Forbes, January 19, 2011
With all the discussion in this country about the 1% vs the 99%, it is a good time to address a question about physician pay & how this affects health care costs.
Fierce Health Payer, January 13, 2012
Medicare Advantage plans may be indirectly cherry picking healthier seniors-
Fierce Practice Management, January 4, 2012
Both physicians and patients should use a more critical eye in determining whether certain diagnostic tests might do more harm than good.
LA Times, January 3, 2012
Despite a slow start, California's push to extend health coverage to those with preexisting
medical conditions — a three-
USA Today, December 31, 2011
Come Jan. 1, physician Carl E. Mitchell knows he will face a 1% cut in payments he gets for seeing Medicare patients.
The Washington Post, December 27, 2011
Kaiser Permanente of Colorado hopes a new incentive-
Amednews, December 26, 2011
Drug and device manufacturers would be required to disclose payments & gifts they give to physicians beginning in 2013.
Amednews, December 26, 2011
As patient visits to physicians have declined, so has their interest in finding information relating to their health.
Insurance News Net, December 20, 2011
The U.S. Senate has passed a measure that delays by two months a 27.4% payment cut from the federal government to doctors who provide medical care to seniors enrolled in the Medicare program.
Amednews, December 19, 2011
Widespread concerns about physician shortages have many states working to keep doctors trained in medical schools and residency programs there from crossing state lines to practice medicine.
HHS.gov, December 19, 2011
32 leading health care organizations from across the country will participate in a new Pioneer Accountable Care Organizations initiative made possible by the Affordable Care Act.
Fierce Practice Management, December 14, 2011
Almost universally when speaking to physicians and healthcare administrators, social media is seen from the perspective of risk & fear.
Forbes, December 13, 2011
If you want to get an understanding of how the health reform law works, both in theory and practice, it would be a good idea to take a look at the process called “rate review.”
Amednews, December 12, 2011
"Horrible results!" "The doctor misdiagnosed the case." "It was a failed surgery." When unhappy patients post these kinds of comments about physicians online.
Fierce Practice Management, December 7, 2011
As demonstrated by the more than 4,700 recent physician remarks about their relations with payers, physicians believe that insurers strive to wear them down.
Fierce Healthcare, December 5, 2011
Patient satisfaction reporting could be affected by the "nocebo effect"-
Amednews, December 5, 2011
Many physicians are familiar with accountable care organizations as a concept, but some are either opting out of them or are unsure whether they will participate, according to a recent survey.
Fierce Health Payer, December 2, 2011
Even if insurers meet the MLR threshold, they will still have to explain to consumers how their premium dollars are spent under the final MLR rule released Dec. 2 by the HHS.
CMS, December 2, 2011
Final Rule Fact Sheet.
Kaiser Health News, December 1, 2011
Accountable Care Organizations are the hot new health care trend, and there’s a new study out by Leavitt Partners trying to quantify just how hot they really are.
Fierce Practice Management, November 30, 2011
The CMS’s recently announced 90-
Amednews, November 14, 2011
As the nation heads into the year-
Fierce Health Payer, November 11, 2011
11 insurance companies operating in NY, including Aetna, UnitedHealth & WellPoint, must refund a total of $114.5 million to policyholders who were overcharged for health insurance premiums last year.
Fierce Practice Management, November 9, 2011
By investing 90 minutes per week to reaching patients via Twitter, YouTube, Google+, and three Facebook accounts, Dr. Vandna Jerath said she's been able to build her credibility and build a bond with patients before they ever step through the door to her office.
Wall Street Journal, November 7, 2011
There’s a lot of concern today that paying fees to medical providers for each service may lead to unnecessary care.
Marketwatch.com, November 7, 2011
Health care needs a total revolution so it starts promoting and paying for health instead of disease. That’s the conclusion Dr. Walter Bortz has come to after writing 150 scientific articles.
Kaiser Health News, November 6, 2011
Over the last two decades, venture capitalists helped make possible striking advances in health care, including robotic surgery, cancer vaccines and genomics.
Healthcare Finance, November 4, 2011
Healthcare costs are in a constant state of expansion yet physicians do not understand how much the care they recommend costs and they are not getting the training they should have so that they will understand those costs.
Amednews, October 31, 2011
Studies suggest recent declines reflect cost-
Amednews, October 31, 2011
The AMA has launched an online group for practices, payers & others who want to share tips, questions & success stories related to getting claims processed & paid electronically.
The Washington Post, October 28, 2011
Perhaps no part of Medicare has done as well in reining in costs as Medicare Part D, the prescription drug benefit, signed into law by President G W. Bush in 2003.
The New York Times, October 27, 2011
Monthly Medicare premiums for most beneficiaries will rise next year by $3.50, to $99.90, a much smaller increase than had been expected.
Money Magazine, October 21, 2011
For all the chatter about how politicians have to buckle down and get serious about reining in Medicare, you might have missed this development.
LA Times, October 20, 2011
While many practices struggle to convince parents that vaccinating their children is safe & necessary, new research indicates younger physicians may not be fully sold on that message.
Becker’s Hospital Review, October 20, 2011
The HHS today released its final rule for the Medicare Shared Savings Program, which involves the establishment of accountable care organizations and is set to take effect Jan. 1, 2012.
Physicians Practice, October 19 2011
First, let's define "inexpensive." According to the AMA, the average cost of an EHR, per physician is $50,000. That includes hardware, software & training, of course, but it is still a hefty investment.
Fierce Health Payer, October 18, 2011
To be successful in developing and implementing ACOs, senior leaders must buy into the collaborative care model, but they also should take a backseat & let others drive.
Becker’s Hospital Review, October 18, 2011
Physicians across all types of healthcare organizations can expect their salary increases to be around 2.5% in 2012.
Fierce Practice Management, October 17, 2011
If you've ever posed as or hired a mystery patient at your practice, you've likely gained valuable insights into how your office could provide better customer service.
Fierce Health Payer, October 17, 2011
Thanks to mandates that establish administrative cost caps on payers, the customary transaction processes between providers and payers are no longer practical.
Amednews, October 17, 2011
Among the posts analyzed by a social media reputation-
Washington Post, October 10, 2011
As far as building blocks of the health reform law go, the insurance exchanges are pretty crucial. They’re the health insurance marketplaces that every state will have in 2014, where individuals and small businesses can compare and purchase plans.
USA Today, October 10, 2011
The Kaiser Family Foundation released recently its latest estimate of what health insurance will cost in the future. By 2021, average family premiums are set to double, to more than $32,000.
Amednews, October 10, 2011
"Doctor, can you lower that bill?" How patients negotiate payments with their physicians has been the subject of numerous stories in the media.
Amed news, October 10, 2011
Attorney John Fanburg likes to say that medical partnerships are "marriages without love." He should know, as part of what keeps him busy is helping medical practices divorce as peacefully as possible.
The Fiscal Times, October 8, 2011
PCPs in America are struggling with what is & what will be: a broken health care system & the coming influx of aging baby boomers.
Chron, October 7, 2011
The federal government is taking on a crucial new role in the nation's health care, designing a basic benefits package for millions of privately insured Americans.
Iwatch, October 7, 2011
Cancer screening tests are vastly overused in the US, with about 40% of Medicare spending on common preventive screenings regarded as medically unnecessary.
Fierce Health Payer, October 7, 2011
Health insurers are no strangers to fines & other disciplinary actions. Payers this year have felt increasing pressure from state insurance departments to improve efficiency and quality or pay the price.
HHS.gov, October 6, 2011
The CMS reported today nearly 20.5 million people with Medicare reviewed their health status at a free Annual Wellness Visit or received other preventive services with no deductible or cost sharing this year.
The Washington Post, October 4, 2011
This Friday, the IOM will take a first stab at answering one of health reform’s most important unknowns: What counts as an “essential health benefit”?
Insurance News Net, October 3, 2011
Health insurers continue to lead lobbying spending in Washington, while the property/casualty
side and life insurers are investing in influencing Dodd-
Fierce Healthcare, October 3, 2011
Although some hospitals are limiting social media use among their physicians in fear of possible legal repercussions, Univ of Buffalo is encouraging its surgeons to tweet.
Amednews, October 3, 2011
Proposed changes to federal regulations would override existing laws in 20 states and give patients access to laboratory test results without having first to talk with the physicians who ordered the tests.
USA Today, October 3, 2011
Nearly 50 million people on Medicare, as well as those entering the program at a pace of one every eight seconds, are likely to get more than their money’s worth before they die.
Amednews, October 3, 2011
The cost of operating a medical practice declined an average of 2.2% in 2010, according to an annual report.
The Fiscal Times, September 27, 2011
Improper payments – to the wrong person, in the wrong amount, or for the wrong reason — cost Medicare $48 billion last year.
The California Report, September 12, 2011
Last year about one in four adults under 65 reported having medical debt, an all-
Politico, September 11, 2011
It has only met once, but the new deficit-
Kaiser Health News, September 11, 2011
Amanda Hite says she felt "really healthy" when she applied recently for health insurance. But Anthem Blue Cross and Blue Shield denied her.
Reuters, September 9, 2011
Health systems haven't figured out how best to structure financial incentives to encourage primary care doctors to do their jobs better, suggests a new paper.
The New York Times, September 7, 2011
WASHINGTON — Doctors are paid higher fees in the United States than in several other countries, and this is a major factor in the nation’s higher overall cost of health care, says a new study.
NPR, September 1, 2011
If you live in Southern California, the chances that your doctor's paycheck will be cut by a UnitedHealth Group company are on the rise.
The Wall Street Journal, September 1, 2011
Fierce Practice Management, August 31, 2011
Still not on the social media bandwagon? Think the Facebook fad will pass? If so, consider these stats recently released from Pew Research Center & reported in WSJ.
The Hill, August 29, 2011
A new medical research body created by the healthcare reform law should not consider the cost of treatments when evaluating them, the nation's largest physician lobby argues.
Fierce Healthcare, August 29, 2011
Careful not to call them mergers or acquisitions, Mayo Clinic and Cleveland Clinic separately are launching campaigns to affiliate with physician practices.
Amednews, August 29, 2011
Health plans will be required to provide consumers with a standardized, six-
Amednews, August 29, 2011
Doctors are concerned that enrollment problems could lead some in good standing to get kicked out of the program.
USA Today, August 28, 2011
One morning last month, when 12yr-
Bloomberg, August 26, 2011
U.S. policy makers wrestling with the deficit should focus on reducing the number of angioplasties & other medical procedures that don't always deliver clinical benefits.
Becker’s Hospital Review, August 22, 2011
Recruiting physicians into existing private practices is recognized as the ideal medical staff development scenario, the private practice expands its service & revenue base while adding only incremental expense.
Fierce health Payer, August 19, 2011
Hoping to increase communication between doctors and patients and better coordinate healthcare, Aetna is providing physicians with new mobile tools.
Kaiser Health News, August 18, 2011
The race among hospitals to hire local physicians is heating up, even though the consequences for the cost & quality of health care are still unclear.
Bloomberg, August 17, 2011
Health insurers will have to provide descriptive labels similar to those found on food products.
Fierce Practice Management, August 17, 2011
With very slight increases in compensation across specialties, most medical groups operated at a significant financial loss in 2010, reveals the AMGA.
The Columbian, August 17, 2011
When Helen & Rick Gill moved from Pensacola, Fla., to Clark County 4 yrs ago, one
of the tasks on their to-
Fierce Health Finance, August 16, 2011
Although Medicaid coverage is expected to be dramatically expanded in 2014 as a result of the PPACA, program, cuts enacted on the state level could hamper coverage options.
Amednews, August 15, 2011
A message to all physicians from Robert M. Wah, MD, chair of the AMA Board of Trustees.
Amednews, August 15, 2011
The largest shareholder-
The Washington Post, August 12, 2011
THE CONSTITUTIONALITY of the new health-
The Hill, August 11, 2011
HHS Secretary Sebelius highlighted the national healthcare plans that will be available
Kaiser Health News, August 11, 2011
The deal President Obama & Congress struck this week to raise the nation's debt ceiling has prompted many questions about how a special "super committee" established by law will affect federal health care programs.
Medcity, August 10, 2011
I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping /logistics, or the financial services industry...
Fierce Practice Management, August 10, 2011
Even with signs of economic recovery, patients are struggling to pay their medical bills, making it continually difficult for practices to maintain healthy bottom lines.
Kaiser Health News, August 10, 2011
Emergency department patients are getting CT scans at rates 5 times higher than in
The Hill, August 8, 2011
The Medicare agency heralded a test program Monday that it says will serve as a model for healthcare reform's ACOs.
New York Times, August 8, 2011
After 5 years of testing the idea, Medicare officials said they believe that doctors who coordinate care & keep their patients out of the hospital can help reduce the nation’s health care costs.
Amednews, August 8, 2011
Scenario: How should professionals respond to physician-
Fierce Healthcare, August 5, 2011
New coordinated care models, like ACOs, are being touted as ways to eliminate unnecessary tests & procedures & improve care.
Kaiser Health News, August 4, 2011
One key to reducing medical costs is collaboration among insurers, their members, providers & their patients within ACOs because everyone is focused on providing the best healthcare at the lowest costs.
Los Angeles Times, August 3, 2011
Washington policymakers demanded more savings from hospitals, doctors & other medical providers in the deal President Obama signed, a move designed to protect seniors & others who rely on Medicare.
Fierce Practice Management, August 3, 2011
If there's ever been a time to right size your office staff, it's now, practice management expert Elizabeth Woodcock recently wrote in ModernMedicine.
Bloomberg, August 3, 2011
A U.S. appeals court rejected a bid by group of NJ doctors to reinstate their lawsuit
challenging federal health-
Physician News, August 1, 2011
With economic pressures on physicians mounting & regulatory incentives to affiliate with larger entities expanding, an increasing number of physicians are becoming employees of larger medical groups/health care systems.
Amednews, August 1, 2011
When schools send kids home with their report cards, it's not only so parents can keep tabs on their children's education. It's also so the students who are not making the grade can see the areas where they need to improve.
Amednews, August 1, 2011
A small but enthusiastic minority of primary care physicians believe they have found
a practice model that can save money, improve patients' long-
New York Times, August 1, 2011
WASHINGTON — The Obama administration issued new standards on Monday that require
health insurance plans to cover all government-
Information Week, July 29, 2011
Clinical informatics could soon become a recognized, board-
Kaiser Health News, July 29, 2011
KHN’s "Insuring Your Health" columnist Michelle Andrews talks with Jackie Judd about
convenient ways consumers are getting health care: House calls, workplace clinics
Amednews, July 25, 2011
The biggest challenge to forming an accountable care organization is physician alignment, according to one survey.
Kaiser Health News, July 25, 2011
Long before the sweeping health law was even a notion on Capitol Hill, HMOs were a force in American medicine.
Amednews, July 25, 2011
The Medicare program is taking a more direct approach to determining whether physicians are willing to take on new Medicare patients.
Amednews, July 25, 2011
Dr. Maria Angelica Montenegro practiced more than 5 years as a family physician in Colombia before moving to the US in 2004.
San Francisco Chronicle, July 25, 2011
The cost of prescription medicines used by millions of people every day is about to plummet.
Bloomberg, July 25 2011
One of the first prongs of President Obama's health care law has been in effect for a year, the result in Missouri is that about 500 additional people with chronic health problems now have insurance.
New York Times, July 25, 2011
One of the nation's largest providers of kidney dialysis deliberately wasted medicine
in order to reap hundreds of millions of dollars in extra payments from Medicare,
a former clinic nurse & doctor are charging in a whistle-
Forbes, July 21, 2011
Earlier this month, Mike Cannon published an important, must-
The Washington Post, July 20, 2011
A budding model for primary care that encourages the family doctor to act as a health coach who focuses as much on preventing illness as on treating it has shown promising results and saved insurers millions of dollars.
New York Times, July 20, 2011
In an encouraging development for women’s health, an advisory panel of leading experts has recommended all insurers be required to offer contraceptives as well as other preventive services free of charge under the new health care law.
Fierce Practice Management, July 20, 2011
New studies by SSI & TRiG show two-
NPR, July 20, 2011
The group that advises the U.S. government on vaccination thinks some new vaccines may not be worth the cost.
Health Affairs, July 19, 2011
Most medical malpractice claims are neither settled nor adjudicated. They are abandoned by the plaintiffs who bring them.
Health Affairs, July 19, 2011
The exchange and the reinsurance, risk adjustment, and risk corridor (3R) proposed
regulations released by HHS July 11 were only the first two in a series of exchange-
Amednews, July 18, 2011
As physicians try to stop an across-
PC World, July 18, 2011
A new federally mandated medical coding system designed to better track diagnoses and treatments is requiring a massive overhaul of healthcare IT systems that some say will be nearly impossible to complete on time.
Reuters, July 15, 2011
In a study that flies in the face of common sense, sicker patients turned out to fare worse under the care of seasoned doctors than when newcomers to medicine looked after them.
Med Page Today, July 15, 2011
Physician offices need to up their game to meet basic infection control standards, according to the CDC.
Bloomberg, July 13, 2011
Kaiser Health News, July 13, 2011
Just as airline pilots are required to use safety checklists before taking off, so should medical facilities who are treating people on an outpatient basis, said the Centers for Disease Control and Prevention.
The Washington Post, July 11, 2011
Three words to watch out for next time you get a new prescription: “Dispense as Written.” Scrawled across the prescription form in your doctor’s hand, or, more likely, ticked off on a check box.
Health Resources Publishing, July 11, 2011
Insurance plans encouraging patients to receive care from physicians who keep medical costs lower are based on unreliable information, according to a new RAND. Study.
Kaiser Health News, July 11, 2011
Federal regulators released proposed rules that will govern how states set up and run new marketplaces where individuals and small businesses can shop for health insurance.
New York Times, July 10, 2011
A new admission process at medical schools involves a series of encounters meant to examine aspiring doctors' ability to communicate and work in teams.
Fierce Health Payer, July 8, 2011
Hoping to encourage enrollment in high-
Healthcare It News, July 7, 2011
There is no one, and I do mean no one, in your medical practice who does not need to know the basics of coding. Here is why: Providing services to patients is the business of healthcare.
Kaiser Health News, July 7, 2011
In Dr. Sandra Berglund’s well-
Salon, July 6, 2011
With 60% of all bankruptcies related to medical costs; with many of those medical-
Fierce Practice Management, July 6, 2011
For the fourth year, medical practice professionals sounded off to the Medical Group Management Association about their biggest daily professional challenges.
Amednews, July 4, 2011
Barbara McAneny, MD, says insurers' inability to consistently pay claims correctly
is costing her practice a lot of money -
The Hill, July 1, 2011
The CMS on Friday unveiled its proposed payment rates for physicians, outpatient hospitals and dialysis facilities in 2012.
Fierce Practice Management, July 1, 2011
CMS issued a proposed rule that would update payment policies & rates for physicians & non physician practitioners (NPPs) for services paid under the Medicare Physician Fee Schedule.
The Washington Post, July 1, 2011
United health services wing is quietly gaining control of doctors who treat patients covered by United plans — buying medical groups and launching physician management companies.
USA Today, July 1, 2011
Patients pay as much as 683% more for the same medical procedures, such as MRIs or CT scans, in the same town, depending on which doctor they choose, according to a new study by a national health care group.
New York Times, June 30, 2011
Not long ago, the receptionist on the hospital floor where I work went on a family leave. Calm & with a wisecracking wit she attributes to her NJ roots, she worked at the hospital for years and knew better than anyone how to make things happen in the system.
Fierce Health Payer, June 30, 2011
BSCA and the hospitals and physicians it partners with say their arrangement, which has successfully kept premiums flat, could be an example for federal officials and other healthcare businesses looking to create ACOs.
Kaiser Health News, June 30, 2011
In one year, infection specialists saved a Midwest hospital system $110,000 and 2,700 staff hours, by using duct tape.
HSS, June 29, 2011
HHS announces new draft standards to improve the monitoring of health data by race, ethnicity, sex, primary language, and disability status.
New York Times, June 28, 2011
The Obama administration said Tuesday that it had shelved plans for a survey in which “mystery shoppers” posing as patients would call doctors’ offices to see how difficult it was to get appointments.
RWJF, June 28, 2011
The Robert Wood Johnson Foundation launched the nation’s most comprehensive online directory for patients to find reliable information on the quality of health care provided by physicians and hospitals in their communities.
NPR, June 27, 2011
There's a lot of chatter about how public policy can influence doctors' decisions about which new patients to see & which to turn away.
Amednews, June 27, 2011
The NQF in June proposed an updated version of its list of serious reportable events, such as medication errors that kill or gravely injure patients.
Amednews, June 27, 2011
Certain physicians who interpret the results of diagnostic imaging procedures should undergo fee reductions, & physicians who order far more imaging than their colleagues should be subject to prior authorization requirements, according to MedPAC recommendations in its June report to Congress.
L.A. Times, June 27, 2011
Concierge medicine — you may have heard of it — is gaining in popularity. Patients
pay a monthly fee directly to the doctor, on top of their regular health insurance
premiums and co-
Politico, June 23, 2011
Electronic health records are at the center of some of the key reforms of the ACA, because having reliable data to track patients, trends & possible fraud is one of the ways reformers think they will eventually be able to bend the cost curve.
Fierce Practice Management, June 22, 2011
For practices that want to furnish their offices with state-
Fierce Practice Management, June 22, 2011
From longevity to 24/7 physician access, the promises from a growing crop of concierge
Seeking Alpha, June 20, 2011
MOVING THE MARKET: Recent unrest in the Middle East and higher oil prices have overtaken much of the financial media attention since the beginning of 2011 and masked what could become the Achilles' Heel of the U.S. Economy.
Wall Street Journal, June 19, 2011
Consumers know they will have to pay out of their pockets if they use medical providers
outside their insurers' networks. Because of a little-
Minnesota Public Radio, June 17, 2011
As part of the federal government's push to get hospitals & clinics to adopt electronic medical records, it's subsidizing IT training classes across the country.
Minyanville, June 16, 2011
The government can't get cost control without goring the oxes of patients, physicians, pharmaceutical companies, insurers, device manufacturers and hospitals.
InsuranceNewsNet, June 16, 2011
Americans are covered by Health Savings Account (HSA)-
U.S.News, June 14, 2011
Your chances of suffering harm because of a medical error are about the same in a doctor's office as in a hospital, according to a new study.
USA Today, June 14, 2011
A combination of giving patients more information about their conditions & better managing their medications can slow the revolving door of Medicare patients in and out of hospitals by about 20%, a study shoms, released by Harvard University.
The New York Times, June 12, 2011
I've already written about Joe Lieberman’s very bad, no good idea of raising the Medicare eligibility age.
Kaiser Health News, June 13, 2011
The Obama administration’s bid to slash funding for training pediatricians at children’s hospitals is provoking intense protests from medical educators and lawmakers on both sides of the aisle.
The Record, June 13, 2011
While Hackensack UMC forges ahead with an application to reopen Pascack Valley Hospital, its opponents say a medical mall with OP care would better serve a region they believe already has too many hospital beds
The New York Times, June 12, 2011
In Justice Douglas E. McKeon’s fluorescent-
Forbes, June 10, 2011
Earlier this week, I wrote about the new McKinsey study, which found 30% of employers
are likely to drop employer-
FierceHealthPayer, June 10, 2011
In an attempt to better compete within the senior healthcare market, WellPoint is purchasing Medicare specialist CareMore Health Group for $800 million.
Fierce Practice Management, June 8, 2011
The public comment period for the CMS proposed rule regarding ACOs closed June 6, and major organizations that represent physicians made sure to contribute their thoughts.
The Hill, June 7, 2011
States and territories are eligible for up to $40 million to strengthen and coordinate efforts to prevent chronic disease, the Health and Human Services Department announced Tuesday.
The Lund Report, June 7 2011
A bill that sets in motion the creation of a health insurance exchange in Oregon passed the House of Representatives today with 48 votes in favor & 12 opposed.
The Washington Post, June 6, 2011
Everyone in Washington claims to want the same thing lately: a “serious conversation”
Insurance News Net, June 2, 2011
Young adults ages 19-
Becker’s Hospital Review, June 1, 2011
Three healthcare experts weighed in on accountable care organizations during a recent panel session at the Becker's Hospital Review Annual Meeting.
Managed Care Information Center, June 1, 2011
Empire BCBS, the largest insurer in NY, is unveiling a P4P program to reward doctors who comply with certain best practices. It won’t penalize those who fall short. Empire plans to use claims data to better monitor whether physicians are complying with widely accepted medical best practices.
Kaiser Health News, June 1, 2011
Medicare pays more to doctors and hospitals in expensive parts of the country. A prestigious panel says Medicare’s methods of evaluating regional costs are disturbingly imprecise & need to be overhauled.
Time, May 31, 2011
"Remember the 1990s" retrospective lists always include Nirvana, Monica Lewinsky and Wayne's World, but leave out another major product that defined American life in the '90s: the health maintenance organization, or HMO
Medical News Today, May 27, 2011
Physician compensation accounts for roughly 8% of the total annual healthcare costs
in the U.S., according to Jackson Healthcare, an Atlanta-
Bloomberg, May 26, 2011
The U.S. government paid more than $158.3 million to hospitals & doctors this year to encourage adoption of electronic health records.
Fierce Practice Management, Mat 25, 2011
Of course, the ideal medical office waiting room is one in which patients spend very
little time. given the reality that patients' experience in your reception area goes
a long way toward their impressions about your practice, consider the following ideas
to make it more patient-
Managed Care Information Center, May 24, 2011
The Clinical Documentation Industry Association (CDIA) announced the launch of a new industry trade association dedicated to ensuring the accuracy, consistency and security of clinical documentation contained within all patient health records.
Managed Care Information Center, May 24, 2011
The Integrated Healthcare Association (IHA) has been awarded an 18-
Kaiser Health News, May 24, 2011
"That's where the money is," Willie Sutton famously quipped when asked why he robbed banks. There's a similar rationale for employers who hope to improve employee health and contain costs with workplace health clinics: That's where the people are.
Managed Care Information Center, May 24, 2011
The Clinical Documentation Industry Association (CDIA) announced the launch of a new industry trade association dedicated to ensuring the accuracy, consistency and security of clinical documentation contained within all patient health records.
American College of Emergency Physicians, May 23, 2011
Nearly half (44%) of almost 1,800 emergency physicians responding to a poll report that the biggest challenge to cutting costs in the emergency department is the fear of lawsuits.
Forbes, May 23, 2011
Recent data provided by the nation’s largest health insurance companies reveals that a provision of the ACA – or Obamacare – is bringing big numbers of the uninsured into the health care insurance system. And they are precisely the uninsured that we want– the young people who tend not to get sick.
Amednews, May 23, 2011
NY physicians may have to take off their neckties, jewelry, wristwatches & long-
Amednews, May 23, 2011
Preventive care, a long list of services including mammograms, childhood vaccines
& tobacco cessation counseling, for patients covered by private insurance is, in
most cases, supposed to be covered without co-
LA Times, May 19, 2011
Smart phones have already supplemented the doctor’s office & personal computers as
sources of health advice, now it appears car companies are driving into the on-
NJ.com, May 18, 2011
Horizon BCBSNJ officially called off its plan to become a for-
Wall Street Journal, May 17, 2011
Making physicians aware of the costs of blood tests can lower a hospital's daily bill for those tests by as much 27%, a new study suggests.
IhealthBeat, May 17, 2011
It's no secret that small physician practices are less likely than larger practices and hospitals to adopt and use electronic health record systems. The federal government's meaningful use incentive program aims to drive widespread EHR adoption. But, small practices are lagging behind.
Becker’s Hospital Review, May16, 2011
The current estimated start-
Amednews, May 16, 2011
Before dawn, nearly every morning in the days leading to his trial, Stephen Lutz, MD, woke abruptly, his mind filled with thoughts of the looming witness stand.
Kaiser Health News, May 10, 2011
Nobody likes taking time out of a busy day to cool their heels in a doctor's waiting
room. Now you may not have to. Some primary-
Stanford School of Medicine, May 9, 2011
For all the technological advances that enable today’s physicians to get a better view of what’s going on inside their patients, many neglect one key source of insight, direct & engaged conversation.
Reuters, May 9, 2011
While doctors believe industry funding may bias their continuing medical education, they are unwilling to pay for impartial information, a new survey finds.
Kaiser Health News, May 9, 2011
In a move that could absolve health insurers of paying more than $95 million in consumer rebates, nine states are pressing for relief from a federal rule limiting insurers’ profits and administrative costs.
Amednews, May 9, 2011
Increasing patient capacity for PCPs already seeing a large number of Medicaid patients might be the best way to prepare for the millions of people who will become eligible for the program in 2014 under the health system reform law.
Amednews, May 9, 2011
Amednews, May 9, 2011
Doctors & other health professionals are disheartened with what they've found out about themselves on Medicare's Physician Compare web site.
Kaiser Health News, May 8, 2011
It sounds like a new Apple product, but IPAB is actually a controversial board at the heart of a highly charged battle over Medicare, the federal health program for the elderly and disabled.
Beckers Hospital Review, May 6, 2011
When it comes to compliance and liability, the safety of your physical office space is probably the last thing that comes to mind.
Beckers Hospital Review, May 4, 2011
At the end of March, the FTC and the DOJ released a proposed antitrust policy statement for ACOs. While the guidance is directed toward ACOs that participate in the Medicare Shared Savings Program, it also addresses antitrust issues for these ACOs' dealings with commercial insurers.
Fierce Practice Management, May 4, 2011
Today's physicians will ultimately have to embrace new technologies in order to keep making their livings as doctors.
Kaiser Health News, May 4, 2011
Every few months, James S. Miller, a 68-
Kaiser Health News, May 3, 2011
Hundreds of thousands of young adults are taking advantage of the health care law provision that allows people under 26 to remain on their parents' health plans, some of the nation's largest insurers are reporting.
Physician’s Money Digest, May 2, 2011
Retailers, hotel chains & financial-
The Boston Globe, May 2, 2011
Time, May 2, 2011
Recently the University of Wisconsin and the RWJF released its second annual County
Health Rankings, a within-
AmedNews, May 2, 2011
The Medicare program paid a record $234 million in quality reporting bonuses to doctors in 2009, but participation in the Physician Quality Reporting System continued to falter as a large segment of eligible professionals either failed to meet minimum requirements or did not bother with the initiative.
USA Today, April 30, 2011
Fed up with the unpredictable cost of health insurance for his small business, Mike Sarafolean last year made a dramatic change: Instead of picking a plan to offer workers, he now sends them to a "private exchange" or marketplace where they compare & choose their own insurance.
Bloomberg, April 27, 2011
Aetna and Wellpoint continued the trend of health insurers reporting better-
Beckers Hospital Review, April 26, 2011
A merger may cause organizations to lose their marketplace standing. An important question to ask during a merger is this: If Hospital A is merging with Hospital B, what is Hospital C doing during this time?
Becker’s Hospital Review, April 21, 2011
It takes twice as long to recruit a physician today than it did just a decade ago, due to a growing shortage that is expected to worsen as demand for physicians grows & supply remains flat.
Insurance News Net, April 19, 2011
Amednews, April 25, 2011
On Jan. 1, 2012, if physicians' practice management systems are not up to new standards, they will risk not getting electronic payments from private insurers and Medicare.
Amednews, April 20, 2011
Flush with cash, America's largest publicly traded health plans are ready to accelerate their pace of mergers and acquisitions. However, they're not necessarily looking to buy other insurers.
MarketWatch, April 21, 2011
If you feel like the more health-
The Boston Globe, April 17, 2011
Concierge medicine is expanding as more doctors and patients, tire of assembly-
Kansas Health Institute, April 15, 2011
Medical providers, especially those in rural and small offices, who are shopping for an electronic health record vendor should consider the issue of data portability before making a decision.
Amednews, April 14, 2011
In the first quarter of 2011, physician practices added jobs at a rate more than 3 times higher than in Q1 of the previous year.
HSS.gov, April 14, 2011
The U.S. DHHS announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families.
Beckers Hospital Review, April 12, 2011
As hospitals and large multispecialty group practices gear up for ACOs, procedure-
Beckers Hospital Review, April 7, 2011
CMS recently released the long-
Bloomberg, April 4, 2011
Medicare payments to U.S. health insurers led by UnitedHealth and Humana will increase
0.4% in 2012, less than projected because of lower-
NY Times, April 6, 2011
The ideal of computerizing patient records is captured in the words behind the government’s aspirational acronym, N.H.I.N., for Nationwide Health Information Network.
Kaiser Health News, April 6, 2011
Much has been made of the health insurance exchanges in Utah and Massachusetts, for many observers they sit on opposite points of a continuum of what exchanges can & should provide for consumers and small businesses.
Common Health, April 1, 2011
A story of a patient who tried to be a smart health care shopper. But the system wouldn’t let him. The patient, Matt S., works in the health care industry & is pretty savvy.
Amednews, April 4, 2011
A Senate bill aimed at curtailing Medicare fraud would publish physician billing data online, letting viewers determine how much individual doctors earn annually from the program. The release of the data has been prohibited by a court ruling for more than 30 years.
NY Times, April 1, 2011
Health Resource Publishing, April 4, 2011
The Illinois Dept of Healthcare and Family Services (HFS) paid approx $5 million in incentives to physicians who treated patients enrolled in the state’s Health Connect program – a primary care case management program administered by HFS.
Kaiser Health News, March 31, 2011
Doctors and hospitals that join together under a new model of care could pocket as much as 60 percent of the money they save Medicare but could also face hefty penalties if they fall short under rules proposed by the Obama administration.
Kaiser Health News, March 30, 2011
Conservatives think traditional health insurance provides too much financial protection from medical expenses. They also think that the Affordable Care Act will make this situation worse. That's one reason they want to repeal it.
Amednews, March 29, 2011
As several states consider whether, or how, to restrict balance billing by out-
LA Times, March 29, 2011
Although this year's Match Day placed more physicians in primary care residencies than last year (which itself was an improvement on 2009), the American Association of Medical Colleges estimates that the US could still face a shortage of 45,000 primary care physicians by the end of the decade.
Kaiser Health News, March 30, 2011
It seems like a simple idea: create new marketplaces, called "exchanges," where consumers
can comparison shop for health insurance, sort of like shopping online for a hotel
room or airline ticket. But, like almost everything else connected with the health
overhaul law, state-
Fierce Health Payer, March 25, 2011
It just seems like common sense that when you ask someone to reduce their spending, you shouldn't be seen throwing around your own money as if it grows on trees. This, unfortunately, doesn't seem to be a lesson that health insurers have learned.
The Wall Street Journal, March 28, 2011
The 2010 health-
Insurance News Net, March 23, 2011
Enrollment in Medicare Advantage plans is projected to plunge more than 25.6% over the next decade as a result of changes in the ACA, according to a nonpartisan Congressional Budget Office study.
The Wall Street Journal, March 26, 2011
The U.S. Justice Department is widening a probe of BCBS health insurance plans in
several states, examining whether they are effectively raising health-
Health Resource Publishing, March 28, 2011
Rethinking the approach to performance measurement in ambulatory care may be necessary for Medicare if the US is to reverse the high & rising costs of healthcare, even as evidence grows that quality is lagging.
The Boston Globe, March 25, 2011
Some people in these plans indeed spent significantly less on their medical care, compared with families with more traditional coverage, but they also cut back on preventive health care, such as cancer screenings and childhood vaccinations.
The Dayton Business Journal, March 20, 2011
Interacting with friends, posting photos and updating status changes are common practices on Facebook. But now more users are relying on the social networking site for health information.
Health Leaders Media, March 22, 2011
The DHHS on Monday unveiled a 3-
Amednews, March 21, 2011
Medical associations are warning that overly strict meaningful use criteria proposed by the DHHS for the next phase of the Medicare and Medicaid electronic medical records incentive program could dissuade physicians from participating.
Amednews, March 21, 2011
Lawmakers should increase Medicare payment rates to physicians & prevent a massive
Fierce Health IT, March 10, 2011
Four medical societies have released a new set of guidelines for organizations accrediting
Kaiser Health News, March 15, 2011
Some House and Senate Republicans have said they will vote against a three-
Insurance News Net, March 3, 2011
The U.S. DHHS provided an update on implementation of the Early Retiree Reinsurance Program in health reform. As of the end of 2010, more than 5,000 employers received more than $535 million in health benefit reimbursements.
The Boston Globe, March 2, 2011
Cleve L. Killingsworth, who abruptly resigned last March as chief executive of the nonprofit Blue Cross Blue Shield of Massachusetts, collected $8.6 million in compensation from the state’s largest health insurer in 2010.
Fierce Health Payer, March 4, 2011
An increasingly popular way to control rising healthcare costs has become so-
Kaiser Health News, March 8, 2011
Some regions of the country that have been lambasted for high levels of Medicare spending actually are below the national average once the severity of patient sickness and special local expenses are taken into account, according to data from a new government analysis.
Fierce Health Care, March 8, 2011
Much of the debate over the Medicare shared savings program and their contracting ACOs has focused on the forms of provider risk sharing, patient attribution methodologies and whether beneficiary consent should be obtained.
AMA, March 7, 2011
A federal appeals court issued a decision that further validates the AMA's long-
The Wall Street Journal, March 10, 2011
Across the country, cash-
The Connecticut Mirror, March 7, 2011
Physician Compare might not seem like the kind of tool that would spark a divisive policy debate. It's a website, recently launched by Medicare officials & allows patients to find a cardiologist, a pediatrician, or other Medicare provider in their zip code.
Kaiser Health News, March 8, 2011
Under the current insurance model, doctors get paid for procedures and tests rather than for time spent with patients, which makes doctors and patients alike unhappy and increases costs.
Connected World Mag., February 28, 2011
The concept of telehealth has made sense to the M2M world for a while, recent movements by some major manufacturers are helping push the connected concept into mainstream reality. GE and Intel’s recent “Care Innovation” venture was one of the first notable advancements.
CMS, March 7 ,2011
The CMS published proposed consumer disclosure notices, required by the Affordable Care Act, that insurers would be required to complete and report electronically when they propose rate increases over 10%.
Insurance News Net, March 2, 2011
73% of Americans surveyed would use a secure online communication solution to make it easier to get lab results, request appointments, pay medical bills & communicate with their doctor’s office.
Insurance News Net, March 3, 2011
The U.S. DHHS provided an update on implementation of the Early Retiree Reinsurance Program in health reform. As of the end of 2010, more than 5,000 employers received more than $535 million in health benefit reimbursements.
Boston.com, March 2, 2011
Cleve L. Killingsworth, who abruptly resigned last March as chief executive of the nonprofit Blue Cross Blue Shield of Massachusetts, collected $8.6 million in compensation from the state’s largest health insurer in 2010.
Fierce Health Payer, March 4, 2011
An increasingly popular way to control rising healthcare costs has become so-
Bloomberg, March 3, 2011
Thomas Rosch, a Republican member of the FTC, urged the Obama administration to clarify
a centerpiece of the new health-
Kaiser Health News, February 25, 2011
Implementation With the nation’s governors about to descend on Washington for their
winter meeting, the HHS today continued its campaign to calm concerns that the health
law is too expensive & complex for cash-
The Hill, February 24, 2011
About one in five Americans believe, inaccurately, that last year’s sweeping healthcare reform law was wiped out when House Republicans voted to repeal it in January, according to a new poll.
Health Resources Online, February 22, 2011
In today’s austere economy, American workers’ attention is focused on spending less
& saving more, according to recent research from the Principal Financial Well-
USA Today, February 21, 2011
Two years after Holly Hawthorne was severely brain damaged when her motorcycle was hit by a bus in India, she passed a huge milestone in January: She moved out of a nursing home here and into the house where she grew up. Her mother, Diane Allison, credits Hawthorne's managed care health plan for making the move possible.
Amednews, February 21, 2011
Profits at the nation's seven largest publicly traded insurers went up in 2010 as
plans spent less on care and used income to buy back their stock to boost per-
Amednews, February 21, 2011
President Obama's fiscal 2012 budget proposal would freeze current Medicare pay rates for physicians until 2014, spreading the $54 billion cost of the freeze over a decade in part by squeezing savings from drug manufacturers and states.
Amednews, February 21, 2011
Physicians who fail to tackle quality improvement, adopt electronic medical records and embrace teamwork risk being at a competitive disadvantage with doctors who join the modern era of health care, federal officials warned physicians at the AMA National Advocacy Conference in Washington, D.C.
Usnews.com, February 17, 2011
Some doctors post unethical and unprofessional content on Twitter, a finding that suggests the need for more oversight of physicians' use of social media, according to a recent study.
Health Leaders, February 18, 2011
The average per capita cost of healthcare services covered by commercial health plans and Medicare programs rose 6.06% in 2010, matching the lowest growth rates in four years, and continuing seven consecutive months of cost growth deceleration, according to the Standard & Poor's Healthcare Economic Indices.
Amdenews, February 21, 2011
When health insurance companies want to renew or set new contracts with Pikes Peak
Urology in Colorado Springs, Colo., they simply don't dictate a fee schedule & send
it over for a physician's signature. Urologist Jeff Moody, MD, who works at the four-
Becker’s Hospital Review, February 15, 2011
In 2002, Oak Brook, Ill.-
Kaiser Health News, February 18, 2011
A few months ago, Gov. Perry led a group of Texas lawmakers threatening to drop out
of Medicaid, the state-
Wall Street Journal, February 18, 2011
The Justice Department on Thursday asked a federal judge to clarify the immediate
impact of his ruling last month that declared the new health-
Managed Care Information Center, February 15, 2011
The salary gap between primary care & specialty physicians is beginning to close. That’s the conclusion of a study by the Detroit office of Sullivan, Cotter and Associates Inc.
HealthLeaders Media, February 9, 2011
The admission of making a mistake resulting in damage to patient trust & threat of litigation is a weight on the minds of all physicians. Failing to address the values of error, near miss & unsafe condition reporting with residents is detrimental to both the institution and the trainee.
Amednews, February 14, 2011
Physicians who are outside big insurers' networks in several states can expect health plans to pay even less of the cost of their services as Medicare rates replace fee schedules based on "usual, customary & reasonable" rates, doctors organizations say.
Beckers Hospital Review, February 11, 2011
Letters from an influential Republican member of the FTC to the White House and CMS suggest a struggle between the FTC and DOJ to compromise on antitrust issues surrounding ACOs, according to the New York Times.
Kaiser Health News, February 11, 2011
The widely unpopular "doughnut hole", the coverage gap in the Medicare drug benefit
is headed for oblivion, under the new health law. Beginning this year, seniors who
hit the doughnut hole will get substantial discounts on both brand-
Hartford Business, February 7, 2011
UnitedHealthcare must pay more than $1 million in back wages and penalties for failing to pay overtime to 479 Hartford employees, authorities said.
Bloomberg, February 9, 2011
Initial 2012 reimbursement rates for Medicare Advantage plans should be roughly flat, which tops the consensus expectation of a 2% drop, according to Citi analyst Carl McDonald said Tuesday in a research note.
MCIC, February 9, 2011
Large multispecialty groups and organized healthcare delivery systems deliver higher quality care at a lower cost than other providers in their market regions.
Fierce Practice Management, February 9, 2011
Another reason to look forward to spring, if you're a PCP. Those who qualify for primary care incentive payments under the new health law should expect to see their first bonus checks arrive in their offices sometime after March 31.
Kaiser Health News, February 8, 2011
Vermont Gov. Peter Shumlin, elected last November after promising to reform health care in the state, unveiled a bill Tuesday to abolish most forms of private health insurance and move state residents into a publicly funded insurance pool.
Miami Herald, February 8, 2011
As arguments about the constitutionality of health care reform reverberate through courtrooms in Florida and across the nation, two provisions that have already kicked in are sparking opposite reactions from insurers.
NPR, February 7, 2011
Amednews, February 7, 2011
Congressional Republicans continued their offensive against the national health system reform law by introducing a bill that would eliminate the Medicare Independent Payment Advisory Board. The board could mandate physician pay cuts starting in about 4 years.
Amednews, February 7, 2011
Congress should pass the HEALTH Act to restrain health spending growth while preserving
patient access to high-
Reuters, February 3, 2011
Health insurer Cigna posted a higher-
FierceHealthIT, February 2, 2011
Searching for healthcare information is now the third most common reason for going online, just behind checking email and using search engines, according to a poll conducted last August & September by the Pew Internet Project and the California HealthCare Foundation.
Amednews, January 31, 2011
A hospital partner may not be necessary for an ACO to be effective, according to
a report analyzing a primary care-
Kaiser Health News, January 27, 2010
Amidst last year's battle over healthcare reform & Medicare payments to physicians,
the AMA ratcheted up its spending on lobbying, reports Kaiser Health News. The Chicago-
The New York Times, February 1, 2010
With a court decision on Monday declaring the health care law unconstitutional and Republicans intent on repealing at least parts of it, thousands of Americans with major illnesses are facing the renewed prospect of losing their health insurance coverage.
The Boston Globe, January 26, 2011
The leaders of Harvard Pilgrim Health Care & Tufts Health Plan said yesterday joining forces will give them the scale to expand across New England and beyond at a time when sweeping changes in the health care industry demand larger & more competitive players.
Kaiser Health News, February 1, 2011
When a health-
The Lund Report, January 20, 2011
Now physician assistants can be supervised by a panel of physicians regulated by
the Oregon Medical Board. Physician assistants (PAs) can now play a larger role in
primary care, thanks to legislation passed during the 2010 legislative special session
(House Bill 3642), which is being heralded by physicians and the co-
The Washington Post, January 21, 2011
It's the age of civility in American politics, but there's one institution that's been civil all along: the CBO (sorry, but sometimes civility is boring). The nonpartisan agency, which calculates the official cost of legislation for Congress, speaks in the polite language of actuarial tables, refuses to reliably please or disappoint either party & is the closest thing American politics has to an umpire.
Kaiser Health News, January 19, 2011
Recently, a Wall Street Journal expose and a New York Times column by Princeton economist
Uwe Reinhardt detailed how vast health care resources are steered by the American
Medical Association’s Relative Value Scale Update Committee -
Yahoo Finance, January 18, 2011
A Goldman Sachs analyst said Tuesday he remains bullish on the managed-
Kaiser Health News, January 18, 2011
The Republicans insist they want not just to repeal the Affordable Care Act but also to replace it. But replace it with what, exactly? It's not an easy question to answer.
Insurance News Net, January 17, 2011
Some states are moving forward on developing state-
Health News Florida, January 7, 2011
Two HMOs have been hit with nearly $4 million in fines after a long-
Politico, January 13, 2011
As Republicans push forward on repealing health reform, planning the law’s demise, a different conversation is happening among thousands of health care investors gathered in San Francisco for this week’s J.P Morgan Health Care Conference.
Health Affairs, January 14, 2011
Small businesses frequently face steep premiums for health insurance coverage and, as a result, their workers are more likely to be uninsured than those who work for larger companies. Various provisions of the Affordable Care Act are intended to address the problem.
Kaiser Health News, January 14, 2011
Lawmakers in a handful of states have introduced legislation that would criminalize PPACA. No, that's not the acronym for a designer street drug or racketeering syndicate — it's the Patient Protection and Affordable Care Act, the new federal health law, that they're talking about.
The Hill, January 13, 2011
The health insurance lobby urged federal advisers against recommending specific "essential" items or services that must be included in health plans offered on new insurance exchanges starting up in 2014.
LA Times, January 12, 2011
Bolstered by billions of dollars in aid from Washington, states managed to hold their healthcare safety nets together last year despite the fallout from the recession, a new survey shows.
MarketWatch, January 11, 2011
With significant changes from the new health-
Managed Care Information Center, January 11, 2011
P4P reimbursement of surgeons, intended to reward doctors and hospitals for good patient outcomes, may instead be creating financial incentives for discriminating against obese patients. This population is much more likely to suffer expensive complications after even the most routine surgeries, according to new Johns Hopkins research.
The Washington Post, January 9, 2011
The new health law encourages doctors, hospitals and insurers to team up in treating patients, but these groups already are at odds as they urge the government to set rules protecting their financial interests.
Amednews, January 10, 2011
Acknowledging that the U.S. health care system as structured is geared largely toward
treating just one disease or condition at a time, the DHHS recently announced the
creation of a public-
Amednews, January 10, 2011
For the first time, a majority of office-
PR Newswire, January 3, 2011
Midwest Business Group on Health (MBGH) has released the results of a recent national
employer survey gauging the reactions and concerns related to health reform after
Amednews, January 3, 2011
For a time during his 17 yrs of running a house call-
Politico, January 5, 2011
Health care reform was a big job in 2009 & it paid very well for some executives: Nine of 12 CEOs of health care trade associations made $1 million or more. Lobbyists at the associations received compensation ranging from $250,000 to more than $1 million.
WSJ, January 5, 2011
The new Congress prepared to begin business Wednesday much where lawmakers left off
before the November election—battling over the merits of the Democrats' health-
The Hill, January 1, 2011
The incoming chairman of the House Energy and Commerce Committee said Sunday that Republicans will bring up a healthcare repeal measure before President Obama even delivers his annual address to Congress this month.
Amednews, December 27, 2010
The percentage of Americans younger than 65 who receive health insurance through their employer has fallen below 60% not only because of high unemployment. It's also because many of those who remained on the job saw their coverage eliminated or reduced, or dropped it themselves because their plan became too expensive.
Kaiser Health News, December 21, 2010
When examining your health benefits for the new year, you'll probably notice that
your plan has eliminated lifetime and most annual dollar limits on coverage. That
was mandated by the federal health-
Becker’s Hospital Review, December 21, 2010
Just a few years ago, 431-
Kaiser Health News, December 16, 2010
With Republicans vowing to dismantle the health law and courts wrestling with its constitutionality, some health policy experts are pondering a possible "Plan B" in case the individual mandate – the requirement that everyone get health insurance starting in 2014 – is weakened or struck down.
Fierce Practice Management, December 14, 2010
As patients find themselves next month unable to use their flexible spending accounts
and other tax-
A.M. Best Company, Inc., December 20, 2010
Private Medicare Advantage health plans could soften major payment cuts from the federal government that start in 2012 under U.S. health care reform with a new star ratings program by the U.S. CMS.
Kaiser Health News, December 15, 2010
Choosing a health insurance policy should be easier if consumers use the simple chart and other information that state insurance commissioners approved Thursday.
Wall Street Journal, December 15, 2010
Here’s a premise we’ll bet you’ve heard before: If only the rest of the country could
deliver the kind of high-
Health Affairs, December 2010
Advocate Physician partners, an organization of over 3,500 physicians, created a new kind of accountable care model by organizing physicians into partnerships with hospitals to improve care, cut costs and be held accountable for the results.
The Washington Post, December 16, 2010
Opponents of President Obama's health care overhaul law are a cheering a federal court ruling that one of its core provisions is unconstitutional. They may not realize that Obama has a fallback option that also could do the job.
The Hartford Courant, December 3, 2010
The Connecticut Insurance Department has rejected a 20% rate hike proposed by Anthem BCBS, calling the request "excessive," according to the Hartford Courant. The department's analysis upheld many of the assumptions made by Anthem to justify an increase, but not the claims trend.
Amednews, December 13, 2010
Congress has voted to block a Medicare physician pay cut through 2011. In another
closely watched physician issue, lawmakers exempted doctors from the so-
New York Times, December 11, 2010
UNEQUAL access to health care is hardly a new phenomenon in the US, but the country is moving toward rationing on a scale that is unprecedented. Wealthy people will always be able to buy most of what they want. But for everyone else if we stay on the current course the lines are likely to get longer & longer.
Politico, December 7, 2010
Senate leaders have reached a tentative, one-
Reuters, Decenber 7, 2010
Aetna said it would pay about $500 million for privately held Medicity, which provides technology to exchange health information, in the latest sign that U.S. health insurers want to diversify.
Beckers Hospital Review, December 6, 2010
In a letter to CMS, Medicare Payment Advisory Commission warned that patients might have the same negative reaction to accountable care organizations as it did to HMOs some 15 years ago, according to a report by the Hill.
Amednews, December 6, 2010
The HHS Dept. issued final regulations Nov. 22 on what health insurers must do to
Slate, December 1, 2010
Sen. Jay Rockefeller chaired a Dec. 1 commerce committee hearing, "Are Mini Med Policies
Really Health Insurance?" That question answers itself. With payout ceilings of $25,000,
$10,000, $5,000, even $2,000, a mini-
Fierce Practice Management, November 24, 2010
It's no secret that physicians are frequently frustrated by insurers' preauthorization requirements, but a new AMA survey of about 2,400 physicians quantifies their opinions on the subject.
WSJ, November 28, 2010
Spurred by incentives in the federal health-
Amednews, November 29, 2010
The health system reform law requires an increasing number of insurance plans to
cover 100% of widely accepted preventive health care without co-
Businessweek, November 23, 2010
The Washington Post, November 23, 2010
These days, most health reformers can agree about two things. They believe, based
on pretty good evidence, that growing concentration among insurers, hospitals, pharmacy
benefit managers & drug companies helps explain why health-
Centers for Medicare & Medicaid Services, November 16, 2010
CMS today formally established the new Center for Medicare and Medicaid Innovation (Innovation Center). Created by the Affordable Care Act, the Innovation Center will examine new ways of delivering health care and paying health care providers that can save money for Medicare and Medicaid while improving the quality of care.
WSJ, November 15, 2010
Electronic health records are on the way — thanks to big financial incentives included in the stimulus bill — but they can also cause unforeseen effects and errors.
Inc., November 11, 2010
Thank heavens the windows were sealed because our recent Inc. Business Owners Council "New Member Invitational" on the subject of healthcare reform's impact on business owners was positively depressing.
WSJ, November 10, 2010
Creating a public health insurance option — perhaps the most contentious idea of last year’s health overhaul debate — is among the possible solutions for reducing federal spending outlined in today’s debt commission report.
Corporate Research Group, November 10, 2010
Two separate readers — on opposite sides of the nation — have now asked me if there’s any truth to rumors that UnitedHealth is interested in acquiring physician practices as a stepping stone into accountable care organizations.
WSJ, October 26, 2010
Minimally invasive surgical procedures and new anesthesia techniques at outpatient
facilities are making it easier than ever before to have surgery -
Becker’s Hospital Review, November 2, 2010
As reimbursements continue to decline, physicians may look to hospitals for financial support beyond the compensation they receive for clinical services.
Amednews, November 8, 2010
The American Medical Association and others in organized medicine say they are pushing for a Medicare pay solution that would prevent any threatened cuts through 2011.
Forbes, November 8, 2010
Earnings season has been a good one this year for health insurers. The recession means that patients are delaying surgeries, avoiding the doctor and filling fewer prescriptions.
The Washington Post, November 5, 2010
The Obama administration said Nov 5 it will cut premiums & upgrade coverage in a new health plan for people with medical problems, because enrollment has been disappointingly low.
InformationWeek, November 4, 2010
With newly elected Republicans in Congress pledging to repeal President Obama's healthcare reform, you've got to wonder whether those threats will stymie healthcare providers and IT vendors.
WSJ, November 2, 2010
The number of small businesses offering health insurance to workers is projected to increase sharply this year, recent data show, a shift that researchers attribute to a tax credit in the health law. Many small businesses, however, remain opposed to the law. Some small businesses are benefiting from portions of the law, which includes a tax credit beginning this year that covers as much as 35% of a company's insurance premiums. According to a report by Bernstein Research in New York, the percentage of employers with between three and nine workers and which are offering insurance has increased to 59% this year, up from 46% last year. The report relies on data from a September survey by the nonprofit Kaiser Family Foundation.
Washington Post, November 1, 2010
While most people are focused on the midterm elections Tuesday, the American Medical
Association is gearing up for the lame-
Healthcare Payors face a strategic dilemma: remediate outdated legacy systems to
ModernMedicine, Ronald Wheeland, M.D.
October 26, 2010
A lot of physicians are scrambling to convert their paper medical records into digital electronic ones. This is due to the fact that Congress recently passed the Patient Protection and Affordable Care Act.
The Wichita Eagle via Insurance News Net
October 10, 2010
Information about quality is beginning to be considered by some employers as they make purchasing decisions about health care, particularly care provided in hospitals.
RWJF, December 19, 2011
Patients are enthusiastic about embracing access to their medical notes, while doctors are cautious. That’s one of the key findings from a new study in the Annals of Internal Medicine reporting on OpenNotes.
Deloitte, December 2011
A representive random sample of U.S. physicians surveyed to understand their attitudes toward health reform and how it may impact the future practice of medicine.
RWJF, December 15, 2011
A new policy brief from Health Affairs and the RWJF, authored by Politico’s Jennifer Haberkorn, explores the ACA’s Independent Payment Advisory Board.
RWJF, December 8, 2011
Physicians Believe Addressing Patients' Social Needs Is As Important As Addressing Their Medical Conditions.
RWJF, November 2011
A new report released by the RWJF provides states with recommendations on how to best use available data to drive enrollment and retention in public insurance programs like Medicaid and CHIP.
CDC, November 2011
Data from the National Ambulatory Medical Care Survey.
Holters Kluwer, November 2011
Wolters Kluwer Health has launched a Point-
RWJF, November 7, 2011
52% of Americans, prefer a bigger government providing more health services, while just 37% support a smaller government providing fewer health services.
Kaiser Family Foundation, October 2011
Medicaid has evolved to become our nation’s primary payer for long-
Common Wealth Fund, October, 2011
Results from the National Scorecard on U.S. Health System Performance, 2011.
RWJF, September 2011
Ten Criteria for Meaningful and Usable Measures of Performance
RWJF, September 2011
A new report identifies options states could pursue to use the health insurance exchanges to help drive health care quality improvement and delivery system reform.
RWJF, September 2011
A report identifies options states could pursue to use the health insurance exchanges to help drive health care quality improvement and delivery system reform.
RWJF, July 2011
This issue brief provides state-
SK&A, July 2011
The number of physician practices that adopted EHRs has increased from 38.7% in Oct 2010 to 40.4% in July of this year, according to a recent study.
Thomson Reuters, August 2011
Study Finds Spending Gap of $4,600 per Person. A recent study released has found
vast differences from one city to the next in the amount spent on healthcare for
Americans with employer-
McGraw Hill, August 18, 2011
Data released by S&P Indices for the S&P Healthcare ECI indicate that the average
per capita cost of healthcare services covered by commercial insurance and Medicare
programs increased by 5.61% over the 12-
The New England Journal of Medicine, August 18, 2011
The New England Journal of Medicine has released this study that attempts to measure the economic and emotional impact of medical malpractice cases on doctors.
RWJF, August 2011
A new report funded by the RWJF reveals infrastructure and health IT alone won't be enough to be recognized and reimbursed as a medical home for long.
RWJF, August 2011
This brief by Wakely Consulting Group examines the proposed rules, which apply standards for reinsurance, risk corridors and risk adjustment.
RWJF, August 9, 2011
A policy paper that examines the promise of the medical home model of care concludes it has the potential to transform health care delivery, but that organizations promoting the model should tread carefully.
Jackson & Coker, August 2, 2011
As recently reported by FierceHealthcare, the recent U.S. recession has forced many physicians to delay or even come out of retirement.
Commonwealth Fund, July 2011
The US continues to outspend the rest of the world's 12 most advanced nations on
healthcare by a wide margin, according to the latest Commonwealth Fund study. The
latest data continues to be a wake-
Health Affairs, July 2011
In 2010, US health spending is estimated to have grown at a historic low of 3.9 percent, due in part to the effects of the recently ended recession. In 2014, national health spending growth is expected to reach 8.3 percent when major coverage expansions from the Affordable Care Act of 2010 begin.
HSS.gov, July 8, 2011
The HHS Office of the Inspector General (OIG) has urged the CMS to take immediate
action on the way skilled nursing facilities bill for concurrent and high-
Russell Herder, July 2011
When patients are diagnosed with a new acute or chronic illness, the Internet is often one of the first places they share the news when they get home from the doctor's office.
The Medicus Firm, June 26, 2011
The average change in physician compensation from 2009 to 2010 was -
QuantiaMD, June 15, 2011
A study of more than 3,700 physicians sheds light on the new ways doctors are embracing mobile technology.
Journal of American Physicians and Surgeons, Summer 2011
While most physicians are dedicated to constantly improving their skills, increasingly costly bureaucratic demands for recertification may cause many to say “Enough!” just as baby boomers retire & physician shortage looms.
NIHCM Foundation, July 2011
RWJF, June 21, 2011
Small employers will likely increase offers of insurance—and their premium costs will fall—under the Affordable Care Act.
PwC, May 2011
Employers will likely face health-
The Common Health Fund, April 2011
Using a budget-
RWJF, April 29, 2011
Americans’ confidence in their ability to afford future care & maintain health coverage fell slightly March 2011. The RWJF Health Care Public Perception Index decreased from 100.2 points in Feb to 99.6 points in March.
RWJF, April 21, 2011
Although the U.S. spends more per person on health care than any other nation, the quality of that care frequently falls far short of what it should.
RWJF, April 2011
Although the malpractice crisis—the inability of health care providers to obtain affordable liability insurance—has abated in many states, medical liability costs & pressures remain a concern.
The Commowealth Fund, April 14, 2011
A key provision of the Affordable Care Act is the establishment of the Medicare Shared Savings Program, which provides incentives for improved quality & efficiency to a new category of provider—the ACO.
RWJF, March 15, 2011
Three issue briefs detail the work of the High-
To support better care while reducing or controlling costs, ACOs and medical homes will need to emphasize ways that the healthcare community can enhance access, promote better care coordination, use health information technology better, and apply coordinated payments.
RWJ, March 2011
A study, funded by RWJF and the California HealthCare Foundation, investigates the
effects of high-
RWJF, March 2011
A study, funded by the RWJF Changes in Health Care Financing and Organization program looks at the potential impact of medical loss ratios (MLRs) on the individual health insurance market.
RWJF, March 17, 2011
A new study finds that in much of the country, Medicaid enrollment expansion under health reform is likely to greatly outpace growth in the number of PCPs willing to treat these new patients.
RWJF, March 9, 2011
Starting in 2014, the Affordable Care Act will require mid-
CDC.gov, February 2011
Health, United States, 2010 is the 34th report on the health status of the Nation and is submitted by the Secretary of the DHHS to the President and the Congress of the US.
Kaiser Family Foundation, February 23, 2011
Three papers on Medicaid & the Uninsured examine Medicaid enrollment and spending
during the recent recession. The analyses show Medicaid enrollment rose above 50
million people nationally for the first time in 2010, reflecting the program’s counter-
The papers include:
Medicaid Spending Growth Over The Last Decade and the Great Recession, 2000 to 2009
Medicaid Spending Growth and the Great Recession, 2007-
Medicaid Enrollment June 2010 Data Snapshot
HealthReformGPS, February 9, 2011
Health care quality represents a constantly recurring theme in U.S. health policy. What is it? How do we measure it? How do we encourage and reward it? How does the nation reconcile explosive growth in health care costs with evidence from leading researchers and experts such as Elliott Fisher, Elizabeth McGlynn, John Wennberg and colleagues, and Francois de Brantes and colleagues that collectively points to serious deficiencies in health care quality and the disconnect between high spending and health care quality?
The New Yorker, January 24, 2011
Dr. Atul Gawande discusses medical hot spotting in his latest article in the New
Yorker. "Hot spotting" -
RWJF, February 14, 2011
Both Democrats and Republicans largely agree on repealing the provision in the Affordable
Care Act (ACA) that requires businesses file Form 1099 with the Internal Revenue
Service for all vendor purchases totaling $600 or more annually. This so-
The Commonwealth Fund, February 2, 2011
The State Scorecard on Child Health System Performance, 2011, examines states’ performance on 20 key indicators of children’s health care access, affordability of care, prevention and treatment, the potential to lead healthy lives & health system equity.
RWJF January, 2011
Americans’ confidence in their ability to afford future care and maintain coverage fell in December. The Robert Wood Johnson Foundation Health Care Public Perception Index (RWJF Index) decreased from 98.1 points in November to 96.1 points in December.
AMA, January 20, 2011
The medical liability system is in desperate need of reform. It is neither fair
nor cost effective in compensating injured patients. It has become an increasingly
irrational system driven by time consuming litigation & open-
Medpac, January 2011
The utilization of Medicare services varies dramatically in different parts of the
country, according to a new report by the Medicare Payment Advisory Commission. "We
find that regional variation is particularly high for post-
Health Affairs, December 28, 2010
This brief covers details regarding 2011 rules for new group and individual health plans that must cover 45 different preventive services that are rated highest by the United States Preventive Services Task Force. (A chart in the brief lists the services covered.)
The Center for American Progress, December, 2010
Under the reform law, an ACO is a group of physicians & hospitals collaborating to provide efficient & quality care for a certain group of patients. The Center for American Progress report said ACOs should follow 3 major principles.
RWJF, December, 2010
With conflicting rulings about the constitutionality of the individual mandate in the Affordable Care Act, we are left to wonder: what would the ACA look like if its individual mandate were stripped off? A report shows that the number of uninsured would be cut 50% if the mandate is left in place—20% without the mandate.
HSC, December, 2010
Commonplace in the 1980s among the heavy industry/manufacturing and financial sectors, workplace clinics were geared primarily toward treating workplace injuries or minimizing employees’ time away from work.
The Commonwealth Fund, December 14, 2010
The Patient Protection and Affordable Care Act, which will provide health insurance to nearly all U.S. citizens and improve the quality of health insurance, will particularly benefit adults ages 50 to 64, a group suffering from extended unemployment and a loss of employer health benefits.
CDW Healthcare, December, 2010
With Meaningful Use incentives scheduled to start in 2011, physician practices are actively assessing the costs and benefits associated with implementing an Electronic Health Record (EHR) solution.
Health Affairs, December, 2010
This Health Affairs paper examines both the changes in income and coverage over the entire decade, with a closer examination of the economic changes from 2007 to 2009.
The Physicians Foundation, October, 2010
Healthcare reform will usher in a new era of medicine in which physicians will largely
cease to operate as full-
Healthcare Finance News, October 27, 2010
A national study of physician wages conducted by the UC Davis Health System has found that specialists are paid as much as 52% more than primary care doctors, even though primary care doctors see far more patients.
State Health Access Data Assistance Center, November, 2010
Functional insurance exchanges will require careful operational and financial planning by states in order to ensure they are efficient and able to compete in the insurance market.
Health Affairs, November 17, 2010
A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the requirements outlined in the Affordable Care Act concerning "medical loss ratios" (the percentage of premiums that insurance companies must spend on health care services).
Healthcare Informatics Research
Despite being identified as an essential tool to support quality care initiatives, improve patient safety and reduce healthcare costs, electronic medical and health record (EMR/EHR) systems have been stuck in a slow growth cycle.
Healthcare Finance News, Nov 2, 2010
The Healthcare Performance Management Institute says recent research indicates insurers and benefits consultants are hindering employers' efforts to reduce healthcare costs.
The National Committee for Quality Assurance is seeking input from the public on draft accountable care organization standards. Comments may be submitted until 5 p.m. Nov. 19 on the NCQA's website.
AHIP, October 2010
With the economic stimulus package bankrolling comparative effectiveness research (CER) to the tune of $1.1 billion, the health care industry is preparing to integrate CER. However, many important issues remain under consideration.
Millman Group, October 2010
This paper, the latest in a series of papers on exchanges, addresses the functions of an exchange and examines various operational considerations.
RWJF/Health Affairs, Oct 2010
A new policy brief from Health Affairs and the Robert Wood Johnson Foundation examines
what grandfathered plans mean, and explores just how much a grandfathered plan may
change over time and still retain its grandfathered status—such as altering the list
of preferred providers or changing the prescription drug formulary. The authors conclude
that there are no clear indicators about whether sticking with a grandfathered plan
is the best option—and therefore these decisions must be evaluated on a case-
The Washington Post, January 19, 2012
It’s an oft-
Determining what medical spending is wasteful is the hard part. What procedures should doctors not provide, and insurance companies not pay for? Figuring out which treatments are wasteful is both a policy and politics challenge, one that can often invoke accusations of “rationing” or denied care.
Despite all those hurdles, a new campaign called Choosing Wisely aims to answer just that question. Run by the American Board of Internal Medicine, Choosing Wisely has brought nine major medical societies on board to identify five common procedures that are often wasteful and unnecessary. The groups will provide their answers at the end of January and make them public in April.
On Wednesday, I spoke with Christine Cassel, president and chief executive of the American Board of Internal Medicine, about the new project, why it’s happening and the big challenges in finding waste in health care. What follows is a transcript of our discussion, lightly edited for length and content.
Sarah Kliff: Tell me the back story on this. How did the Choosing Wisely initiative get started?
Christine Cassel: The back story started exactly 10 years ago, when we published a charter on physician professionalism. It was a kind of update to the traditional Hippocratic Oath, an ethics statement for the profession in the modern environment that was endorsed by 130 different medical associations. In that document, there were 10 commitments that we agreed were central to the profession, and one was stewardship of medical resources.
In the past two years, the financial crisis combined with the discussion of rising
SK: Patients don’t want to undergo unnecessary medical treatment, and doctors probably don’t want to provide it. So why hasn’t this problem resolved itself without intervention?
CC: One of the clearest reasons is our fee-
Patients also haven’t been as informed as they are now. Now, unfortunately there are a lot more of us having to pay out of pocket. It used to be, if you were lucky, you didn’t see the bills. Now, people are asking themselves if certain treatments are necessary.
SK: How much of unnecessary care has to do with defensive medicine, doctors looking to avoid a medical malpractice lawsuit?
CC: That comes up a lot in our discussions. Physicians hate the threat of malpractice. The data show it’s a very small part of the cost of health care, but in terms of a doctor’s attitude, if you’re in the emergency room and have any doubt, the thought is probably it’s better to order the test. I hope this will help offer doctors some backbone not to.
SK: From what I understand, the speciality societies will have to get their recommendations to you by the end of January. How is the work going for them? Is it difficult to settle on which treatments are unnecessary?
CC: The good news is we had a conference call last week and they are taking this very seriously. They have set up major committees of experts to review the evidence and come up with things that matter. We’ve said to them, “We don’t want you to have things that are hardly done anyway, things that aren’t going to make difference.” They’re looking for real interventions where new evidence has emerged, where something used to be done routinely but may not need to be.
SK: Is there disagreement between doctors over whether a certain treatment is necessary?
CC: There are some hard questions and might be disagreements among different experts within a given speciality. In cancer, for example, there may be people who have different experience, and who may question the literature. But that’s what you want scientists. It’s going to force them to all look at the same evidence and come up with their best answer.
SK: You all will publish the results of your work in April. These aren’t going to bind physicians’ practice in anyway, so what’s the hope for how they’ll change medicine?
CC: The way we’ll communicate this is through Consumer Reports, through their Web site and magazine. We hope that patients will start asking questions and also doctors will want to know more. They’ll come to their societies, see it in their journals. I sense some real enthusiasm, and these groups taking it seriously. They recognize the pressures of professionalism.
Another factor that is related to this is the new methods of paying for health care,
which pushes doctors to be more efficient with resources. These are things like the
SK: Identifying unnecessary treatments can be politically challenging. I think we saw, during the health reform debate, a lot of accusations about doctors or governments “rationing” or denying health care. How do you handle those kinds of challenges?
CC: My hope here is we can get away from that rhetoric, which is really misleading to the public and is, I think, scare tactics. None of this is rationing. Rationing is withholding care that is needed. And we’re not talking about needed care here. We’re talking about prudent uses of resources to get what is best for each patient.
Amednews, December 5, 2011
What is your practice going to accomplish next year?
Experts say setting goals for the coming year that do not fall by the wayside like many New Year's resolutions is increasingly important to help medical practices stay focused and in business, what with all the changes being wrought by health system reform.
"We're in a very dynamic time in health care, but it's not a stable time," said Manuel Lowenhaupt, MD, a partner in Accenture's health provider practice in Boston. "Practices need to recognize that their ability to flex and change and focus is much more important than it has been in the past."
And December is not too late to set goals for 2012. "It's never too late," Dr. Lowenhaupt said.
People who work with medical practices say the first step in goal setting is to identify
aspirations that are large and overarching. Experts advise that any list of goals
include ones that are both realistic to achieve within the next year and ones that
are more long-
"You need to have goals to build a strategy and manage a successful business, but if you have more than 10 goals that you hope to implement, it can become unmanageable," said Jason Hwang, MD, executive director of health care with the Innosight Institute, a think tank in Mountain View, Calif., that focuses on innovation and business.
Goals should be in line with the needs and priorities of the practice.
"Each individual practice is going to have their own mission or vision as well as their own financial or operational goals, and they should be tied into where you want to bring your business," said David MacDonald, president and CEO of health care consultancy Aegle Advisors in Marion, Mass. "You need to know what the practice's challenges are."
For example, is the practice so busy that patients are frustrated with long wait times? Are phone calls from patients not returned in a timely manner, or not at all? Are new physicians or staffers needed to maintain a level of care and keep patients coming back, as appropriate? Are employees disengaged from their jobs? Even if the practice is financially successful, ignoring such issues may jeopardize its future, experts said.
"A practice may need better logistical planning," MacDonald said. "In this economy, patients are paying more for health insurance and more for care. They expect more value and to get the service they require on their terms."
Various aspects of health system reform, such as the move toward accountable care
organizations and quality-
"There are a lot of things changing right now," Dr. Lowenhaupt said. "The key is to make sure that the patient experience aligns with evolving needs."
Or is the practice already struggling financially? Does the practice need to find
ways to bring more patients into the door or collect a higher percentage of co-
When the larger goals are identified, the next step is to identify how to get there by breaking things down into smaller, measurable targets. For example, a practice struggling with wait times and patient satisfaction may want to look at improving how patients flow through the office. Where can the process get better? Which staffers should be given specific tasks to achieve this end? If practice financials need improving, are there ways to ensure that patients do not leave the office without at least discussing how to cover their share? How can this goal be broken down so each staffer knows how to achieve the goal?
"You need to link everybody in that chain to the success of the goals," MacDonald said.
After goals have been devised and broken down, practice management consultants say the next step is to communicate to staffers the overarching goals and what they mean to each employee. This can include information about how employees and the practice may be rewarded if targets are hit.
For example, practice goals for next year can be incorporated into performance reviews or various bonuses. Staff rewards for hitting respective targets can be financial but may be nonmonetary, such as additional time off or public recognition.
"Every time you achieve something you should be talking about it," MacDonald said. "People will feel valued, and it gives them that positive reinforcement around these common goals."
People who work with medical practices caution that any plan take into account that change takes time.
"A practice needs to ask: How do we want to move our people in the right direction?" MacDonald said. "None of this stuff happens overnight, but once you lay it out there, you will start to see movement. You can really move an organization forward."
Modern Medicine, November 1, 2011
Service is especially important now, as physicians face declining reimbursements
and increasing competition. Patients evaluate practices based on ease of making appointments,
National report — Superior service doesn't just happen. Experts say it requires having a proactive plan for an element of medical practice that many physicians unfortunately overlook.
As physicians, says Victor J. Marks, M.D., "Service is what we do. We don't make or grow anything. We serve other people." He is director, department of dermatology, and section chief of dermatologic surgery at Geisinger Health System, Danville, Pa.
He says it's crucial that dermatologists provide service that patients can recognize as exceptional. In a competitive marketplace, "People will come to us based on whether they believe that the service we provide is better than the competition," he says.
Although service is always important, says Sandra Ellison, it's especially important
now, as physicians face declining reimbursements and increasing competition for their
services, particularly in the cash-
"When patients have the power to choose which practice they go to, they're more likely to choose a practice that meets not just their medical needs, but their overall needs," she says. Ms. Ellison is president, Ellison Consulting Group, and an adjunct faculty member at the Center for Creative Leadership's Colorado Springs, Colo., campus.
Dr. Marks says that when it comes to marketing, "We tend to focus our efforts on our diagnostic, clinical and technical skills. The problem is, patients can't evaluate our clinical abilities very well. Most patients give us the benefit of the doubt." Instead, he says, they base their opinions of a physician mainly on their interactions with the physician and his or her practice.
"People remember how you made them feel, especially patients. They often find medical
settings uncertain and frightening. The more high-
When people visit a doctor, she says, "They are usually entering the situation with some anxiety and trepidation. They have had to take time away from work to be there. They come to your door worried about something, perhaps something that they fear will result in debilitation or death. They worry what it will cost, if it will hurt and when they can get back to normal. These simple fears can be easily overlooked by busy physicians and staff, but they shouldn't be."
Patient anxiety is often further increased by annoying things that a practice does, she says. Examples include subjecting patients to excessive wait times before they can see the physician, or staff members asking the same questions repeatedly.
"When staff are rude or gruff in the way they approach patients, anxiety increases further," Ms. Ellison says. "A highly anxious patient often doesn't hear what you said, and as a consequence, is less likely to follow the instructions you've given them. This obviously affects outcomes."
Dr. Marks says that when it comes to practice systems and processes, "Patients evaluate
us on the ease of making appointments, the check-
In other words, he says, "Is there excessive levity, or is the decorum in the hallways as we would want our patients to perceive it? Are our waiting rooms neat and tidy," with appropriate music, magazines and other accoutrements? In the latter area, Ms. Ellison says that amenities ranging from aesthetic features such as waterfalls to warm cookies can surprise and delight patients, thereby differentiating one's practice from the competition.
Patients also judge the way a practice communicates, both verbally and nonverbally, Dr. Marks says. "Are patients addressed appropriately? Are there smiles on our faces? Probably the most important component of communication is the behaviors we exhibit. We tend to rely on the behaviors that come naturally to us and our employees," though some of these behaviors might not be pleasing to patients.
Fortunately, he says, desirable behaviors can be discussed, scripted and practiced until they become natural. Examples include answering the phone in a cheerful, upbeat manner, or having nurses introduce themselves to patients a standard fashion, Dr. Marks says.
Physicians also must model the behaviors they expect of their employees. Conversely, "If you roll your eyes at a difficult or demanding patient, your employees will do the same," he says.
In hiring staff, Dr. Marks says, "Hire for personality over experience." Experience comes with time and training, he says, but personality is very difficult to change if it does not fit the practice you're trying to create.
"If you want a bubbly, happy office, hire people like that. Also consider who you like being around. If you want someone who's vivacious and effervescent and that fits your personality type, that's great.
"Sometimes physicians don't sit down and create a vision or picture in their mind's eye of what they're trying to create," he says. "They just go into practice, start seeing patients and react to that inundation of patients," rather than first determining what they want their patients' experience at their offices to be.
For physicians, Ms. Ellison says, "It's important to have a clear, compelling vision
for your office, clinic or department. And 'I want to make a lot of money' is not
something your staff can rally around." She says a more fruitful vision might involve
becoming the most sought-
"The path to service excellence is not something you do overnight," she adds. "It's
grounded in your values, beliefs and vision. And it's not enough for you as the practice
owner or department chairman to say, 'Here's what we're going to do.' You must gain
Typically, she says, this process includes a series of meetings that get people aligned around a common vision. At each step, "Find ways to include as many people as you can. Even consider places where you need to hear the voice of your patients in the process. Gather data about four key areas: processes, environment, culture and amenities. Within these areas, look for the things in your practice that really annoy people," Ms. Ellison says.
In one practice she has worked with, Ms. Ellison says, patients felt their sense
of confidentiality betrayed by a paper sign-
"Most patients will not tell these things to a doctor's face — they'll leave your practice, but they won't tell you why," she says. "Form a team to work on building service excellence. One thing the team must decide is how to get the voice of the customer."
Fierce Healthcare, October 21, 2011
After delivering severe criticisms when the Centers for Medicare & Medicaid Services
(CMS) issued its proposed rules in the spring, professional medical groups-
With the notably relaxed changes, the final rule is being hailed by some healthcare organizations.
American Hospital Association:
"Today's rules represent the direction in which the hospital field is moving-
American Medical Association:
"We are pleased that the final rule ... includes many of the important changes recommended
by the AMA to allow all interested physicians to lead and participate in these new
models of care," said Dr. Peter W. Carmel, the Association's president, in an American
Medical News article. "The AMA has stressed throughout this rule-
Association of American Medical Colleges:
"The AAMC is pleased that the ACO final rule excludes indirect medical education
payments from the methodology used to assess shared savings under the program. By
not including these policy payments in the historical cost analysis, medical schools
and teaching hospitals-
"The programs announced today can benefit people in Medicare by encouraging providers to work together to better coordinate patient care, which can lead to fewer hospital readmissions and lower Medicare costs. AARP believes today's announcement is a good first step and we welcome the chance to further review these programs," AARP Legislative Policy Director David Certner said in a statement yesterday.
Campaign for Better Care:
"We are very pleased that this final rule will require ACOs to adhere to strong patient-
New York Times, September 27, 2011
Medical schools are starting to train doctors to be less intimidating to patients. And patients are starting to train themselves to be less intimidated by doctors.
We haven’t completely gotten away from the syndrome so perfectly described by Alec Baldwin’s arrogant surgeon in the movie “Malice”: “When someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn’t miscarry or that their daughter doesn’t bleed to death or that their mother doesn’t suffer acute neural trauma from postoperative shock, who do you think they’re praying to? ... You ask me if I have a God complex. Let me tell you something: I am God.”
But there have been baby steps away from the Omniscient Doctor. The federal Agency for Healthcare Research and Quality has begun a new campaign to encourage patients to ask more pertinent questions and to prod doctors to elicit more relevant answers.
“I used to think, ‘He’s a doctor. Who am I to ask a question?’ ” Bill Lee, a Baltimore man who has suffered 10 heart attacks, says in a video on the agency’s Web site urging people to speak up.
Patients have more options, a flood of Internet information and a bombardment of drug ads listing side effects — and that can be terrifying. It adds to the general anxiety level that health insurance costs are rising sharply and that President Obama’s health care law seems headed toward the Supreme Court.
The “experts” are always issuing guidelines, which are soon contradicted by another set of “experts.” It happened with the recommended age for regular mammograms, and it’s happening with guidelines on hormone replacement for postmenopausal women.
First, estrogen was going to be the fountain of youth. Then hormone replacement therapy was going to spell doom, causing heart disease, stroke and breast cancer. And now, as The Wall Street Journal reported on Tuesday, “some experts are reaching a more nuanced view of the risks and benefits and concluding that hormone therapy may still be a good option for healthy women in their 50s, depending on their symptoms, family history and worst fears.”
Each patient, a Michigan gynecologist told The Journal, is like a Rubik’s Cube, and must get an individual solution.
That is also the message of a new book, “Your Medical Mind: How to Decide What Is Right for You,” by Jerome Groopman, an oncologist, and his wife, Pamela Hartzband, an endocrinologist, both members of the Harvard faculty and staff physicians at Beth Israel Deaconess Medical Center in Boston.
Few people have done as much to demystify medicine as Dr. Groopman, who has written four other books and lots of New Yorker essays aiming to help doctors understand that patients are often neglected allies with good intuition, and to help patients get confidence and control by understanding how doctors think.
Like a Middle East peace broker, he aims to lower the stress level and bring together two sides who perpetually misunderstand each other.
With his white beard, 6-
And I can say from personal experience — since I’ve known him, he’s provided guidance that helped save the lives of three members of my family — that he is a fierce, sensitive and generous patient advocate. (And an aficionado of Irish literature.)
Dr. Hartzband and Dr. Groopman warn against excessive reliance on overreaching so-
“The answer often lies not with the experts but within you,” they write, adding that the Albert Einstein line is apt: “Not everything that can be counted counts, and not everything that counts can be counted.”
The authors stress that “the best” and “informed” can be subjective terms, and that your prognosis can often look very different if you “flip the frame” of reference.
They try to decode the Orwellian language that prevents physicians and patients from cooperating, and show how doctors can project their own preferences on patients.
They interview patients who are Doubters and Minimalists, who may agree with Voltaire’s view that “the art of medicine consists in amusing the patient while nature cures the disease.” And they interview Believers and Maximalists, who go for radical treatments too quickly. They confess that they have a mixed marriage: Dr. Hartzband tends to be a Doubter (her mom’s mantra was “Doctors don’t know everything”) while Dr. Groopman tends to be a Believer (a status that got shaken when he jumped into a spinal fusion operation that had “disastrous consequences.”)
“The unsettling reality,” they write, “is that much of medicine still exists in a gray zone, where there is no black or white answer about when to treat or how to treat.”
But they are both optimists who warn against the “focusing illusion” — focusing on what will be lost after a colostomy, mastectomy, prostate surgery or other major procedures.
“The focusing illusion,” they write, “neglects our extraordinary capacity to adapt, to enjoy life with less than ‘perfect’ health.”
The New York Times, August 25, 2011
A former colleague from Canada who practiced medicine with me here in the States never hesitated to make one thing clear to me: He couldn’t wait to get back.
It wasn’t the cultural life that he missed, nor was it the ex-
“It’s different,” he would say wistfully, without elaborating. “Practicing medicine is just different over there.”
A study published this month in the journal Health Affairs made me think of my colleague again and offered one likely possibility for his return to Canada: There, he had more time to focus on his patients.
Researchers asked hundreds of physicians and administrators in private practices
across the United States and Canada how much time they spent each day with insurers
and other third-
Physicians in Canada, where health care is administered mainly by the government, did spend a good deal of time and money communicating with their payers. But American doctors in the study spent far more dealing with multiple health plans: more than $80,000 per year per physician, or roughly four times as much as their northern counterparts. And their offices spent as many as 21 hours per week with payers, nearly 10 times as much as the Canadian offices.
“The amount of time we spend on this is just crazy,” said Dr. Sara L. Star, a partner
in a three-
And when those companies offer multiple “insurance products,” the convoluted coverage grid acquires yet another level of complexity. Each “product” comes with its own unique permutation and combination of authorization requirements, rules for claims and list of approved prescription drugs.
Large practices often choose to outsource the job to firms that specialize in wading through the labyrinthine rules and regulations. Some hire several nurses or administrators to work exclusively with insurers, with each specializing in the arcane rules of a single insurer. But most primary care providers in this country — clinicians who are part of practices with five or fewer physicians — cannot afford to pay for additional help. Instead, they must make their way through the thicket of insurers and rules by themselves.
The complicated task inevitably gets in the way of patient care.
A young patient complaining of extreme fatigue, for example, might benefit from a $40 blood test that could confirm infectious mononucleosis in 10 minutes. But a doctor cannot order the simple test without first checking with the insurance company to see if it is covered and if there are any constraints on where the patient’s blood can be drawn and the test run.
Tracking down answers often means phone calls with long periods on hold, digging up old patient information and even recruiting office workers to act as specimen couriers to other labs and hospitals in order to expedite results or save frail patients or harried family members the hassle of traveling to an “approved site” for a test or procedure. “If someone comes in with a sick infant who needs a test, we often eat the costs and draw the blood ourselves,” Dr. Star said. “We aren’t going to tell them to put that kid in a car seat, drive a mile to an approved lab, park, register, then wait in line.”
Even more confusing are frequent changes in health care plans, particularly regarding prescription drugs. Every week, payers send physicians’ offices notifications of changes in their list of approved medications, lists that run to hundreds of different drugs. The sheer volume of new information makes it impossible for doctors to keep up. “Physicians get into medical school because we can follow rules,” said Dr. Marian Bouchard, a family doctor who practices with two other physicians and a nurse practitioner in Bristol, Vt. “But none of us can or want to follow the minutiae of a hundred rules at once, especially when we are trying to be present for our patients.”
The authors of the study offer several recommendations to reduce the confusion and inefficiency of interactions between physician practices and payers. Not surprisingly, they propose simplifying the forms and procedures that add to costs without improving quality. “There are rules that really save money or improve patient care that health plans won’t want to change,” said Sean Nicholson, one of the study authors and an economist in the department of policy analysis and management at Cornell University. “But there are also a lot of things that don’t matter that they could and should standardize.”
The insurance industry, for example, could embrace a single set of universal standards to measure quality rather than the dozens that are currently used. They could adopt a uniform process of obtaining authorization for tests, procedures or consultations. And while widespread adoption of electronic medical records and changes in how doctors are reimbursed may eventually decrease some administrative burdens, the results of the study leave little doubt as to the costs now and in the foreseeable future for doctors and patients.
“We aren’t saying that we should go to a single-
Amednews, August 15, 2011
To err is human. To tell the world about the cases when things went wrong requires courage.
In September 2010, Kimberly Hiatt made a medical error. The critical care nurse at
Seattle Children's Hospital miscalculated and gave a fragile 8-
The mistake contributed to the death of the child and led to Hiatt's firing and an investigation by the state's nursing commission. In April 2011, devastated by the loss of her job and an infant patient, Hiatt committed suicide.
Hiatt, who had worked as a nurse for more than two decades, was another in a long line of "second victims" of medical error, the term used in medical literature to describe physicians and other health professionals who often feel guilty and depressed after adverse events. Many physicians and other health professionals hold themselves to a standard of perfection, and when things go wrong, they feel alone.
Physician health experts estimate that 250 doctors commit suicide annually -
If the first instinct after an adverse event is to retreat from scrutiny into a spiral of shame and fear, sharing the ordeal publicly is probably the last thing to cross a physician's mind. But a small group of doctors has done just that. Here are three physicians who shared their stories with the world in an effort to tell their colleagues and their patients that to err is human.
It was not until he was dictating a report on the last of his six operations that hectic day that orthopedic surgeon David C. Ring, MD, PhD, realized his mistake. He had performed the wrong surgery on a patient.
An estimated 250 doctors commit suicide each year, double the rate of the general U.S. population.
Dr. Ring was distracted. Earlier in the day, he performed a carpal-
"I felt bad for her," says Dr. Ring, associate professor of orthopedic surgery at
Massachusetts General Hospital in Boston. "She was really stressed out from that
painful shot. I was resolved in my mind that my next surgery would be my best carpal-
Dr. Ring alerted the patient to the error and offered to immediately perform the correct procedure, which he did. The unnecessary wound to the hand from the wrong procedure would take about a month to heal and be sensitive to the touch for several months, Dr. Ring says.
"It could have been a lot, lot, lot worse," he says. The patient got follow-
Dr. Ring could have let the matter quietly end there. Instead, he went public.
Shortly after the surgery, Dr. Ring and experts on wrong-
"I knew that the biggest mistake of my life and the worst event in my life was also an opportunity," Dr. Ring says. "In my role as a teacher and mentor, if I make a mistake in diagnosis, a mistake in surgery or a mistake in judgment, it's always been a teaching opportunity. There's always been something to discuss. It's not something to sweep under the rug."
Despite the risk to his reputation of going public with his mistake, Dr. Ring believes it was worth it to spread the idea that safety checks are needed to help prevent mistakes and that even the most accomplished physicians can err.
"I knew that if I was willing to have that difficult discussion, it would help other people," he says. "It was the right thing to do."
"The outliers we all dread"
Bryan E. Bledsoe, DO, was working in a small community emergency department when
"this countrified, slow-
"She said she had a subarachnoid hemorrhage," says Dr. Bledsoe, now a professor of emergency medicine at the University of Nevada School of Medicine. "I thought, 'How could she know such a thing?' "
Dr. Bledsoe discounted what the woman said, making assumptions about her intelligence and social class. She was wearing a soft neck collar, but had it on upside down and backward. The woman complained of neck pain, but not of headache, vomiting or other symptoms more typical of subarachnoid hemorrhage.
Today, Dr. Bledsoe says, he would not think twice about ordering a computed tomography
scan, but then such imaging was costlier and less common. Dr. Bledsoe, then only
a few years out of residency, took x-
The next morning, an ambulance brought in a female patient who required cardiopulmonary resuscitation but could not be revived. It was the same woman who had come the day before. Dr. Bledsoe walked into the room where the woman's children were gathered with their recently deceased mother.
"They were standing around holding her hand -
Though no autopsy was performed, Dr. Bledsoe believes he missed the diagnosis. "From a prima facie standpoint, she was alive yesterday and now she's dead," he says. "That's not generally considered a good outcome. ... Whether I'm right or wrong doesn't matter, it's how I feel that does. That lady's dead, and I can't bring her back.
"I was just rushed," he adds. "I assumed it wasn't something too bad, and I was wrong. These are the outliers we all dread. Of every 100 patients, there's going to be one who hasn't read the book on how to present for a particular disease process. I learned that the hard way."
Wracked with guilt, Dr. Bledsoe had trouble getting the case off his mind. He attended the woman's "big Pentecostal funeral." The family wasn't upset with him. "They embraced me," he says.
He has kept the case in mind as a warning to avoid jumping to conclusions when diagnosing patients, and has used it as an example when teaching emergency medicine residents. When contacted by a reporter, he chose to go public with the story in a September 2010 article in Reader's Digest.
"I figured, 'What's the harm in talking about it if it helps somebody else?' " Dr. Bledsoe says. "I'm not proud of it, but any doctor who says they haven't made a mistake is a liar. Physicians are human. For anyone to expect absolute perfection in everything is a fool's errand."
Tearing down "wall of silence"
Jo Shapiro, MD, specializes in surgically repairing Zenker's diverticulum, an outpouching of the throat. The surgery involves cutting through the lining of the pouch but stopping just before getting to the outer lining. The procedure is done using a microscope that exposes a small part of the anatomy to the surgeon.
"It's a matter of millimeters," says Dr. Shapiro, chief of the division of otolaryngology at Brigham and Women's Hospital in Boston.
A known complication of this procedure is that, about 1% of the time, the surgeon will pierce the lining of the throat. Despite her best effort, that is what Dr. Shapiro did to a patient in the late 1990s. Though warned of the potential surgical complication, the patient and his family perceived the adverse event as a medical error. The man survived but developed a chest and neck infection and later sued unsuccessfully. It is emotionally trying anytime the patient's outcome is poor, Dr. Shapiro says.
"Intellectually, you say that something might go wrong with the care you're giving. But when it actually does, at that moment you realize you've made the person worse rather than better," she says. "You feel terrible for the patient, and you feel like you've let them down. You feel that you should have done better. Somehow you call into question all of your competence."
Dr. Shapiro spoke about her experience for the first time publicly before 3,000 physicians, nurses and health care administrators at a patient safety conference in 2006. At the time, she says, pressure on physicians to disclose adverse events was mounting, but health care organizations were doing little to help them deal with the emotional hurdles that make disclosure a difficult thing for doctors.
"We have to understand that, despite our best efforts, things will not always go well," Dr. Shapiro says. "The public needs to understand that, and health care providers need to really integrate that into their way of thinking. ... I'm just one of many people to say, 'We're going to tear down the wall of silence, and let's just talk about it.' "
Before the big speech, Dr. Shapiro was uncertain about her colleagues' reaction, but afterward received "an amazing amount of warm and wonderful" responses from other health professionals. Additional doctors interviewed for this article also reported receiving many supportive comments from colleagues, and even letters from patients who said they wished they had such caring and compassionate physicians.
Peter J. Pronovost, MD, PhD, also publicly has told the story of a mistake he made early in his career that could have resulted in permanent brain damage to a patient but luckily did not.
Going public about the times when things go wrong "shows that just because you have an MD after your name doesn't mean you can't make a mistake," says Dr. Pronovost, a noted patient safety researcher who directs the Division of Adult Critical Care Medicine at Johns Hopkins Hospital in Baltimore.
"If it's OK that I make a mistake because I'm human, that also means there is an approach to make this better that doesn't just require my personal vigilance. There's a system and a science of safety here that can help."
Supporting physicians when things go wrong
Few physicians talk publicly about their medical errors, but a growing number are benefiting from programs dedicated to helping doctors deal with the emotional turmoil that often comes in the wake of adverse events.
Jo Shapiro, MD, helped start the Center for Professionalism & Peer Support at Boston's Brigham and Women's Hospital in October 2008. There are 55 physicians and other health professionals at the hospital trained to offer emotional support to peers involved in cases of patient harm.
"When there's any kind of adverse event that we hear about, one of us will make an outreach call to the physician involved," Dr. Shapiro says. "We ask them simple questions like, 'How are you doing? How are you feeling? Is there anything I can do to help you?' "
A call from another doctor means a lot, she says. "They say, 'The fact that people care about this just made me feel so much better,' " Dr. Shapiro says. The encounter gives doctors a chance to talk in confidence with a peer about the guilt, fear and shame that often accompany adverse events.
"We point out how unrealistic it is that we're trained to think that we should never make a mistake," she says. "We also validate what they are feeling. We tell them that the suffering they're feeling means that they care. We wouldn't want people not to care. It is very hard when someone comes to harm."
Other health care organizations such as Children's Hospital Boston, Johns Hopkins Hospital in Baltimore, the University of Illinois Medical Center in Chicago and the University of Missouri Health System have peer support programs, says Linda K. Kenney, president and executive director of Medically Induced Trauma Support Services in Chestnut Hill, Mass.
Kenney, who was nearly killed by a medical error in November 1999, now advises hospitals on how to disclose adverse events and support the patients, families, physicians and other health professionals involved. Nearly 400 people have requested her organization's tool kit on setting up peer support systems.
"I feel like we've reached the tipping point," Kenney says. "Several years ago, people in health care were patting me on the head saying, 'You're doing a good thing, but we're really OK.' Now, they're saying, 'We really need to do something. We're now acknowledging that things go wrong in health care.' "
Dr. Shapiro also sees momentum. She has spoken to 10 groups about peer support programs. "The interest level is off the charts. This resonates so well with the idea that we've got to do something to help each other."
Iwatch, August 4, 2011
Seattle's Qliance eliminated the middleman, and everyone seems happier
For health insurance executives, there is no scarier word than "disintermediation." It’s a fancy word that means eliminating the middleman, and those executives know that to many folks, they are the middlemen who all too often stand between patients and their doctors.
Now a small but growing number of doctors are figuring out that they and their patients can do quite well without the middleman. If this nascent trend catches on, insurance executives might soon discover that they have been disintermediated, at least as far as the delivery of primary care is concerned.
No other country in the developed world allows insurance companies to control its health care system like the United States does, and the fact that we do is one big reason why America spends so much more on health care than anyone else on the planet.
In a 2007 McKinsey & Co. report titled “Accounting for the Cost of Health Care in the United States,” the authors, who had studied numerous health care systems abroad, noted that 30 percent of U.S. health care costs are spent on administrative functions unknown in other countries.
Not only do U.S. insurance companies themselves devote up to a fifth or more of the premiums they collect from us on overhead, they also make it necessary for providers and employers to maintain large staffs doing nothing more than dealing with insurance companies all day.
Citing a 1999 study, McKinsey said the United States could spend $209 billion less every year by eliminating administrative expenses that add little if anything to quality of care. And that was in 1999 dollars. The savings would be much greater today.
Among the Americans most fed up with insurance industry bureaucracies are an endangered species of medical professionals: primary care physicians. Believing that there is no real reason why health insurers should be involved in their work at all, several have started a movement to liberate themselves.
One of the leaders of the movement is Garrison Bliss, a Seattle doctor who is one of the founders of an alliance of docs called the Direct Primary Care Coalition .
Direct primary care practices charge their patients a set amount each month, often as low as $49 for an individual. Because their patient populations are smaller than conventional practices, they are able to spend considerably more time with each patient. While most primary care doctors spend on average no more than 10 minutes with each patient, doctors in direct care practices say they spend 30 minutes to an hour with each patient.
Bliss’s practice, Qliance, charges patients between $49 and $89 per month based on age, regardless of health status. Qliance is able to offer those rates — even though it schedules appointments seven days a week — primarily because it has eliminated the costs and time associated with insurance billing. Qliance patients can also be in contact with Bliss and his colleagues by phone or email, which reduces the need for many office visits. There is no restriction on utilization of services.
Bliss told me he started Qliance because, “I had a fear that primary care itself was not going to make it.
“There were a lot of economic issues and practical issues and reimbursement issues
that had crept into primary care,” he said. “Reimbursements (from insurers) were
going down and costs were going up. As a result, primary care practices had gotten
into the habit of seeing more and more patients, doing more and more lab work and
Primary care doctors, he said, found themselves on an exasperating professional treadmill. Many doctors began retiring early and fewer medical students were even considering primary care as an option.
Bliss noted that about half of every graduating class of medical students once went into primary care. Now, he says, it’s about 10 percent, and even less at some schools.
“When primary care is weaker all kinds of disasters happen,” Bliss said. “There are more visits to the ER, people delay getting the care they need, many others end up seeing specialists and being admitted to the hospital unnecessarily.”
Bliss says that about 90 percent of health care services provided today are referred to as primary care or preventive care. And he contends that those services can be delivered more cost effectively if insurers are removed from the equation.
Bliss does not advocate the abolition of insurance companies or suggest that people who are currently insured give up their coverage. He does, however, think insurance coverage is more suitable to protecting people from catastrophic illness.
“Insurance as a business model is extremely efficient at taking care of a limited
number of very serious health-
Bliss says patient satisfaction has gone up and utilization of many medical services has gone down since he switched to the direct primary care model. Compared to more traditional practices in the Seattle area, he said, Qliance patients made 65 percent fewer visits to the ER, were hospitalized 43 percent fewer days and had 66 percent fewer appointments with specialists last year.
Lawmakers are beginning to take notice of the emergence of direct primary care practices and are passing laws at both the state and federal level to encourage their growth.
In fact, a provision of the federal health care reform law should give such practices
a big boost in 2014. When the state health care exchanges are up and running that
year, direct primary care practices can be listed as a qualified option and can be
eligible for federal subsidies for their patients so long as they have a “wrap-
Bliss is confident that by getting insurers out of the primary care business, health care costs will start to come down and patient satisfaction and outcomes will go up.
News analyst Wendell Potter , a former insurance company executive, is the author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans.
New York Times, August 1, 2011
In San Francisco, where bicycle commuters often wear full-
He was the only patient I’ve ever had who rode a bike to his medical appointments,
making his way from the docks under the Bay Bridge to our roving clinic about three
miles across town. Our clinic for uninsured patients like Carlos was actually a converted
cargo van that drove the back alleys of the city, stopping behind big-
We saw Carlos arrive in the van’s rear-
What I had noticed, though, was a growth the size of a golf ball emerging above his left clavicle that had begun to press on his airway, causing him to wheeze. “I come here as fast as I can,” he would say every time, apologizing for how long it took to ascend San Francisco’s hills.
Carlos propped himself up on the exam table in the back of the van as our nurse rushed back and forth between the steering wheel and the filing cabinets of medical paperwork chained to the walls. In a normal doctor’s office, each of Carlos’s visits would have been carefully documented in a folder labeled with his last name in block letters, slipped into a wall of manila patient records.
But here, we stapled the sheets together and slid them into an envelope at the back of a cabinet labeled “Undocumented.”
Unlike most of our other patients, Carlos didn’t have any identification. He gladly paid out of pocket for ointments and creams for incidental cuts and bruises. But what he really needed was a biopsy, a $200 procedure that, given the location of the mass in his neck, could not be done safely in the back of a van.
We could find no medical office willing to schedule an appointment for a man without identification. One private hospital sent us a typed note: “This unfortunate gentleman will not be eligible for services here.”
We told Carlos to go to the emergency room of the public hospital, San Francisco General. He was not yet sick enough to be formally admitted, though, so he sat on a gurney for six hours and was charged $1,085 for a bag of intravenous salt water he didn’t really need. He was passed a note instructing him to “follow up with your primary care provider.”
The hospital eventually gave him an appointment for a biopsy; it was scheduled in five months and three weeks. Carlos kept the yellow appointment slip in the front pocket of his overalls. He would bike with it; his sweat stained the paper until the edges wore thin.
“I will not miss this,” he said whenever we reminded him of the date. As a temporizing show of support before his biopsy, we would see him every Tuesday at 5:30 p.m. He would roll in, wheezing, but would smile after a brief breathing treatment or 15 minutes with a heating pad on his shoulder.
During those early weeks of September, the health care debates raged on television. We watched as President Obama told Congress that illegal immigrants would not get health care coverage. We heard someone yell, “You lie!”
On any given day, the bodies of illegal immigrants lie in San Francisco’s coroner’s office, found by police or firefighters in alleys or on sidewalks, unclaimed and unnamed.
Before they died, their medical costs may well have been passed on to taxpayers. But it’s also true that many were taxpayers themselves. From 2000 to 2005, illegal immigrant workers paid an estimated $6 billion to $7 billion in Social Security taxes and about $1.5 billion to Medicare, according to the Social Security Administration. And the president’s Council of Economic Advisers has estimated that illegal immigrants pay $80,000 more in taxes per person than they consume in government benefits over their lifetimes.
The question of whether to insure Carlos and others like him is really a decision about whether to pay now or later — that is, to pay for preventive medical care now, or to pay in the future for hospital and emergency services, or for the internment of unclaimed bodies.
Carlos stopped coming to his appointments. Our driver would wait an extra 30 minutes for him to reappear, brushing off demands from traffic cops to make way for the evening restaurant crowd. Weeks passed. Carlos’s friends from the docks approached the van, wondering if we had seen him.
Early one morning, a clerk at the public hospital handed me a message. Carlos’s red bike had turned up at a police auction. Sold, for $32.
I fear the growth in his throat may have been cancer, that it may have killed him. The coroner’s office cannot tell us, but it would not be that surprising, really. At the age of 50, Carlos already had surpassed by an entire year the average life expectancy of a migrant laborer in the United States.
Dr. Sanjay Basu is a resident in internal medicine at the University of California, San Francisco. This essay was written as part of the university’s Partnership for Physician Advocacy Skills program.
Dr. Sanjay Basu is a resident in internal medicine at the University of California, San Francisco. This essay was written as part of the university’s Partnership for Physician Advocacy Skills program.
Amednews, July 18, 2011
The number of small, privately owned practices continues to shrink as economic pressures
and long hours take their toll on the owner-
But private practice doesn't need to go the way of the dinosaur, experts say. There
are many reasons -
One reason is having more autonomy. If you have your own practice, you are the boss and you run your own ship, said family physician Sanford J. Brown, MD, who has had a solo practice in Fort Bragg, Calif., for more than 30 years.
You set your own work hours, implement your own philosophy of care, spend as much
time as you want with a patient and are not strangled by policy like you could be
when working for some larger medical groups, said Nina Grant, vice president, managing
agency director, with Practice Builders, an Irvine, Calif.-
"You can design your own office the way you want it," said family physician Roland A. Goertz, MD, president of the American Academy of Family Physicians. "If you can't be happy in that environment, I'm not sure what environment you could be happy in."
Maintaining a strong sense of personality is another reason to keep your practice.
"This is what people went into medicine for. Plus, doctors tend to be Renaissance
In addition, a practice can match a physician's values. Dr. Goertz lives in a church-
You can create a legacy. When a doctor builds a practice, he or she develops trust between themselves and patients that continues to grow and becomes bigger than just the doctor, Grant said. It also includes paraprofessionals and other staff in the practice.
Other reasons why a physician should not sell his or her practice:
* You despise politics: Grant said large conglomerate-
* You have a loyal staff: You're paying your staff's salary so they're loyal to you when you have your own office, Dr. Brown said. Irene Doti, a spokeswoman for Practice Builders, said doctors like to keep their own staffs and some doctors have a difficult time relating to hospital staffs. Plus, Doti said some physicians hire family members, including spouses, to help run their private practices. "The reality is, if the doctor works for someone else, the family member probably won't be able to come, too," she said.
* You have guaranteed income: Once you sell your practice, you have no guarantee of an ongoing income, Grant said. Dr. Brown said the only real job security in today's medical marketplace is the patients. If one mismatched patient leaves your practice, there still are plenty of others. However, if there is a mismatch between a doctor and his or her employer, it could leave the doctor without a job.
* Your practice is filling a need: Dr. Goertz said there are certain areas in the country that will need independent small practices because their location doesn't attract a large number of physicians or large groups.
* You don't have to work around the clock: Dr. Brown said most areas have hospitalists,
who free solo practice physicians from making those rounds. "That really freed up
my time in the last 10 years," he said. Dr. Goertz said physicians can retain their
independent practices, but share after-
* Your practice can make a good income: "The biggest fear of some doctors is they won't be able to make it financially. I believe that is an irrational fear," Dr. Brown said. He said small physician practices like his can survive, provided doctors know the nuts and bolts of business. For instance, he said practices tend to be too heavy on the payroll side. "My rule of thumb is one employee per doctor," said Dr. Brown, who offers tutorials at his office to show doctors how they can successfully operate on their own. You can cut costs by not buying expensive décor and sharing overhead with other practices, Dr. Goertz said.
Grant said small practices can grow their income by bringing in additional cash revenue
through ancillary products like weight management, hormone balance, allergy management,
nutrition supplements and an on-
* It makes you happy: Last, but not least, is the personal satisfaction factor. Experts say many established physicians and new residents went into medicine to be in their own practice, and that is what makes them happy. A heavy college debt load and other economic factors cause them to look for a set income and other perks of being an employee. But Dr. Goertz advised, "Doctors shouldn't look at just the monetary gain they could get from selling their practice. They need to look inside themselves and ask will they be happy."
Iwatch, June 30, 2011
Firms lure consumers into 'high deductible' plans with lower premiums. But guess what happens later?
More and more Americans are falling victim to one of the most insidious bait-
It also explains why the insurance industry and its allies are pulling out all the stops to kill a measure in the California legislature that could protect state residents from losing their homes and being forced into bankruptcy if they get seriously sick or injured.
On June 2, the California Assembly passed AB 52, a bill that would give state regulators the authority to reject excessive health insurance rate increases. Similar legislation has been introduced in other state legislatures, but nowhere are the stakes higher than in California—not only because AB 52 would allow the insurance commissioner to turn down requests for unjustifiably high rate hikes, but also because it would enable the commissioner to reject increases in deductibles as well.
Over the past several years, insurers have been implementing a strategic plan to
“migrate” (their term) all of their policyholders out of traditional indemnity and
managed care plans into so-
At first glance, these plans appear to be a good deal to a lot of people. Not only are the premiums relatively more affordable, but also the deductibles usually appear to be manageable—again, at least at the outset.
Insurers are aggressively marketing high-
I was still serving as head of corporate communications at CIGNA when the company
went full replacement. If we wanted to continue receiving subsidized coverage, we
had no choice but to leave our HMOs and PPOs and enroll in a high-
One of the rationales for going full replacement is that if employers don’t do that,
workers who are older or who have chronic conditions requiring expensive care will
stay in their low-
As young and healthy people happily desert managed care plans for high-
Former California Insurance Commissioner and now Congressman John Garamendi saw this
coming several years ago and did his best to halt the growth of high-
Garamendi, regrettably, was prescient, although probably even he would be amazed at how fast the forced exodus from HMOs and PPOs would be and how soon the day would come when plans with affordable copayments would be a thing of the past.
The industry’s long-
Many of the people who made that statistic possible undoubtedly had experiences similar
to my son, Alex, who was initially enrolled in a Blue Cross PPO. To take advantage
of lower premiums, he switched in 2009 to a “consumer-
I noted in a previous column that Kaiser Permanente, California’s biggest insurer,
was part of an industry-
And once insurers have people locked into these plans, they are free in most states to raise the deductibles to astronomical heights, as Anthem Blue Cross has done in Maine and Indiana.
Earlier this year, many people enrolled in Anthem’s plans in Maine, especially it’s
Campground owner Mike Stella told Kofman that all of his salary and part of his wife’s goes to health insurance. “Another rate increase is probably going to put us over the top,” the Portland Press Herald quoted him as saying.
Stella said he and his wife pay nearly $1,000 a month in insurance premiums, and they must spend $17,000 a year—more than his annual salary—on premiums and medical care before their Anthem policy starts to cover their costs.
Another small business owner, John Costin of Kennebunk, said Anthem had notified
him that the monthly premium for his $30,000-
“We ration our health care,” he said. “We do whatever we need to for the kids (but) my wife and I delay trips to the doctor. We don’t fill prescriptions.”
Matters could be even worse for the Stellas and Costins if they lived in Indiana,
where Anthem’s for-
So now you see why insurance companies are spending millions of their policyholders premium dollars lobbying federal lawmakers to weaken last year’s health care reform bill to allow them to continue marketing these outrageous plans at the same time they’re lobbying state lawmakers to kill legislation that would empower regulators to reject excessive increases in rates and deductibles.
By being able to shift more and more of the costs of care from them to American families, they will continue to rack up record profits. Good luck finding a single insurance company executive or shareholder who will express any concern—or even any interest—in the lives of millions of people ruined by such greed.
The Economist, June 16, 2011
Private firms are taking baby steps to curb soaring health costs.
ABOVE a valley in Pennsylvania sits an old hospital that gives an optimistic hint
about the future of American health care. Geisinger Health Systems was founded in
1915 but is as adaptable and creative as a start-
Geisinger is changing the way it delivers primary care, co-
America spends far more on health care than other countries, such as Britain (see
article). The waste is staggering (see chart). The main problem is loopy incentives.
Topmost among them is a plan for Medicare to reward “accountable care organisations” (ACOs) for keeping people healthy, rather than lavishing treatment on them. The plan seems sensible enough. But it has provoked uproar in every corner of the health industry. This month the Centres for Medicare and Medicaid Services (CMS), the body that oversees government health schemes for the old and the poor, was barraged with irate letters about it.
An entrenched system is hard to change. Hospitals currently have little incentive to keep patients healthy. On the contrary, fitter patients would mean lower volumes and smaller margins, says Michael Nugent of Navigant Consulting, an expert on ACOs. Nevertheless, the current system is clearly unsustainable.
Wonks have buzzed about ACOs for years. In 2005 CMS began a pilot with ten health systems, including Geisinger, to reward them for improving the quality of care while lowering costs. America is dotted with examples of reform. Utah’s Intermountain Healthcare is a hospital system with its own health plan. Clever use of data has helped to streamline care: a new protocol for delivering babies has reduced the number of unplanned caesarean sections and saved about $50m a year.
Insurers are experimenting with reform as well. Aetna, Humana and Wellpoint are testing
new payment models. In Massachusetts, Blue Cross Blue Shield has created an “alternative
quality contract” that gives hospitals a fixed budget for a patient, with additional
rewards for improving the quality of care. In the programme’s first year hospitals
cut the number of unnecessary emergency-
“The train is moving in the right direction,” says Mark McClellan, a former head of CMS who has championed ACOs. Real progress, however, requires change in the public sector. Medicare, the public health programme for the old, provides a whopping 35% of American hospitals’ revenue.
CMS’s proposed rule for ACOs would allow doctors, hospitals and other health providers
to form networks to co-
Alas, the regulations are a mess. “The ACO policy is an example of why the government
is not always a great change agent,” sighs Chip Kahn, president of the Federation
of American Hospitals. The insurance lobby frets that the rules will prompt hospitals
to merge, reducing competition and driving up prices. The American Hospital Association
says that the rewards for saving money are too low and the risks too high. The rules
include 65 quality measures, more than twice the number in CMS’s earlier, smaller
pilot. “I was very disappointed with their over-
CMS is likely to make at least some changes to the programme. “I’m delighted to have the feedback,” says Donald Berwick, CMS’s boss. Last month Dr Berwick unveiled a few new enticements for ACOs, such as more flexible rules for experienced hospitals such as Intermountain. But it is unlikely that the ACO programme will be in place by January, as originally planned.
Dr Berwick points to other efforts to spur reform, including a pilot scheme to improve
primary care and new penalties for hospitals where too many patients acquire new
diseases or are readmitted because their treatment failed. The trick will be aligning
these programmes with one another—and with innovations in the private sector. Health-
New York Times, June 7, 2011
Blue Shield of California, a large nonprofit health insurer that has come under sharp
criticism in recent months for its double-
The insurer said it would limit its profit to no more than 2 percent of its revenue and said it already planned to return $180 million, the profit the company says it made above its 2010 target.
“With our 2 percent pledge, we hope to make coverage a bit more affordable for our members,” Bruce Bodaken, Blue Shield’s chairman and chief executive, said in a speech at the Commonwealth Club in San Francisco. “But more important, we want to demonstrate that health care affordability, which is the key to universal coverage, is Blue Shield’s top priority.”
In a telephone interview, Mr. Bodaken said: “It’s one further step in a long series of steps in which we believe that we and others all need to step up and reduce the cost of health care.”
While it is unclear whether other insurers will make similar pledges, the federal health care law is aimed at making sure insurers are not able to set their premiums too much above their costs. Some experts expect other insurers to take similar actions as the law goes into effect.
“This would be the logical next step,” said Timothy S. Jost, a law professor at Washington and Lee University, who said some insurers have already started considering similar refunds. Last September, for example, Blue Cross and Blue Shield of North Carolina said it planned to refund $156 million to policyholders.
Blue Shield of California said it would refund $167 million to policyholders, typically giving them a 30 percent credit toward one month’s premiums. A family of four, for example, may receive $250 toward the cost of a policy. Hospitals and doctors that participate in programs aimed at better coordinating care for patients will receive $10 million, and the insurer’s foundation will receive $3 million.
As a nonprofit, the insurer does not generate returns for investors but uses any money it earns to further its mission.
An early proponent of many of the changes in the federal health care law, Blue Shield has been the target of public outcry. Like many nonprofit insurers, Blue Shield has been criticized for seeking large premium increases and for maintaining overly generous reserves. Federal and state regulators are increasingly scrutinizing the rate requests of all insurers because of the federal health care law, and medical costs have been lower than many companies had anticipated, leading to substantial profits.
Mr. Bodaken said the decision to limit profits was made well before state insurance regulators raised concerns about its rate increases. Earlier this year, Blue Shield bowed to pressure from regulators and consumer groups and dropped a request for higher rates. “It really has nothing to do with our rate increases,” he said.
California lawmakers are considering legislation that would give state regulators the authority to approve insurers’ rate requests before they go into effect. Federal and state officials emphasized that Blue Shield’s actions did not diminish the need for strong regulatory oversight.
Kathleen Sebelius, the secretary of health and human services, said in a statement: “While such voluntary efforts are great for Blue Shield’s policyholders in California, today’s announcement also reinforces the importance of the Affordable Care Act and rigorous state review of insurance rates.”
California’s state insurance commissioner, Dave Jones, who has pushed for state legislation that would allow him to block excessive rate increases, said Blue Shield’s action demonstrated the need for the law. “The announcement is an admission by an insurer, in this case a nonprofit insurer, that they are making excessive profits,” he said.
The insurer’s profits about doubled from 2009 to 2010 and he said its $3.5 billion in reserves were higher than regulations require.
Consumer advocates also emphasized that Blue Shield’s pledge did not change the need for regulators to make sure insurers were not charging people too much. “Certainly, there are some consumers who will be getting rebates who will welcome the news,” said Anthony Wright, executive director of Health Access California, a state advocacy group. Still, he said, “consumers should not be overcharged on the front end.”
Given the recent outcry over its high rate requests and the generous pay package of its chief executive, which amounted to $4.6 million last year, Blue Shield may be trying to improve its image, Mr. Wright said.
To address the high cost of health care, Mr. Bodaken said that insurers like Blue Shield must work with hospitals, doctors and patients to address some of the underlying cost pressures. But he said the insurer’s goal was to demonstrate that it was not seeking higher profits when it asked for higher rates.
“It makes it very clear that we are not about profits,” he said. “We are about getting people health care they need and deserve.”
New York Times, May 19, 2011
WASHINGTON — Alarmed at soaring premiums and profits in the health insurance industry, the Obama administration demanded on Thursday that insurers justify proposed rate increases of more than 10 percent, starting in September.
Kathleen Sebelius, the secretary of health and human services, issued a final rule establishing procedures for federal and state insurance experts to scrutinize premiums. Insurers, she said, will have to justify rate increases in an environment in which they are doing well financially, with profits exceeding the expectations of many Wall Street analysts.
“Health insurance companies have recently reported some of their highest profits in years and are holding record reserves,” Ms. Sebelius said. “Insurers are seeing lower medical costs as people put off care and treatment in a recovering economy, but many insurance companies continue to raise their rates. Often, these increases come without any explanation or justification.”
Federal health officials proposed the 10 percent threshold in December. The insurance industry criticized it as an arbitrary test that could brand a majority of rate increases as presumptively unreasonable. But the administration rejected the criticism and insisted on the 10 percent standard in the final rule, issued Thursday.
Starting in September 2012, the federal government will set a separate threshold for each state, reflecting trends in insurance and health care costs.
In some states like New Hampshire, groups of more than 20 workers have experienced premium increases of around 20 percent this year, while smaller groups have seen increases of 40 percent or more. At the same time, insurance agents say, coverage is shrinking as deductibles have increased and insurers limit the choice of hospitals.
To ensure that “consumers get value for their dollars,” the new health care law required annual reviews of “unreasonable increases in premiums.”
Under the new rule, federal and state officials will review rates in the individual
Federal officials acknowledged that they did not have the authority to block rates that were found to be unjustified. But they said many states had such authority, and the federal government is providing $250 million to states to strengthen their capacity. A small number of states, opposed to the federal health care law, have turned down the money.
The new rule says a rate increase is unreasonable if it is excessive, unjustified or “unfairly discriminatory.” An increase is deemed excessive if it is “unreasonably high in relation to the benefits provided.”
Consumer advocates generally welcomed the rule. “The days of insurance companies running roughshod over consumers and jacking up rates whenever they want are over,” said Ethan S. Rome, executive director of Health Care for America Now, a coalition that includes labor unions and civil rights groups.
Insurers said the rule did nothing to address the underlying costs of health care, which they described as the main factor driving up premiums.
“If we believe health care costs are crushing the economy, we ought to have a debate about how to bring costs under control,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. “Focusing on premiums diverts attention from that debate.”
In many cases, Ms. Ignagni said, rate increases of more than 10 percent may be justified by rising health costs and the tendency of younger, healthier people to drop coverage, forcing up costs for other policyholders.
States will have the primary responsibility for reviewing rate increases. “But if a state does not have the authority or the resources to conduct a review, our department will step in,” said Ms. Sebelius, a former state insurance commissioner in Kansas.
Under the rule, as part of an effective rate review program, states must have “a mechanism for receiving public comments” on proposed rate increases.
Elizabeth P. Sammis, the acting insurance commissioner in Maryland, said this would be a big change. In many cases, she said, consumers learn of premium increases when they receive notices in the mail, and then they call the commissioner’s office to ask, “Why are rates going up?”
Amednews, May 16, 2011
When a physician practice's cash flow slows, there are many strategies for coping until the stream begins running again.
In 2008, the cash flow of the medical practice of Daniel Lensink, MD, an ophthalmic plastic surgeon in Redding, Calif., slowed to a trickle. A large insurer significantly cut reimbursement rates for covered reconstructive procedures. The recession meant that fewer patients were having noncovered cosmetic procedures. He had plenty of Medicare patients to fill up his schedule, but as expenses went up, Medicare pay rates stayed flat.
"When I entered medicine, there was a promise that if I took care of everybody who
came my way, I could make a living," said Dr. Lensink, who has a solo practice with
His practice has returned to financial health, but, like many others, seasonal variations, economic fluctuations, regulatory changes, issues with private payers, severe weather and office burglaries all can create a cash crunch. There are several ways a practice can ride out these storms and survive, although effective solutions vary. Choosing the wrong option can worsen the situation.
"Physicians should think of themselves as small-
Dr. Lensink got through the rough patch by tapping into a long-
"I had the home line of credit for a rainy day, and I was afraid to ask [for a business
loan] when the banks were in such turmoil. I just didn't think they would lend money
to a business in the red, and I had that home-
Experts recommend that practices hold three to six months of cash in reserve to cover any shortfalls. This is common advice for nearly any business or individual managing personal finances, but many physicians say money is so tight that this may be unfeasible.
"My practice has a lot of expenses, and it's not possible at this point," said Warren Brandle, MD, a family physician in solo practice in Gold River, Calif. His practice has an unsecured line of credit that has been tapped into three times in 13 years to help pay taxes.
Borrowing from yourself
Unable to build or maintain a practice reserve, many physicians access other options. The most common step is to tap into personal reserves or defer salary. For instance, Dr. Lensink didn't pay himself in 2009, although he did cover the payroll for his staffers. Dr. Gruss frequently defers her compensation in the first few months of the year, when cash is tight.
"Payroll comes No. 1," Dr. Gruss said. "We have to make payroll, and we have to pay the bills."
Deferring salary is really a form of lending to the practice, but linking personal and professional funds in this way is risky. Most practices are in some type of corporate structure to protect personal assets, but the protection can be lost if personal and professional funds are merged.
"Once the money is put into the practice entity, it becomes available for creditors," said Bob Berg, an attorney with EpsteinBeckerGreen in Atlanta who works with medical practices. "If a physician commingles their personal stuff with their business stuff and they stop following corporate procedures, that raises a whole different risk. It's called piercing the corporate veil. Some could allege that a physician did not follow corporate formalities, and this could put the physician's personal assets at risk."
Aside from dipping into personal funds, there are other resources for short-
The credit crunch has loosened somewhat, and physicians are attractive to banks and other sources of credit. Medical practices can contact a bank for a secured or unsecured line of credit, preferably before problems occur.
"It's worth talking to a bank now," said Manoj Pawar, MD, vice president of clinical operations and physician leadership development at Catholic Health Initiatives in Englewood, Colo. "When there is a problem with cash flow, they are not going to be as open to talk to you."
Experts recommend that practices have access to a credit line that can cover at least three to six months of operating expenses. "You want to have access to six and hope you only have to use three," said Michael Fleischman, a principal at GatesMoore, a health care consulting and accounting firm in Atlanta.
Secured lines tend to have lower interest rates and usually are connected either to a medical practice's assets or accounts receivables.
If a practice owns a medical office building, this is not usually a source of additional lending. Most medical practices that own their offices hold them in a separate corporation, and borrowing against the building and then having the corporation lend to the practice could get incredibly complicated.
Borrowing, however, may not be the only answer. If short-
"Where doctors get in trouble is when they are taking out every cent on a monthly basis," said David Wold, CEO of Health Information Services in Park Ridge, Ill. "It creates a lot of stress for the practice."
Experts recommend that practices conduct an audit to determine where cash is going out and whether it is coming in appropriately. Audits can address cash shortfalls when they occur but also may be a way of preventing those shortfalls.
"The first goal is really to make sure [the shortfall] doesn't happen," said Marc Lion, president of the National CPA Health Care Advisors Assn.
"And if it does happen, take a look at your billing, collection and denial-
This can be carried out within the practice or by an outside consultant or accountant. "It all depends on the skill set of the folks that are there to be able to tell you about the shape of your practice," said Kevin Weinstein, vice president of marketing at ZirMed, a revenue cycle management company in Louisville, Ky.
If an outside entity is brought in, the price of an audit or revenue analysis would vary widely. It can be as much as a few thousand dollars per physician, although experts said the payback can be significant.
People who conduct audits say expenses are rarely the root of the problem. The way money comes in is usually the issue. "We always try to look at ways to work with practices to lower expenses, but the more common problem is billing," Fleischman said.
For instance, if a practice is having problems with cash flow at the beginning of the year, is it possible to collect more at the time of service? When a patient has met a deductible, can insurance claims be submitted more quickly? Are they usually submitted correctly?
"Revenue cycle management is so critical, especially when the co-
Looking at all concerns
Audits also may identify other issues. Office staff might not be following up on denied claims. Claims may not be coded properly.
Is the front desk verifying insurance and collecting appropriate co-
"You want to understand what you are actually collecting and what you are not collecting," Weinstein said.
For example, a few years ago, Eric Ramos, MD, a solo family physician in Modesto,
Calif., was outsourcing his medical billing and noticed that his accounts receivables
were growing but that his balance sheet was not. So he brought the billing back in-
"If you don't manage billing, if you don't oversee things in your practice, you are
going to go bankrupt," Dr. Ramos said. "It's very difficult for a physician to be
a practitioner and a business person at the same time, but you have to make sure
that the business end is working well, is productive and is well-
He has borrowed money from his family to keep his practice going, but these loans have been repaid.
Such an analysis may reveal staffing problems that explain why various billing procedures are not being completed. Having too many people run the practice can get expensive. Having too few means that some tasks that bring money into the practice, such as submitting clean claims and following up on denials, are not getting done.
"Sometimes you need to spend more money to bring money in," Fleischman said.
As for Dr. Lensink, he is slowly paying off the home-
PBS NewsHour, May 3, 2011
Anybody who's got more than one medical condition knows the drill. You go to the cardiologist with a heart problem. You go to the orthopedic surgeon if your back hurts. You find an oncologist if you need chemotherapy.
They all get paid by an insurance company or the government (if you're on Medicare or Medicaid) or by you. But it's rare when all three doctors talk to each other and they almost never compare notes. You see each one of them in a kind of vacuum. And you, the patient, are left to figure out what each piece of your medical puzzle means to the other.
Meanwhile, the chances are good that all three doctors have ordered expensive tests that may duplicate each other.
It could be that the back problem has something to do with your heart problem or the cancer is causing one of the other two conditions to get worse. But the only way you'll ever find out is if you take all of your doctors out to dinner, sit them down at the table and lock the restaurant door.
Fragmentation and unnecessary testing are two of the hallmarks of medical care in the United States. They're also a major factor in what's driving the cost of health care through the roof. The Kaiser Family Foundation has just released its annual report on health care spending in the United States and found that $7,538 a year is now spent on each American. That's at least $2,535 more or 51 percent higher than Norway, the next largest per capita spender.
The rate of growth in health care spending is also going up faster than any other industrialized nation. If this trend keeps up it won't be many years before health care accounts for more than a quarter of the nation's gross domestic product.
Enter a new idea: The Accountable Care Organization (ACO), a key provision in the new federal healthcare law.
One of it's promoters is Dr. Eliott Fisher who for 30 years has headed the Dartmouth Atlas which painstakingly has documented the discrepancies in American health care, and although questions have been raised in some quarters about the research, most health policy professionals rely on the work.
Dartmouth found that a person who lives in one county could have health care costs of more than $15,000 a year, while his neighbor one county over with the same condition costs $5,000 a year. And the guy who has the $15,000 tab is no better off health wise than the neighbor who cost the system $5,000.
So Fisher suggests that doctors, hospitals and other providers get together and coordinate care for their patients. The idea is that these ACOs would improve medical care to patients and save money.
Theoretically, these health care providers would get together and decide what the
average cost per year is to treat people who live in that part of the country, and
stick to that amount. At the end of the year, providers who can prove their patients
got better care and didn't spend all of the pre-
Dartmouth found that a person who lives in one county could have health care costs of more than $15,000 a year, while his neighbor one county over with the same condition costs $5,000 a year.
That would mean you would no longer have to go one place for your heart, another for you back and still another to get chemotherapy. You would get one stop shopping all within this group of doctors. And guess what? The doctors would all TALK to each other about your various medical conditions.
Some so called integrated health systems have been practicing this kind of medicine for years. The Cleveland and Mayo Clinics come to mind, along with the Geisinger Health System in western Pennsylvania. But they are hospital systems where the doctors are on salary, not paid for each service they provide like most of the rest of the country. That's called fee for service.
Under the new ACO concept doctors would still be paid on a fee for service basis. But Fisher and other supporters of this idea believe better coordinated care would spell less expense because there would not be so many duplicative tests performed. And another point, these ACOs would all have electronic medical records so the computers could talk to each other.
Rules from the federal government on how to do these Accountable Health Organizations recently were made public after months of anticipation in health policy circles.
Basically, they say there should be at least 5,000 patients in each ACO. Groups of doctors would form networks where patient information was shared. There would be doctors, health care providers and Medicare recipients on each ACOs board of directors. And the population of each ACO would consist entirely of Medicare patients at the outset.
When the rules were announced, Health and Human Services chief Kathleen Sebelius said Accountable Care Organizations will "improve the quality of care patients receive and help lower costs."
Another major figure in the movement to ACOs is Dr. Mark McClellan who heads the Engelberg Center for Health Care Reform at the Brookings Institution. He also knows his way around the federal government, having served as both Commissioner of the Food and Drug Administration and head of the Centers for Medicare and Medicaid Services.
Dr. McClellan told the PBS NewsHour online that ACOs will "enable care providers
to get paid more when they do what they really want to do for patients-
"It's not a silver bullet," he said, but "done right it can be an important new resource for health care providers."
Dr. Jay Goldsmith, who's an associate professor of Health Science at the University of Virginia is not so sure. He is not a fan of ACOs. He thinks the new networks will be nothing more than "a cost containment compact between ad hoc care providers and Medicare," and he says "this is going to be something that is done to patients, not WITH them."
After reading 102 pages of the new regulations which cover 472 pages, Dr. Goldsmith said: "I have this huge headache. I'm going to get up at 5:30 tomorrow morning, drink three cups of coffee and see how much father I make it before I get another headache."
Goldsmith doesn't see that much difference between Accountable Care Organizations and Managed Care plans run by Health Maintenance Organizations in the 1980's, which were a flop because they were a "value system" which made doctors make choice to compromise care.
Some members of the American Medical Association are also skeptical of ACOs. Dr. Jeremy Lazarus, speaker of the AMA's House of Delegates, told American Medical News ACOs will only work is doctors want to participate. "For this to happen," he said, "significant barriers must be addressed, including the large capital requirements to fund an ACO and to make required changes to an individual physician's practice."
Michael Cannon, director of health policy studies at the libertarian CATO Institute was more blunt. He said he gives the concept of ACOs "zero percent" chance of making significant savings and he doubts doctors will want to join because they "will get paid less."
So the verdict is out. But it doesn't take rocket science to understand the U.S.
must do something about the amount of money it's spending on everyone's health care.
Experts on both sides of this ACO argument agree on that -
The New York Times, April 21, 2011
Earlier this week, The Times reported on Congressional backlash against the Independent Payment Advisory Board, a key part of efforts to rein in health care costs. This backlash was predictable; it is also profoundly irresponsible, as I’ll explain in a minute.
But something else struck me as I looked at Republican arguments against the board, which hinge on the notion that what we really need to do, as the House budget proposal put it, is to “make government health care programs more responsive to consumer choice.”
Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.
What has gone wrong with us?
About that advisory board: We have to do something about health care costs, which
means that we have to find a way to start saying no. In particular, given continuing
medical innovation, we can’t maintain a system in which Medicare essentially pays
for anything a doctor recommends. And that’s especially true when that blank-
Hence the advisory board, whose creation was mandated by last year’s health reform.
The board, composed of health-
Before you start yelling about “rationing” and “death panels,” bear in mind that
we’re not talking about limits on what health care you’re allowed to buy with your
own (or your insurance company’s) money. We’re talking only about what will be paid
for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence
didn’t declare that we had the right to life, liberty, and the all-
And the point is that choices must be made; one way or another, government spending on health care must be limited.
Now, what House Republicans propose is that the government simply push the problem of rising health care costs on to seniors; that is, that we replace Medicare with vouchers that can be applied to private insurance, and that we count on seniors and insurance companies to work it out somehow. This, they claim, would be superior to expert review because it would open health care to the wonders of “consumer choice.”
What’s wrong with this idea (aside from the grossly inadequate value of the proposed
vouchers)? One answer is that it wouldn’t work. “Consumer-
But the fact that Republicans are demanding that we literally stake our health, even our lives, on an already failed approach is only part of what’s wrong here. As I said earlier, there’s something terribly wrong with the whole notion of patients as “consumers” and health care as simply a financial transaction.
Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.
That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.
The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.
Kaiser Health News, March 31, 2011
Accountable care organizations take up only seven pages of the massive new health law yet have become one of the most talked about provisions. This latest model for delivering services offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. A cottage industry of consultants has sprung up to help even ordinary hospitals become the first ACOs on the block.
Yet the concept has been short on details. ACOs have been compared to the elusive unicorn: everyone seems to know what it looks like, but no one has actually seen one. But the health care industry has already embarked on a frenzied quest to create them as quickly as possible. Today, after many delays and false starts, the Obama administration proposed guidelines on how ACOs will work.
Here is a brief guide to what we know about ACOs.
What is an accountable care organization?
An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the new law, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.
Think of it as buying a television, says Harold Miller, president and CEO of the Network for Regional Healthcare Improvement and executive director of the Center for Healthcare Quality & Payment Reform in Pittsburgh. A TV manufacturer like Sony may contract with many suppliers to build sets. Like Sony does for TVs, Miller says, an ACO would bring together the different component parts of care for the patient – primary care, specialists, hospitals, home health care, etc. – and ensure that all of the "parts work well together."
The problem today, Miller says, is that patients are getting each part of their health care separately. "People want to buy individual circuit boards, not a whole TV,” he says. “If we can show them that the TV works better, maybe they'll buy it," rather than assembling a patchwork of services themselves. "But ACOs will need to prove that the overall health care product they’re creating does work better and costs less in order to encourage patients and payers to buy it."
When will ACOs begin operating?
The ACO initiative is scheduled to launch in January 2012, but the race to form ACOs has already begun. Hospitals, physician practices and insurers across the country, from New Hampshire to Arizona, are announcing their plans to form ACOs, not only for Medicare beneficiaries but for patients with private insurance as well. Some groups have already created what they call ACOs.
Why did Congress include ACOs in the law?
As lawmakers search for ways to reduce the national deficit, Medicare is a prime target. With baby boomers entering retirement age, the costs of the program for elderly and disabled Americans are expected to soar.
ACOs would make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work they’d have to seamlessly share information. Those that save money while also meeting quality targets would keep a portion of the savings. But some providers could also be at risk of losing money.
HHS estimates that ACOs could save Medicare up to $960 million in the first three years. That’s far less than one percent of Medicare spending during that period. If the program is successful, it can be expanded by the Secretary of Health and Human Services.
How would ACOs be paid?
In Medicare’s traditional fee-
If an ACO is not able to save money, it would be stuck with the costs of investments made to improve care, such as adding new nurse care managers, but would still get to keep the standard Medicare fees. The law also gives regulators the ability to devise other payment methods, which would likely ask ACOs to bear more risk. For example, an ACO could be paid a flat fee for each patient it cares for.
How would an ACO be different for patients?
Primary care doctors who are part of an ACO would be required to tell their patients. But although physicians will likely want to refer patients to hospitals and specialists within the ACO network, patients would still be free to see doctors of their choice outside the network without paying more. ACOs also will be under pressure to provide high quality care because if they don’t meet standards, they won’t get to share in any savings – and could lose their contracts.
Who's in charge — hospitals, doctors or insurers?
Hospitals, doctors and insurers are all vying to run ACOs. Kelly Devers, a senior fellow at the nonprofit Urban Institute, explains that the question was left purposely vague in order to be flexible. "We know there are a range of provider organizations" that could manage an ACO, "but we don't know which one is superior."
Some regions of the country, including parts of California, already have large multispecialty physician groups that may become an ACO on their own, likely by networking with neighboring hospitals. "A lot of health care organizations are going to dust off the existing structures they had in place" in the past, Devers says.
In other regions, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment required by an ACO.
Some of the largest health insurers in the country, including Humana, United Healthcare and Cigna, already have announced plans to form their own ACOs. Insurers say they can play an important role in ACOs because they track and collect data on patients, which is critical for coordinating care and reporting on the results.
If I don't like HMOs, why should I consider an ACO?
ACOs may sound a lot like health maintenance organizations. "Some people say ACOs are HMOs in drag," says Devers. But there are some critical differences – notably, an ACO patient is not required to stay in the network.
Steve Lieberman, a visiting scholar at the Engelberg Center for Health Care Reform at the Brookings Institution and the president of Lieberman Consulting Inc., explains that ACOs aim to replicate "the performance of an HMO" in holding down the cost of care while avoiding "the structural features that give the HMO control over [patient] referral patterns," which limited patient options and created a consumer backlash in the 1990s.
What can go wrong?
Lieberman cautions that ACOs are not a panacea. "ACO has become the three-
Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs.
But Lieberman says while ACOs could accelerate consolidations, it’s already "such a powerful and pervasive trend that it's a little like worrying about the calories I get when I eat the maraschino cherry on top of my hot fudge sundae. It's a serious public policy issue with or without ACOs."
Are there any possible legal concerns?
Doctors, hospitals and others in the health care industry have raised concerns that
ACOs could run afoul of antitrust and anti-
To help providers avoid legal problems, the U.S. Justice Department's antitrust division
promises to provide an expedited antitrust review process for these new doctor-
Kaiser Health News, March 25, 2011
As governors across the land struggle with fiscal pressures and pepper the federal government with requests to scale back Medicaid – many people are losing sight of the fact that health care reform (what some call ObamaCare) requires a huge expansion of Medicaid.
In fact, in just three years the nation is expected to start insuring about 32 million uninsured people. About half will enroll in Medicaid directly. If the Massachusetts experience is repeated, most of the remainder will be in heavily subsidized private plans that pay providers little more than Medicaid does.
That raises an important question: How good is Medicaid? Will the people who enroll in it or in private plans that function like Medicaid get more care, or better care, than they would have gotten without health reform? The answer to that question is not obvious. In fact it's probably fair to say that we are about to spend close to $1 trillion over the next 10 years insuring the uninsured and we really don't know what we expect to accomplish by spending all that money.
Here's a stab at an answer. The 32 million newly insured may not get more health
care. They may even get less care – because of difficulties getting a doctor. And
even if they do get more, odds are that low-
Both anecdotal and scholarly reports from Massachusetts are consistent with this prediction. The wait to see a family doctor in Boston is now longer than in any other U.S. city. More people are going to emergency rooms for their care in the state than before its health reform became law. A Boston cab driver went through a list of twenty doctors (a list the state's Medicaid program gave her!) before she found a doctor who would see her. A preliminary report on the state as a whole found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. Further, state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.
That brings us back to the initial question: Is Medicaid real insurance? Or is there little practical difference between being on Medicaid and being uninsured? It would appear at the margin that there's not much difference.
Currently there are roughly 10 million people in the U.S. who are eligible for Medicaid and CHIP but have not bothered to enroll. That implies that for about one in every six eligibles, Medicaid insurance is not worth the effort it would take them to fill out the enrollment papers!
Consider the case of Dallas emergency rooms. At Parkland Memorial Hospital both uninsured and Medicaid patients enter the same emergency room door and see the same doctors. The hospital rooms are the same, the beds are the same and the care is the same. As a result, patients have no reason to fill out the lengthy forms and answer the intrusive questions that Medicaid enrollment so often requires. At Children's Medical Center, next door to Parkland, a similar exercise takes place. Medicaid, CHIP and uninsured children all enter the same emergency room door; they all see the same doctors and receive the same care.
Interestingly, at both institutions, paid staffers make a heroic effort to enroll
people in public programs -
Clearly, Medicaid enrollment is important to hospital administrators. It determines how they get paid. Enrollment may also be important to different sets of taxpayers. It means federal taxpayers pay more and Dallas County taxpayers pay less. But aside from the administrative, accounting and financial issues, is there any social reason we should care?
Economics teaches that people reveal these preferences through their actions. If
people act as though they are indifferent between being uninsured and being on Medicaid,
we may infer -
Against this conclusion, there are two counter arguments worth considering. First,
some claim that transactions costs (administrative difficulties) are the real reason
why so many eligibles don't enroll. At Parkland and Children's Hospital those costs
are close to zero, however. Second, there is the argument from paternalism: that
people will be better off if we push them into Medicaid, whether they prefer it or
not. But even on that score, the evidence is weak. A very comprehensive RAND study
found that the type of insurance people have -
Health economist Austin Frakt takes issue with these studies, claiming that Medicaid
Bottom line: after we get through 10 years of spending our $1 trillion under ObamaCare, there is no convincing reason to believe that the bottom half of the income distribution will have more care, better care, or better access to care than they have today.
Amednews, March 21,2011
Practicing medicine will present new challenges and opportunities after new rules
are implemented -
Complying with meaningful use rules can earn bonus money for your practice from Medicaid
or Medicare -
As hospitals and practices prepare for attestation of having met the requirements, many convened at the 2011 Healthcare Information and Management Systems Society annual conference in February in Orlando, Fla., to learn what they can expect after going electronic.
Meeting meaningful use will involve more than receiving incentive pay up to $44,000
from Medicare or nearly $64,000 from Medicaid for using an EMR. It means a lot of
Those changes are expected to trickle down even to those who have no plans to seek the incentives, said Natalie Berger, PhD, chair of the HIMSS Ambulatory Information Systems Committee. So physicians need to prepare. "Right now it's only Medicaid and Medicare providers ... getting those reimbursements. But eventually [private] payers are going to follow those guidelines. And then I think patients are going to demand it. It's no longer going to be OK to go to a doctor's office that doesn't have your records or doesn't know you are allergic to those medications."
Some of the changes EMRs bring will be for the better, some for the worse, depending on how the change is managed. Much of the 2011 HIMSS conference focused on those changes, and how physician practices and hospitals could prepare for them. Many discussions revolved around five basic themes: patient engagement; reporting; collaboration; efficiencies; and security and privacy.
Patients will be more involved in their care
With more information in their hands because of meaningful use, and more data available to physicians at the time of a visit, patients are going to be more involved in health care decisions, experts said at HIMSS. One way meaningful use rules address this is by granting patients access to medical records, including diagnostic results, problem lists and medication lists.
Many practices and hospitals already provide this access through patient portals,
many of which combine data with patient education tools. Some of these organizations
offered a glimpse of what other practices can expect when the physician-
Michael Solomon, PhD, is practice lead of eCare Management at the Coral Springs,
"If we expect the patient to play a critical role in a patient-
For Miramont Family Medicine, a family medicine practice in Fort Collins, Colo.,
adopting an EMR meant that patient visits were more meaningful because of the information
available and collected at the time of visit. John Bender, MD, a family physician
at Miramont, said "value-
"Now that doesn't sound large," he said, "But a 3 [percentage point] improvement
across all 10,000 patients we were seeing at the time -
Dr. Bender said this was especially significant, given that the average appointment time increased from 41 to 51 minutes after going electronic. Doctors are documenting several metrics they weren't documenting before, and patients "are getting a lot more time per visit with the physician."
Doctors will find it easier to see how they're doing
Stephen Wagner, PhD, vice president of Carolinas Healthcare System, division of medical education and research, said patients can be engaged, but measures are needed to see how that engagement has affected their outcomes.
"We're very good in health care at finding things that make lots of intuitive sense, and then we find out sometimes too late or way down the road that they really aren't working the way we thought they would," he said. "We need better intermediate markers."
EMRs are expected to make these intermediate markers easier to measure what is and isn't working. Before Miramont installed an EMR, Dr. Bender said, only 42% of diabetic patients had an A1c documented within the past year. Since implementation, the practice improved its metrics reporting to 91%.
"We all think we're doing a good job but had no way of knowing that. We had to find out where we are," he said. "We finally knew how many diabetic patients we had."
"Doctors are Type A. You give them a report card and ... then they start working really hard and they will fix [the problems]. And they will do it on their own without being told," he said.
Physicians will collaborate more with other doctors
When physicians are making decisions about a patient's care, "it's not about the data, it's about the knowledge that you create," said Hal Wolf, senior vice president and chief operating officer of the Permanente Federation, which represents Kaiser Permanente's eight Permanente Medical Groups.
Wolf said elderly, chronically ill patients see, on average, 14 physicians. Those doctors collectively write an average of 50 prescriptions a year during the course of 37 clinical visits.
The interoperability spelled out under meaningful use means that measures of progress
physicians have access to also are available to other members of the patient's care
team. This interoperability, and the subsequent collaboration of care team members,
will help ensure that integrated patient-
EMRs "create a fully integrated approach to an entire effort to take care of a patient,"
he said. "When you have the information, as you all know, you have turned the magical
corner, because every caregiver is looking at one up-
Dept. of Health and Human Services Secretary Kathleen Sebelius said in her keynote address to HIMSS attendees that, on a national level, having this integration will make it easier for doctors to compare treatments quickly and cheaply to see what works. "Those same records connected together can help spread the knowledge at the speed of light throughout our health care system. In the Obama administration, we look at health IT not just as an opportunity to grow our economy but also as a powerful tool to help improve the health of our nation."
Despite all the promises of improved efficiencies and quality of care, experts are quick to warn that practices need to identify inefficiencies before even looking at an EMR. They must know how an EMR system will help solve those inefficiencies. Otherwise, they could be made worse by going electronic.
You must build a foundation before you implement and have a clear plan for execution, said Paul Kleeberg, MD, clinical director of REACH, the federally funded regional extension center serving Minnesota and North Dakota. The execution plan needs to address work flow and process problems that, if not addressed, will plague EMR adoption.
"Turning on the [EMR] will be like shining the flashlight in the corner. You get to see all the cockroaches," Dr. Kleeberg said.
"That which was bad before gets worse," said Tina Buop, chief information officer of Muir Medical Group in Walnut Creek, Calif. When a practice goes electronic, there will be a "beacon light" shining on poor work practices.
She used the example of physicians taking patient files home at the end of the day. "It's now a beacon light, because everyone will now know they didn't finish charting that day."
Buop said the importance of training and work flow tracking during implementation cannot be overstated, because work flow changes when a new technology is introduced.
After implementation, physicians might discover new data that come to doctors electronically. But a lot of the work of charting that data can be delegated to medical assistants or nurses. Otherwise, physicians may find that the workday has gotten longer, she said.
Physicians will need a firmer grip on data security
One area that is a relatively minor provision in the stage 1 meaningful use requirements, but needs to be a major focus of any adoption plan, is patient privacy and security, Buop said.
The stage 1 requirements include only one line on security and privacy, she said. "And it's a shame, because privacy and security, honestly, can be one of the biggest nemeses of the success of stage 2 and stage 3" meaningful use criteria.
Under stage 1, a gap risk assessment needs to be conducted that will identify security and privacy vulnerabilities. Stages 2 and 3 have not yet been finalized but will focus on an increased use of data, which could create more vulnerabilities.
The confidentiality, integrity and availability of data is part of the Health Information Portability and Accountability Act, which is separate from meaningful use, Buop said.
"If you are a solo practitioner with your own EMR and are trying to qualify for meaningful use, you are responsible for the information for privacy and security," she added. That means you need processes in writing that ensure confidentiality, integrity and availability of data.
Pittsford, N.Y., pediatrician Alice Loveys, MD, is the chief medical information officer for the Monroe County Medical Society Health Information Technology Service Bureau, which assists physicians in technology issues. She strongly suggests that practices have a HIPAA security manual in place at the start of implementation. The manual is something a practice develops and writes itself that details how it ensures the security of patient information.
She said developing the manual is no small feat, and something that the RECs cannot do for a practice, because each one is unique to that practice. But the REC can help direct doctors to other resources that can help.
Physicians Practice, March 15, 2011
You are probably hearing a lot about patient centered medical homes (PCMH) these days. Perhaps an insurance company that you participate with has sent you information about a medical home incentive or you've learned that your state Medicaid program pays additional fees to practices that have PCMH accreditation. Whatever your level of interest, considerable investment in time, resources, and money is required for practices to make the transition to becoming accredited as medical homes. To help you assess your readiness and make the transition, here are a few guidelines to get you started:
Assess your practice
1. Take a look at your practice's current policies and procedures to determine if your practice operations currently meet with the basic tenets of a PCMH. Looking at the NCQA survey standards for PCMH is a good place to start.
2. Determine if adjustments need to be made to foster the creation of a patient-
3. Identify gaps in processes and policies and move forward with developing a plan of action that will allow your practice to meet all standards for recognition as a PCMH. Some of the items that may need to be addressed include:
• Staffing needs and education
• Technology — current needs and efficient usage
• Patient outreach, tracking, and follow-
• Evidence based medicine and decision support
• Care coordination, resource integration, and care management
• Scheduling and access
4. While a practice does not have to obtain NCQA recognition as a medical home (or other certifying bodies), doing so greatly increases the credibility of your practice's model and provides leverage for payment discussions at the payer level.
Create a plan of action
1. Once you've identified the gaps, determine how best to fill them. You'll need to create a solid and implementable plan of action. This will require you to draft protocols and train staff on how to work within them; implement scheduling changes; improve resource utilization through reallocation and job enhancements; and improve patient education.
2. After you’ve begun implementing these changes, monitor your progress regularly
to see how you are doing. Re-
Apply for certification
Submitting an application for accreditation can be a daunting process. In addition to providing protocols and policies, there is a lot of supporting documentation that needs to be submitted, along with the application fee. You may also need to gather three months worth of data to prove that criteria for accreditation are being met. But don't be discouraged, the benefits to your practice will more than make up the inconvenience.
Educate your patients
Lastly, educate your patients on the medical home model and their responsibility for participating in their own care. You can advertise your practice's PCMH accreditation in your reception area and exam rooms, and also post this information on the practice website. You should explain what a patient centered medical home is and how it benefits your patients. Two ways to accomplish this are: 1) publishing a short article in your practice newsletter and 2) creating a pamphlet on the PCMH to be distributed to your patients. Also, don't forget to give your patients a "being responsible for your own care" brochure to get them actively involved in playing their part too.
When done right, transforming your practice to a medical home model can reap big dividends in improved patient care, more effective practice operations, and a better bottom line.
Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She can be reached at email@example.com or by visiting www.theverdengroup.com.
Health Resource Online, March 7, 2011
Everyone enjoys a pay raise for a job well done – physicians are no exception – but in some instances, financial incentives for healthcare performance may actually backfire.
That’s the conclusion of a UCLA study, showing that patient-
Hector P. Rodriguez, assistant professor in UCLA’s School of Public Health and his colleagues found evidence that certain kinds of financial incentives for the purpose of improving patient care, in combination with public reporting of medical group performance ratings, have a positive effect on patient care experiences. They also found that some types of incentives may have a negative overall impact on how patients experienced their care.
Rodriguez looked at how medical group performance ratings changed over time and found
that ratings in specific measures, representing three broad categories – physician
communication, care coordination and office-
Incentives for addressing the quality of patient-
The greatest improvements were seen within those groups that placed less emphasis on physician productivity and greater emphasis on clinical quality and patient experience. Within groups where financial incentives were paid directly to physicians, Rodriguez found that placing too much emphasis on physician productivity actually had a negative impact on the experiences patients had when visiting their primary care physician.
Medical groups were free to use the additional funds in various ways, with some groups paying incentives directly to physicians and others using the incentives more broadly, focusing on organizational priorities. The groups also participated in a public reporting program in which ratings in two of the three broad categories were released annually to the public in the form of a "healthcare report card" comparing the performance of the medical groups and insurers to one another.
Rodriguez’s research team based its findings on information collected from 124,021
patients of 1,444 primary care physicians at 25 California medical groups between
2003 and 2006. It conducted interviews with group medical directors to determine
how financial incentives were used. All 25 groups, which represent six insurers,
were awarded financial incentives for achievements in the broad categories of clinical
care processes, patient care experiences and office-
The Fiscal Times, February 3, 2011
Beyond the legal challenges, a major new hurdle is emerging for the health care reform law. Recent studies show that the major players in the health care marketplace – insurers, hospitals and physician practices – are consolidating, which increases the likelihood they will collude on prices charged to employers and to consumers and defeat cost control measures in the law.
Government officials are already grappling with the issue as they move to implement one of the signature cost control elements of reform – the formation of Accountable Care Organizations (ACOs). Conceived as a delivery system alternative to health maintenance organizations, ACOs are supposed to achieve greater coordination of care by linking together physician practices and hospitals, and will be financially rewarded if they improve quality while lowering costs.
The rules for ACOs, which are being written now, won’t go into effect until next year and will only apply to the Medicare market. While the Centers for Medicare and Medicaid Services (CMS) is likely to endorse several different payment models, the law calls for sharing savings when the Medicare payments for beneficiaries covered by the ACO fall below recent regional trends.
Top officials at the Centers for Medicare and Medicaid Services are already worried
some of the new entities will become a vehicle for recouping Medicare losses. Raising
rates in the private market would ultimately undermine any short-
“There will be parties out there who want to repackage what they do and call it an ACO,” CMS administrator Donald Berwick told a forum at the Brookings Institution earlier this week. “We have to maintain the integrity of markets and not let concentrated entities emerge.”
That’s exactly what happened in California over the last decade after hospitals merged
and physicians joined large independent practices to counter the price-
A national study conducted for the Robert Wood Johnson Foundation found that after the merger wave between 1990 and 2003, 90 percent of large metropolitan area hospitals wielded excessive market power as defined by the Federal Trade Commission. The study suggested the mergers raised prices by anywhere from 5 to 40 percent (depending on how close the merged facilities were to each other) and probably led to lower quality.
The fear now is that “ACOs could make an existing problem marginally worse,” said Robert Berenson, a senior fellow at the Urban Institute, who conducted the California survey. “The issue is market power.”
It isn’t just mergers and consolidation that give provider groups greater market
power. Sometimes insurers need to include prestigious institutions within their networks
– like Cedars Sinai Hospital in Los Angeles, which caters to Hollywood stars and
is the focal point for their high-
Some large hospital chains use their dominant status in a few of their markets to drive up rates everywhere in the chain. Sutter Health, for instance, which has more than two dozen medical centers and hospitals in separate northern California cities, requires insurers to sign “all or none” contracts, according to Berenson.
Blue Shield of California, a major insurer in the state, wanted CMS to set the ground
rules for ACOs. “In order to qualify for safe harbor treatment under antitrust laws,”
Paul Markovich, chief operating officer of Blue Shield, wrote, the agency must insist
that “an ACO . . . that is part of a multi-
Meanwhile, the insurance industry continues to come under fire from consumer groups and the medical profession for its monopolistic practices. While the insurance exchanges, which were ruled unconstitutional by a Florida federal court earlier this week, were designed to address the lack of competition in the individual and small group market, they will have minimal impact on large groups which deal mainly with major insurers like UnitedHealth, Wellpoint, Cigna and Aetna.
The American Medical Association’s bi-
“High concentration levels in health insurance markets are largely the result of consolidation, which likely has led to the exercise of market power and, in turn, harm to consumers and providers of care,” the report said. “Past and future consolidation of health insurers should raise serious antitrust concerns.”
America’s Health Insurance Plans, the industry trade group, commissioned a study the last time the AMA issued its report that faulted its methods. “Research examining competition in health care markets increasingly points to provider consolidation as a significant factor contributing to rising health care costs,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry trade group.
Most experts who study the dysfunctional health care marketplace say both sides are correct when it comes to accusations about excessive market power. “I would say both provider and insurer concentration are problematic to high quality, efficient and sustainable health care system,” said Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University. “In different markets, insurers, hospitals or physician groups wield disproportionate market power. Where one has it, the others and consumers suffer.”
The net effect of these dueling monopolies, he said, is that providers can easily demand higher prices. Insurers, because they face minimal competition, simply pass those costs along. The tab for both is paid by employers, families and government agencies.
The Federal Trade Commission, which didn’t file any cases against hospital mergers between 1999 and 2007 and has only filed three since, promises to step up its monitoring of the health care sector. But it generally looks favorably on the emergence of ACOs, at least as conceived under the reform law. “We need to make sure that they drive down health care costs,” FTC chairman Jon Leibowitz said recently, “but vertical integration can sometimes be good.”
“We’ll have a better chance of holding down costs through rate regulation than by using antitrust,” argued Berenson of the Urban Institute. “Where there is a dominant insurer or two, there is no competitive pressure to take on provider market power. It is easier to get along.”
NEJM, January 2011
The emergence of health reform and a burgeoning arena of physician and hospital payment
reforms are spawning a new crop of buzzwords and ways of paying physicians for their
services. Most industry watchers agree that the fee-
Although FFS’s replacement hasn’t been developed, the movement toward a new payment
model has begun. The way physicians are compensated will evolve as pay-
On the plus side, changes associated with health reform are expected to translate into improved physician reimbursement for previously poorly compensated or uncompensated services, improved quality, and better care coordination. However, some physician organizations are understandably concerned that payment reforms, as well as compensation structures based on them, could have problematic consequences.
In the American Medical Association’s (AMA’s) recent report, “Pathways for Physician Success Under Healthcare Payment and Delivery Reforms,” author Harold Miller, executive director of the Center for Healthcare Quality and Payment Reform, cites one example. If separate services are bundled into an episode or combined for the purposes of a single payment, physicians’ payment may then depend on the number or cost of services other providers deliver. Likewise, physicians could be docked for poor quality care delivered by another physician.
Although it’s unlikely that the emerging payment models will directly affect physicians’ paychecks in the next year, that change is surely coming, predicts Benjamin Isgur, director of PricewaterhouseCoopers’ Health Research Institute. As reimbursement changes and ACOs and other models move into the marketplace, physicians should expect compensation model adjustments. “There is a lot more tinkering with these incentive mechanisms now,” Mr. Isgur reported. “Over the next two to four years, step two will be that as reimbursement changes, how employed physicians are compensated will change as well. But how do you develop the right mix between salary, and quality and patient experience incentives? That’s very top of mind right now for hospital executives.”
Internist and infectious disease specialist Ardis Hoven, MD, chair of the AMA board of trustees and a frequent speaker on health and payment reform, urges physicians to educate themselves about current payment systems and stay abreast of and participate in reform developments.
“Participation in ongoing quality improvement initiatives that help physicians collect
data is an important first step as our system begins to explore transitioning away
from a strictly fee-
As the brave but uncertain world of health reform unfolds, what can physicians heading into initial practice opportunities or making a move to new ones expect in compensation models? Changes occurring now are mostly subtle, but there’s greater focus on quality incentives than in the past, suggested Jeffrey Milburn, a consultant with the Medical Group Management Association who focuses on physician compensation and financial management.
“The models we’re seeing appear to stress quality, production, and utilization incentives in the larger practices and integrated systems,” he observed. “Usually, these incentives amount to 5 to 10 percent of the base compensation, and some are set up as reward or risk only.”
What that means, Mr. Milburn explained, is that employing entities might use compensation
“withholds” until physicians meet the objectives. That’s a model he doesn’t agree
with because it’s inherently negative, but it is one that’s taking hold in some large
organizations. On the other end of the spectrum, progressive organizations are focusing
on the positives. “Some employers are using bonus-
The trend toward employing physicians and devising multifaceted bonus structures has gained even more impetus in the past two years, as hospitals move toward tighter alignment with or even full ownership of physician practices. Although that model gained steam in the early 1990s, it all but disappeared a decade later when it proved a deterrent to productivity.
Incentive plans, regardless of how they’re structured, are becoming more prevalent
in part because of the movement toward employment and away from private-
MHA data also shows a decline in salary-
These trends are revealed in findings from a May 2010 focus group of residents and
fellows conducted by the national physician recruiting firm Cejka Search in St. Louis,
Missouri. Nearly 82 percent of the 150 physician participants rated production incentives
as either important or very important, and 78 percent preferred that model over either
salary only or income guarantees. Only 6.5 percent preferred income guarantees, while
15 percent were drawn to salary-
“Generally, salary only is a turnoff. In conversations with hundreds of physicians
every week, our consultants report that candidates are not interested in a straight
salary, but a base-
The era of physicians being able to choose from a reasonable variety of compensation
models will likely end, Mr. Milburn predicts, if structures such as ACOs and episodes
of care become predominant care-
“Newer doctors coming in will still receive the base compensation rate that they negotiate, I think, at least for the first few years. However, whoever hires and pays them ultimately will want to switch to a compensation model that reflects how they’re reimbursed,” Mr. Milburn said. “We won’t see this tomorrow, but it will evolve over the next few years and then employers will jump on this model.”
CNN Money, February 16, 2011
NEW YORK (CNNMoney) -
Weiss, an independent provider of insurance company ratings, based its findings on a study of 852 health insurers.
The study showed that medical costs fell 1.6% in the first nine months of 2010.
For all of 2010, Weiss estimates that insurers' medical expenses,will fall 3% less 'reinsurance costs' bought by health insurers to limit risk.
"This is a critical change from the steady and rapid increases of prior years," said Gavin Magor, senior insurance analyst for Weiss.
"If it continues in 2011, it should help boost health insurer profits while also
pressuring them to curb premium increases and give consumers some much-
Insurers have been increasing premiums between 6% and 8% every year, blaming the
increases on the annual double-
Some insurers, such as Blue Shield of California, have recently threatened their customers with even more premium hikes of as much as 59%.
That makes the Weiss report even more startling.
0:00 /3:40The $50,000 bionic leg
Said Magnor, "It is a significant finding and it's hard to pinpoint the reasons for this change in trend at this point."
Even though total enrollment in health insurance declined slightly in 2010, Magnor said that downtick was not large enough to push medical costs lower.
However, Michael McRaith, director of Illinois department of insurance, says that while medical costs are actually rising, insurers may have taken steps to counteract the increases.
"It may be that as health care costs become increasingly expensive, insurers are more aggressively excluding people from coverage, denying payment of claims or more aggressively pricing coverage so that fewer people can afford to pay premiums," McRaith said.
"Any one of those reasons could explain why insurers are paying less or flat amounts
on medical expenses at the same time that some publicly-
The report showed that among the companies that reported a decline in medical costs, Aetna's (AET, Fortune 500) medical expenses fell by 14.1% in the first nine months of 2010 versus the same period a year earlier.
Keystone Health Plan West's medical costs also fell by 11.1% in that period.
However, that decline wasn't felt across the board. Group Health's medical costs rose more than 16% while Blue Cross of Idaho saw a 12.9% increase in medical expenses in that period.
Weiss' study was based on mandatory data on medical expenses that health insurers provide to the National Association of Insurance Commissioners.
America's Health Insurance Plan, the trade group of health insurers, was not immediately available to comment on the report.
The Hill, February 14, 2011
The White House on Monday unveiled a budget proposal that prevents cuts in Medicare payments to doctors while leaving other healthcare providers largely unscathed.
The budget's two-
"The administration's in a political battle with Republicans who are basically telling
docs, if you support our goal of repealing (healthcare reform), we'll use the money
(from the law's subsidies) for a doc fix," said healthcare analyst Alexander Vachon,
a former Republican Senate aide. "The minimum bid here was a two-
Republicans have made a permanent repeal of the SGR part of House committees' mandate as they prepare replacement legislation for the healthcare reform law.
The American Medical Association initial response Monday was favorable.
"The President’s budget includes a renewed commitment to permanently fix the broken Medicare physician payment system, which the AMA strongly supports," AMA President Cecil Wilson said in a statement. "It also contains funding to delay the devastating cuts scheduled to occur January 1, 2012 for another two years, which is important for providing stability in the Medicare system while a permanent solution is enacted."
While placating the AMA, the administration is proposing $62 billion in offsets that largely avoid other providers such as hospitals and home health agencies. Instead, the budget proposal offers up White House and Democratic priorities that have so far failed to gain traction in Congress.
For example, the budget proposes saving $2.3 billion by getting generic versions
of biologic drugs to market faster. The White House wants the brand-
The nation's biotech industry association said the move contradicted President Obama's State of the Union address call to invest in research and technology.
"Under this proposal, most biotech firms would be unable to recoup their investments in new medicines which ordinarily top $1 billon and involve 15 years of research and development," the Biotechnology Industry Organization said in a statement.
The budget would also save $8.8 billion by restricting generic manufacturers' ability to drop patent challenges in exchange for cash payments from drug makers, another proposal that has so far failed to clear Congress.
The pharmaceutical industry would turn out to be the biggest loser in the president's health budget. Pharmaceutical companies agreed to $80 billion in cuts to help pass the healthcare reform law, and less than a year after it was enacted, the Obama administration is asking for more.
"We think that the beneficiaries of Medicare and Medicaid and the taxpayers of this
country deserve to have the best possible outcomes with the most effective and cost-
President Obama's Medicare chief deflected a question about which offset proposals he expected to receive the most opposition in Congress.
"I don't know yet," said Centers for Medicare and Medicaid Services Administrator
Don Berwick. "I think there have been some very wise choices made about where the
The Washington Post, February 10, 2011
As governor of Kansas, I saw up close the urgent need for health-
The Affordable Care Act puts states in the driver's seat because they often understand
their health needs better than anyone else -
The truth is that states aren't just participating in implementation of the law; they're leading it.
Consider the state-
Although the law gives states the option to design and run their own exchanges, some critics have claimed this could burden states if they're not given adequate resources and flexibility.
I agree. But what these critics miss is that the law already gives states most of the resources and flexibility they're asking for.
States have discretion, for example, to offer a wide variety of plans through their exchanges, including those that feature health savings accounts. Utah and Massachusetts already operate exchanges but take very different approaches: Utah allows all insurers to participate; Massachusetts has stricter standards. Under the law, both approaches could work.
States also have the flexibility to decide what benefits plans must offer. They can choose to require basic protections, based on the typical benefits people get through their jobs, or set higher standards.
And states' costs of designing their exchanges will be fully funded by the federal government through 2015, with additional funds available to help determine which residents are eligible.
Some critics have said there has not been enough analysis of how exchanges would
The law gives states new flexibility in Medicaid, too. Beginning in 2014, states
will be able to offer more affordable Medicaid benefits that resemble typical employer
plans. Because costs of long-
The law does make Medicaid available to more working families. But the federal government will cover 96 percent of this expansion, and nonpartisan experts suggest that states will save money overall through reductions in the "hidden cost" they pay for uncompensated care provided to the uninsured.
The Affordable Care Act gives states incredible freedom to tailor reforms to their needs. The one thing the law does not permit is going back to the broken health insurance system we had a year ago.
Since the law was passed last March, our department has worked with states to keep
premiums down, hold insurers accountable and give Americans more freedom in their
I look forward to working with governors to build on these achievements. States are
the laboratories of our democracy, and I will continue to welcome their ideas about
how to improve the law or implement it more effectively. What we cannot do is allow
this progress to be blocked or reversed by overheated rhetoric about a "government
takeover of health care" -
The writer is secretary of health and human services.
Physicians News, February 7, 2011
As many physicians have concluded, out-
The benefits of participation may be eroding. Participation does not reward providers
with reimbursement rates that reflect the physician’s level of service and clinical
skills. To the contrary, out-
The Benefits Participation do not Accrue to the Provider
A provider’s participation with an insurance carrier contractually locks in the insurer’s cost for medical services. The participating provider contract specifies a fee schedule which places limits on the physician’s reimbursement for services rendered. From the insurer’s perspective, a provider’s participation is a great mechanism for controlling costs and predicting expenses. The insurer has economies of scale, and is able to use its market presence to ratchet down reimbursement rates. The patient also benefits from a provider’s participation, through the depressed contractual reimbursement allowances. Additionally, the patient can also estimate treatment costs through the existence of a fixed fee schedule. Physicians generally have little to no leverage in negotiating with insurance carriers over fees. (Exceptions to this generalization sometimes exist depending on the size of the physician group or the type and availability of the particular type of physician specialty.) Consequently, from a reimbursement perspective, the benefits of a physician’s participating provider status belong to the insurance carrier and patient.
In contrast, the physician may benefit by electing to pursue a non-
The Hurdles Facing Non-
Exceptional service and value are inducements that the physician may offer to substantiate
the higher cost to the patient. Value is extremely relative in today’s medical marketplace.
As copayments and deductibles have risen in recent years, so too have the patient’s
expectations. Higher out of pocket costs have generally led consumers to demand
more. Value may be demonstrated in many ways, ranging from board certifications,
acclaim, and bedside manner. The non-
A more controversial strategy to induce patients to use a non-
Some Potential Legal Risks of a Non-
Some states have made it illegal to waive patient’s deductibles and copayments for
commercial health insurance plans. In addition, the physician using such a strategy
may face potential statutory risks to his/her ability to practice medicine. Federal
legislation may also be applicable. Even if there are no state statutes that make
the waiver of copayments and deductibles illegal, the physician may be subject to
civil claims made by the insurance carrier if copayments and deductible are routinely
waived to induce patients. Prior to pursuing an out-
In New Jersey, an ambulatory surgery center terminated its participation with Horizon
Blue Cross. Thereafter, the surgery center continued to provide services to Horizon
subscribers, but on an out-
In another New Jersey case, Aetna filed a complaint against a chiropractor alleging
insurance fraud, negligent misrepresentation, and tortious interference with Aetna’s
subscriber contracts. Aetna alleged that the chiropractor waived the patients’
There are legal and ethical considerations in play when a physician practice engages
in an out-
MarketWatch, February 1, 2011
Health insurers are consolidating their market power throughout the nation as nearly
In its annual examination of the potential for monopolies among health insurers, the American Medical Association contends that in 60% of the nation’s 359 largest metro areas, the two largest health insurers had a combined market share of 70% or more.
The study also finds that in 48% of cities, one insurer had a market share of 50% or more. AMA’s examination also finds that virtually all — 99% — of health insurance markets in the U.S. are “highly concentrated” according to Department of Justice and Federal Trade Commission guidelines.
“The market power of health insurers places physicians and patients at a significant disadvantage,” Dr. Cecil B. Wilson, the AMA’s president, said in a press release. “When insurers dominate a market, people pay higher health insurance premiums than they should, and physicians are pressured to accept unfair contract terms and corporate policies, which undermines the physician role as patient advocate.”
The study, however, has often become a bone of contention for America’s Health Insurance
Plans, the trade group that represents managed-
Speaking just before the study was available, AHIP President Karen Ignagni said that
a variety of health coverage is more widely available than AMA studies in the past
have contended. She adds the examinations “cherry pick” data to paint a monopolistic
picture but often doesn’t include figures from self-
“In the past, the data have been seriously flawed,” Ignagni said.
The AMA counters, however, that the lion’s share of the self-
AHIP officials also point out that one state highlighted for its heavily concentrated market, Alabama, has some of the lowest insurance rates in the nation.
The AMA study shows that 93% of the state’s combined preferred-
The New Doctor in the House: Consolidation
Other states where a single insurer controls at least half the market include Alaska, Arkansas, Hawaii, Idaho, Illinois, Iowa, Kansas, Louisiana, Maine, Massachusetts and Michigan.
There’s also Minnesota, Mississippi, Nebraska, New Hampshire, North Carolina, Rhode Island, South Carolina, South Dakota, Tennessee and Virginia.
The study didn’t examine four states, including North Dakota, which at last check was found to have its Blue Cross Blue Shield in control of more than 90% of the market.
But the paper did find that in 24 states, the two largest insurers had combined share of 70% or more. Growing more consolidated were markets in Florida, New Mexico, Oklahoma, South Carolina and Tennessee.
The AMA points out that figures from 2008 show that the health insurance market is getting more consolidated on every front.
In its 2008 examination, the AMA found that the two top insurers held a combined share of 70% or more in 53% of the markets. It also says the earlier study showed a single insurer with a majority market share in 44% of the cities and that the two largest insurers held a combined 70% share in 18 states.
Managed Care Information Center, January 25, 2011
Insurance plans encouraging patients to receive care from physicians who keep medical costs lower are based on unreliable information, according to a new RAND Corp. study. Notably, estimates of doctor performance may not achieve the intended savings.
The first major assessment of physician cost profiling found that about one-
Health purchasers have focused cost-
"Our findings raise questions about the utility of cost profiling tools for high-
RAND analyzed insurance claims information for 2004 and 2005 from four Massachusetts
health plans that covered about 80 percent of the non-
Studying 28 physician specialties in detail, researchers found that only about 40 percent of physicians had cost profile scores that were at least 70 percent reliable – a common threshold for reliability –and fewer than 10 percent of physicians had cost profiles that were at least 90 percent reliable.
Reliability of Physician Cost Studies
Among physicians in a hypothetical two-
Funding for the study was provided by the U.S. Department of Labor.
Using statistical tools, researchers evaluated the reliability of physician cost
scores by considering factors such as the number and types of patients physicians
treated. The results show that the reliability of cost-
Researchers also examined how reliability scores might change across several different scenarios, suchas requiring at least 30 episodes of treatment to create a profile and different methods for assigning episodes to physicians. While some scenarios modestly increased reliability, the results still fell short, according to the study.
"These ranking systems may be useful for some purposes, but they are not reliable enough at this point to make decisions about encouraging patients to see certain providers or excluding some doctors from insurance networks," Adams said.
He said the current systems may be useful for efforts such as warning physicians that their treatment methods appear to cost more than those used by their peers and urging them to reexamine their practice styles.
While cost profiling shows promise as a strategy to reduce health costs, it cannot be successful until more robust tools are developed to use claims data and other information to create reliable cost profiles for physicians.
NPR, January 19, 2011
Confused about the new health law? You’re not alone. Over the past couple of weeks,
All Things Considered asked listeners to e-
One question, by far the most common query, accounted for nearly half the e-
Q: How accurate is the Republican mantra that the new law kills jobs?
A: According to the Republicans, the job toll is about 650,000. But that statistic — which the GOP says comes from the Congressional Budget Office — has been pretty thoroughly debunked, among others by the group factcheck.org.
It turns out that what the CBO actually said about job loss is that the law would allow people to stop working because they could get health insurance — not prompt employers to cut jobs or fire people.
Now there are estimates that some low-
Dane Schumacher, of Huntsville, Ark., is full-
Q: Will I be required to purchase health insurance? If so, how in the world does the government expect me to afford to do so?
A: In a word, no. People who earn less than 133 percent of the poverty line (about $14,400 in 2010; soon to be updated for 2011) will get Medicaid coverage, which costs them nothing. That's a big change. Before the law, qualifying for Medicaid meant you had to be poor and belong to another specific group, such as single mothers or the blind. Now you’ll just have to have a low income.
But there are other exceptions to the insurance requirement. You also won’t have
to buy insurance if your income is too low to owe federal taxes (which is about $10,000
this year for an individual; about $18,000 for a couple) or if the lowest-
Steve Rosenbaum asks from San Rafael, Calif., about what will happen to privately administered Medicare plans.
Q: What will be the situation when the new health care law ends Medicare Senior Advantage? Will the law require my HMO to continue my coverage/membership and provide a Medicare supplemental program at a reasonable cost?
A: First, the law doesn't end Medicare Advantage. That's a myth. It does reduce substantial subsidies the Republican Congress added to the program as part of the 2003 Medicare prescription drug law. Those were supposed to get more seniors to leave the traditional Medicare program and join privately managed care and other types of health plans.
The Medicare Payment Advisory Commission found in 2009 those plans were getting 14 percent more per beneficiary than it actually cost to provide Medicare's basic benefits.
Now it's true that the last time Congress cut subsidies to private Medicare plans, back in 1997, many of them left the market, and beneficiaries were upset. But this time the cuts are going to be much more gradual and are much less dramatic, and most analysts predict that the vast majority of beneficiaries will still have access to an affordable plan.
Dave Manley of Boston wonders why the law is taking so long to kick in.
Q: Why does most of the current law not go into effect for several years? If the purpose of the bill is to expand and improve health care in the U.S. and reduce its cost, why the multiyear rollout?
A: Two reasons. One, as Republicans are fond of reminding everyone, is that it does
help with budgeting to push some of the costs outside the 10-
But the there's a more nuts-
Now could they have made most of this health law operational Jan. 1, 2013, rather than 2014? Probably. Could they have made it start Jan. 1, 2012? Probably not.
Q: A friend of mine works for a law firm in New York City. The owners of the law firm said that when the new health care law takes effect, they will just refuse to provide health insurance for their employees and accept the government's fine for not providing it. They said this will be cheaper than actually providing the required health insurance. If this is true, wouldn't all companies do this? What is there in the law to prevent companies from blatantly refusing to provide health insurance for their employees? How will these employees of the law firm obtain health insurance if their company refuses to provide it?"
A: First, of all, let's get straight what's required and what isn't. There's no employer mandate in the law. For employers with fewer than 50 workers, there's no requirement — period. For those with fewer than 25 workers, there’s actually a tax credit to help them pay for coverage for their workers. But for those with more than 50 employees, there is a potential penalty. That would kick in if they don't offer coverage and have workers who go into these new health insurance exchanges they have incomes low enough to qualify for government subsidies. Those penalties are $2,000 per worker. And some companies may well do that.
But if they do, those workers will be able to get coverage in the new exchanges, so they won't be left high and dry. Plus, most businesses will still offer coverage as a way to recruit and retain workers, according to several surveys done of business executives. And, in Massachusetts, which already has a mandate for individuals, employer coverage has actually gone up since it was implemented, not down.
Here's one from Marita Eddy of Silver Spring, Md.
Q: What are the new rules regarding Flexible Spending Accounts and Medical Savings Accounts?
A: For those of you who are unfamiliar with these, they are various types of savings
accounts from which you can pay medical bills that aren’t covered by your health
insurance. The main new rule this year is that as of Jan. 1, you can no longer be
reimbursed for over-
Starting in 2013, there's another change, at least for the Flexible Spending Accounts
— you’ll be limited to putting away just $2,500 a year tax-
Both changes are not for policy reasons, but to help pay for the rest of the health law.
Mark Sandifer from Seattle asked about the profits of insurance companies in various parts of the world.
Q: I've read that the return on investment for health insurance companies averages around 16 percent. How does that compare with other countries?
Private insurance — particularly for-
Fierce Health Finance, January 19, 2011
If, understandably, Rep. Gabrielle Giffords (D-
If the House was actually run like a small business with 435 employees, its human
resources manager would get a rude shock: the premiums it paid for healthcare coverage
would skyrocket due to the cost of Giffords' treatment (in reality, the Federal Employees
Health Benefits Program is community rated, but many private sector plans are not).
The business might have to start cost-
The Patient Protection Act isn't perfect, but it will expand coverage to 30 million Americans who currently have no insurance at all, whose physical devastation would be joined with financial ruin should some random madman shoot them in the head. And I could go on and on about how reform would actually assist the House's most gravely wounded member. But why should I?
The GOP's continued press to repeal reform after the Tucson bloodbath and its outrageously
named resolution ("Repealing the Job-
Such a question is going to be left to the voters in 2012, who hopefully will kill some jobs on their own: those held by the politicians who don't see a hole in their colleague's head as a wound to be healed at all costs, but an unpleasant distraction to be sidestepped as surely as a puddle on the sidewalk.
HealthLeaders Media , January 6, 2011
With rapid changes in healthcare comes a new vocabulary with terms and phrases every provider should know.
Culled from journal articles, conferences, blogs and other media, some of these phrases might not be all that new. But it's our bet that even if you've heard some of them before, you're going to hear a lot more references to them in 2011.
EHR is a complete, long-
An EHR, also connects multiple providers, such as hospitals and clinicians, laboratories, and prescription and/or pharmacy histories, test results, and care notes for a particular patient.
Also see Meaningful Use, the phrase whose definition is specified in federal regulations governing dispersal of stimulus refunds and credits to providers who achieve it with their electronic record systems.
2. Creative Destruction. The oxymoronic phrase that's derived from economic theory refers to the healthcare idea that in order to create a new healthcare system, we will have to tear down the old one, as referenced in a Nov. 11 article about accountable care organizations in the New England Journal of Medicine by Robert Kocher, MD, and Nikhil R. Sahni of the McKinsey Center for U.S. Health System Reform and the Engleberg Center for Health Care Reform.
Kocher and Sahni say that under the healthcare reform legislation "the next few years
will be a period of what economists call “creative destruction”: our fragmented,
3. HAIs -
4. Teachback. Because patients are sick, sleep-
In many hospital and clinical settings, patients are being asked to repeat back what has been said to them to make sure they understand it, or "teach it back" to the provider. Patients are being given written instructions and asked to read those back too. A nod of the head is not okay.
5. Pink Fatigue or Pinkification. The plethora of pink – in commercialized products,
Some bloggers have rightfully asked whether pink buckets of Kentucky Fried Chicken really send the right message. Pinkathon publicity campaigns also may tend to minimize the sometimes equally significant risks of obesity and heart disease these same patients.
6. Sat Scores. We're not talking about tests that measure scholastic aptitude. Increasingly
heard in hospital hallways, clinic and physician waiting rooms, and even emergency
Look for modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems survey that ask even more detailed questions about length of wait times, and whether patients feel their care was well explained. Also anticipate better utilization of volunteers (think Walmart greeters) to ask if waiting patients would like something to read or drink, and improved access to entertainment or the web (movies, TV and internet access) to ease patients' anxiety while they are in a healthcare setting.
7. Alignment. This word means many things to many people, but in this context we're talking about standardization of equipment, procedures and supply purchases, programs, and policies.
Alignment can be considered a fighting word, because hospital systems with multiple facilities and autonomous programs that cater to individual physician or administrator preferences may balk at the imposition of limits. But systems that are steering full steam toward these goals believe that they will be the ones to succeed.
8. Respectful Crisis Management. Sometimes, providers make very big mistakes. But how healthcare systems respond to these unfortunate events can determine whether the next mistake is prevented, or whether it embitters staff, family, the public and the community in a toxic cloud of mistrust and blame.
This term actually represents a growing area of scientific research to find the best management strategies that provide productive responses to a critical healthcare error. Responses that unify the team to acknowledge and mitigate harm and prevent a similar mistake from occurring are the ones to adopt. No one benefits if those who made the mistake are so afraid, they won't dare explain what factors contributed to their making it.
9. Checklists, Checklists. Look for increasing agreement that these strategies –
10. Medical Apps. Whether it's on an iPhone, iPad or other mobile device, look for healthcare to be informed and prescribed, delivered, and monitored by doctors and patients using mobile apps. It might sound trivial to joke that "The App will see you now," but increasingly patients will use these devices to check and transmit their glucose levels, and physicians will use them to detect and treat abnormalities.
11. Medical Loss Ratio.
Affordable Care Act, insurance companies are now required to spend no more than 15% to 20% on administrative expenses such as executive salaries, overhead, and marketing, and the rest must be spent on patient care and/or quality improvement. Moreover, they must be transparent about how they spend their money. The act covers plans that insure nearly 75 million insured Americans.
Kaiser Health News, January 10, 2011
Lake Wobegon has come to Medicare – and a key advisory panel doesn't like it.
The panel, the Medicare Payment Advisory Commission (MedPac), in a Jan. 6 letter does not mention the fictional Lake Wobegon, where all the children are above average. But it hints that not every Medicare Advantage insurer deserves to be above average.
The letter, to Dr. Donald Berwick, who heads the agency overseeing Medicare, criticizes
a move to extend quality bonus payments meant for top-
The effort by the Centers for Medicare and Medicaid Services (CMS) will likely result in "far greater program costs" than the reward system called for by Congress in the health law and reduces insurers' incentive to achieve high performance, the letter concludes.
Medicare Advantage plans are those offered by private insurers as an alternative to traditional Medicare. About 11 million people – or 24 percent of all Medicare beneficiaries – are enrolled in Medicare Advantage plans nationwide.
The comments are included in a letter concerning a separate change in Medicare and
come in response to a move made by CMS officials late last year to adjust the standard
that Medicare Advantage insurers must meet in order to qualify for a bonus payment.
The change – made by CMS officials using their authority to create demonstration
projects – "increases program spending at a time when Medicare already faces serious
problems with cost control and long-
The health care law cut $136 billion over 10 years from the Medicare Advantage program, following years of concern that the private sector plans cost the government more than traditional Medicare.
But the law also called for bonuses starting next year for insurers who score at least four out of five "stars" on a set of quality measurements.
However, under the three-
Based on Medicare's 2010 star ratings, the change means 62 percent of all Medicare
Advantage insurers -
Medicare officials have said that extending the quality bonuses to more plans -
CMS spokesman Peter Ashkenaz said the agency could not comment on the MedPac concerns because they came as part of public comments gathered on a separate proposal. The agency will respond to comments, including those from MedPac, in the final regulations, he says. It isn't clear if those responses will include discussion of MedPac’s criticism of the bonus program, however, because it is a demonstration project that does not require a final regulation.
The star rating system was established a few years ago to help Medicare officials monitor plans and to guide consumers in choosing coverage, although some advocates say the measurements don't go far enough. Insurers are rated based on dozens of measures, including the percentage of members who get certain vaccinations, how well they monitor diabetics and the percentage of complaints filed by members.
Still, the way the demonstration program is designed would allow nine plans that have been rated as poor performers over three consecutive years to quality for the quality bonuses, the MedPac letter says.
In making the move, the agency is employing an "overly broad" use of its authority to create demonstration programs, which are generally smaller pilot projects testing innovations in how health care is delivered, the letter says.
"Demonstrations should not be used as a mechanism to increase payments," says the MedPac letter, which concludes by urging CMS to reconsider its decision.
Politico, January 9, 2011
Lawmakers on Sunday said they still expect to have a spirited but delayed and toned-
Within hours of the massacre, Majority Leader Eric Cantor postponed the House’s entire legislative agenda for the week, including the vote on repealing the law, which was planned for Wednesday. His office said he’ll make further announcements on the schedule today.
Sen. Lamar Alexander (R-
“We ought to cool it, tone it down, treat each other with great respect, respect each other’s ideas, and even on difficult issues like immigration or taxes or the health care law, do our best not to inflame passions.”
Republicans said Sunday that repealing health reform is still a priority, but not the focus in Congress next week.
“In light of yesterday’s tragedy, our focus has changed, the focus of Congress, as
well as the focus of millions of Americans all across this country,” Rep. Cathy McMorris
Both opponents and supporters of health reform had scheduled numerous events next week to make their case to lawmakers and the American public about health reform. Organizing for America and leaders of the Energy and Commerce Committee have both cancelled events next week where they were set to attack the Republican repeal effort.
Republicans on Sunday reiterated their campaign promise to repeal the law.
“We believe that that the bill needs to be repealed and replaced with a much better approach to ensuring that we have quality and affordable health care in this country. And that continues to be a high priority for the House Republicans and the new majority,” McMorris Rodgers said. “We’re just going to wait and make sure that we’re responding appropriately to the current situation.”
Rep. Chris Van Hollen (D-
“I think that we’re obviously going to have a spirited debate. There are strong feelings on both sides,” Van Hollen said on ABC’s “This Week.” “But I hope that, in that process, people will reflect on the tone of the debate and be respectful of differences in opinion going forward.”
“The question is, how can you have that debate without somehow crossing a line in
a way that can lead to super-
Even if the rhetoric does cool, the reality of health reform isn’t likely to change. Alexander said he expected “almost all or all” Senate Republicans to fully support repealing the law.
Sen. Dick Durbin (D-
But Durbin said Democrats are open to making improvements to the law, such as repealing the 1099 tax reporting requirements.
“The only perfect law I know of was carried on stone tablets down a mountain by Senator Moses. All the other efforts that have been made… have been subject to review and should be, and I’m open to that conversation. But I don’t believe repeal has any legs in the Senate at this point.”
Amadnews, January 3, 2011
HHS won't have the power to block "unreasonable" increases, but it plans to work with states to ensure they have the resources to stop them.
Under a proposed rule issued Dec. 21, the Dept. of Health and Human Services will not have enforcement authority to prevent insurance premium increases even if they are deemed "unreasonable" after a federal or state review. However, the department plans to work with state insurance agencies to ensure that they have the resources to highlight excessive premium hikes and nullify them when allowed by state law.
"The proposed rate review policy will empower consumers, promote competition, encourage insurers to do more to control health care costs and discourage insurers from charging premiums which are unjustified," said Jay Angoff, director of the HHS Office of Consumer Information and Insurance Oversight.
At the very least, HHS Secretary Kathleen Sebelius said, the requirement for public disclosure by insurers could prompt them to alter their plans when the proposed increases are considered unreasonable.
"Most consumers are operating entirely in the dark, and this is a very bright light," she said.
If the proposed rule is finalized this year, states with effective rate review systems of their own would conduct the investigations into questionable premium increases. The department said this system has proved effective. For example, Connecticut regulators recently blocked an insurer's proposed 20% rate increase after their review found it excessive.
For states that lack the authority or the resources to carry out such investigations, HHS would conduct its own review and publicize the results. The department noted that states will be eligible for funding through the national health reform law to begin closer scrutiny of insurer activity.
The new proposed regulation is the result of a mandate in the health reform law.
However, not every health insurance premium filing will be subject to review. Thousands of existing plans will be grandfathered in under the reform law because they were operating when the legislation was enacted.
The American Medical Association and other members of organized medicine that backed the health reform law also support taking a harder look at premium hikes.
The American Medical Association "is optimistic that the new regulation on health insurance rates will lead to greater transparency of the insurance industry," said AMA President Cecil B. Wilson, MD. "We will continue to review the regulation and work with HHS to ensure it benefits patients and physicians."
Patient advocacy organizations hailed the proposed rules and called on the federal government to enforce them aggressively. "No longer will the insurance industry be able to operate in a Wild, Wild West through unreasonable premium increases without any accountability for their actions," said Ron Pollack, Families USA's executive director.
But Karen Ignagni, president and CEO of America's Health Insurance Plans, said the focus on premium increases ignores the cost drivers behind them, including "soaring medical prices, new benefit mandates and changes to health plans' risk pools." She said the federal government investigating premium changes based on an arbitrary threshold of reasonableness would not reveal the full picture.
"We agree that states are best suited to review premiums because they have the experience, infrastructure and local market knowledge needed to ensure that consumers are protected and health plans are solvent," Ignagni said. "The federal government is not in position to make these assessments."
Sebelius said a proposed premium increase exceeding 10% -
Christopher Koller, Rhode Island's health insurance commissioner, said at the unveiling of the proposed rule that the appropriate balance would need to be struck to ensure fairness for insurers and consumers alike. If one side thinks the regulation is too strict and the other considers it too lenient, "you've probably hit it in the right place," he said.
The most recent proposed regulation, which could be finalized within months, is the
latest in a string of rules tightening scrutiny of health insurance practices under
the health reform law. One such recent rule on medical-
National Underwriter, December 23, 2010
Proposed federal health insurance rate review regulations could lead to reviews of about 40% of the increase requests in the small group market and 60% of the requests in the individual market.
Officials at the U.S. Department of Health and Human Services (HHS) have given those estimates in a discussion of the possible impact of a proposed rate increase disclosure and review rule.
The proposed rate review rule, which was released earlier this week, would implement PPACA provisions in the Affordable Care Act that would require the federal government to work with states to promote vigorous health insurance rate review programs.
The Affordable Care Act is the legislative package that includes the Patient Protection and Affordable Care Act (PPACA).
HHS officials are proposing that state or federal regulators should review requests
for rate hikes greater than 10% for non-
The HHS officials who conducted the impact analysis used data from the System for Electronic Rate and Form Filing, a service provided by the National Association of Insurance Commissioners, Kansas City, Mo., to come up with an estimate that carriers will file a total of 3,635 to 4,015 individual and small group rate filings this year.
Rate justification requirements could increase the number of individual and small group filings to 4,858 to 5,828 in 2011, officials say.
About 33% to 60% of the individual policies and 58% to 80% of the small group policies
probably will grandfathered, but, if recent trends continue, the number of non-
The total number of filings subject to review could range from 371 to 1,396, with
If that mid-
Officials are estimating each report would take 125 to 175 hours to complete, at a cost of about $200 per hour. HHS officials say hourly rates seem to range from $80 to $120 for actuaries' administrative support staffers; $120 to $180 for actuarial analysts; $200 to $275 for support actuaries; and $340 to $360 for principal actuaries.
Once the rate review system was up and running, total insurer annual costs could be $400,000 to $4.5 million, officials say.
The Council for Affordable Health Insurance (CAHI), Alexandria, Va., a group that opposes government efforts to increase control over the health insurance market, says HHS officials seem to be ignoring the impact of the rate review requirement and other Affordable Care Act mandates on insurers' ability and willingness to provide coverage.
Given the effects of all of the new mandates on coverage costs, "setting arbitrary rate limits will threaten the availability of health insurance," CAHI says.
Kaiser Health News, December 21, 2010
Health insurers seeking a rate increase of 10 percent or more in 2011 must publicly detail why the increase is needed, under proposed rules released by the Obama administration Tuesday.
Under the proposal, the flagged premium increases would be subject to review by the states – or the federal government in some cases – to determine if they are unreasonable.
In following years, the Department of Health and Human Services will adjust the specific percentage threshold for each individual state. Thresholds would vary partly because medical costs vary by state.
The proposed rules, which would affect insurance policies sold to individuals and small businesses but not large employers, result from the new health care law. Administration officials repeatedly criticized insurers for raising rates excessively during and after the long debate leading up to passage of the law in March.
Evidence "suggests that the majority of increases in the individual market have exceeded 10 percent each year for the past three years," significantly exceeding some national measures of cost inflation, according to the proposal.
While consumers may see any large increase as unjust, the government proposal says it is not possible to know whether an increase is unreasonable until its underlying assumptions are analyzed.
Final rules could be issued in about six months, after a public comment period. They would affect rate increases filed or effective after July 1, 2011.
America's Health Insurance Plans, the industry lobby, says rising premiums are caused by a variety of factors, including rapidly increasing medical costs. The regulation considers some of those costs, the group says, but doesn't adequately factor in new benefit mandates and the recession, which is causing younger and healthier people to drop coverage, leaving fewer premium dollars to cover a pool of relatively older or sicker policyholders.
"For example, data from the state of Oregon show that prices of many medical services have increased at an average annual rate exceeding 10 percent," says AHIP CEO Karen Ignagni. "California data show that prices for a hospital stay increased by more than 150 percent between 2000 and 2009—an average annual growth rate of 11 percent. Trends likes these are being seen across the country."
Some consumer advocates say the proposed regulation doesn't go far enough. The proposal, for example, gives states discretion on revealing some of the detailed data provided by insurers. States could reveal simpler summaries of the data.
"The whole point of this regulation, as the HHS secretary has said, is to shine a light on the actuarial assumptions … in the hope that public scrutiny will shame insurers into doing the right thing," says Carmen Balber, director of Consumer Watchdog's Washington office. "If full data is not disclosed, in many cases we're left with the status quo."
The health care law requires review and justification for increases deemed unreasonable, but does not give the federal government authority to reject rate increases. Federal officials hope public disclosure will discourage unnecessarily large rate increases, encourage state regulators to take a closer look and help individuals and businesses make wise choices. State officials can also bar insurers with a pattern of unreasonable increases from selling their products in new marketplaces, called exchanges, which are set to open in 2014.
State regulation of premiums varies widely. Some states review proposed rate changes and can deny increases before they go into effect; others allow insurers to put new rates into effect and examine them only if questions are raised.
HHS says it will look at several factors in determining whether rates are unreasonable, including whether an insurer meets a requirement that it spend at least 80 percent of its revenue on medical costs and whether it produces substantial evidence for the increase.
Insurers would have to post on their websites proposed increases above the thresholds and if the rates ultimately are deemed unreasonable they'd have to post that fact as well, in addition to explaining reasons for the increases. Insurers would need to publicly detail what they are spending on medical care, expected future claims costs and administrative spending, including executive compensation.
States would do their own rate reviews unless HHS determines they don't have an effective system. Among other things, states must show they collect data sufficient to determine whether a rate increase is unreasonable and review that data effectively, the proposal says.
Associated Press, December 20, 2010
1. Healthcare Reform. The Patient Protection and Affordable Care Act of 2010 (PPACA)
shook the health care world this year, causing companies to revisit their benefits
strategies to determine efficient ways of becoming compliant with the reform's immediate
2. Cost Sharing and Rewarding Healthy Lifestyles. Employee benefit contribution structures
held steady over the past decade -
3. Plan Design. There's nothing like limited resources to inspire creative thinking.
4. Communications Game Plan. Confusion and uncertainty among employees over how they
and their families will be affected by health care reform led companies to adopt
proactive and innovative communication strategies to dispel misperceptions, alleviate
fears and prepare workers for the changes to come. From reassuring messages and use
of the company intranet to submit basic questions to HR staff to on-
5. Claims Analysis. While it is important to understand the financial performance of a plan and the financial justification of premiums, employers are using claims data to take more focused directions on plan design, wellness initiatives, and communication. The data mining of claims allows employers to weigh the financial costs and member impact of any changes to their plans and helps balance disruption and cost containment. Even a review of a group's top disease states or major diagnostic categories provides focus for wellness initiatives and opportunities to avoid claims, giving employers more control of their health care costs.
6. Chronic Disease Management. Alarming rates of chronic diseases like diabetes and
heart disease are taking their toll on Americans' health and on employers' bottom
lines, since companies bear much of the cost associated with treatment. A remarkably
positive partnership has developed between companies and employees joining forces
to improve their quality of life through health management and wellness programs.
These targeted approaches to specific conditions (i.e., glucose levels, blood pressure,
and cholesterol) and "knowing your numbers" through health screenings and health
risk assessments, help companies stay ahead of the cost curve by offering preventive
care to at-
7. Self Funding. Self-
8. Product Bundling. Employers capitalized on premium discounts offered by carriers that combine medical plans with comprehensive specialty benefits such as dental, vision, life and disability. With just one team to administer benefits and one premium statement, employers saved money through lower administration fees. Plus, the more employees enrolled and lines of coverage bundled, the greater the savings.
9. Going Online. Despite initial reluctance to use the Internet for benefit administration,
most employers are jumping on the information superhighway, recognizing not only
the willingness of employees across all demographics to use a Web interface, but
also how online tools simplify processes for HR departments. Computer-
10. Executive Benefits. Executive benefits, an important tool for attracting and retaining talented staff, were a casualty of the economic downturn and new health care reform legislation, both of which put these programs under greater scrutiny than ever before. Many companies have had to weigh the competitive edge these benefits provide against the costs and risks they entail, and some faced with no choice but to set these policies aside as they struggled to stay afloat in challenging economic times.
"Perhaps the most important lesson of 2010 is that getting employees more involved
in their medical decisions, expenses and overall health is a key to sustaining a
financially viable, work-
Seeking Alpha, December 15, 2010
The news this week that a federal judge ruled a key portion of the Obama Administration’s healthcare reform legislation to be unconstitutional – the part requiring people to have insurance — might seem to rescue UnitedHealth Group (UNH), the big insurer, which has groused about the high costs of complying with the new law.
But the truth is UnitedHealth doesn’t need rescuing, and there is probably as much
benefit to the company in healthcare reform as there is harm. U.S. District Court
Judge Henry Hudson of Virginia’s ruling may stand or may be thrown out on appeal,
but what seems certain is that UnitedHealth and other insurers will profitably adapt.
And the recent doubt that has dogged UnitedHealth’s stock presents a buying opportunity
Yes, the company is predicting as much as an 11% decline in earnings per share next
year in part because of reform-
UnitedHealth threw wary investors a bone earlier this year, substantially increasing the company’s dividend to 50 cents a year (in quarterly payouts) from 3 cents. As a result, UnitedHealth has the only respectable dividend yield among the biggest insurers.
As for reform, UnitedHealth knows how to deal with adversity. Four years ago, the
One thing UnitedHealth does well is covers its bets. While employer health plans
are big business for the insurer ($10.4 billion in third-
Indeed, despite headwinds, UnitedHealth was able to increase revenue steadily in recent years.
While premiums sold for employer, government and individual insurance plans account for more than 90% of revenue, UnitedHealth has a number of smaller businesses that can benefit from the new health reform law, including disease management and wellness programs as well as consulting, health data and software businesses for doctors, hospitals and employers.
The idea that slow-
New York Times, December 13, 2010
A federal judge in Virginia ruled on Monday that the keystone provision in the Obama health care law is unconstitutional, becoming the first judge to invalidate any part of the sprawling act and ensuring that appellate courts will receive contradictory opinions from below.
The judge, Henry E. Hudson of Federal District Court in Richmond, said the law’s requirement that most Americans obtain insurance exceeded the regulatory authority granted to Congress under the Commerce Clause.
Judge Hudson, who was appointed by President George W. Bush, declined the plaintiff’s request to suspend the act’s implementation pending appeal, meaning there should be no immediate effect on its rollout.
But the ruling seemed likely to create confusion among the public and to further destabilize political support for a law that is under fierce attack from Republicans in Congress and in many statehouses. Party leaders, including the incoming House speaker, Representative John A. Boehner of Ohio, quickly used the opinion to reiterate their call for repealing the law.
In a 42-
Allowing Congress to exert such authority, he said, “would invite unbridled exercise of federal police powers.”
Compelling vehicle owners to carry accident insurance, as states do, is considered a different matter because the Constitution gives the states broad police powers that have been interpreted to encompass that. Furthermore, there is no statutory requirement that people possess cars, only a requirement that they have insurance as a condition of doing so. By contrast, the plaintiffs in the health care case argue that the new law requires people to obtain health insurance simply because they exist.
The insurance mandate is central to the law’s mission of covering more than 30 million people who are uninsured. Insurers argue that only by requiring healthy people to have policies can they afford to pay for those with expensive conditions. But Judge Hudson ruled that many of the law’s other provisions could be severed legally and would survive even if the mandate is invalidated.
Judge Hudson is the third district court judge to reach a determination on the merits in one of the two dozen lawsuits challenging the health care law. The other judges, in Detroit and Lynchburg, Va., have upheld the law. Lawyers say the appellate process could last another two years before the Supreme Court settles the dispute.
The opinion by Judge Hudson, who has a long history in Republican politics in Northern Virginia, continued a partisan pattern in the health care cases. Thus far, judges appointed by Republican presidents have ruled consistently against the Obama administration, while Democratic appointees have found for it.
That has reinforced the notion — fueled by the White House — that the lawsuits are as much a political assault as a constitutional one. The Richmond case was filed by Virginia’s attorney general, Kenneth T. Cuccinelli II, a Republican, and all but one of the 20 attorneys general and governors who filed a similar case in Pensacola, Fla., are Republicans.
The two cases previously decided by district courts are already before the midlevel courts of appeal, with the Detroit case in the Sixth Circuit in Cincinnati and the Lynchburg case in the Fourth Circuit in Richmond.
The Justice Department, which is defending the statute, is considering whether to appeal Judge Hudson’s ruling to the Fourth Circuit, which hears cases from Virginia and four other states. That would leave that court to consider opposite rulings handed down over two weeks in courthouses situated only 116 miles apart.
Administration officials emphasized that Judge Hudson’s opinion was just one among several and said they were pleased he had not stopped the law from going into effect.
“We are disappointed in today’s ruling,” said Tracy Schmaler, a Justice Department spokeswoman, “but continue to believe — as other federal courts in Virginia and Michigan have found — that the Affordable Care Act is constitutional.”
Ms. Schmaler added, “We are confident that we will ultimately prevail.”
The administration acknowledges that if the insurance requirement falls before taking
effect in 2014, related changes would necessarily collapse with it, most notably
provisions that would prevent insurers from denying coverage to those with pre-
But officials said other innovations, including a vast expansion of Medicaid eligibility
and the sale of subsidized insurance policies through state-
Some state officials said Monday’s ruling would reinforce calls by many Republican governors and lawmakers to slow down its implementation.
“I think you might see some air taken out of the balloon nationwide,” said Jason A. Helgerson, the Medicaid director in Wisconsin, where Republicans are about to take control of both the executive and legislative branches.
Judge Hudson, who was previously best known for sentencing the N.F.L. quarterback Michael Vick to 23 months for his involvement in a dog fighting ring, had telegraphed his leanings in a series of hearings and preliminary opinions. But the ruling was nonetheless striking given that only nine months ago, prominent law professors were dismissing the constitutional claims as just north of frivolous.
The case centers on whether Congress can use its powers under the Commerce Clause to compel citizens to buy a commercial product — namely health insurance — for the purpose of regulating an interstate economic market. Absent that authority, the administration argued, Congress could use the taxation powers granted by the Constitution to justify the insurance requirement, because the fine for not obtaining coverage will be assessed as an income tax penalty.
While commending Congress’s “laudable intentions,” Judge Hudson shot down both arguments.
“At its core,” he wrote, “this dispute is not simply about regulating the business of insurance — or crafting a scheme of universal health insurance coverage — it’s about an individual’s right to choose to participate.”
The ruling is a political score for Mr. Cuccinelli, who filed the lawsuit on his own rather than joining the Pensacola case. It upstages a major hearing in Florida scheduled for Thursday.
“This case is not about health insurance, it is not about health care,” Mr. Cuccinelli said at a news conference in Richmond. “It is about liberty.”
Mr. Cuccinelli, who was elected in 2009, said he had filed on his own because Virginia
passed a law this year aimed at nullifying the federal insurance requirement, giving
the commonwealth a distinct constitutional claim. Others attribute the strategy to
political ambition, suggesting that Mr. Cuccinelli did not want to share the spotlight
and knew he could exploit the accelerated pace of judging in Richmond’s so-
Mr. Cuccinelli filed the lawsuit minutes after President Obama signed the law on
March 23 and has been discussing the case on cable television ever since. By late
afternoon Monday, he had already posted campaign fund-
Even before Monday’s ruling, Mr. Cuccinelli and Gov. Bob McDonnell of Virginia, also a Republican, were seeking an agreement with the Justice Department to bypass the United States Circuit Court of Appeals and file for expedited review by the Supreme Court. That would have the effect of further marginalizing the Pensacola case. The Supreme Court rarely takes such requests, and the Justice Department has not publicly expressed an opinion.
MarketWatch, December 7, 2010
It’s hard to find a public figure as candid and compelling as Elizabeth Edwards,
a lawyer and health-
Edwards first got confirmation she had breast cancer hours after her husband and
Sen. John Kerry conceded the 2004 presidential election to George W. Bush. Then in
March of 2007, she announced, with John Edwards by her side, that a coincidental
John Edwards dropped out of the primary race in January of 2008 after putting out
the first and perhaps most stringent health-
Many people drew inspiration from Elizabeth Edwards even though she raised questions about how much she knew and whether she had an obligation to disclose it when revelations about her husband’s extramarital affair began to surface in 2008. Earlier this year, John Edwards finally admitted to fathering a child with a former campaign videographer. Elizabeth Edwards wrote about her family and health crises in two books, “Saving Graces” and “Resilience.”
The public largely sympathized with Elizabeth’s plight and identified with her will
to survive. She and John Edwards had endured the loss of their 16-
Recent research suggests that starting palliative care early — at the time of diagnosis
— can actually prolong life and not just increase its quality. That doesn’t mean
you have to give up on aggressive treatments, and it sounds like Elizabeth Edwards
went that route as long as she could and as long as that made sense to her. Maybe
her life and death will usher in a new era of frank talk about what end-
The Washington Post, November 29, 2010
What if, instead of you making a $10 insurance co-
Now, what if your employer said that if you want certain procedures that it believes to be overused, such as an MRI scan or knee surgery, you'll have to pay $500 extra? Those employer decisions might not be nearly as welcome.
Both, however, are part of an approach to health care that shares a common perspective:
the idea that consumers' out-
Although relatively rare, the model is garnering increasing attention among employers,
insurers and policy experts. Mercer, a benefits consulting company, found in a 2008
survey that 19 percent of employers with at least 500 employees were charging workers
less for services the companies considered to have a higher value for workers' health.
In addition, more than 80 percent of employers with at least 10,000 workers surveyed
by Mercer in 2007 said they were interested in adopting this model in the next five
years, according to a paper published in the November issue of Health Affairs. It
was one of several on value-
Some provisions of this year's health-
"It's all in keeping with the idea that some things are so valuable to health care that there should be no barriers to their use," says Niteesh Choudhry, an assistant professor at Harvard Medical School and lead author of two of the Health Affairs articles.
A landmark 1982 study showed that consumers spend less on health care as their out-
Mike Hardy had a heart attack during the lunch hour at his job at office products
and services supplier Pitney Bowes nearly three years ago. The 65-
Pitney Bowes is an old hand at value-
The pharmacy plan works in tandem with comprehensive disease management and wellness programs to help employees prevent and manage chronic conditions, says Brent Pawlecki, medical director for Pitney Bowes.
Indeed, experts agree that eliminating financial barriers isn't enough to ensure
that people stick with their medication regimens, get necessary preventive screenings
and seek high-
So far, nearly all employers and insurers that have adopted value-
To reduce costs, some experts say employers and insurers should use a stick in addition to the carrot, with financial disincentives that might discourage people from using medical services that are considered low value.
In October, 155,000 Oregon public education employees and their dependents began
to experience this stick approach. Their plans already offered carrots: free preventive
care and low-
But members are now being charged an extra $500 if they get services that the state
Educators Benefit Board has determined are overused or "preference-
"We explained that the reason the rates were going up was because people were using the benefits a lot," says Joan Kapowich, administrator for the boards.
The board showed employees, for example, that nationwide the average amount spent on sleep studies was 37 cents a year. In the Oregon state plans, however, it was a whopping $7.36. "Everybody who snores was getting a sleep study," she says.
It's too soon to know whether the new approach will be successful at improving employees'
health or bringing down health-
People are willing to compromise, says Marge Ginsburg, executive director of the
Center for Healthcare Decisions, a Sacramento-
Outright denials, on the other hand, don't sit so well. "People are really unhappy if you draw a line in the sand."
Amednews, November 29, 2010
Accountable care organizations are defined slightly differently depending on the source, but generally involve a combination of physicians and hospitals taking responsibility for a defined population, working together to improve care and cutting costs.
The Centers for Medicare & Medicaid Services is working on rules for ACOs that will determine exactly what clinical and financial benchmarks will quality ACOs for additonal payments. Under the health reform law, to be recognized by Medicare as an ACO, the organization must exist for a minimum of three years and serve at least 5,000 patients. Generally, all the participants share in the savings created, but models differ in how that happens. Physicians and hospitals do not need formal business affiliations with each other before forming an ACO.
As the "silly season" peaked during the last few months and the first pilots got running, the potential pitfalls and practical conundrums emerged. At the November AHIP meeting, insurance company executives talked through some of them.
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.
Stephanie Kanwit, a former Federal Trade Commission attorney and a former general counsel for AHIP who is now a private consultant, moderated two conference sessions on ACOs. She listed several reasons why health plans will and should be involved in ACO development.
Health plans can track the health of large populations. They have the information technology infrastructure to help monitor the health of patients enrolled with an ACO. They are experts in managing networks like those used in an ACO. They can carry the financial risk that allows an ACO to move forward. And they are experienced in developing multiple insurance products for patients.
So, in one sense, plans have the expertise on hand to make ACOs work.
On the other hand, as Bruce Bagley, MD, medical director for quality improvement for the American Academy of Family Physicians, said, "There are probably no experts about ACOs. It's a developing concept."
As of this article's deadline, Medicare was preparing to release its ACO regulations,
as required by the Patient Protection and Affordable Care Act. The Centers for Medicare
& Medicaid Services plans to start the ACO three-
Meanwhile, private plans, including Humana and Cigna, are piloting ACOs in the first
forays for the industry. In each case, the plans joined with certain physicians and
hospitals to provide care for the plans' members under the ACO. Physicians and hospitals
would be paid on a fee-
Health insurance companies are trying to figure out where they fit in with accountable care organizations.
Executives gathered for trade group America's Health Insurance Plans' annual fall
forum in Chicago Nov. 8-
Joining physicians and hospitals in an ACO creates the opportunity and pressure for the two groups to merge, experts said at the AHIP conference. In that way, pushing the ACO model could end up creating highly concentrated hospital and physician markets in which the large ACO groups can demand higher payments.
Jeff Goldsmith, PhD, a University of Virginia professor of public health sciences
and president of Health Futures Inc., criticized ACOs as he addressed a standing-
"I just think this is a stupid idea," he told the audience. "Managed care without
the risk -
He thinks hospitals and physicians will have a hard time working together. "What aligning incentives means to hospital executives is: You work for me, and we'll do what I tell you to do," Goldsmith said.
In another ACO-
Ascension physicians and nurse leaders met in June and agreed that the status quo,
"Regardless of what happens with the big picture, we feel like we need to move ahead with reforming our delivery system," she said. "We felt we needed to do this because it's the right way to manage care for our patients."
Standing Up for Quality and Affordable Health Care Kathleen Sebelious, Secretary of Health and Human Servicies, November 12, 2010
This week, I had the opportunity to meet with consumer advocacy organizations from around the country that are working on the front lines every day on behalf of individuals and families as they seek quality, affordable health care.
As we implement the Affordable Care Act, we are working closely with States to help
consumers take more control over their health care. Already, the Affordable Care
Act is helping States to crack down on unreasonable premium increases, provide coverage
for people with pre-
Consumer organizations also play an important role in helping individuals and families better understand the benefits and opportunities available to them in the communities in which they live. And that’s why it is so important to receive feedback from those who are on the ground each day in the States, advocating on behalf of consumers.
On Wednesday, I met with representatives from:
Health Care for All (MA)
TakeAction Minnesota (MN)
Center for Public Policy Priorities (TX)
Florida CHAIN (FL)
NJ Citizen Action (NJ)
Health Access California (CA)
Commonwealth Institute for Fiscal Analysis (VA)
Many of these consumer groups are long time advocates for the new rights, benefits
and protections that are kicking in under the Affordable Care Act. Already, young
adults are able to stay on their parents coverage until age 26, businesses are getting
help providing their employees and early retirees with health coverage, and insurers
are prohibited from denying coverage to children because of a pre-
During our meeting, we also discussed the new options available to consumers under
Another big item on the horizon is this year’s Medicare Open Enrollment period, which begins next week on November 15 and is a key opportunity for our seniors to gain important new benefits. As a result of the Affordable Care Act, Medicare is getting stronger.
The Open Enrollment period is an opportunity for seniors to begin comparing their
current coverage and needs to the options available next year. The Affordable Care
Act provides new benefits in 2011, including a 50% discount on brand name drugs if
you hit the donut hole, a free annual wellness visit and no co-
There’s a lot to do to get out the word on all these important milestones, and I look forward to continuing to work with the extraordinary organizations that support our efforts throughout the country to enable consumers to gain more control over their health care.
FierceHealthcare, November 8, 2010
While members of the AMA may have their doubts about whether nurses are up to the
task of serving as primary-
The announcement is the culmination of a collaboration between the Maryland Coalition
of Nurse Practitioners, the Nurse Practitioner Association of Maryland and CareFirst
to expand coverage in the wake of both the new health reform law and the physician
shortage plaguing the U.S. Bruce Edwards, CareFirst senior vp for networks management,
added in a press release that the insurer aims to increase its emphasis on primary
care through its Primary Care Medical Home Program (PCMH), set to begin this January.
"With these developments ahead and an existing need to expand access to these services,
allowing nurse practitioners to practice independently as primary-
In response to CareFirst's announcement, Gary Simmons, vice president with UnitedHealthcare
of the Mid-
The Fiscal Times, November 2, 2010
Here’s a health care reform idea that proponents say will bring Republicans and Democrats
together: Make people pay more for high-
They’re giving it a shot in Oregon, a blue state where public employees and teachers
next year will pay an extra $500 out of pocket when they get back surgery, an endoscopy,
or an artificial knee, hip or shoulder. The state benefits board also slapped large
New York Times, November 3, 2010
In the name of fiscal probity, the incoming Republican leadership in Congress has committed to doing whatever it takes to stop the health care reform act from taking effect. Yet many of the provisions that politicians have been taking aim at are the ones that save money — like those that reduce excessive provider payments and create new institutions to curb cost growth.
If the newly elected representatives and senators are truly concerned about rising
health care costs, they should work to deploy the law’s cost-
Why do so many people assume that the act does almost nothing to save money? One
explanation is that people’s first impressions of health care reform were formed
during the summer of 2009, when the debate was dominated by the House bill. In health
care reform, there’s always an underlying tension between those who are more concerned
about expanding coverage and those who are more concerned about containing costs
and improving quality. The House bill tilted toward coverage; the Senate bill, toward
The act’s money-
There are four ways to contain health care costs: by reducing payments to providers and suppliers; by rationing services; by having consumers pay a greater share; and by giving providers incentives to be more efficient.
The health care reform act includes hundreds of billions of dollars worth of cuts in payments to providers. Lowering payments within Medicare, though, without also reducing the quantity of services provided throughout the health care system ultimately only makes it harder for those on Medicare to find a doctor or hospital willing to treat them, because so many providers stop seeing Medicare patients.
The growth in health care services could be reduced by denying access to specific procedures. But even if such rationing were desirable, which is debatable, it is not remotely politically viable.
The third way to contain the expansion of health care services, theoretically, is
to give consumers more “skin in the game” by increasing their share of the bill.
There is no doubt that consumers would become more cost-
PRNewswire, October 29, 2010
Results from Milliman's 2010 Group Health Insurance Survey indicate estimated premium rate increases for January 2011 renewals will average 10.2% for Health Maintenance Organizations (HMOs) and 11.7% for Preferred Provider Organizations (PPOs). In addition to typical rate increases due to utilization and cost experience, these planned increases also likely reflect some change due to implementing the requirements of the Patient Protection and Affordable Care Act (PPACA).
The reported annual historical increase in premium rates (July 2010 versus July 2009
assuming no changes in benefit or cost-
The Milliman survey is unique in that it asks HMOs and PPOs to respond regarding a given set of group health benefits and demographics. The survey removes three important factors that can skew the results presented in other health cost surveys: changes in plan design, shifts in premium sharing between employer and employee, and member demographics. These trends, therefore, reflect the increase in medical utilization and costs experienced/anticipated by the HMOs and PPOs.
This year's survey also asked insurers what provider contracting changes and cost saving initiatives they are considering making due to the PPACA. Insurers generally plan to utilize more quality incentive programs, introduce more shared risk with their provider networks, provide more price transparency for members, more aggressively tier provider networks, and reduce broker commissions. Almost all report they are preparing to participate in the PPACA insurance exchanges in 2014.
The 2010 report includes premium rates, trends for medical and prescription drug
coverage, prescription drug costs, views toward recent health care reform legislation,
and progress toward implementing ICD-
This marks the seventeenth year that Milliman has conducted the survey. The survey
was sent to HMOs and fully insured PPOs that serve the nation's commercial, large
Milliman is among the world's largest independent actuarial and consulting firms. Founded in Seattle in 1947 as Milliman & Robertson, the company currently has 53 offices in key locations worldwide. Milliman employs more than 2,400 people. The firm has consulting practices in healthcare, employee benefits, property & casualty insurance, life insurance and financial services. Milliman serves the full spectrum of business, financial, government, union, education and nonprofit organizations. For further information, visit www.milliman.com.
Read more: Milliman Group Health Insurance Survey Indicates Average 2011 Rate Increases
of 10.2% for HMOs, 11.7% for PPOs -
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