverse transparency." Can you tell us a little more about the equipment issue?
Bill: The hospital leases the practice, but owns the equipment and the ancillaries. So it could be things like MRI machines, but it could also be the Durable Medical Equipment experts, the Physical Therapists, and the like. They can then pick and choose who and what they want to "keep."
IB: So it's a kind of "shell game?" How does that fit in with the Economic Credentialing?
Bill: Well, now they own (or at least control) the "structure," so they can micro-manage all they want. "Why did you keep Mrs Jones in an extra day?" or "Why did you use the expensive hip replacement unit on Mr Smith when the less expensive one would work just as well?" That last is especially onerous: yes, the cheaper unit might "work," but it's more likely to cause Mr Smith years of pain and, perhaps, a limp. But he survived and the follow-up is manageable, just prescribe some pills.
IB: So what you're saying is that the promise that "if you like your doctor" (which implies that you like the way your doctor practices) "you can keep your doctor" is under the bus?
Bill: Oh, absolutely! You may be able to see him, but maybe not. If you're on Medicare, and you need emergency surgery, for example, you're going to get the hospital-owned doc, who may or may not be your own, and you get no say in it. And the numbers are huge: your resident Medical Office Manager said Medicare patients make up 20% of her practice? Well, it's over 30% for us. So we can sell out to the hospital, or we can try to make do with a 30% cut in patients.
IB: Okay, that's a legitimate point, but yours is sort of an exception, isn't it? Most towns have multiple hospitals, so they're competing against each other. The doc's would be in the driver's seat, right?
Bill: You believe that? Tell me, how many hospitals in Dayton? Six or seven, right? But how many are owned by the same companies? They're all owned by two hospital groups. How much competition is there really?
Thanks, Bill!
So let's bring this full circle: remember those Data Points?
DP 1: Few doc's believe that ObamaCare© will improve health care, and
DP 2: There will be fewer physician-owned and/or specialty hospitals available, and
DP 3: ACO's will further consolidate available providers...
All of which, when put together, give us this:
"If Obamacare is completely implemented, doctors will no longer be practicing medicine. They will instead become the drones tasked with deciding who gets the meager healthcare crumbs doled out by the bureaucrats who have the ultimate power over patient life and death ... It spends 1.1 billion dollars to create ... the Coordinating Council on Comparative Effectiveness Research ... The council consists of 15 people appointed by the President ... A second board created by the stimulus bill called The National Coordinator for Health Information Technology “will determine treatment at the time and place of care."
Says whom? Some right-wing pundit with an axe to grind?
Nope, that would be Dr. Elaina George, a Board-certified Otolaryngologist (aka ENT doc)
That's the framework; here's the result:
"[These councils] are all isolated from day to day patient care; and therefore, are insulated from the real practice of the art of medicine."
But that, ultimately, is the goal: by removing the "human factor" from the equation, it's that much easier to commoditize the availability and delivery of health care. That is, they're there to ration care based not on the value of life but on the cost of the care. Dots connected.
IB: Okay, then in what way are hospitals becoming "predatory?"
Bill: Here's the catch for the hospitals: they want access to certain kinds of ancillary services, and want control those services in the community. So they look at, say, cardiologists that have EKG machines and cardiac imaging or the like, and say "well, we can lease up Dr So-and-so's practice, and make his practice a hospital outpatient department (HOPD) and increase Dr XYZ's earnings because now the hospital is billing services at hospital higher rates," part of which the hospital shares with Dr XYZ. The Hospital buys and owns the practices ancillary equipment which gets us the staff and the equipment." And then, of course, they don't really need all that staff...
IB: Okay, we get that. But how would that work from the physician's perspective?
Bill: Think of it as leasing the practice, with an option to buy. The hospital can then bill Medicare at its own, usually higher rates, and reimburse the doc at somewhat lower rates, pocketing the difference. But it's really a one-way street: the hospital gets paid more, but doesn't necessarily pay the doctor more, and the doctor has no idea what that differential is. As part of the agreement, the doctor has to disclose all his reimbursement info to the hospital, but the hospital doesn't have to reciprocate.
IB: A kind of "reverse transparency." Can you tell us a little more about the equipment issue?
Bill: The hospital leases the practice, but owns the equipment and the ancillaries. So it could be things like MRI machines, but it could also be the Durable Medical Equipment experts, the Physical Therapists, and the like. They can then pick and choose who and what they want to "keep."
IB: So it's a kind of "shell game?" How does that fit in with the Economic Credentialing?
Bill: Well, now they own (or at least control) the "structure," so they can micro-manage all they want. "Why did you keep Mrs Jones in an extra day?" or "Why did you use the expensive hip replacement unit on Mr Smith when the less expensive one would work just as well?" That last is especially onerous: yes, the cheaper unit might "work," but it's more likely to cause Mr Smith years of pain and, perhaps, a limp. But he survived and the follow-up is manageable, just prescribe some pills.
IB: So what you're saying is that the promise that "if you like your doctor" (which implies that you like the way your doctor practices) "you can keep your doctor" is under the bus?
Bill: Oh, absolutely! You may be able to see him, but maybe not. If you're on Medicare, and you need emergency surgery, for example, you're going to get the hospital-owned doc, who may or may not be your own, and you get no say in it. And the numbers are huge: your resident Medical Office Manager said Medicare patients make up 20% of her practice? Well, it's over 30% for us. So we can sell out to the hospital, or we can try to make do with a 30% cut in patients.
IB: Okay, that's a legitimate point, but yours is sort of an exception, isn't it? Most towns have multiple hospitals, so they're competing against each other. The doc's would be in the driver's seat, right?
Bill: You believe that? Tell me, how many hospitals in Dayton? Six or seven, right? But how many are owned by the same companies? They're all owned by two hospital groups. How much competition is there really?
Thanks, Bill!
So let's bring this full circle: remember those Data Points?
DP 1: Few doc's believe that ObamaCare© will improve health care, and
DP 2: There will be fewer physician-owned and/or specialty hospitals available, and
DP 3: ACO's will further consolidate available providers...
All of which, when put together, give us this:
"If Obamacare is completely implemented, doctors will no longer be practicing medicine. They will instead become the drones tasked with deciding who gets the meager healthcare crumbs doled out by the bureaucrats who have the ultimate power over patient life and death ... It spends 1.1 billion dollars to create ... the Coordinating Council on Comparative Effectiveness Research ... The council consists of 15 people appointed by the President ... A second board created by the stimulus bill called The National Coordinator for Health Information Technology “will determine treatment at the time and place of care."
Says whom? Some right-wing pundit with an axe to grind?
Nope, that would be Dr. Elaina George, a Board-certified Otolaryngologist (aka ENT doc)
That's the framework; here's the result:
"[These councils] are all isolated from day to day patient care; and therefore, are insulated from the real practice of the art of medicine."
But that, ultimately, is the goal: by removing the "human factor" from the equation, it's that much easier to commoditize the availability and delivery of health care. That is, they're there to ration care based not on the value of life but on the cost of the care. Dots connected.
Tuesday, April 12, 2011
Don't get sick on the MVNHS©
One of the more odious aspects of rationed care is that, just like at the deli, waiting on line until one's number is called can be tedious. Unlike the line at the deli, of course, is what's at stake while you're tapping your feet:
"The most seriously ill patients in the NHS have become the victims of “neglect” as surgeons are forced to focus on hitting waiting list targets for pre-planned operations ... while the NHS has succeeded in reducing waiting times for pre-planned operations ... this has come “at the cost of relative neglect of the needs of the patients admitted as emergencies.”
Translated, this means that the concept of "triage" is taking a back seat to expediency. When the government runs health care, it's the bean counters - not the caregivers - that set the priorities, often to the detriment to those whose very lives are at risk.
It's simple supply and demand, really: when the government promises "free" health care to everyone, then everyone wants their piece of the pie. Of course, the supply of those able to actually deliver that care is finite, and so waiting lists become the de facto order of the day. What happens if you're in dire straits but have a high number? Well, the odds are you're not going to get the best of (or perhaps any) care.
This is, of course, a direct consequence of the nature of the Brits' system, and soon to be of ours. Not to be a tease, but our Resident MOM (Medical Office Manager) will have some words on this as regards the new ACO's (Accountable Care Organizations) shortly.
Stay tuned....
"The most seriously ill patients in the NHS have become the victims of “neglect” as surgeons are forced to focus on hitting waiting list targets for pre-planned operations ... while the NHS has succeeded in reducing waiting times for pre-planned operations ... this has come “at the cost of relative neglect of the needs of the patients admitted as emergencies.”
Translated, this means that the concept of "triage" is taking a back seat to expediency. When the government runs health care, it's the bean counters - not the caregivers - that set the priorities, often to the detriment to those whose very lives are at risk.
It's simple supply and demand, really: when the government promises "free" health care to everyone, then everyone wants their piece of the pie. Of course, the supply of those able to actually deliver that care is finite, and so waiting lists become the de facto order of the day. What happens if you're in dire straits but have a high number? Well, the odds are you're not going to get the best of (or perhaps any) care.
This is, of course, a direct consequence of the nature of the Brits' system, and soon to be of ours. Not to be a tease, but our Resident MOM (Medical Office Manager) will have some words on this as regards the new ACO's (Accountable Care Organizations) shortly.
Stay tuned....
Friday, June 17, 2011
What to make of this...
Consulting firm Accenture recently published the results of their survey of physicians, which reveals a disturbing (but unsurprising) trend:
"(T)he rate of independent physicians being employed by health systems will grow by an annual five percent over three years. By 2013, less than one-third of physicians are expected to remain truly independent."
I characterized this as "unsurprising" because we've been predicting this for quite some time. For example:
"As we reported ... 40% of doctors said they would "retire, seek a nonclinical job in health care, or seek a job or business unrelated to health care ... Dr Bradley Wertheim ... finds that new physician training standards will exacerbate the problem ... We have too many patients and too few doctors."
The interesting twist in the Accenture study is that so many docs seem to be casting their lots with hospital-based practices, aka ACO's. When hospital bean-counters, not physicians themselves, are calling the health care shots (so to speak), what do you think will happen to quality of care?
"(T)he rate of independent physicians being employed by health systems will grow by an annual five percent over three years. By 2013, less than one-third of physicians are expected to remain truly independent."
I characterized this as "unsurprising" because we've been predicting this for quite some time. For example:
"As we reported ... 40% of doctors said they would "retire, seek a nonclinical job in health care, or seek a job or business unrelated to health care ... Dr Bradley Wertheim ... finds that new physician training standards will exacerbate the problem ... We have too many patients and too few doctors."
The interesting twist in the Accenture study is that so many docs seem to be casting their lots with hospital-based practices, aka ACO's. When hospital bean-counters, not physicians themselves, are calling the health care shots (so to speak), what do you think will happen to quality of care?
Friday, August 21, 2015
And the 2015 Award for Excellence in Product Positioning goes to...
Aetna for their new ACO in Southern California: Aetna Whole Health - MemorialCare.
I don't know about you, but it makes me think of funeral homes and tombstones.
(Yeah, I know, it uses Long Beach Memorial Medical Center and MemorialCare Medical Group, but honestly guys, you ever think of running focus groups?)
I don't know about you, but it makes me think of funeral homes and tombstones.
(Yeah, I know, it uses Long Beach Memorial Medical Center and MemorialCare Medical Group, but honestly guys, you ever think of running focus groups?)
Monday, December 17, 2012
Docs + Hospitals: 1,000 Words
What happens when hospitals buy up doc practices? Well, they're now called ACO's (Accountable Care Organizations), but it appears that the only "accounting" is in the increased cost of that care. FoIB Jeff M tips us that:
"Some routine cardiac tests cost more than twice as much in hospital-owned clinics as they do in independent cardiology offices."
Or to put it another way:
"Some routine cardiac tests cost more than twice as much in hospital-owned clinics as they do in independent cardiology offices."
Or to put it another way:
Monday, April 16, 2012
When is a battle not a battle
The title of the article says it all: “The Battle over Billing Codes.”
On Marketplace Tuesday (April 10, 2012), Gregory Warner did a report about one physician who has decided to use the billing codes, known as CPT’s to the maximum effect for maximum revenue. The physician states that by maximizing codes he has increased his revenue “by 70 percent -- hundreds of thousands of dollars per year” by doing the same thing he did.
The article also states that we are paying for medicine the way we have been doing it for years, by procedures. As a business professional, with over 15 years in retail and medicine, I have a question for Mr. Warner. How else are we to pay for services rendered than for the service rendered?
At the end of the segment there is a tease related to ObamaCare:
“So can we get rid of the codes? Well, some doctors and hospitals are already signing up for a new program under the health care reform law that would pay doctors by a lump sum instead of per procedure. “
The new program is the ACO initiative, which is a revised capitation HMO program. A capitation program is where the provider is paid a lump sum at the beginning of a set time frame, usually the beginning of the year, to take care of a patient. What is left at the end of the year, i.e Fee Paid less Medical Expenses = Physician Revenue, is the doc's to keep. But wait: if the care for the patient exceeds the fee paid, can the doctor go back and request more money to take care of the patient? The answer is no, because that would be fee for service. The doctor then has to take money from other patients to pay for the really sick patient or take money from his own coffers. Once the docs realized they were on the losing end in capitation, it went the way of the dinosaurs and the only docs who do capitation today are the ones straight out of med school.
Mr Warner continues:
“But other doctors don't want to give up their independence. Larry Rabon and his family have gotten used to playing the chess game. And if every doctor played as well as they do, then our deficit would really be in trouble. “
Mr. Warner refers to payment for procedure as a chess game, meaning there are winners and losers. The implication is that doctors are “winners” because they want to be paid for their services rendered, as any other service professional. Payment for services rendered is how all services are paid. We pay our hairdresser for a haircut, we pay our tarot card reader for a tarot card session, we pay for a ticket to see a movie or play, etc.
Then as a winner, he states that if all doctors understand the CPT rules and bill as Dr. Rabon does, then it will expand our deficit. I hate to tell Mr. Warner, but with people living longer, 86 is now average, and with the Baby Boomers entering Medicare in droves, that is enough to destroy the Medicare system. Dr. Rabon is not only billing Medicare, which has the strictest billing rules, but also the private insurers in order to maintain his revenue stream.
After years of berating doctors to take coding more seriously, which results in them getting paid for what they do, it is refreshing to find out that one doctor has decided his time has worth.
On Marketplace Tuesday (April 10, 2012), Gregory Warner did a report about one physician who has decided to use the billing codes, known as CPT’s to the maximum effect for maximum revenue. The physician states that by maximizing codes he has increased his revenue “by 70 percent -- hundreds of thousands of dollars per year” by doing the same thing he did.
The article also states that we are paying for medicine the way we have been doing it for years, by procedures. As a business professional, with over 15 years in retail and medicine, I have a question for Mr. Warner. How else are we to pay for services rendered than for the service rendered?
At the end of the segment there is a tease related to ObamaCare:
“So can we get rid of the codes? Well, some doctors and hospitals are already signing up for a new program under the health care reform law that would pay doctors by a lump sum instead of per procedure. “
The new program is the ACO initiative, which is a revised capitation HMO program. A capitation program is where the provider is paid a lump sum at the beginning of a set time frame, usually the beginning of the year, to take care of a patient. What is left at the end of the year, i.e Fee Paid less Medical Expenses = Physician Revenue, is the doc's to keep. But wait: if the care for the patient exceeds the fee paid, can the doctor go back and request more money to take care of the patient? The answer is no, because that would be fee for service. The doctor then has to take money from other patients to pay for the really sick patient or take money from his own coffers. Once the docs realized they were on the losing end in capitation, it went the way of the dinosaurs and the only docs who do capitation today are the ones straight out of med school.
Mr Warner continues:
“But other doctors don't want to give up their independence. Larry Rabon and his family have gotten used to playing the chess game. And if every doctor played as well as they do, then our deficit would really be in trouble. “
Mr. Warner refers to payment for procedure as a chess game, meaning there are winners and losers. The implication is that doctors are “winners” because they want to be paid for their services rendered, as any other service professional. Payment for services rendered is how all services are paid. We pay our hairdresser for a haircut, we pay our tarot card reader for a tarot card session, we pay for a ticket to see a movie or play, etc.
Then as a winner, he states that if all doctors understand the CPT rules and bill as Dr. Rabon does, then it will expand our deficit. I hate to tell Mr. Warner, but with people living longer, 86 is now average, and with the Baby Boomers entering Medicare in droves, that is enough to destroy the Medicare system. Dr. Rabon is not only billing Medicare, which has the strictest billing rules, but also the private insurers in order to maintain his revenue stream.
After years of berating doctors to take coding more seriously, which results in them getting paid for what they do, it is refreshing to find out that one doctor has decided his time has worth.
Wednesday, October 20, 2010
ACO's: Accountable Care Organizations and Keeping Your Doc
Once again, we're delighted to present our favorite Medical Office Manager Kelley Beloff. Regular readers know that she brings to the table a unique perspective, and is willing to share with us some of the "backroom dealings" of health care. This time out, she reports on the devastation that looms ahead due to ObamaCare©'s new rules on Accountable Care Organizations:
Several months ago, Hank and I had a discussion about Accountable Care Organizations. What is this concept in Obamacare? As a medical practice manager, I actively read all aspects of Obamacare and how it would affect my profession. In April I attended a Medical Management Seminar, where this policy was discussed. I asked the lawyer leading the discussion what this guideline meant for privately owned businesses. He stated that no one knew what would happen.
Now we know:
"In 2005, more than two-thirds of medical practices were doctor-owned, a share that was largely constant for many years. By next year, the share of practices owned by physicians will probably drop below 40 percent, according to data from the Medical Group Management Association. Hospitals or health plans will own the balance of doctor practices."
I work for one of those doctor-owned medical practices, and Medicare Patients currently account for approximately 20% of the practice. If our practice is not purchased by a hospital before Jan. 2012, my physicians can no longer get paid by Medicare for treating Medicare patients. As with most micro and small businesses, we operate on a tight profit margin. A loss of 20% of our revenue is enough to cause our business to fold. So we have two options: go out of business in Dec. 2011 or negotiate with a hospital to purchase our business. This creates a buyers market, so hospitals can name the price and the physician has to accept or go out of business. Physicians will be forced to accept the pay from a Hospital, or go out of business.
The government, through legislation, will cause the demise of privately owned physician practices.
Physicians are already opting out of Medicare. Opting out of being in network with Medicare. Opting out of treating Medicare patients.
Currently "Medicine" is the only business where revenue is regulated by the Federal Government. In 2012, your medical care will be regulated by the Federal Government through Hospitals.
This is short post because the article says it all.
Thanks, Kelley!
Several months ago, Hank and I had a discussion about Accountable Care Organizations. What is this concept in Obamacare? As a medical practice manager, I actively read all aspects of Obamacare and how it would affect my profession. In April I attended a Medical Management Seminar, where this policy was discussed. I asked the lawyer leading the discussion what this guideline meant for privately owned businesses. He stated that no one knew what would happen.
Now we know:
"In 2005, more than two-thirds of medical practices were doctor-owned, a share that was largely constant for many years. By next year, the share of practices owned by physicians will probably drop below 40 percent, according to data from the Medical Group Management Association. Hospitals or health plans will own the balance of doctor practices."
I work for one of those doctor-owned medical practices, and Medicare Patients currently account for approximately 20% of the practice. If our practice is not purchased by a hospital before Jan. 2012, my physicians can no longer get paid by Medicare for treating Medicare patients. As with most micro and small businesses, we operate on a tight profit margin. A loss of 20% of our revenue is enough to cause our business to fold. So we have two options: go out of business in Dec. 2011 or negotiate with a hospital to purchase our business. This creates a buyers market, so hospitals can name the price and the physician has to accept or go out of business. Physicians will be forced to accept the pay from a Hospital, or go out of business.
The government, through legislation, will cause the demise of privately owned physician practices.
Physicians are already opting out of Medicare. Opting out of being in network with Medicare. Opting out of treating Medicare patients.
Currently "Medicine" is the only business where revenue is regulated by the Federal Government. In 2012, your medical care will be regulated by the Federal Government through Hospitals.
This is short post because the article says it all.
Thanks, Kelley!
Monday, October 20, 2014
Have Faith (and Insurance)!
For the past 14 or so years, I've participated in a healing prayer group with some friends. We meet weekly and pray for the health of folks running the gamut from broken limbs to terminal illnesses. The one hard-and-fast rule we have is that the person for whom we're praying must know that we are praying for him (or her) and must have given us explicit permission to do so (there are exceptions, of course: someone in a coma is unlikely to meet those criteria for a while).
That rule is because we believe that the key to our efforts is that we are connected to and with the folks on the list. To that end, we also endeavor to get regular, timely updates from them on their progress (If any). We acknowledge that we don't know - can never "know" - whether or not our efforts have been successful, but we continue to meet week in and week out because we believe that we are making a difference in these people's lives.
Which may explain why my interest was immediately piqued by this item:
"I was parked in front of a patient’s home before my visit, running through my checklist. Patient’s diagnosis and prognosis. Any known family members or friends supporting the patient. Religious affiliation, if any. Patient’s name – you should always recheck the patient’s name. It’s good to know little about a patient’s medical concerns, but as chaplain, my concern is not what the patient’s illness is, but who the patient is. I want to address their spiritual needs and see how their spiritual health affects their overall health."
Turns out, the (anonymous) author works for an ACO (Accountable Care Organization - healthcare companies that are paid as a percentage of the money saved through their care management) called MissionPoint Health Partners. The folks in my healing prayer group were also intrigued,and urged me to connect with the firm to find out more.
So I reached out via their site's contact form, and even sent a LinkedIn invite to whom it appears is their media outreach person.
Days later: /crickets.
That's a shame, too, since this concept shows real promise, and there are some key questions that we'd like to see addressed.
For assistance: how do they deal with atheists who express an interest in this service?
And what metric do they employ to measure "success?" That is, they claim that this service reduces expenses, but how do they know this?
Oh, well, they missed an opportunity.
That rule is because we believe that the key to our efforts is that we are connected to and with the folks on the list. To that end, we also endeavor to get regular, timely updates from them on their progress (If any). We acknowledge that we don't know - can never "know" - whether or not our efforts have been successful, but we continue to meet week in and week out because we believe that we are making a difference in these people's lives.
Which may explain why my interest was immediately piqued by this item:
"I was parked in front of a patient’s home before my visit, running through my checklist. Patient’s diagnosis and prognosis. Any known family members or friends supporting the patient. Religious affiliation, if any. Patient’s name – you should always recheck the patient’s name. It’s good to know little about a patient’s medical concerns, but as chaplain, my concern is not what the patient’s illness is, but who the patient is. I want to address their spiritual needs and see how their spiritual health affects their overall health."
Turns out, the (anonymous) author works for an ACO (Accountable Care Organization - healthcare companies that are paid as a percentage of the money saved through their care management) called MissionPoint Health Partners. The folks in my healing prayer group were also intrigued,and urged me to connect with the firm to find out more.
So I reached out via their site's contact form, and even sent a LinkedIn invite to whom it appears is their media outreach person.
Days later: /crickets.
That's a shame, too, since this concept shows real promise, and there are some key questions that we'd like to see addressed.
For assistance: how do they deal with atheists who express an interest in this service?
And what metric do they employ to measure "success?" That is, they claim that this service reduces expenses, but how do they know this?
Oh, well, they missed an opportunity.
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