Posts tagged with susanne madden

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!

Gosh, a guy makes a couple statements in a blog and now people actually want him to explain the numbers so that they make sense. There's no satisfying the mercurial reader any more. My word isn't good enough?

Actually, my apologies for some confusing data. Let me explain yesterday's post in more detail and, perhaps, add some information. Igor and Susanne Madden pointed out that I accidentally cut off the Y-axis label/Title (d'oh!), which makes it confusing.

I decided to measure the average E&M reimbursement for PCC clients in a different manner than Physician's Practice for a variety of reasons.

• First, they use absolute dollars and not a specific year as a yardstick. I think this makes it difficult to actually gauge any changes in relative terms without looking closely at the graph (and then guessing what the values really are) and then doing some math in your head.. If you look at their first graph, for example, Middle Atlantic seems to have gone from a $90 to a $70 average E&M payment, more-or-less, from 2004 to 2007. Wouldn't you rather know that this is a 28% decrease? I would, I guess.
• Second, from what I can tell, PP doesn't take the code volume into account. That is:

CPT
Volume
Reimbursement

99213
10000
$100

99215
10
$500

...is the average E&M reimbursement here about $100.39 or is it $300? I say it's $100.39, and I think PP lists it as $300.

Therefore, the numbers from yesterday look at overall "average E&M reimbursement" and use 2004 as a base year for measurement. In our data, the Middle Atlantic group has seen their E&M reimbursement improve 16% since 2004 (vs. an estimated 28% decrease in the PP data).  I also took some care to make sure that the scale of our graph resembled theirs so that, even though we measure things differently, they approximate a similar message with different results.  The bottom line?  PP continues to measure a downward trend in E&M reimbursement and we measure an upward one.  Which is correct?

I've updated the graph so that the explanatory title is back.

More in a bit.

They usually write themselves.

Reason #1156 to pay attention to Susanne Madden and the Verden Group - the AMA itself has turned to her for an analysis of the exodus of patients from many of the large, national plans. Apparently - based on the quote above, from Wellpoint's CEO - the insurance companies are more interested in their short-term bottom lines than anything else.

For the record, NO this isn't a surprise and YES we realize that these are businesses and exist to make money. Perhaps insurance companies shouldn't be publicly traded? The president of the AAFP wonders, too:

"They have a problem in that they are for-profit corporations. They've got to answer to their stockholders and look for profit," he said. "At the same time they do have a responsibility to society. They need to make sure they are working together to make sure as many people are insured as possible by holding down premiums."

Oh, what does this have to do with Susanne? I love her quote:

"With consolidation and there being fewer players comes a certain amount of arrogance," she said. "The response from the insurers is quite miserly."

I love that word, "miserly." Didn't Ebenezer Scrooge change his ways, in the end? When does the Ghost of Healthcare Future show up and scare us all? Go read the piece and save it in your "Next Time We Negotiate" folder. I wonder if this is a warning to practices that they aren't going to care as much if you drop them?

Yes, I'm breaking my promise to post the appeal letter today. However, that's not the promise for which today's entry is titled. Something more important needs to be communicated.

I've written many times about Susanne Madden and her Verden Alerts. Why the world hasn't pounded down her door and signed up for her service is beyond me. Fortunately, in her own version of herd immunity, Susanne sometimes makes important information available to us all for free. Below, please find an update about some recent UHC payment/policy changes that will affect any pediatrician who participates with them.

Thank you, Susanne. The rest of you: start your engines. [Note that the Synagis change may even be retroactive.]

For those of you that are not Verden Alert subscribers, I wanted to make you aware of a couple of UHC policy changes that will affect Pediatrics:

Please note that 1. is titled After Hours and Weekend Care but only addresses services provided on an emergency basis . . .

1. After Hours and Weekend Care Policy

Under the current UnitedHealthcare policy for reimbursement of services provided in the office on an emergency basis, CPT code 99058 is reimbursed in certain places of service when reported with basic service codes. This CPT code has a status of 'B" (bundled into payment for other services not specified) on the National Physician Fee Schedule resulting in no additional CMS reimbursement. Effective in the fourth quarter of 2008, UnitedHealthcare will align reimbursement of this code with the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS). As a result, reimbursement for services provided on an emergency basis, CPT code 99058, will not be separately reimbursed.

Go to http://content.4at5.net/email_domains/unr/21553/hosted/reimburse_6.html

2. New Synagis Drug Procurement Protocol Effective July 1

A new protocol for the ordering, clinical coverage review and purchase of palivizumab (Synagis) takes effect July 1 for all participating physicians and health care providers. Beginning on that date, Synagis must be procured from our preferred specialty pharmacy provider, PharmaCare/CVS Caremark.

Palivizumab (Synagis) - Requirement to Use Participating Specialty Pharmacy to Obtain Synagis

UnitedHealthcare has selected PharmaCare/CVS Caremark, a national distributor of Synagis, as our preferred specialty pharmacy provider. PharmaCare/CVS Caremark's national network provides timely Synagis prescriptions and clinical services to meet the needs of participating physicians and our members. PharmaCare/CVS Caremark has been instructed to deliver Synagis consistent with UnitedHealthcare's Drug Policy for Synagis. PharmaCare/CVS Caremark works directly with our Clinical Coverage Review team in the Consumer Decision Support Advocacy unit to determine whether proposed Synagis use is consistent with the member's benefit plan.

Continued Use of a Non-Network Specialty Pharmacy for the Acquisition of Synagis Effective July 1, 2008, continued use of a non-specialty network pharmacy, wholesalers, or direct purchase from the manufacturer of Synagis, without prior approval from UnitedHealthcare may result in the physician or other health care professional not being reimbursed in whole or in part, as provided in the Participation Agreement. In addition, the physician or other health care professional must not bill our members for any amounts not paid due to non-compliance with the Synagis drug procurement policy.

Physicians who prescribed Synagis in 2007 will be sent a letter about the preferred specialty pharmacy providers to obtain Synagis and the drug policy for Synagis.

For more information, view the above protocol in the 2008 Physician Administration Guide and the drug policy at UnitedHealthcareOnline.com>Policies & Protocols> Medical Policies.