I get a lot of little messages every day that I feel like I should save and/or share, but they don't add up to an entire blog entry (I don't like to do more than one a day, if that, as it feels like spamming). So, here's my house cleaning:
In response to concerns raised by the AAP and several pediatricians across the country, UHC revised its clinical policy on palivizumab. Effective January 1, 2008, benefits coverage for palivizumab will now be aligned with the AAP recommendations published in the Red Book. UHC is in the process of sending notification letters to its physician provider network. A copy of the AAP letter to UHC can be accessed on the AAP Member Center, private payer advocacy page. Many thanks to SOAPM members for sharing information about the change.
Thanks to The Verden Group for that text.
Pricing up 4%, effective Mar 1, on Gardisil, MMR, Rotashield, Varivax
Gardisil promo (if you purchase >70 doses) extended until Feb 29
Time to negotiate with your inscos for an increase in reimbursement
before you have to buy in at the higher price
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 really can't make too much of the quarterly Verden Rankings. Anyone sitting down to negotiate with an insurance company or analyze contracts should have a copy in hand. It's not only free, but you can't get that kind of information anywhere else. Amazing.
Anyway, check out Susanne Madden's latest blog, which points out a relationship between the scores generated by Verden and the financial performance of the MCOs in question. Ultimately, I find that this relationship verifies the measurements that Verden chose to use - by identifying the very issues that are truly important to a practicing physician, we're seeing (potentially) a cause -> effect between service/quality. What remains to be seen, as Susanne points out, is which comes first. In her words:
Will UnitedHealthcare be the number 1 ranked worst network by end of Q2? We'll have to wait and see . . .
Indeed, we will. That there is a direct link - or "No Coincidence" in Susanne's words - between policy/procedure changes (my words) and medical cost ratios is no surprise. What is surprising is that none of the major media have picked up on it.
Now, a consumer is raising the stakes a bit by attempting to get class action status for a suit against Ingenix itself.
I've written about my experience with the Ingenix "data" and their relationship with UHC, though I did conclude that this issue would go nowhere. Now that a consumer has gotten in on the deal, perhaps I'm wrong. I can only hope.
In the good news department, get this: Oxford just announced that they are changing the way their policy updates are communicated on-line. Instead of just listing the policies, they are providing a summary for each (like Aetna). This is much more human-friendly and will go a long way to improving their scores in the Verden Report. Given the proximity of this action to the release of the data which shows them scoring so poorly, I can only wonder what the coincidence level is. I'd like to think it was the Verden Group that pushed this into happening. Oxford would, of course, tell us that they have been working on this "for months" I am sure.
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?
A couple weeks ago, the Verden Alert gave me this little notice about Oxford:
Please note that in an effort to become more transparent and communicate more clearly, Oxford has modified its policy change listings. Oxford now posts exactly what revisions have been made to its changed policies.
Interesting, because happened shortly after the release of the Verden Report, showing Oxford at the bottom of the pile when it comes to transparency and clarity. Is it possible they were listening? Is it possible that they noticed? [BTW, you would have learned this and a lot more if you were a Verden Subscriber...]
Well, check out the ad that Aetna ran in the WSJ earlier this week. There it is, clear as day:
Ranked #1 for providing clear information to doctors
The Verden Group, April 2008
It's likely that the folks at the bottom are paying attention as much as those at the top. Kudus to Oxford. And to the Verden Group. That's some validation, imo, of the work being done over there. Good work, Susanne.
This time, next year, we'll all be talking about the Verden Effect.
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.
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.
It’s late on a Sunday night and my brain is fried from a bad combination of Drupal, planning for Bear Scouts, watching a messed up (but excellent) movie, working on our bathroom for the second year (almost done!), and wanting to blog about a really super-cool benchmark Igor and I have been working on, but I can’t handle the pressure.
So, I get to talk about Susanne for a minute. She’s very popular right now, as the links below will show. See, it isn’t just because I think she has a really cool service, other people do too.
The new blog is almost ready to go, too. A lot going on, stay tuned.
So, the furnace broke some time last night, just in time for our
first real snow. As I waited at home for the repair guy to arrive (his
truck broke down on the way), I’ve had to be on the phone with my neck
scrunched for the last hour. Which means no great updates to the blog
when I have some pretty awesome stuff to share. So, I’ll just play catch up and then we’ll get back to RVUs for a bit, immunization purchasing organizations, etc.
Things I want to share with the world in the meantime:
I have a PILE of RVU-related data to share, including the BIG ITEM
(what is the real effect on the 2009 RVUs on pediatricians), so I’ll
have to get up at dawn to do it. Sorry for the delay.