Sick Visits Always Win

Even when patients come in for preventive services, their satisfaction depends on whether or not the "pain" or "illness" that they have at the same time is addressed.

So when someone comes in for a physical, many times they really have something specific they're worried about.

Do you address the preventive care, or do you address the illness?

(Or do you address both and eat the cost of one?)

If you want us to focus on wellness, you've got to pay for it....this is the bottom line.

Pharmacists Help in Controlling Diabetes

At $60-$90 for a 30-minute session, I'd do it too.

Oh, but then again, I can't as a physician....I'm legally required to accept the Medicare rate (or non-rate, as payment for patient education and prevention is often denied).

The fact that the pharmacy also cashes in on the margin from selling the meds can't hurt either, huh? No Stark Laws here.

Seriously, I think anyone/everyone in the health care team must play a role in chronic disease management, so I'm happy for that. But this phenomenon is one of those un-intended consequences of a dysfunctional reimbursement methodology.

Virtual Bundling to Penalize Health Care Wasters

Virtual bundling to reduce payments to wasteful hospitals and physicians is likely to be coming soon from CMS.

It's a payment penalty. It's going to spank those that are inefficient and wasteful, thus depleting our precious health care resources.

I like it.

Even more, I like the concept of redistributing some of these funds to reward those with more responsible resource utilization, but only if this is not the sole variable (e.g., outcomes must also be considered if we want to ultimately reward on value).

I'm not quite sure what the "virtual bundling" concept will look like in practice, however.

Medicare Cuts Reimbursement 15.4% on 1/1/09

Don't fix the formula, and here's what you get.

(P.S., It'll be handled through the veil of efforts to improve quality and efficiency, with measures that place the burden for this on primary care physicians, without requiring tighter management of specialty referrals and procedures.)

Medicare Advantage Plan Spending

"Of the monthly per-beneficiary payments to MA plans, 87% is used for medical expenses, or $683 of $783 per beneficiary per month, according to the report. About 9%, or $71 per beneficiary per month, is used for nonmedical expenses, including administration, marketing and sales. About 4%, or $30, is considered profit, the report found."

Read the Kaiser Daily Policy Report here.

Warning to Medicare Advantage Plans: Watch Out!

Looks like CMS and Pete Stark have these plans in the cross-hairs.

It's true that the FFS/PPO versions of these plans have much higher costs (and much higher profit margins for health plans). I just hope that the more tightly managed HMO versions don't get hit.

Arrgh! Fuck the RUC!

More on this bitch of an organization from Kevin, M.D.

Read the full piece on the RUC in Family Practice Management here.

Do you think 5 caths (assuming they are actually necessary) should be equal to 80 99214's?

How Physicians are Paid: More on the SGR Problem

Check this out....another post on the problems with the sustainable growth rate formula used by Medicare.

I'd definitely take your time reading this because it's great insight into how physicians are paid, how the SGR creates incentives for the wrong things, and how to fix it.

Time to Fuck with the Candidates...Because It's Our Job

When I woke up this morning, I knew it would be a great day to fuck with the candidates.

The candidates are getting more detailed in what they're willing to share in terms of health care reform.

For both democratic candidates, reform is a priority "...with the stated goal of providing coverage for everyone."  Yeah, yeah.  We get it.  I like it.  But is anyone thinking about funding?  Everyone wants to maximize their share of the health pie.  What happens to access if we don't have any statement about funding and how primary care reimburesements will have to increase?  (What about rationing?  If anyone has a way to do this without rationing, I'd love to hear it!)

The republican candidates want reform too (if you don't, you won't get elected). If we just make health care more affordable for the uninsured by providing "...subsidies to help people with modest incomes buy health insurance." Yeah, like that's going to change spending patterns. We know that people tend to decline coverage options via their employer if it involves even modest outlays--it's because they're deciding about covering costs of living and making mortgage payements. You can't blame them for making the same choice. So this solution is worthless (mandates don't work, either, by the way).  

Huckabee's just a fucking joke when it comes to healthcare....the article I linked to just sugar coats it.

The biggest potential challenge with all ideas is that unless everyone has to participate in the same risk pool, (or at least in geographically distributed risk pools that each require everyone to participate), then there will always be selection bias.  Sicker and "less desirable" patients from the standpoint of impact on medical loss ratio will have no choice but to migrate to these defaults.  The healthier (wealthier? white?) individuals will also self-select.  Anyone who thinks you can manage a risk pool with having sufficient healthy patients (low-utilizers) in the pool is smoking crack.

Regarding the republican candidates' proposals, how the hell can you decrease insurance industry regulations and also ensure that selection bias doesn't take place in terms of who's "insurable" and who's not?  The "who's not" category would be less profitable, and thus less insurable.  Even if you don't link premiums to health status, there are clearly ways around this.

Regarding McCain's tax credits, $2,500 for an individual and $5,000 for a family won't cut it.  Seriously, $5,000 for a family?  As it currently stands, my family would burn that up in 6 months (I contribute a portion to my employer's coverage).

Pessimistic...yes.  I think there's still a very large commitment to the future success of the health insurance industry.

"The candidates also have largely sidestepped the hard choices and tradeoffs that many economists contend will need to be part of any significant health care reform.

That includes the pending fiscal collapse of Medicare, projected to be insolvent by 2019."

In any case, I'm definitely glad that health care is taking center stage in this election.  I'm also glad that the candidates are getting to a level of detail that can lead to good debate.

But just in case you were wondering, I think we're fucked for a little (?) while.  Not enough pain yet to motivate action.

Insurance Companies: No Business Argument for Quality

In a recent article, Ezra Klein says it like it is regarding why it would be poor business for insurers to compete on value:

1.  When we want insurance, we go through an underwriting process.  What's really happening here is that the insurer is trying to evaluate the value of "the deal".  They want to, like any rationally-operating business, secure profitable clients, and avoid those that are unprofitable.  

2.  Don't get pissed off.  Or do.  I don't really care.  The issue is that this is what you get when you throw healthcare coverage completely to the private market.  It must operate effectively as any other business would in this environment.

3.  Good quality in managing chronic diseases may actually end up attracting more of the "less profitable" type of customer--those that use more resources than those that don't have the disease state.  Bad business deal.

4.  In addition, the more sick people you insure, the more healthy people you need to offset this.  But in order to insure these sick people, you also have to raise premiums.  Raising premiums will ultimately scare away the healthy and more profitable patients.

In this structure, there isn't a business argument for quality.  

Ezra Klein's article also discusses some ways to get around this--avoid risk-pool selection bias, acuity-adjust funding (such as in Medicare Advantage), etc.

AMA Banned from Hearings: I Don't Care

Here's the deal.  The AMA has been banned from the hearings dealing with the impending 10.1% Medicare cuts will happen or not.  Apparently, they've just pissed people off.

I don't care.  I've always felt the AMA sucks ass, and that it could never adequately represent me and my colleagues.  In fact, if they were involved in these hearings, I still believe that they more strongly represent subspecialists.  

The AAFP and ACP got it covered, among a number of other good organizations.

With that said, I really hope they can achieve a complete formula fix instead of another patch. 

God help everyone on Medicare if they don't.

Medicare Advantage Plans are not All the Same

There's a lot of pressure on Medicare Advantage plans.

Lots of people see a substantial amount of subsidization for these plans.

In fact, a bunch of these MA plans were instructed to halt all marketing activities last year, based on the finding that the costs of those plans was significantly higher.

It's worth looking closer here.

The Medicare Advantage FFS plans are actually the plans with the higher costs, as they really aren't managed tightly.  The MA plans that have been managed via risk-sharing (capitated) arrangements have demonstrated approximately 19% lower costs.

These plans are not all the same, and legislative approaches must recognize this fact.  

MA plans are not all the same, and it would be a shame for the plans that have risk-sharing contracts to be lumped in with the PPO plans.  The risk arrangements produce better outcomes at lower costs precisely because the primary care physicians are taking the risk, and are thus rewarded/penalized for their ability to truly coordinate care.

Don't kill this.   

More on the SGR and RBRVS

Yes.  It's boring.

But it's important to your reimbursement and to your viability.  It's also important to the health of our communities.

Suck it up and read the next installment from Health Affairs on SGR and RBRVS.

Your mom will be proud.  Maybe you'll get a hug or something.

Major Medicare Reform & Sustainable Growth Rate: Everything You Want to Know

Paul Ginsburg speaks the truth. This is a great summary of the history of Medicare's sustainable growth rate for anyone serious about this stuff.

Not for the faint of heart....or the hopelessly stupid, for that matter.

Immigrant Workers Don't Hurt the Health System

Do people realize that in order to both fund the health care costs of an aging population and to offset the shared actuarial risk for the US population, we need more young and healthy workers?

Immigrant workers will not have a significant impact on increasing health care costs, as this Kaiser Foundation report states.

In fact, they'll actually be helping.

If you're against this, I sure hope you've got money to help pay for your own costs. If they paid for their own, their actuarial risk would be lower, and they'd actually get a better deal.

What pisses me off the most (beyond just immigration issues and health care) is that I think that there are a lot of latent racists that use these issues to justify or re-route their deeper sentiments.

Bush Budget Reveals $178 Billion Cut in Medicare Spending

From the Kaiser Daily Health Policy Report on Feb 5, 2008:

"....President Bush on Monday released a $3.1 trillion fiscal year 2009 budget request that would reduce Medicare spending by $178 billion over five years, the Baltimore Sun reports (Hay Brown, Baltimore Sun, 2/5). Over 10 years, the budget request would reduce Medicare spending by about $560 billion....In an effort to reduce Medicare spending growth, the budget request 'asks doctors and hospitals to hold the line on what they charge the elderly for medical care' and maintains that 'cuts in Medicare can be painless -- even lowering premiums that seniors pay by capping what doctors and hospitals can charge...'"

Fuck you.

And good luck finding a primary care doc...they get hurt disproportionately.

You know, this is actually the tip of the iceberg in terms of what we can expect to see as a result of diverted funds due to war spending.

Again, fuck you and the one that made you.