More on SGR...and How It Contributes to Growing Disparity Between Specialist and Primary Care Reimbursement

From the Health Affairs Blog..."Splitting the Sustainable Growth Rate..."

"...Lost in this debate is an appreciation of how the SGR approach has contributed to a large and widening gap in earnings between specialists and primary care physicians, an income gap that is a major contributor to the dwindling number of physicians entering careers in primary care, putting the foundation of the American health care system at risk...."

Yes.  We've argued about whether or not this pay differential is real and whether it's justified.  And primary care physicians (like me) continue to be pissed.  Fuck everyone.

Well, I think this author does a great job of analysis, as well as recommending a logical and feasible solution.

I'd love to know what I'm missing here....would it put specialists at more risk?  Fuck yeah.  But the same would apply to PCP's.

Fair.

Choking Your Chicken is OK....Not Your Neck!

Kids, especially boys, are apparently enjoying the near-suffocation experience of self-strangulation.  Honestly, I'd rather have my kid smoking pot.

Classic comment in the category of "warning signs" from the CDC:

• "A thud in the bedroom or against a wall."

So....watch out for a "thud".

Thud bad.

Is United Healthcare Overcharging for Out-of-Network Services?

NY State Attorney General Andrew Cuomo is going after United Healthcare for allegedly overcharging patients that receive out-of-network services.

An interesting question is raised here.

The principles are as follows:

1.  You get healthcare at a better rate via a group.

2.  The better rate is possible because the actuarial risk is shared across more people (and more premium dollars).  In addition, the rate is possible because the in-network folks have agreed to accept certain rates and to abide by certain guidelines.

3.  Out-of-network services, thus, take advantage of the concessions made by others.  The costs are higher precisely because they are unmanaged.

4.  Excessive out-of-network utilization makes it impossible for the health plan (government or private) to keep premiums low and affordable.  It also makes it difficult to recruit physicians to be in-network providers.

So, the deal is this.  Cuomo alleges that the health plans are charging patients the difference between the out-of-network cost and the "usual and customary" costs, and that by understating these "usual and customary" costs, is overcharging patients.

If I were on the health plan side of this, I'd be wondering whether he really cared about affordability.

From a patient perspective, I'd just want to things to be transparent...what's the cost if I use an OON provider?  

I personally don't have a problem with penalties for OON utilization.  If you rape the system, then you should pay up to offset the pain you inflict on the rest of us.

But if the penalties are over-stated in order to build in a % profit margin, then I've got a huge problem.

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.   

Medicare Goes Broke, Bush Must Fix Problem

Doooh!

It looks like a "trigger" has been tripped that requires El Presidente Bush to fix the issue of excess Medicare costs.

So, he's now got to provide a legislated plan (post budget) to achieve Medicare savings.

HHS Secretary Mike Leavitt:

"...Leavitt suggested that the proposal would be in line with the administration's beliefs that health care should be a "private market where consumers choose, where insurance plans compete and where innovation drives the quality of health care up and may drive the cost down." He added that the competing vision of health care is a "Washington-run, government-owned plan, where government makes the choices, sets the prices and [then] taxes people to pay the bill." Leavitt said Bush likely would have the proposal to Congress before Feb. 21..."

Hint for dumb-ass:  Health care doesn't function as a private market right now, and consumers don't really choose (and if they were to really choose, they don't have the information needed to make the educated purchasing decisions essential for healthy markets).

Leavitt suggests an either-or approach.  What about a new choice...a blend between private and government-run?  

McGill University & House

Yes.

It's true.

Health Punk is a McGill alumnus.  Faculty of Medicine.  

So, whether or not you like the show, "House, M.D." should really be "House, M.D., C.M."

And whether or not you like the show, and for the non-Canadians reading this, McGill is and will always be better than University of Toronto. 

More Cost-Shifting

More cost-shifting adaptations in NYC emergency departments.

Too bad that the bigger issue is that many patients shouldn't end up in the ED anyway.  If only there were primary care incentives to help.