Jun

Government-run health care – how bad is it?

Posted by Joe Paduda on Thursday, June 3rd, 2010 | Comments

There’s been a minor flurry of articles about the Veteran’s Administration health care system recently, a flurry that is both welcome and a bit tardy. It would have been helpful indeed if these had come out during the furor over health reform. Better late than never.
Let’s tackle cost first. The CBO’s most recent report indicates the VA does a much better job controlling cost than the private sector delivery system (used by Medicare). According to the CBO,
“Adjusting for the changing mix of patients (using data on reliance and relative costs by priority group), the Congressional Budget Office (CBO) estimates that VHA’s budget authority per enrollee grew by 1.7 percent in real terms from 1999 to 2005 (0.3 percent annually) [emphasis added] .2 Though not the decline in cost per capita that is suggested by the unadjusted figures, that estimate still indicates some degree of cost control when compared with Medicare’s real rate of growth of 29.4 percent in cost per capita over that same period (4.4 percent per year).”
In contrast, the private insurance sector [pdf] saw premiums increase over 70% over the same period (I know this isn’t exactly apples-to-apples, but no matter how you slice the apple, 70% is still a lot more than 1.7%)
How about patient satisfaction? Again, the VA scores better than the private sector.
“In 2005, VA achieved a satisfaction score of 83 (out of 100) on the ACSI for inpatient care and 80 (out of 100) for outpatient care, compared with averages for private-sector providers of 73 for inpatient care and 75 for outpatient care…For VA, the scores for inpatient and outpatient care were 84 and 83, respectively, while the average scores for the private sector were 79 and 81.”
In the press, Maggie Mahar posted on Phillip Longman’s new edition of Best Care Anywhere; Why VA Healthcare is Better than Yours; quoting Longman’s foreword “Health care quality experts hail it [the VA health care system] for its exceptional safety record, its use of evidence-based medicine, its heath promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, it is the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.”
Merrill Goozner published an interview with Longman, who noted “In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the
leading edge of medical research, due to its close affiliation with the nation’s
leading medical schools, where many VA doctors have faculty positions.”
Longman’s book is a timely update to his 2007 edition, providing new insights into the effectiveness of the VA’s VistA IT infrastructure and coverage of adoption by the private sector of VistA.
Another recent article noted the system is responsible for 24 million veterans (treating about 5.5 million last year), has a budget of “$50 billion and operates more than 1,400 care sites, including 950 outpatient clinics, 153 hospitals and 134 nursing homes.”
The piece quoted Elizabeth McGlynn, associate director of Rand Health and author of a study of the VA: “You’re much better off in the VA than in a lot of the rest of the U.S. health-care system,” she said. “You’ve got a fighting chance there’s going to be some organized, thoughtful, evidence-based response to dealing effectively with the health problem that somebody brings to them.”
Which brings up this question –
Where would you like to get your health care, and which inflation rate would you prefer?

Apr

Ethics, clinical guidelines and profits

Posted by Joe Paduda on Tuesday, April 13th, 2010 | Comments

On Thursday I’ll be speaking at the Geisinger Clinic in Danville, PA on Comparative Effectiveness; the Payer’s ethical dilemma.
This is one of those ‘honored to be asked’, followed almost immediately by ‘I’ve a lot of work to do’ things. And a lot of work it indeed has been, but the deeper I’ve gotten into this, the more…gratifying it has become.
One example. In my research I came across Jim Sabin, MD. Dr Sabin, clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School; he also directs the ethics program at Harvard Pilgrim Health Care and writes an excellent blog, Health Care Organizational Ethics.
Here’s a few of the things I’ve learned from Dr Sabin.
1. Harvard Pilgrim may be the only health insurer in the country that has an inhouse ethics program that includes members, employers, brokers, community members, administrators and physicians. (If there are others out there I’d love to hear about them)
2, This isn’t a program set up merely for PR; rather it has studied significant issues, taken tough stands, and been public about its role and results.
3. The issue of ethics in medical research on effectiveness has another dimension, one that I hadn’t thought thru or explored in enough detail – health plans and health systems can be and in many cases are ‘sites’ for research; there are several ethical issues inherent in that role, issues that involve informed consent, public involvement and education, funding sources and use of those funds, the balance of cost and effectiveness, and the potential impact on the physician-patient relationship inherent in many research efforts.
4. Perhaps the most helpful discussion was around the not for profit status of HPHC. As a not for profit, Harvard Pilgrim doesn’t have to deal with the primacy of stockholder returns inherent in the for profit world; that’s not to say it doesn’t have to ensure financial stability and long-term viability. The difference is in what’s most important – profits or patients.
The primacy of stockholder returns influences ethical and business decisions, or rather should. For profit companies must consider shareholder returns first and foremost; to do otherwise would be an ethical problem. There are for-profit health plans and insurers that work diligently to deliver services ethically and responsibly, bending over backwards to do the right thing. Aetna is one that comes first to mind. And there are others that don’t bend at all.
Which is ‘right’? A compelling argument could be made for either position.

Mar

The ethics of clinical guidelines

Posted by Joe Paduda on Tuesday, March 9th, 2010 | Comments

Next month I’m going to be speaking at the Geisinger Clinic on the subject of Comparative Effectiveness – the payer’s ethical dilemma. I’m fascinated by this issue as it strikes at the heart of the problems with, and perhaps solutions for, the health insurance crisis.
If we are to solve the access and cost problem, payers, providers, and patients must be comfortable with the decision process and methodology. Today, there’s precious little ‘comfort’ with the current ‘system’. And that’s understandable.
There’s a lot of ‘art’ in medicine; physicians diagnose conditions and recommend specific treatments based on what they think will help, often without much in the way of peer-reviewed research supporting their views. Much is based on their own training and experience and the knowledge passed on to them by their medical school professors and colleagues, provided in specialty society and other medical journals, passed on by medical device and pharmaceutical firms, and learned at conferences and symposia.
Most of the time this knowledge delivers the ‘right’ outcome; the patient gets better. But in some instances there are at least a couple different treatment options for the patient’s condition. Physicians recommend what they think will work based on the patient’s unique characteristics (physical, emotional, financial, history), and these ‘recommendations’ may be several. For example, chronic lower back pain treatment options may include surgery, physical therapy, medications, some of the above, all of the above, and variations of each of the above.
Sticking with the back pain issue, think of this from the payer’s perspective. The wide variation in back surgery rates is well-documented, with Medicare data indicating a 500% variation between Ft Myers and Miami Florida. We don’t know why there’s such a wide difference, but it is safe to assume that the rate is too high in Ft Myers, too low in Miami, or perhaps both.
When a physician in Ft Myers recommends surgery for a patient with a back condition, it is understandable why payers would have concern over the appropriateness of the procedure. To address this concern, payers utilize clinical treatment guidelines in an effort to determine if the recommendation is ‘appropriate’.
In some cases, the guidelines provide clear and convincing support for or against the procedure, but in many others the finding is not so clear cut. The patient may have some but not all of the clinical findings that are ‘necessary’ to support surgery; there may be other medical conditions present that complicate treatment determination; the patient may want one type of treatment for their own reasons.
The result is the payer – and the physician – are functioning in a somewhat grey area.
There are obvious financial factors in play as well. The physician gets paid to do the procedure, the pharma company gets paid if the patient takes their meds, the device company gains revenue for each device sold, the payer saves money if expensive procedures aren’t performed, the patient may want drugs for inappropriate reasons.
The ethical issues are apparent. While we would hope that decisions would be based solely on the evidence, there often isn’t enough of the right type of evidence to arrive at a clear cut decision. When that occurs, what other factors affect the decision? How are disagreements resolved, and what is that resolution? When there’s strong disagreement, what factors, evidence, criteria are ‘used’ to support the parties’ different positions?
If you have experience with situations that speak to this ethical dilemma, I’d appreciate hearing from you.

Mar

Texas’ efforts to add science to the art of work comp medicine

Posted by Joe Paduda on Thursday, March 4th, 2010 | Comments

As anyone who has studied physician practice patterns is only too aware, there is wide variation in how physicians practice; the kinds of tests they order, whether they admit patients to the hospital or treat on an outpatient basis, the drugs they prescribe and the outcomes they deliver.
If we are to gain control over health care costs and ensure patients receive the right treatment and payers get value for their dollars, we have to force more science into the art of medicine.
Texas’ Division of Workers Comp’s push to publish data [sub req] on work comp physicians’ compliance with clinical guidelines is a step in the right direction. While only in the formative stage, and pretty limited at that, the effort is long overdue but nonetheless a critical step in reforming the dysfunctional mess that is our health care system.
Unlike any other good or service, when employers ‘buy’ health care they have no idea of what that investment returns; they don’t know what they get for their dollars. When an automobile manufacturer buys tires, it makes its decision on which tires it buys based on the performance of those tires, their durability, ability to carry the car’s weight, handling, cost, and value compared to other tires on the market.
That same auto manufacturer has no idea what it gets when it spends millions on health care. What is the return on investment on the premiums paid and the services bought with its dollars? How does it measure the value of the office visit, the return on the MRI, the 30 day supply of medication?
Because employers don’t know and can’t measure the return on their medical spend, they focus on spending as little as possible – they have to provide health and workers comp insurance, but want to spend as few dollars as they can because there’s no way to know what the return is on that investment.
Which is why Texas’ efforts are so important. While one can (and I’m sure some will) argue that they are starting too small, (WorkCompCentral reports that one recommendation is to begin looking “at compliance by doctors with treatment guidelines in ordering MRIs for back and spine injuries”), it is far more beneficial for all concerned to begin the effort, to engage providers, payers, regulators, and claimant advocates than to wait till there’s broad consensus on multiple performance measures.
What’s great about workers’ comp is that unlike group health or medicare or medicaid, the same dataset includes information about return to work, the cost and duration of disability, and the final ‘functional’ outcome (I’ll concede that these data aren’t always accurate or consistent). When we’re evaluating medical care, the ultimate outcome should always be based on the degree to which the patient recovered and returned to functionality.
What does this mean for you?
Do not let the perfect be the enemy of the good – encourage Texas’ DWC to proceed quickly with their initial efforts, engage with them in a positive way, share data, and push for more measures, more results, more openness. Understand that physicians have concerns about outcomes, many of them legitimate, and work with them wherever possible.

Feb

Hospitals’ strategy – survival thru cost shifting

Posted by Joe Paduda on Thursday, February 25th, 2010 | Comments

Over the next few weeks, I’m going to be writing extensively about the death spiral of the American health insurance system, a fate as certain as it is unthinkable.
As enrollment in private insurance plans declines, and the Medicaid population increases, providers will have to increasingly rely on the remaining private pay patients to cover the costs of the uninsured and, in the case of Medicaid, under-reimbursed. I’ll begin the discussion with a story that clearly illustrates the problem.
Hartford Hospital’s announcement that its primary strategic focus is to achieve a “Solid Foundation” is prima facie evidence of the future of health care – the continuation of the private insurance death spiral.
In its press release, HH says:
“Negotiating with managed care companies is one key element of Solid Foundation. In 2010, Hartford Healthcare has two more major contracts to negotiate, and these contracts have a common thread – historic underpayments from private insurance companies. Hartford Healthcare physicians and hospitals have been paid too little for too long compared to hospitals across the country with similar services and capabilities.”
That’s not to say they’re out there looking to make billions; HH is aiming for margins in the 1% – 2% range.
But in order to make those modest margins, HH is going to have to fill beds – and the data indicate the Hartford area has too many beds, which will result in higher costs without an improvement in quality of care.
Compared to New Haven, CT, [link opens the Dartmouth Atlas for New England as pdf] Hartford has 23% more excess bed capacity and hospital costs that are more than 10% higher per capita.
I don’t know if the hospitalization rate in New Haven is appropriate or not; I don’t know if the hospitalization rate in Hartford is appropriate or not. I do know that one of the two, or perhaps both, aren’t the ‘right’ rate.
Hartford Hospital is responding to its need to preserve it’s organizational existence, and therefore will push hard to raise reimbursement while filing beds, a double hit for private insurers and employers who are being ‘taxed’ to help offset declining reimbursement from CMS and an increase in the number of Connecticut citizens without health insurance.
An intelligent approach to our nation’s coming health care disaster would be to address the supply issue. Reduce the number of beds in Hartford (while I don’t know there are too many in Hartford, that’s a pretty good guess).
What does this mean for you?
Until intelligence appears in the health care reform debate, you’ll see more and more announcements like Hartford Hospital’s. While they work to solidify their financial foundation, we’ll be watching our nation’s health care system crumble.

Feb

How many dollars are wasted on physical therapy?

Posted by Joe Paduda on Friday, February 12th, 2010 | Comments

Probably a lot. Perhaps most. And certainly a big chunk of the bucks your insurer/TPA is paying.
Unlike surgery, imaging, drugs, and other types of medical treatment, PT has long been a bit of a black art.
The clinical guidelines for PT that do exist (with one exception I’ll get to in a minute) usually say something like ‘two visits a week for four weeks’, without describing what is to be done during those visits, who’s supposed to do what gets done, and equally important, what shouldn’t be done.
That’s the primary reason physical medicine (PT and chiro) accounts for about one out of every five dollars spent on medical care in work comp, and would account for big bucks in group if it weren’t for tightly written benefit limits (x visits at a 50% copay).
Before the PTs out there start flaming me, know that I’m a believer in the ability of appropriate PT and have seen lots of data that support the use of PT in helping injured folks return to functionality. But I’ve also audited many work comp claims where the claimant had been to PT hundreds of times. I recall one where the claimant had over five hundred (500) visits over a three year period, with each PT note looking identical to the previous one. The payer couldn’t cut off the treatment because the treating physician had ordered it, and the clinical guidelines weren’t robust enough to force the issue in court.
Last month the NYTimes had an excellent article by Gina Kolata on just this issue. Here’s an excerpt:
“My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion [that much of PT is waste]. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”
So has physical therapy been tested for garden-variety sports injuries like tendinosis? Or is it just accepted without much question by people who urgently want to get better?
It depends, says James J. Irrgang, a researcher in the department of orthopedic surgery at the University of Pittsburgh and president of the orthopedic section of the American Physical Therapy Association.
“There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”

(not in Ms Kolata’s article, but helpful for perspective…)
Sometimes, manual stretching by a physical therapist can actually eliminate a sports injury, he said…They are the exceptions. More common are the “voodoo” treatments, he said. And what might those be? None other than ice and heat and ultrasound, Dr. Irrgang said.
Ice and heat, Dr. Irrgang said, “can control pain a little bit” but “are not going to take care of the problem.” The underlying injury remains.”
But the lack of credible evidence-based clinical guidelines can make it difficult for payers to contest unnecessary treatment, especially in those states where regulations make it tough for payers to stop paying for unnecessary treatments.
There are credible, thoroughly researched clinical guidelines specific to PT, with the best focused not only on how many visits over how many weeks, but what should be done during those visits. I’ve reviewed all of the guidelines used in work comp for PT, and the most thorough are published by Expert Clinical Benchmarks, a subsidiary of MedRisk. (MedRisk is an HSA client)
Guidelines can’t be developed in six months; rather they must be carefully researched, assessed by acknowledged experts in the field, tested against claims and medical billing data, and reviewed periodically. There are far too many companies touting their ‘utilization review’ programs which are based on little more than the ‘same old same old’ guidelines that have never worked in the past, or quickly-assembled amalgamations of journal articles, neither of which will be of any help in front of a work comp judge.
What does this mean for you?
If you’re serious about managing PT, start with science.
UPDATE
I received an email from a good friend and colleague in the PT business who felt my post was an insult.

Let me reiterate – there are good PTs, and bad PTs.
There is good PT management, and bad PT management.
Some PT is quite useful, appropriate, and necessary, and some is not. When payers don’t use solid clinical guidelines it makes it very difficult for adjusters, case managers, peer reviewers, and hearing judges to differentiate between appropriate and inappropriate PT. And there’s lots of inappropriate PT in work comp.
In the course of my consulting practice, I’ve seen dozens of cases where claimants received more than a hundred PT visits over a year, and many where the total number was well over two hundred. This type of utilization is simply indefensible, and unfortunately often results in adoption of regulatory control mechanisms.
Some states have chosen to use caps on visits as proxies for utilization management, with 24 appearing to be the most common limit. This is at best a blunt instrument, but nonetheless it appears to have resulted in lower costs for physical medicine in the jurisdictions that have adopted the ’24 visit rule’.

Nov

Clarification – Last chance to avoid higher comp costs in Florida

Posted by Joe Paduda on Monday, November 30th, 2009 | Comments

Florida is scheduled to dramatically change the way hospitals get paid to care for workers comp patients, and if payers don’t get their act together, they’re going to be paying more – a lot more – for medical care.
WorkCompCentral reports today that a hearing, tentatively scheduled for this Wednesday to review the change, will not be held if no public comments have been submitted. That was the case as of the day before Thanksgiving.
Here’s why payers should shuck off their post-prandial lethargy and get their comments/objections/concerns in to DWC.
The revised fee schedule would have payers owing hospitals 174% of Medicare for surgeries and 395% of Medicare for other compensable charges. Workers comp is already the most profitable line of business for Florida hospitals, and this methodology makes it even more lucrative.
Clarification – in the original post, I noted that “according to an analysis performed by FairPay Solutions, this methodology will increase payers’ costs – today – by 181% for surgeries and 330% for other hospital outpatient services.” This was actually from FPS’ review of the Florida Dept of Financial Services’ 2006 analysis.
Not only are the hospitals going to prosper under this new scheme, work comp networks contracted with hospitals at a percent off charges are going to be rolling in dough, as the charges are going to be much higher, and their ‘savings’ are going to be as well.
It’s not just a price issue – Expect to see many surgeries and other services currently performed on an outpatient basis shifted to inpatient to take advantage of the much higher reimbursement. Thus procedures which were being done in offices will now be billed – at the much higher rates – by hospitals.
This isn’t just speculation. South Carolina put in a Medicare+ hospital fee schedule on 10/01/06. NCCI recently filed a 23.7% WC rate increase. Even though SC’s adoption of a Medicare+ hospital fee that pays hospitals less than the fee schedule proposed by Florida (140% of Medicare in SC vs 174% to 395% of what Medicare pays being proposed for Florida by DFS), paying SC hospitals more has significantly increased medical costs and utilization in SC.
For more detail on this (and be careful what you ask for), see here and here and here.
What does this mean for you?
If you’re a network or hospital, happy days.
If you’re a payer, higher costs – much higher costs.

Nov

Note to CBO – don’t forget to add that quarter trillion to the cost of health reform

Posted by Joe Paduda on Wednesday, November 11th, 2009 | Comments

Because that’s what it is going to ‘cost’ to replace the current Medicare physician reimbursement scheme with something else. And make no mistake, as Trudy Lieberman of the Columbia Journalism Review points out, most of the nation’s physicians are adamant about ‘fixing’ Medicare reimbursement.
The issue is the Medicare Sustainable Growth Rate (details here). The net is simple – if the SGR formula/process is eliminated, a quarter trillion dollars gets added to the deficit, because that’s the amount the formula/process says has been paid to docs over and above SGR ‘limits’.
Current Congressional protocol requires CBO to ‘score’ any and all health reform proposals; unsurprisingly the SGR ‘fix’ has not been included in any reform measure, because it will push the cost way, way over a trillion dollars.
Thus, thru legislative legerdemain, Congress is avoiding talking about and being held responsible for the real cost of reform.
As long as we have to ‘fix’ the SGR – and I’m not arguing that Part B (physician reimbursement) doesn’t badly need fixing, hows’ about we ‘trade’ SGR elimination for some real reform, like, say, bundled pricing for specific procedures/conditions? Like, maybe, a flat cost for treating an asthmatic patient over a year including facility and physician and lab and other costs?
Or, for those chronic patients with more than one condition, a formula that pays for all their care based on a multiplier indexed to the number, cost, and severity of their conditions?
Or a requirement that all physician bills from practices that don’t have all patients on a share-able electronic medical/health record are paid under a non-fixed SGR, while bills from practices using ‘certified’ EMR are paid under a new schema?
Pretty draconian, you say? Not as draconian as anteing up another quarter trillion bucks, I respond. Sure it will be hard and take some time and isn’t easy and all that other blather. It’s a huge knotty ugly problem, requiring some ugly solutions, and none of them are going to be perfect. But they will be a damn sight more perfect than what we have if we don’t get reform-with-cost-control done this time around – family health care costs above $30,000 within ten years.
It’s time we got more from stakeholders than just their agreement to not block reform. We need a good more arm-twisting and a lot less gentle cajoling.
What’s the net?
Watch to see how Congress and the President handle the SGR redo issue. Do they use SGR as a lever, or do the docs use it as a club?

Oct

Who’s the crook?

Posted by Joe Paduda on Friday, October 30th, 2009 | Comments

Few things I’ve encountered in my twenty-five-plus years in the insurance business are as outrageous as the prosecution of Sandy Blunt, the former head of the North Dakota work comp fund.
I’ve posted on this case several times; what originally caught my attention was the announcement that Bryan Klipfel, a former State Trooper had been named the head of the ND work comp fund.
According to a local paper in ND, when asked about his qualifications, Klipfel said “I’m going to work with Bruce (Furness) for a couple of weeks, and I’ll just have to learn some of that information as time goes on…My strong points are that I have leadership ability, and I understand human resources, how to deal with people. And I think that’s the big part (of the job) right now.”
That got me thinking – “He’s going to learn on the job? While getting mentoring for a ‘couple of weeks”? In a business that is incredibly complex? At a time when investments and reserving practices are critically important? And his qualifications are his understanding of human resources and leadership ability?” – with the result that I dug deep into the story, only to find out what can only be characterized as a witch hunt, conducted for unknown reasons by a prosecutor’s office that went way beyond what could be construed appropriate behavior.
The deeper I dug, the stinkier it got. Blunt was convicted of felony charges, which could only be brought because the prosecutor ‘rolled up’ several smaller charges related to gifts for workers (trinkets, food for parties, etc) and his authorization of sick leave. In fact there aren’t any charges that Blunt took money himself.
At the time, I thought ‘Ok, so Blunt made a few bad decisions and/or didn’t follow all the rules by the book. But a felony conviction for a sick leave authorization and some inexpensive ‘gifts’?’ Seemed wildly excessive – at any other big organization – public or private – this wouldn’t merit anything more than a reproachful email from the corporate compliance officer/legal counsel.
Turns out it was way more than ‘wildly excessive’; the Blunt conviction was the result of egregious prosecutorial misconduct.
The prosecutor didn’t give Blunt’s attorney exculpatory evidence – evidence that would have proven that the sick leave charge was insignificant – it wasn’t even a concern to state auditors who had gone thru the state fund’s books with a fine-toothed comb. More importantly, the prosecutor didn’t give the memo from the state auditor pertaining to this issue to Blunt’s attorney.
Anyone who’s watched even a little TV knows that prosecutors MUST give all evidence to the defense. Anyone except Cynthia Freland, the assistant state’s attorney who tried the case.

I have no idea what in the hell is going on up in North Dakota, but I do know this. Sandy Blunt is a decent, honest, very capable guy who has been absolutely screwed, apparently in no small part by a prosecutor who broke the law.
Blunt is currently appealing the case before the state supreme court, primarily on the basis of the prosecutor’s ‘roll-up’ of charges. His contention appears to be because one of the charges was thrown out, the jury should have been allowed to consider each of the other charges independently, which not coincidentally may well have resulted in acquittal as the remaining alleged offenses may not have met the standard for a felony conviction.
If there’s any justice in this country, Blunt will be acquitted and Freland fired and investigated for possible commission of a crime. Regardless, Blunt’s reputation will be forever tarnished with his professional life ruined due to some bizarre personal vendetta on the part of an at-least incompetent and possibly criminal state prosecutor.
Disclosure – I’ve come to know Sandy pretty well. I called him to hear his side of the story earlier this year. He is a very smart, humble, positive gentleman who is a consummate professional. Sandy and I have worked together on a couple projects, and I have been very impressed. Sandy’s performance at the ND Fund speaks for itself – and I can – and will – put my personal reputation on the line for him.
It’s a no-brainer.

Oct

How horrible is Medicare?

Posted by Joe Paduda on Tuesday, October 27th, 2009 | Comments

Depends on who you ask. If you ask group practice administrators about how Medicare compares to the private insurance industry, it is pretty darn good – in several categories, Medicare Part B is rated higher than any other large payer.
That’s partly due to the lousy performance of some of the private insurers, but administrators actually rate Medicare’s responsiveness, transparency, prompt payment, and overall administrative functions highly.
Yes, you read that correctly.
On a five-point scale, with 5 the highest rating, the much-maligned and oft-decried public plan for the aged has an overall satisfaction rating of 3.6, with Aetna at 3.1 and UnitedHealthcare bringing up the rear at 2.5.
Medicare was considered the most timely responder to inquiries, with Aetna second and UHC at the back of the pack; the same standings hold for accuracy and consistency of the payer’s responses to questions, speed of payment (Medicare 4.1, Aetna 3.5, UHC 3.1), disclosure of payment policies, and claims appeal process (Aetna was excluded from the report).
Medicare doesn’t appear on the list of questions regarding satisfaction with the contracting process, except in the ‘willingness to disclose the fee schedule’ category, where it is again rated at the top. This isn’t surprising, as CMS is not engaged in ‘2-way good-faith negotiations’ nor do practices have ‘leverage during the negotiation process’. I don’t know if responders didn’t ask about Medicare or if Medicare was ranked at all; I’ll let you know when I hear back from the Medical Group Management Association (MGMA), the organization that conducted the study.
As with any study or survey, you can find data to support any perspective.
That said, the ratings of the health plans are generally consistent with those reported by the Verden Group, an independent firm focused on helping providers deal with managed care organizations.
Aetna received top marks for clarity of communications, and was rated the most ‘provider friendly network’ by respondents to the Verden Survey in 2008.
As the public option becomes possible once more, and opponents lament the inefficiency, lousy service, and incompetence of the faceless bureaucrats that run Medicare, it is helpful to know what the people on the other end of the transaction think.
If you listen to them, on a number of fronts, Medicare’s a darn sight better than most of the private insurers they have to deal with

Category: Providers