Insight, analysis & opinion from Joe Paduda
A group of docs in Texas has decided that two can play the ratings game. They are working on a project to rate insurers – on their “billing procedures and issues”.
It strikes me that these physicians may be engaging in the same type of behavior that infuriates them when exhibited by insurers – using an arbitrary, internally-developed methodology to evaluate payers solely on administrative indicators.
Carol Gentry of the Tampa Tribune has authored one of the more accessible pieces on the hows and whats of hospital price variation.
Carol’s piece illustrates two key issues – the data is available, and consumers aren’t using it.
The bright light of practice evaluation is making more than a few physicians uncomfortable; these docs have decided that it is somehow unfair for insurers to suggest members go to specific physicians.
So, like all red-blooded Americans, the docs are suing the insurers.
While the docs in question may think they are standing up for their rights, their actions look more childish than professional from here.
CMS’ hospital reimbursement change is going to create winners and losers; among the biggest winners will be UnitedHealthcare.
Among the losers, their competitors.
The adage goes something like – when the US sneezes, the world catches a cold, signifying just how much influence this country has on the rest of the world.
That’s analogous to Medicare’s impact on the health care sector. And Medicare is about to change the way it pays hospitals, a change that will have a dramatic effect on every private payer from HMO to individual carrier to workers comp insurer to self-insured employer.
Coventry’s latest quarter was a good one. The key to financial success in the health plan business is the MLR, or medical loss ratio; Coventry delivered a Q2 MLR of 77.5% resulting from a combination of higher premiums and lower than expected medical claims. Premiums were up 5.1% YTD, while the medical expense increase was slightly lower at 4.9%.
Pharmacy and Therapeutics committees have been around for ages in the provider community – they are the “link between medicine and pharmacy”. In the managed care world, P&T committees take on a somewhat different role, establishing formularies, reviewing medical device reimbursement (at some health plans), contributing to coverage determinations and benefit design.
Mostly, they provide the health plan or insurer with an expert opinion on most things pharmacy-related. Without a P&T Committee, these decisions often are left to a medical director, or worse, claims adjuster (in the P&C world), individuals who are not equiped to make educated decisions about pharmaceuticals.
Actiq has hit the big-time.
Newsweek’s latest edition will feature an article on the off-label prescribing of the highly potent narcotic lollypop, an article noting that as much as 80% of scripts for Actiq are for off-label use.
Sources indicate this was brought to the reporter’s attention by an unusual source – the risk management department of The Washington Post, Newsweek’s sister publication, noticed a high incidence of Actiq scripts among its workers comp patients, and started digging into the issue.
Humana is guaranteeing it will keep customers’ medical trend increases under control, or it will refund part of its admin expenses.
Sort of.
Bob Laszewski cuts to the heart of the matter; it isn’t much of a guarantee, but it sure makes for good marketing.
The merger and consolidation process continues. Coventry Healthcare is acquiring two small health plans in the midwest and another chunk of the Federal Employee Health Benefit Plan.
Coventry is a strong player in the mid to smaller employer market, and a major player in the FEHBP (due to their First Health acquisition). This deal, which is valued at about $130 million and is all cash, makes sense for Coventry and Mutual of Omaha. MoO has long played at the periphery of group health, never quite getting to any significant mass.
And the consolidation continues…