Will the Bubble Burst?

Brian Klepper

Posted 8/19/12 on Medscape Connect’s Care and Cost Blog

My recent 3-hour outpatient prostate biopsy generated nearly $25,000 in charges. My health plan will probably settle for four to five thousand dollars – this is the real market value – but if we were uninsured we’d be on the hook for the whole thing. All in all, a minor diagnostic procedure – nothing cured or treated – for the cost of a pretty nice car.

The capricious insanity of health care pricing is delivered with straight faces by health care professionals and executives to flabbergasted patients and benefits managers. It is the by-product of a system utterly devoid for decades of transparency, accountability or market pressures.

Continue reading “Will the Bubble Burst?”

The Most Important Health Care Group You’ve Never Heard Of

Brian Klepper and Paul Fischer

Posted 8/06/12 on Medscape Connect’s Care and Cost Blog

Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.

American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.

Continue reading “The Most Important Health Care Group You’ve Never Heard Of”

Why Medical Management Will Re-Emerge

Brian Klepper

Posted 7/31/12 on Medscape Connect’s Care and Cost

Several years ago I had dinner with a woman who had served in the late 1990s as the national Chief Medical Officer of a major health plan. At the time, she said, she had developed a strategic initiative that called for abandoning the plan’s utilization review and medical management efforts, which had produced heartburn and a backlash among both physicians and patients. Instead, the idea was to retrospectively analyze utilization to identify unnecessary care.

This was at the height of anti-managed care fervor. A popular movie at the time, As Good As It Gets, cast Helen Hunt as the mother of a sick kid. When someone mentioned an HMO, Ms. Hunt’s character let fly a flurry of expletives. America’s theater audiences exploded in applause.

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Galvanizing Primary Care’s Power: A Call For A New Society

Brian Klepper

Posted 6/25/12 on Medscape’s Care & Cost Blog

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

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Implementing Health Reform: Increasing Medicaid Payments for Primary Care Physicians

Timothy Jost

Posted 5/10/12 on the Health Affairs Blog

On May 9, 2012, the Center for Medicare and Medicaid Services released proposed regulations to implement section 1202 of the Health Care and Education Reform Act of 2010. Section 1202 increases Medicaid payments made to primary care physicians for primary care services during the years 2013 and 2014 to Medicare payment rates, with the additional cost covered by the federal government.

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GOP Alternatives to ObamaCare

Joe Paduda

Posted 5/2/12 on Managed Care Matters

When it comes to health reform, perhaps the only thing Congressional Republicans agree on is they hate ObamaCare.

There’s no agreement on a basic framework much less consensus on an actual bill. Moreover, there are parts of ObamaCare that enjoy solid support amongst many Republicans, complicating the GOP’s efforts to develop an alternative without conceding political ground.

Their dilemma is certainly understandable; as anyone who followed the tortuous path of the PPACA (aka Obamacare), there was precious little consensus among the Democrats who passed the bill. While most had serious issues with various bits and pieces, they held their noses and voted “aye” when pressed.

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Why Do Hospitals Still Allow Preventable Adverse Events?

Michael Wong

Posted 5/01/12 on The Doctor Weighs In

Can Hospitals Afford to Give Away Money? If not, then why are Preventable Adverse Events Still Occur in Hospitals?

This are questions that I posed to lawyers, insurers, and healthcare professionals attending a major healthcare conference, the Crittenden Medical Conference.

According to the Institute of Medicine, each preventable adverse event costs about $8,750 — and this excludes potential litigation costs.

Can hospitals afford to give away money? So, why do preventable adverse events still occur in hospitals?

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Cappers vs.Skinners in the Struggle To Control Costs

Jaan Sidorov

Posted 4/25/12 on The Disease Management Care Blog

The Disease Management Care Blog agrees that if you want a peek at a potential future scenario for health care reform, look at what has happened in Massachusetts since 2006. That’s when the Bay State passed a law that, just like its cousin the Affordable Care Act (ACA), emphasized insurance reforms that included exchanges, subsidies and changes in Medicaid eligibility.

According to this recent New England Journal of Medicine article, the reforms resulted in both good and bad news. The good news is that 98% of Massachusetts’ citizens have insurance coverage; the bad news is that health care now consumes a whopping 54% of the state’s total budget.

In response, the state is now pursuing cost reforms. As the DMCB understands it, Massachusetts is banking on the principle of “global payment” to incent health care providers to work within a budget. If it works out, the providers will embrace “value” by delivering needed services and cutting waste. If it doesn’t work out, the providers could end up putting savings before patients by withholding medical care.

Continue reading “Cappers vs.Skinners in the Struggle To Control Costs”

How Much Does It Cost To Have An Appendectomy?

Kenneth Lin

Posted 4/24/12 on Common Sense Family Doctor

A few years ago, a good friend of mine who holds bachelor’s and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital’s emergency department, where he was diagnosed with acute appendicitis. Despite his critical condition and the need for immediate surgery, he refused treatment until the hospital’s billing department gave him an estimate of how much an emergency appendectomy would cost. Then, as he was being prepared for the operating room, he somehow managed to bargain with the surgeon to reduce his customary fees.
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The Medical Loss Ratio (MLR) Report—Just Fiddling While Rome is Burning

Robert Laszewski

Posted 4/26/12 on Health Care Policy and Marketplace Review

Today’s headline was, “Millions Expected To Receive Insurance Rebates Totaling $1.3 Billion.”

The Kaiser Family Foundation estimates that 3.4 million people in the individual market will receive $426 million in consumer rebates because of the Affordable Care Act’s new MLR rules. In the small group market 4.9 million enrollees will see $377 million in rebates, and 7.5 million people will get $540 million in the large group market.

Wow!

Continue reading “The Medical Loss Ratio (MLR) Report—Just Fiddling While Rome is Burning”

How Obama Botched and Bungled the Health Reform Message

Michael Millenson

Posted 4/25/12 on the Huffington Post

While it’s comforting to just blame the GOP for the unhappiness with health reform threatening the president’s re-election, the truth is that Barack Obama repeatedly botched, bungled and bobbled the health reform message. There were three big mistakes:

The Passionless Play While Candidate Obama proclaimed a passionate moral commitment to fix American health care, President Obama delved into legislative details.

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My Take On State Health Insurance Exchanges – Part 1

Kenneth Lin

Posted 4/12/12 on Common Sense Family Doctor

Regardless of whether or not the Supreme Court strikes down the individual mandate or the entire 2010 health reform law in June, state-based health insurance exchanges are a good idea and, if established, should benefit many working Americans who are too well-off to qualify for Medicaid but unable to otherwise afford health insurance coverage on their own. This post and two to follow over the next week are excerpts from an unpublished paper that I recently authored on this topic.

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One of the key elements of the insurance coverage expansion contained in the Affordable Care Act (ACA) is the establishment of health benefits exchanges operated by individual states, groups of states, or the federal government, by January 1, 2014. These exchanges will offer competitive and/or subsidized insurance options for individuals whose employers do not provide insurance, as well as offer plans to small businesses (up to 100 employees) at reasonable rates. Prior to the ACA, Massachusetts and Utah had both operated state insurance exchanges with varying degrees of success. By outlining only basic requirements for the functions of the exchanges, the ACA left many important questions regarding their design unanswered. Some states appear to be pursuing a “wait and see” strategy, hoping that the U.S. Supreme Court will strike down the ACA prior to the January 2013 deadline for showing sufficient progress toward establishing an exchange or ceding control to the federal government. Others are at various stages of the planning process; as of January 2012, 13 states had formally established their exchanges through legislation or executive orders. Maryland and California are at the vanguard of this group.

Continue reading “My Take On State Health Insurance Exchanges – Part 1”

The Supreme Court and the Mathless Health Care Reform Debate

Eugene Steuerle

Posted 4/10/12 on The Government We Deserve

Regardless of how the Supreme Court decides the constitutionality of the individual mandate, the health care debate is now reignited. If the mandate is sustained, the Accountable Care Act enacted under President Obama still has too many kinks to remain unaltered. If it’s thrown out, a return to the unsustainable system with growing numbers of uninsured is not a solution. Yet no fix is possible as long as elected officials dodge the basic arithmetic of health care.

As for the individual mandate, ignore the constitutional briefs for the moment. Ignore also how a mandate helps address problems that arise if insurance companies must offer coverage regardless of prior conditions and people otherwise are tempted to wait until they are sick to buy it. Instead, let’s see how a mandate fits it into the broader arithmetic of paying for health care.

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The GOP Budget, Fiscal Responsibility and Part D

Joe Paduda

Posted 4/06/12 on Managed Care Matters

Rep. Paul Ryan (R WI) and the House Republicans are touting their budget as fiscally responsible and prudent. What Mr Ryan conveniently forgets, or more likely avoids, is this:

Eight short years ago he – and his GOP buddies – passed the single largest entitlement program since Medicare – the Medicare Part D drug benefit – with no dedicated financing, no offsets and no revenue-generators – the entire future cost –which is now around sixteen trillion dollars [see page 148] – simply added to the federal budget deficit.

According to Bruce Bartlett writing in the Fiscal Times, “By 2030, Part D alone will cost taxpayers 1 percent of GDP.”

Continue reading “The GOP Budget, Fiscal Responsibility and Part D”