Posts tagged with managed care

I have to come up with an analogy for the Great Medical Insurance problem here in the US. The Rebels vs. The Empire? Robin Hood vs. The Sheriff of Nottingham? David vs. Goliath? None of these is just right, but they each contain elements of the issue: a giant, controlling source of pain and trouble being fought by the little guy (or woman - see below). It's a matter of time before we see the Erin Brokovitch movie about the insurance industry.

What a delight it was, then, to read this month's SOAPM newsletter (past issues are available at the AAP as well as at PCC, as we sponsor the newsletter). First, I read Dr. Francis' piece reminding pediatricians to go to hmosettlements.com to participate and keep an eye on the settlements with Aetna, Healthnet, Wellpoint, Humana, and Cigna. Just go read the entire site.

Even better was the description, from Dr. Stoller, of how she discovered Aetna was in violation of their settlement terms and, through just a little work, was able to recover a significant amount of income relating to -25 modifiers as well as mis-processed "out-of-network" claims (that were really in-network). As she says, "FIGHT BACK!"

Then, I got the email:

horizon class-action lawsuit settled

Good work. My favorite part of the email reads as follows:

This latest national class-action settlement is one in a series of actions against major healthcare insurers and another milestone in the check against widespread and chronic abuses against physicians. These class-action lawsuits have resulted in significant reforms in the health insurance industry.

The settlement consideration includes a guaranteed cash payment of over $128 million to class members. In addition, the settling defendants have agreed to implement important business practice changes that will bring the estimated value of the entire settlement consideration to well over $1 billion.

Perhaps an Austin Powers analogy would work? "One Billion Dollars."

It gets better, though:

The agreement follows similar settlements with other major managed care companies, with the exception of United Healthcare, who continues to litigate against physicians rather than making the kinds of positive practice changes other insurers have agreed to make.

Indeed, United Healthcare has repeatedly refused to address the significant concerns raised by representatives of the more than 400,000 physicians nationwide who care for United Healthcare's members. According to MSNJ CEO & Executive Director, Michael T. Kornett: United Healthcare simply has not raised its standards to what has become the industry standard in healthcare. United Healthcare has systematically engaged in practices of coercion and intimidation that are akin to the actions of a school-yard bully. When all the other major national healthcare insurers agree to conduct business with their physician/providers in a more transparent and fair manner, it is difficult to understand why United Healthcare refuses to operate on a more level playing field.

Wow. Although I assume it actually isn't difficult for anyone to understand why United behaves this way, kudos to the Medical Society of New Jersey for stepping up.

How's this for breaking news? Here's a sneak phone-camera shot of Dr. Lander presenting a well deserving Dr. Francis with the Buzzy award.

Quite a day.

• We all heard the great news (though overdue) about United and the -25 modifier from Dr. Lander. I'll get the official announcement shortly and post it. Great work.

• The presentation and acceptance from Dr. Francis was wonderful. We are very proud and honored to sponsor the award.

• Wow, the SOAPM room was full of friends and family. I had a chance to say hello to Drs. Lessin, Lander*, Sutter, Stoller*, Simon, Cain*, Bienstock, Craig*, Schaffer, Katz, Oken*, Bradley, Shenkin, Pillsbury*, Diasio*, Khort, and many more - I can't forget Lynn Cramer* and JR Vaught*. (* = PCC client).

It has been interesting to me, as an outsider, to witness the maturation of SOAPM over the last few years. They are clearly on the verge of something great, but they are also struggling with some social management issues that any organization of its size and energy has. They have to do decide what they want to be, where they want to go. It will be interesting.

During some of the conversations (with the AAP board, the medical directors), a number of folks kept referring to medicine as a "market based system." The implication is that the "market" decides what pediatricians are paid. Adam Smith would turn over in his grave - pediatrics is may be a market, but it's not a free market. In a free market, there are not protected monopolies. Information moves freely. Consumers have choices. Consumers understand the value of their decisions. That's not true when it comes to medicine, especially caring for kids.

Drs. Oken and Shenkin both made very good, insightful comments that weren't given enough attention, imo. The former was, essentially, pushing hard on the market conditions pediatricians face (I've heard him ask the same questions every year and beg that he not stop until they are answered). He's the one who, like me, keeps pushing for a standard for payment levels for pediatricians - and I thank him for it. Dr. Shenkin mentioned the concept of Facebook/MySpace for SOAPM and a lot of people chuckled...but couldn't be more correct in his thoughts about where the group should be looking in the future. Sure, it would seem silly - at first - for the AAP or SOAPM to have a Facebook entry, but the more you think about it, the more sense it makes. Especially if you actually try to navigate the AAP site.

Finally, the line of the day came from one of the managed care executives. I don't mean to speak out of school here, and who actually said it doesn't matter, but can you beat this message come from the payers themselves?

"If you don't like what someone is paying you, don't sign the contract."

He was right.

One thing leads to another and I found myself poking around the American Journal of Managed Care today. Doesn't that title seem redundant to you? As though there might be, say, a Canadian version of the same publication?

From this journal, here is an interesting piece about the use of phone reminders to get patients in for their flu shots. The article highlights include:

Conclusion: Telephone intervention was successful at increasing vaccination rates in a diverse managed care population that had already received mailed reminders. Tailored messaging for pneumococcal vaccination through telephone reminders increases patient demand for vaccination and should be implemented by managed care organizations seeking to increase their vaccination rates.

Take-away Points
This randomized trial demonstrates the effectiveness of a telephone intervention for increasing adult pneumococcal vaccination rates among high-risk patients across racially/ethnically diverse managed care clinics.

Not knowing that pneumococcal vaccination is needed is common among high-risk patients, despite their exposure to routine preventive services reminders.

Telephone outreach increases adult vaccination in diverse managed care settings across a broad spectrum of age and comorbid conditions.

Telephone calls are inexpensive for the potential benefit provided.

Increased data capture regarding prior immunizations can improve the targeting of patients and lower the cost of outreach programs.

Note that this study only examines the effect on adult vaccines, but I presume that the results would be similar, if only lower, in a pediatric practice. What the study also doesn't examine is what happens when you run out of vaccine or it comes late.

Still, I would consider this an endorsement for the various phone reminder systems.  If not, why not?

My apologies for brevity and inconsistency, but we are in the midst of a family emergency and I am racing out of town.  In my potential absence over this Thanksgiving week - and later, to augment or even replace your reading here - check out Susanne Madden's blog!  Many of you know her from PedTalk (in particular) and her detailed and passionate analyses of nearly all things managed care.

I suspect her blog will be less frequent, though of higher and more consistent quality than, say, this one.  I am hoping for a little good-impression-by-association.   I sincerely wish there were more competition in this blog business for high quality examination of the managed care industry from the perspective of the private practices.  Perhaps Susanne and I can duke it out for the role - we'd all benefit.

Congrats and good luck, Susanne.

[Before I begin, it looks like there might be an important RVU update later today!]

From hmosettlements.com:

On October 19, 2007, Highmark Inc., and Highmark West Virginia, Inc. d/b/a Mountain State Blue Cross and Blue Shield (“Highmark"), entered into a Settlement Agreement with physicians. The settling parties filed their Joint Motion for Preliminary Approval of Settlement on October 23, 2007; the court issued its preliminary approval order on November 19, 2007...

The deadline for submitted claims is February 27, 2008. Any questions regarding the settlement should be directed to the Highmark/Mountain State Settlement Administrator at 1-866-486-1725.

To make a long story short:

The Complaint in the Action alleges, among other things, that between 1999 and the present, the Blue Plans, among others, engaged in a conspiracy to improperly deny, delay, and/or reduce payment to physicians, physician groups, and physician organizations by engaging in several types of allegedly improper conduct.

I am shocked, shocked I tell you, that the insurance companies might conspire to deny, delay, or reduce payments! Apparently, based on your claim $$ volume from 2004 through 2006, you are potentially entitled to money you earned, but was manipulated from you by BC/BS, Highmark, etc. You can find their claim form on-line, too.

Your deadline is Feb 27, so don't delay.

Medical Economics has commented on Susanne Madden's article about Medical Cost Ratios. Haven't read it yet? Don't do so just before bed, it will keep you up.

Good work, Susanne!

I'm stumped.

PCC has advocated that our clients use the prompt pay laws that exist for every state in the country.  We have heard, from time to time, of the "seven-cent-checks" that our clients receive.  However, I was prompted by a question from Alison over at the Pediatric Coder's Pink Sheet, and asked around.  It turns out that I can't find any PCC clients who actively pursue this interest.  They can generate reports which show the age of any claims (paid off or not), so why not?

Perhaps people aren't aware of the penalties the inscos have to pay when they don't pay you quickly.  Although this resource is two years old, it's still pretty accurate:

Prompt Pay Statutes By State (karenzupko.com)

Typically, the payors owe you 10-20% interest on these late claims!  That's a lot of money.

So - why aren't you all tracking these payments down?  Are they too small to worry about?  Do the laws not help you?  Some of them are really tough (New York offers $500 daily fines!) but some of them are quite vague.

Ideas?

"A few weeks back, I pointed out a living, breathing example of a successful cash only pediatric business. I've also added a few posts about concierge pricing and what our customers are doing.Meanwhile, over on her blog, Susanne Madden adds some insightful commentary on the subject, including one point in there which is quite subtle, but incredibly important:

In the case of insurers, some don't want physicians to charge these fees to their members citing contract provisions excluding them from doing so, while others do not have a problem with it.

Sure enough, some of the major payers (Aetna, Cigna, and others, I believe) are "allowing" their patients to work with "concierge" practices. This is the hole in the dam we've been waiting for, imo. You now no longer immediately alienate some of your patients when you begin to provide a concierge solution. You can develop your solution and then grow it. No need for a radical change.

• I quote "allow" because your patients are always allowed to see you. They might have to pay more, is all. You're worth it, no?

• I quote "concierge" because I don't like that word in this instance and need to come up with a better word. "Concierge" implies some kind of exclusive, wealthy-only practice. Which the model I continue examine is not. Anyone want to help me name it? I'm thinking something like "Human" or "Natural" or "Reasonable" or "Anti-Managed Care."

Susanne has gone so far as to find another living, breathing example of a concierge group. Check out this national program: MDVIP. To become an MDVIP provider you must, among other things, limit yourself to 600 patients (an interesting start). What I like about their sales pitch is that "prevention and wellness" appear so close to the top of benefits of working with them. I think it ought to be #1, personally, but it's a good start!Two additional pieces to read:

• A piece entitled "Concierge Family Practice: A Minor Trend Sparks Major Ethical Questions" from the Dagger Press with some detailed stories about a few concierge groups and their stories.
• I should have known: someone has started a blog about opening a concierge practice.

Awesome, just awesome. I love it.

Over at The Verden Group, they've been busy working on their quarterly ranking program of the 160+ managed care organizations they track. They've developed a unique scoring system that allows you to see, in a wonderful graphic, exactly which insurance companies stink the most.

Perhaps I'll go on in detail later, but don't waste your time reading me today. Read the report. I'll just hit some of the text from the description:

The goal of the Verden rankings system is to evaluate how well or poorly managed care companies (Payers) are performing from the perspective of physician practice management...Our analysis is composed of five categories in which each insurance company was given a score. The more points accumulated, the worse the company fared. Points were designated based on multiple criteria, with each metric carrying a different weight.

You'll be surprised at a few of the rankings, but not all. You can finally quantify your instincts, though! Sneak peek:

I took another “We Think We Need To Merge!” call today from a thoughtful practice on the east coast. A couple small groups, aimed at getting a more fair piece of the pie. Can’t say I blame their intent.

Practice mergers are like tattoos - they sound good when you and all your friends have had a few drinks. They even look good on a few people. “Just picture it: 70 of us, fighting UnitedHealthCare!” sounds suspiciously like, “Just picture it: a rose, right there, where no one can see it!” Face it, can you come up with a tattoo design that will look good on you 10 years from now?

The inspiration to to record this conversation came from one comment in the middle. Apparently, there’s a trustworthy lawyer in the mix (they exist) who has stated, unequivocally, that he believes the practices need to merge in order to negotiate with insurance companies. I wonder if this lawyer has ever actually negotiated a primary care insurance contract? Do you think he sees tens of thousands of dollars in fees making this happen, risk free? I sure do - whenever I see a lawyer pushing for groups to merge, I throw a GIANT RED FLAG. If the plan succeeds, he’s a genius. If it fails, there are 1001 reasons for the failure besides his insistence. And if it neither succeeds nor fails, but rides in the middle for a decade or more…you become one his favorite clients!

I’ll save the long lectures for future posts, but our experience with group mergers (which is significant) has identified a few of the myths of practice mergers:

• Smaller practices cannot negotiate as well or better than larger practices.
• The only way to negotiate is to be a large practice.
  My area is different from the rest of the country and, therefore, we can’t negotiate.
• Practice X grew in a way that I am sure would work here where I live.
• There are significant economies of scale to be gained by merging practices.
• Merging practices isn’t expensive, doesn’t affect your productivity and personal life, and won’t distract you too much.
• In order to save lots of money on ordering supplies, etc., (part 1 of the myth), we have to be large enough to make a difference (part 2 of the myth).
• I could get along with all these practices I’ve competed against for years!

This sounds reactive, I realize, but for every merger success I’ve seen, there have been a half-dozen failures. Perhaps I’ll provide real examples of these items above to act like warning signs for anyone following the merger footsteps.

It’s not that we think they are a bad idea, we just think they are usually done poorly and for the wrong reasons.
Or, more succinctly: groups merging simply to stick it to the insurance companies will fail. FTC issues aside, you’d better have a lot more in common than hatred for managed care or it’s never going to fly and only the lawyers will get wealthy.