The Connecticut Insurance Department rejected a rate hike request from Anthem Blue Cross and Blue Shield for individual health policies. The department followed through with its earlier promise to deny Anthem's request for premium increases as high as 32%. The department instead recommended increases between 13% and 20%, and said the rates would be effective Jan. 1, not Oct. 1, as the company had requested. About 56,000 policies are affected statewide.
Blue Cross Blue Shield of Michigan has reached agreement with Michigan Attorney General Mike Cox to lower its request to raise rates for 163,000 people who buy their own health insurance. But the company and Cox could not reach agreement about a 31% rate hike that affects 210,000 seniors with supplemental Medicare plans.
Amid growing complaints from small businesses about soaring health insurance costs, Massachusetts is eyeing a much-debated proposal that would allow companies to band together, bargain for cheaper rates, and pass the savings on to employees. The idea comes as small-business owners across the country worry about the potential effect of a national insurance overhaul on their companies and look toward Massachusetts for guidance.
Stanford Hospital is testing a drive-through ER, where patients get treated in their cars. The idea is that during a pandemic or bioterrorist attack, patients would drive up in their cars to be registered and triaged by nurses while still outside the hospital.
People who show signs of a contagious condition would be asked to head over to the parking garage, where doctors would evaluate them further either inside the car or on cots.
As Congress flees the nation's capital for the August recess, the location of the healthcare debate moves from the Beltway and into town halls and meeting places.
Many Congresspeople are using their time away from Washington to host town meetings in hopes of hearing from constituents—and promoting their own beliefs about healthcare reform.
With that change of location also brings a larger advertising push. Stakeholders and activists have spent more than $52 million on getting out their message, while galvanizing their base and swaying the undecideds.
Out of these ads, one wonders if there is one that will resonate with the public and we as a nation will look back 20 years from now and say, "That was the turning point in the healthcare reform debate of 2009." In other words, is there a Harry and Louise ad this year?
The jury is still out on that question, but marketing experts say there is one major difference between the healthcare reform debate of the 1990s and the current-day discussion—the Internet.
"The ad that becomes iconic in 2009 won't be because of the exposure it receives on television," says Tracy Weise, principal of Weise Communications in Denver. "This time the ad will have to have viral presence on the Internet. Look for it to be discussed in blogs, mentioned on tweets, and discussed on YouTube. The Internet chatter will feed the television chatter before the ad will have staying power."
Gabrielle DeTora, a private strategic healthcare consultant, says TV ads have lost importance. They have been replaced by word-of-mouth campaigns through social media sites and the Internet.
"The real power here is not in the TV spots, but how they will be used to build word-of-mouth and political traction in the digital arena," she says.
Internet users are watching commercials on YouTube, but whether the messages are registering is in question.
Return of Harry and Louise
The original "Harry and Louise" actors that helped defeat healthcare reform during the Clinton administration are back at the kitchen table. Though they were worried about health reform in the 1990s, a new ad, sponsored by the Pharmaceutical Research and Manufacturers of America and Families USA, supports health reform.
So, will the 2009 Harry and Louise ad work? "While the message is simple and to the point, it's too broad for most consumers. 'A little more cooperation, a little less politics, we can get the job done this time,' is a message for politicians, not for consumers. If you think about the ad at all, you have to wonder: What do I do with that? What does that mean to me?" says Weise.
Simplicity is what made Harry and Louise resonate in the 1990s. "Harry and Louise did not want the government telling them what to do. Consumers never want the government telling them what to do. So the message worked. Unfortunately, the 2009 message seems too broad for Harry and Louise to effectively communicate," Weise adds.
Dan Dunlop, president of Jennings in Chapel Hill, NC, says political advertising is no different than other ads that try to connect with the viewer's personal values and ideology. One example of this is AHIP's "Illness" ad, he says.
"They convey this messaging well without getting sappy. It feels authentic. The DNC also does a good job with this in their spot title 'It's time.' They manage to make healthcare reform relevant, in very human terms. And they use what looks like real people in their ad to add an element of authenticity," says Dunlop.
DeTora points to the Americans United for Change ad as the best 30-second TV spot. "It is optimistic, powerful, and clear," she says. “The actors used reflect the diversity of Americans, but is clearly geared to a younger, more active Obama population. It discussed a few issues, such as protecting choice of doctors and offering a choice between private or public health insurance plans."
Are the messages getting through?
There is plenty of noise about healthcare reform, but there are still questions about whether individual messages are being heard through the commotion. Dunlop says healthcare reform advertising is not adding to the discourse. They are not providing education or information, but simply targeting specific populations for action.
Dunlop suggests healthcare reform spots should speak to the public in terms that are "instantly relatable and authentic. We all understand the idea of losing a job, or having to face chronic illness and the expenses that go along with that. I would work to make the advertising as real as possible, and avoid political messages with no substance behind them. They should strive to tap into shared values and experiences that will mean something to the viewer. Healthcare reform is so complex, no one is ever going to tell the whole story in a TV commercial. The best you can hope for is to make a connection on a human level—to convey a message that is relatable, authentic, and impactful."
DeTora says healthcare reform ads should avoid rhetoric, provide the facts, and build word of mouth. That will influence the debate, she says.
"Remember, no one likes the ads, they complain, but they watch," says DeTora.
Which is the business associate when a medical device company sales representative is in the OR–the sales rep or the company?
Can a covered entity, like a Medicare-certified hospice program, also be considered a business associate if it works on behalf of another covered entity?
Will there be some guidance regarding whether updating the existing business associates is going to be required?
The questions probably won't stop any time soon. However, case-by-case scenarios aside, there is an overlying message to all parties affected by the new HIPAA laws.
"The first thing both the covered entities and the business associates should do is try to understand the new requirements, and analyze the gaps between their existing policies, procedures and practices, and what they should be doing–both under HITECH, and anything they’ve missed or avoided under HIPAA," said John R. Christiansen of Christiansen IT Law in Seattle, one of the speakers on the program.
Chris Apgar, president of Portland, OR-based Apgar & Associates, LLC, also presented tips for compliance during the audio.
The next step is to map out your expectations regarding contract revisions. The last-minute approach will overwhelm each party.
"This could make for an unhappy holiday season and cancelled ski trips for folks in organizations which don’t start this process in the very near future," Christiansen said.
Christiansen serves as chair of the newly formed HITECH Business Associates Task Force of the American Bar Association’s Health Law Section and the HITRUST Business Associates Working Group of the Health Information Trust Alliance.
After hearing the responses during and after the audio conference, Christiansen said some covered entities and BAs need to get past some basic denials:
HITECH covers more than EHRs. The HITECH requirements do not just apply to EHRs or organizations using EHRs. "HITECH is intended in substantial part to promote implementation of EHRs," Christiansen says. However, its requirements–particularly BAs complying with the HIPAA Security Rule and contract revision between covered entities and BAs–apply without regard to EHRs.
No extensions from Congress. The compliance date on the HIPAA Security Rule and contract revisions is February 18, 2010 and is "written in the legislation, which means only Congress has the authority to change it. I think given everything else on Congress’ docket these days, relief on this point–which would be opposed by the privacy community and not understood by most other people–will not happen," he says.
HHS will look for violations. Congress wants enforcement of HIPAA; it wrote into the new laws enhanced civil penalties, expanded regulatory authority, and auditing requirements. "You can’t just assume noncompliance won’t matter because nobody’s looking," Christiansen says. "Congress wants [HHS] to look, and there are increased financial incentives for federal and state regulatory authorities to pursue penalties."
Millions of Medicare patients are being put at risk by a practice that allows physicians to be paid for care actually provided by non-physicians who have no verifiable credentials or appropriate training, according to a new report from the Office of Inspector General, which recommends such procedures be stopped.
"We are concerned about the potential scale of this problem," the Inspector General wrote in a 32-page report, which for the first time analyzed the issue. The investigators reviewed a random selection of 3,165 physicians, 4% of who billed Medicare during the first quarter of 2007.
Unqualified nonphysicians performed 21% of the services that physicians did not perform personally during this period. Medicare paid $12.6 million for approximately 210,000 services performed by unqualified non-physicians.
"These non-physicians did not possess the necessary licenses or certifications, had no verifiable credentials or lacked the training to perform the service," the report said.
Additionally, "non-physicians with inappropriate qualification performed 7% of the invasive services that physicians did not perform." Invasive services in particular put patients at additional risk because they involve more complex procedures that require "entry into the living body (as by incision or by insertion of an instrument)."
They involve venipuncture, surgical procedures, non-oral drug administration, and chemotherapy, according to the report.
The Inspector General examined billings for cardiovascular, diagnostic radiology, ophthalmology, and rehabilitation therapy services under a practice that allows physicians to be reimbursed for services for more than 24 hours a day, the so-called "incident to" rule, even though such services were provided by physician assistants, nurses, medical technicians, and medical assistants concurrent to the physician's billing day.
The report also said the "incident to" rule "may be vulnerable to overutilization," a key buzzword in health reform debates.
Apparently, very large amounts of taxpayer funds are spent on non-physician services. Medicare allowed $105 million for approximately 934,000 services that the physicians personally performed and approximately $85 million for approximately 990,000 services that non-physicians personally performed during this three-month period.
The report recommends that the Centers for Medicare and Medicaid Services change this "incident to" rule to require physicians who do not personally perform the services they bill to Medicare to ensure that no person–except licensed physicians or non-licensed physicians who actually have appropriate training under state laws, regulations and Medicare rules, and only under the direct supervision of a licensed physician–perform this care.
Additionally, the Inspector General recommends that whenever a physician bills CMS for services provided by a non-physician, that service be identified by a service code modifier so the federal government paying the bill can ensure that the non-physicians are appropriately qualified.
The report said that CMS officials agreed with all recommendations except that which would require a service code modifier, saying "incidental services are often shared by physicians and staff, making definition of a service not 'personally performed' operationally difficult."
However, the report added, CMS "agrees with our 'underlying objective of increasing the available data on services provided 'incident to.'"
The OIG also said it will continue to press CMS to gain the ability to identify and monitor physicians' claims for services doctors bill for, but do not personally perform.
"We believe that the lack of a service code modifier to identify physicians' "incident to" claims represents a significant vulnerability to the Medicare program."
Additionally, Medicare does not require physicians to use identifiers indicating the services were provided "incident to" so it's not possible to determine the extent of the problem. However, in 1996, Medicare began a voluntary two-year demonstration project in five states (Illinois, Maryland, Michigan, Pennsylvania, and Texas) to identify such claims by adding a modifier.
Claims data from 1998 indicated that a minimum of $75 million was allowed for "incident to" services in those five states, the report said. "In 2006, Medicare allowed $58.4 billion for physician fee schedule services under Part B. It is uncertain how much of this amount was for 'incident to' services."
The OIG noted that none of the physicians reviewed in the sample or the non-physicians who provided the services "had been reprimanded, (e.g. suspended license, revoked license or official reprimand) from a state licensing agency and/or had been excluded from federal health care programs. No physicians or non-physicians in our sample had active adverse actions that would have precluded them from providing the services we reviewed," the report said.
When a patient decides to find a new physician or select a hospital for a surgical procedure, is he or she more likely to use government health quality data or data supplied by the health plan or employer?
The answer might be neither.
Despite "well-intentioned efforts" by these entities in recent years to advance healthcare price and quality transparency, most patients still choose physicians and hospitals based on recommendations from friends, families, and physicians, said Paul Ginsburg, PhD, president of the Center for Studying Health System Change, and research analyst Nicole Kemper in a recent commentary from the Center.
Even though wide-ranging evidence shows that the quality of U.S. healthcare is "uneven at best" and that Americans pay more for healthcare—with sometimes diminished results—in comparison with other industrialized nations, healthcare price and quality transparency in the U.S. for the most part "remains a product in search of a buyer," they said.
On the cost front, many patients have few incentives to look beyond price when selecting healthcare providers because they usually pay comparable amounts as long as those providers are within a network plan. On the data front, patients may feel indifferent toward information that lists most of the providers as "average" or lumps different services such as cardiovascular care or maternity care into one aggregated hospital measurement that masks variations in these programs throughout a hospital.
However, some changes are occurring at the local levels to make data more accessible—and more relevant, according to a separate briefing by Center researchers. One program they describe—CalHospital Compare, a Web site that was launched in March 2007—rates California hospitals on 70-plus performance measures, including process, outcome, and patient experience measures.
This site goes somewhat beyond the data, for instance, presented by the Center for Medicare and Medicaid Services' Hospital Compare, which at the current time applies to a limited range of conditions and procedures. Hospital Compare uses point estimates for measures—without specifically identifying if differences among provides are statistically significant. With the California site, a five-point scale is used, with multiple benchmarks, to specify an individual hospital's quality as poor, below average, average, above average, or superior.
Going online, patients are likely to encounter many types of data, for instance, about how people like their physicians or the office staff, said Steve Findlay, a healthcare analyst with Consumers Union, last week at a symposium in Washington on "Getting to a High-Value Health System." While that experience-of-care information is helpful, it falls short of providing more detailed comparative, high-quality data that they can link to their care.
"We haven't yet got to a place where this is easy for consumers to use. It's just simply not easy," Findlay said. "It's a conundrum. We [consumers] don't quite yet know what quality of care is or what quality measurements are."
Consumers Union addressed that dilemma in part this week by announcing a new program and Web site by which patients and consumers can look up patient satisfaction ratings to more than 3,400 hospitals across the country.
The data is being used to link patient satisfaction and quality of care issues: Consumers Union, the publisher of Consumer Reports magazine, is using the federal government's Hospital Consumer Assessments of Healthcare Providers and Systems Survey (better known as HCAHPS) and the Dartmouth Atlas of Health Care to view patients' views of their care.
Consumers Union found that hospitals that have above-average patient satisfaction had shorter hospital stays and more conservative care patterns.
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Skeptical physician groups often say poor risk contract financial performance is the reason they stay away from capitation. As a result, capitation is usually associated with physicians not getting paid enough, although the payment method remains popular in California and other pockets of the country. However, a recent study found that poor results are not as common as has generally been believed.
The 2008 Capitation and Risk Contracting Survey, released by the AMGA and ECG Management Consultants, found the following:
Whether risk contracts are financially attractive depends heavily on the dominance of payers or providers in the market
The ability to participate in risk contracting largely depends upon whether a health plan offers the option in a group market's area
Effective risk contract management requires significant investment in contract administration and oversight
Unfavorable contract terms are the single greatest barrier to risk contracting participation
The 2008 capitation survey was based on 2007 data and focused on medical group leaders. Seventy-five AMGA member organizations responded to the survey, which was divided into five topics: prevalence and scope, risk contract management, health plan characteristics and performance, physician acceptance, and barriers and limitations.
Of the 75 organizations that responded to the survey, 64% have participated in risk-bearing contracts in the past three to five years. Not surprisingly, western states had the largest percentage of risk-contracting participation by region (84%), and 67% of respondents have been involved in risk contracts for at least 11 years.
Thirty-six percent of participants reported that the revenue derived from risk contracts is greater than half of their organizations' total revenue, including 62% of respondents in western states. On the other end, 67% of respondents in the Northeast with risk-bearing contracts said risk contracts contribute to less than 10% of their total revenue.
Thirty-three percent of those with risk contracting own a health plan and are most likely to offer commercial HMO-point-of-service and Medicare Advantage plans.
More than half of respondents described their organizations' financial performance in risk contracts as above average or excellent in the past two years. Less than 10% cited poor financial performance.
The survey found that professional and primary care capitation are the most attractive to providers, whereas global risk is the least attractive. Primary care and professional capitation are the most frequent contract types; global and carve-out contracts lag behind.
On the topic of how to influence physicians' behavior, the highest percentage of respondents said they have referrals and prior authorizations to control utilization, with physician bonus payments as the second most popular. P4P and group bonus payments were each used by less than 10% of respondents.
"Managing capitation really requires a culture and a system of incentives that reward physicians for managing health. Many group practices have mixed incentives between traditional fee-for-service and capitation arrangements. To successfully manage risk, there must be an underlying culture and commitment to capitation," says Halverson.
Half of risk-contracting respondents said they purchase stop-loss insurance to protect individual doctors from adverse contract performance, with the most common form of insurance an individual policy purchased from a separate reinsurance carrier.
Most groups perform multiple types of audits and analyses to ensure contract performance and health plan compliance, with adherence to contracted rates and coding audits the most frequently used methods.
Although more than 50% of risk-contracting respondents reconcile patient eligibility with premiums to ensure proper reimbursement, many organizations do not perform any type of premium audit.
This article was adapted from one that originally appeared in the August 2009 issue of The Doctor's Office, a HealthLeaders Media publication.
If you want an idea of where physician practice may be headed, listen closely to the comparisons of the best and worst providers in recent healthcare reform discussions.
In his widely-read New Yorker article, Atul Gawande contrasted the high Medicare spending in entrepreneurial McAllen, TX, with Rochester, MN, where the Mayo Clinic "has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest 15% of the country."
In his most recent press conference, President Obama chastised physicians who factor fee schedule financial incentives into clinical decisions, and then a few minutes later called the Cleveland Clinic "a role model for some of the kind of changes that we want to see."
We even found an anti-McAllen here at HealthLeaders Media. A couple of weeks ago Michelle Ponte wrote about Winona Health, which was named Most Wired-Small and Rural Hospital by Hospitals & Health Networks magazine for the last several years, and is also in a region that boasts the fifth lowest Medicare costs out of more than 1,300 hospital service areas in The Dartmouth Atlas.
What do these three role models have in common? They all employ physicians, for starters.
I wasn't sure if this was the case with Winona when I first read about its success, so I followed up with Mike Allen, CFO of the not-for-profit integrated system. Although Winona only formally began employing doctors in 2008, it "looked and acted more like an employed model" well before then by aligning closely with two practices that essentially contained all of the medical staff doctors.
"I do think that you will find that is one common theme among low-cost areas . . . There is a link between a well-defined, tightly-organized healthcare system in a community and lower costs," Allen says. "Except for cost of living differences, I bet you won't find high costs where there are well-defined systems."
The case for employing physicians is compelling:
It makes it easier to reduce duplication of services and overutilization by taking some of the direct financial incentives out of medical care.
The closer alignment helps hospitals implement uniform practice standards and other quality improvement initiatives.
It can alleviate conflicts over ED call coverage and other sticking points between doctors and administrators.
It can generally improve care coordination and the adoption of health information technology.
While putting doctors on a salary works for an integrated health system, most physicians practice in small groups where revenue is divided up between five or fewer physicians. Salaries aren't really feasible in those situations. Although the number of small practices is declining, the majority of doctors aren't going to be working in integrated systems anytime soon.
And many have no desire to. Although physicians are becoming increasingly receptive to employment, many doctors are quite entrepreneurial and realize that they can earn up to four times as much in private practice. As long as the fee-for-service system rewards high volumes of certain easily-repeatable procedures, specialists will have incentives to practice privately and invest in ambulatory surgery centers, imaging equipment, and specialty hospitals.
Some states, such as California and Texas, don't even allow physician employment. Corporate practice of medicine laws take the view that it is when physicians are employed by an institution, not when they practice independently, that they could potentially be pressured to order tests or increase volume to boost the organization's revenue.
Finally, some physicians argue that employment removes all incentives to work hard and see more patients. While it's true that many hospitals got burned in the 1990s when they tried employing physicians only to see productivity drop dramatically, leaders have since learned to incorporate productivity and quality incentives into salaries to keep physicians motivated.
It's not that employing physicians doesn't work—it does for Cleveland Clinic, Mayo, and Winona Health, and it is worth learning from their successes and emulating their models when possible. But every hospital can't integrate into a system and every physician can't practice on a fixed salary.
Healthcare reform would benefit from a few role models that look a little more like the average provider.
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