OUR CONVOLUTED HEALTH CARE PAYMENT SYSTEM

By Cory Michael, MD

Three men walk into a deli for lunch, take a number, and sit quietly until called. There are no prices on display, nor is the food visible. The first man, Ron, is called to the counter and states that he is hungry when asked what brings him in. He presents his food insurance credentials, and five minutes later, he walks out the door with a 12-inch gourmet sandwich, a side salad, and a smoothie in exchange for a co-pay of $1. The following week, Ron’s insurance company sends him an explanation of benefits in which the deli’s charge for the food was $15, but the large size of the company allowed them to negotiate a price of $9. The remaining $8 was covered as a benefit.

The next customer, Bill, is called and presents with the same complaint. Review of his credentials shows what he is eligible for, a 6-inch generic sandwich and a bottle of water. He gets his food after twenty minutes. His co-pay is $3. The food is unsightly and unsatisfactory in taste. Bill leaves and pays cash for lunch elsewhere. His explanation of benefits later reads that the charged price was $10 negotiated to $7 by the insurance company, but only a $3 benefit is possible for lunch. The deli later sends him a bill for the remaining $1 even though his lunch was inadequate.

The third customer, George, waits thirty minutes until served. His food insurance does not cover primary lunch, and the deli initially refuses to serve him as a result. After some discussion, they agree that he can have a 4-inch mini sandwich and a water cup for a cash price of $15. Hungry, he agrees.

Ridiculous as it sounds, the scenario presented approximates the U.S. health care system, and I have actually been on the customer side of all three types of plans in addition to being uninsured for the first nine years of my adult life. My current insurance is a “mid-level” product similar to Bill’s plan.

Enter my latest health care issue: hypertension. My blood pressure crept up on me about a year ago, but it wasn’t until I sacked my internal medicine physician and opted for a nurse practitioner that I learned sleep apnea may be contributing to my elevated blood pressure, as I had been told that I snore horribly and sometimes stop breathing. I decided to test the possibility by sleeping in my hospital overnight with a pulse oximeter (oxygen monitor) on my finger with a nurse checking in on me periodically. To my surprise, my oxygen levels dropped down to 70 percent (normal is around 95 to 100 percent) during episodes of apnea (cessation of breathing).

I next sought out a continuous positive airway pressure (CPAP) device to remedy the situation and found one I liked fo...

SURPRISE MEDICAL BILLING IS A SCAM BY INSURANCE COMPANIES

By Don R. Read, M.D


Surprise billing is a big problem — physicians agree with our patients.

It’s easy to understand why someone with health insurance gets frustrated with an unexpected bill for dozens or even thousands of dollars from a physician, hospital or medical provider.

“Why did I get this bill?” the patient asks. “I have insurance. I’m covered!”

Why indeed?

People receive surprise bills because that’s what their insurance companies want to happen.

It’s part of their business plan: Make their insurance look valuable.

Price the plan as attractively as possible. Enroll policyholders. Collect their premium dollars … then do whatever they can to keep most of those dollars rather than spend them on healthcare.

For patients, insurance is to help them pay for care. But for insurers it’s a business.

They call paying for care a “medical loss.” And they fight to keep that figure in their favor, to pay less for your care.

Insurance companies advertise robust networks full of physicians and facilities “in-network.”

Then they set up small (or narrow) networks of physicians to save themselves money.

Why? Because if the network is small, odds are more policyholders wind up receiving care from an out-of-network physician.

Meanwhile, the insurers pay just a fraction of the charge to those out-of-network physicians. They know the physicians and hospitals will bill the patient for the balance.

But they don’t tell the policyholder that.

The more enlightened of our patients might ask the doctor, “Do you take x Insurance?”

But x insurance might sell hundreds of plans. Just because we are contracted with some of those plans doesn’t mean we are in-network with all of them.

HERE'S WHY A TRUMP PRESIDENCY IS GOOD FOR PHYSICIANS AND PATIENTS

By Dr. Koka

Improbably, a real estate tycoon turned reality TV star with no political experience has been elected president by a fiercely divided nation.

There are a number of questions about the plans of a Donald Trump administration with regards to healthcare, and patients and physicians are understandably fearful. Seismic shifts like this in the political landscape make it difficult to find certitude in predictions on healthcare policy, but there are a number of clues to suggest that the landscape of healthcare may be an improving one for patients and the physicians charged with taking care of them.

At the top of the agenda for both Trump and Congress is repealing the Affordable Care Act (ACA). Clearly, this is much easier said than done. The healthcare reform law is a complex series of expansive regulations that touches payment reform, healthcare delivery and, oh, by the way, also covers 20 million Americans. The easiest to kill of the three would seem to be the Obamacare marketplace covering all those Americans that is propped up by federal subsidies that take the form of “cost sharing” payments to insurance companies. Eliminating funding for these subsidies would make insurers exit the Obamacare marketplace and make it nonviable.

Millions of patients currently with insurance would suddenly lose their health plans. No one wants this, and Trump and the Republican Party now face intense pressure to come up with a replacement. As a result, I find it very unlikely that physicians or patients will suddenly have to deal with a large number of patients without insurance. There are also encouraging signs that the replacement plans being discussed will more than likely include health savings accounts—a Trump/GOP favorite—that will be allowed to directly pay primary care physicians in a subscription model similar to direct primary care. This capitated model puts physicians, rather than insurance companies, in the driver’s seat and would be music to the ears of primary care physicians in desperate need of a lifeline

 The biggest immediate headache is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which physicians will have to face in less than two months, but it only slightly overlaps with the ACA. The overlap relates to the Center for Medicare & Medicaid Innovation (CMMI) that was funded by the ACA, and created some of the important value-based payment models physicians were going to have to c...

WEALTHIEST -NOT SICKEST -PATIENTS MAY HAVE EDGE IN ORGAN TRANSPLANTS

Source: American Heart Association
 
Registering with more than one organ transplant center appears to give an edge to wealthy patients over those with the most medical need, according to research presented at the American Heart Association's Scientific Sessions 2015.

Researchers studied the national database of organ donors from 2000 to 2013 and found that patients who simultaneously listed at more than one center had higher transplant rates, lower death rates while waiting, were wealthier and were more likely to be insured.

"It's an effective approach to address long waiting times and the shortage of organs available for the increasing demand among transplant candidates. But it undermines a bedrock principle of organ transplantation -- which is that the sickest people should be transplanted first," said Raymond Givens, M.D., Ph.D., study lead author and advanced heart failure and transplant fellow at Columbia University Medical Center in New York. "We firmly believe the multiple listing policy needs to be reconsidered."

Researchers analyzed the United Network for Organ Sharing (UNOS) database, identifying adult patients listed as first-time, single-organ candidates for either heart, lung, liver or kidney transplants. The network is a nonprofit that manages the U.S. organ transplant system under federal contract. UNOS policy allows organ transplant candidates to be listed at multiple centers simultaneously.

Between 2000 through 2013, researchers identified: 33,928 patients waiting for a heart transplant (2 percent were multiple-listed); 24,633 patients waiting for a lung transplant (3.4 percent multiple-listed); 103,332 patients waiting for a liver transplant (6 percent multiple-listed); and 223,644 patients waiting for a kidney transplant (12 percent multiple-listed).

These findings suggest an advantage for wealthier patients who have the money for travel, temporary housing and other costs of multiple listing that are not covered by health insurance, Givens said. Patients with state-run Medicaid generally have lower income and may not have the option to list themselves at a center in a different state.

"The main issue is supply and demand," Givens said. "The need for donor organs increases yearly; the supply does not. We really need more people to volunteer to donate their organs. That would relieve a lot...

ANTHEM TO ACQUIRE CIGNA, LEAVING ONLY 3 BIG INSURANCE COMPANIES

by CNN Money

In another merger of health insurance giants, Anthem has agreed to acquire Cigna in a $54 billion deal.

Anthem (ANTM), a Blue Cross and Blue Shield insurer, said it would buy all of Cigna's (CI)shares in a cash and stock transaction.

The deal is expected to close in the second half of 2016, if it passes state regulatory approvals and other requirements. The merged insurer would cover 53 million members.

The merger would leave only three major players in the insurance industry.

Earlier this month, Aetna (AET) struck a deal to buy Humana (HUM) for $37 billion, which would cover 33 million members.

The third remaining health insurer is UnitedHealth (UNH), which just completed its own $12.8 billion acquisition of Catamaran, a pharmacy-benefits manager and prescription provider.

There are titanic shifts going on in the entire healthcare space, where pharmacies are undergoing their own wave of consolidation. In May, CVS Health (CVS) agreed to acquire Omnicare (OCR) for $12.7 billion. And back in February, Rite Aid (RAD) agree to acquire EnvisionRx for $2 billion.

NATIONAL HEALTH COSTS COULD DECREASE IF MANAGERS REDUCE WORK STRESS

by Michael Blanding

Joel Goh and colleagues estimate that workplace stress is responsible for up to 8 percent of national spending on health care and contributes to 120,000 deaths a year. Is better management the fix?

Our work can literally make us sick. Long hours, impossible demands from bosses, and uncertain job security can take their toll on our mental and physical well-being, leading to stress-induced aches and pains and anxiety. In extreme cases, the consequences can be worse—heart disease, high blood pressure, alcoholism, mental illness.
Even so, the connections between job pressures and health—and what management can do to address the problem—have been little studied.

“We have not placed a lot of emphasis on the role of workplace stress in the high cost of health care”

"We have this body of research that shows workplace stress is very bad for health, and we have this other information that says our health costs are way above that of other countries," says Joel Goh, Harvard Business School assistant professor of business administration in the Technology and Operations Management unit. "But traditionally in the US we have not placed a lot of emphasis on the role of workplace stress in the high cost of health care."
In recent years, General Motors spent more on health care than it did on steel, and across the country, companies are struggling to find affordable plans for their workers, in some cases dropping health coverage or raising premiums on employees in order to combat escalating costs. On the other hand, companies are implementing health programs in an effort to keep workers healthy—and productive.

But those programs can only work if companies aren't at the same time undermining them with stress-inducing management practices.
"Health care programs are no good if your guy is so stressed that he can't take advantage of them," says Goh.

Making the stress-health connection

Unlike in Europe, little or no data exists in the US that correlates exposure to workplace stress with health outco...

PROFESSIONAL NETWORKING MAKES PEOPLE FEEL DIRTY

by Carmen Nobel

 

For many of us, the idea of professional networking conjures unctuous thoughts of pressing the flesh with potential employers, laughing at unfunny jokes, and pretending to enjoy ourselves.
No wonder a recent study found that professional networking makes people feel unclean, so much so that they subconsciously crave cleansing products. The study, titled The Contaminating Effects of Building Instrumental Ties: How Networking Can Make Us Feel Dirty, appeared in the December 2014 issue of Administrative Science Quarterly.

 

“Even when people know networking is beneficial to their careers, they often don't do it”

"Even when people know networking is beneficial to their careers, they often don't do it," says Francesca Gino, a professor in the Negotiation, Organizations & Markets unit at Harvard Business School, who coauthored the study with Tiziana Casciaro (Rotman School, University of Toronto) and Maryam Kouchaki (Kellogg School of Management at Northwestern University.) "From an academic perspective, we thought we could advance the theory of networks by looking at the psychological consequences of networking."
Previous psychology research has shown that people think about morality in terms of cleanliness. A 2006 study found that people felt physically dirtier after recalling past transgressions than after recalling good deeds. The study's authors called it the "Macbeth effect," referring to the Shakespearean scene in which a guilt-racked Lady Macbeth tries to wash imaginary bloodstains off her hands.

 

Based on their personal schmoozing experiences, Casciaro, Gino, and Kouchaki hypothesized that professional networking increases feelings of inauthenticity and immorality—and therefore feelings of dirtiness—much more so than networking to make friends. (Gino, for instance, recalled colleagues using copious amounts of complimentary hand sanitizer after work-related dinners.)
The team also posited that networking felt ickier when a meeting was planned ahead of time, rather than a spontaneous occurrence. "Oftentimes there is a deliberate attempt to create a link with another person, which is a very proactive behavior," Gino says. "But other times you and another person just happen to be at the same event, and you end up talking to each other and networking. We thought the difference was important because o...

NINE STATES INTRODUCE LEGISLATION TO SPEED PHYSICIAN LICENSING

WASHINGTON – With some state legislative sessions only a few weeks old, already legislators in nine states – Iowa, Minnesota, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, and Wyoming have formally introduced the Interstate Medical Licensure Compact, model legislation
that would speed the process of issuing licenses for physicians who wish to practice in multiple states. The Federation of State Medical Boards (FSMB) has launched a new webpage,http://licenseportability.org, to track the progress of the Compact in state legislatures.The Interstate Medical Licensure Compact would modernize and streamline interstate licensing while maintaining oversight, accountability andpatient protections. The new interstate compact system would help physicians improve access to care for patients in multiple jurisdictions and help underserved populations receive the healthcare they need.“The Interstate Medical Licensure Compact, which is now being considered in state legislatures across the country, offers an effective solution to the question of how best to balance patient safety and quality care with the needs of a growing and changing health care market,” said Dr.Humayun J. Chaudhry, president and CEO of FSMB. “We’re pleased to have supported the state medical board community as it developed this groundbreaking model legislation and look forward to working with states that wish to implement this innovative approach to licensure.”

 

The final model Interstate Medical Licensure Compact legislation was released in September 2014. Since then, more than 25 medical and osteopathic boards have publicly expressed support for theCompact.

 


“We applaud the progress being made to ensure that Iowans have access to quality healthcare services,”said Mark Bowden, executive director of the Iowa Board of Medicine. “This legislation would expand access to telemedicine, making it easier for physicians to see patients. Everything
about this legislation is a win-win for our state, our physicians, and most importantly, our patients.”

“We are pleased to see Vermont leading the way on ensuring that all its patients have access to quality healthcare,”said Patricia King, MD, PhD,
immediate past president of the Vermont Board of Medical Practice. “Doctors and patients will benefit from a streamlined and less cumbersome licensing process that expands access to care.”

...

WHAT PHYSICIANS NEED TO KNOW ABOUT TELEMEDICAL LIABILITY

by AMA

As with any medical practice, there are liability issues physicians should consider when engaging in the practice of medicine using telemedicine technologies. An expert in legal medicine gives his take on what physicians should know.
Joseph McMenamin, MD, has more than 28 years of experience practicing health-related law. Dr. McMenamin provided physicians at the AMA State Legislative Strategy Conference last month in New Orleans with insight on the potential liability climate resulting from use of telemedicine and outlined key steps physicians can take to minimize potential risk.


•Define the minimum requirements to establish the doctor-patient relationship. This is the fundamental question in telemedicine, Dr. McMenamin said. It’s crucial to determining whether the physician has a duty to the patient, which is important in tort claims. For example, states could consider adopting the AMA model state legislation (log in), which outlines steps to establish a proper patient-physician relationship prior to the use of telemedicine.

The AMA’s principles for telemedicine specify that a valid patient-physician relationship must exist before using telemedicine, through:
  

◦A face-to-face examination, if a face-to-face encounter would be required in the provision of the same service in the real world


◦A consultation with another physician who has an ongoing patient-physician relationship with the patient


◦Meeting evidence-based practice guidelines on telemedicine regarding establishing a patient-physician relationship developed by major medical   specialty societies

Exceptions to the foregoing include on-call, cross coverage situations; emergency medical treatment; and other exceptions that become recognized as meeting or improving the standard of care.



•Determine who owns the huge amounts of data available to both patients and physicians. Now that patients have wearable technology such as FitBits, how are they sharing health data with their physicians? And what—if anything—are physicians required to do with that data?

“The more information there is, the harder it is to separate the wheat from the chaff,” Dr. McMenamin said. “What are the risks of us missing something in this vast amount of data?”



•Require medical liability carriers to write telemedicine and data-related risks in policies. Telemedicine opens a giant door...

HOW GOVERNMENT KILLED THE MEDICAL PROFESSION

by Jeffrey A. Singer

I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks.
Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.

The Coding Revolution

At first, the decay was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Any provider wishing to get compensated was required to use International Statistical Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to describe the service when submitting a bill. The designers of these systems believed that standardized classifications would lead to more accurate adjudication of Medicare claims.
What it actually did was force doctors to wedge their patients and their services into predetermined, ill-fitting categories. This approach resembled the command-and-control models used in the Soviet bloc and the People’s Republic of China, models that were already failing spectacularly by the end of the 1980s.

Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn’t matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.

Hospitals’ re...

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