Category: Uncategorized

So what’s the real usual, customary and reasonable price of care?

Mar 31, 2009• 43

By Matthew Holt

The Ingenix mess apparently won’t go away. Sen. Jay Rockefeller is now going after the health plans for using Ingenix’ database. Ingenix and some of its customer health plans have already settled with several states, but apparently it’s not enough. Now Rockefeller is after them. And the words are tough. “Fraud”, for one.

Now, health plans don’t exactly have much credibility. And when the politicos find out that Ingenix a) sells tools to help health plans cram down the amount they pay providers, b) sells tools to providers to extract more money from health plans, and c) is owned by the biggest (and not too long ago) baddest insurer on the block, this may get a little more interesting. After all, it’s kind of an arms dealer arming both sides.

But there is one thing that troubles me. I’m quite prepared to believe that Ingenix’s view about what was UCR was different from the local medical society’s view of what was UCR, and therefore that the plans were “under-paying” the consumers and the doctors who serve them.

But let’s remember what Usual, customary and reasonable fees are.

Will CIGNA Remake The Health Plan Marketplace?

Mar 30, 2009• 17

By BRIAN KLEPPER

America’s health plans are floundering. If their job has been to provide the nation’s mainstream families
with access to affordable care (let’s leave quality out of it for the moment), they have failed miserably, though they were very profitable along the way, at least until Q1 2008. In 2008, the Milliman Medical Index – an estimate of the total cost for health coverage premium and out-of-pocket costs for a family of four – was $15,609. Now it is almost certainly above $17,000, more than the total income of more than one-third of American households.

To many health plan execs, these are simply market dynamics that must be accommodated through new product and service designs. I just attended a health plan conference where the overarching themes were the transition away from group to individual coverage, and the use of incentives and touch points like texting, email, and ergonomic Web interfaces to cultivate member competency, loyalty and retention.

There are important steps forward but, to me, the discussion tiptoed
around the more glaring problem – costs this high have exhausted many
purchasers’ ability to pay, and are rapidly shrinking health plans’ commercial market and profitability.

Sustainable Healthcare Reform

Mar 30, 2009• 24

By ROBERT LASZEWSKI

Last week Senate Majority Leader Harry Reid was quoted as raising the possibility
we could take the $600 billion in new revenue projected from a
"cap-and-trade" plan to cut green house-gas emissions and use some or
all of it to help pay the estimated $1.5 trillion cost for
comprehensive health care reform.

Energy and climate change issues aside that would be a bad idea–a really bad idea.

The biggest health care challenge we face in America is the cost of health care. To really reform the system we have to bring its costs under control. The only way we can achieve sustainable health care reform
is to pay for most of the cost of any reform plan out of the savings we
achieve fixing the system and its perverse incentives to spend more
without regard to what we receive.

Commentology

Mar 29, 2009• 4

Steven M. Parker of Levelwing was among those who weighed in on the volatile comment thread on Rick Scott's Friday post. ("Patient-based Health Reform or Fannie Med?") Steve had this response to critics who attacked the CPR founder over his record as CEO of Columbia/HCA in the nineties …

"..one thing all of you need to consider is that you continually point
fingers at Rick for having run a company fraught with Medicare
inconsistency, overbilling and defrauding the government. However, you
lack the details on the actual investigation and from where issues
stemmed. Many of the allegations came from hospitals owned by
Columbia/HCA at the time (yes) – but there are many instances that
originated at points prior to Columbia/HCA purchasing or operating
those facilities. The local levels were ultimately at fault in this
situation. Also as an FYI – Columbia/HCA had better patient
satisfaction than most medical facilities in the country during Rick's
helm. There are many details perhaps you should consider, including the
fact that during this same time period a majority of hospitals in this
country were under investigation for the same issues."

Classified: 2009 DiabetesMine Design Challenge

Mar 28, 2009• 6

Passionate about Diabetes and product design? Whether you're an enterprising patient or parent, a startup company, a design student, an independent developer or engineer, or a pharma R&D pro. Sponsored by the California Healthcare Foundation. (CHCF). Prizes include $10,000 in cash (1st prize), $5,000 (2nd), consultations with health and wellness exerts at the global design and innovation firm IDEO. Submissions are accepted in the form of a 2-minute video to be uploaded to the DiabetesMine YouTube channel, or a 2-3 page written "elevator pitch" plus supporting graphics, also to be uploaded online. The deadline for entries is Friday, May 1st, 2009, at 11:59 pm Pacific time. Winners will be announced on Monday, May 18th, 2009. www.diabetesmine.com/designcontest

Health 2.0 Meets Ix–The Great Debates

Mar 27, 2009• 5

By Matthew Holt, Indu Subaiya and Joshua Seidman

On April 22–23 in Boston, two ideas are going to come together. Health 2.0 has been defined in different ways, but is most often considered to be the use of lightweight online technologies which allow consumers to access and exchange health information via the now familiar search, communities and tools. Information therapy (Ix or information prescriptions) involves the proactive delivery of the right information to the right person at the right time, usually as part of the care delivery process.

However, while both Health 2.0 and Ix are focused on improving patients’ participation in care, they tend to come from different backgrounds. Ix tends to be “prescribed” to the patient, often by a clinician (although system-triggered Ix and consumer-prescribed — either “self-prescribed” or recommended by a peer, caregiver, etc. is also part of the definition). Ix innovations have had the greatest penetration in organized systems of care with robust provider and patient HIT applications like Kaiser Permanente and Group Health Cooperative in Seattle.

CLASSIFIED: Yale School of Management’s Healthcare Conference 2009

Mar 27, 2009• 2

“Where is the Value? Managing Cost and Quality in a Healthcare System Facing Reform.” April 3rd at the Omni Hotel in New Haven, CT. A full-day summit of industry leaders, students, and academics discussing current topics of industry concern as Obama attempts to usher in reform. Our 16 breakout sessions will focus on answering how to unlock additional value in the current system. Our 2 keynote addresses will feature Samuel Nussbaum, MD, Chief Medical Officer of WellPoint, and Helen Darling, President of the National Business Group on Health. Registration and further details can be found at: www.yalehealthcare.com.

PharmaSURVEYOR

Mar 25, 2009

PharmaSURVEYOR is The Most Advanced Drug Safety Utility for consumers
and professionals alike. PharmaSURVEYOR offers a personalized drug assessment tool designed to
show users not only drug-drug interactions but the much more common and
often dangerous adverse drug side effects making it a valuable tool for Medication
Therapy Management and Medication Reconcilliation. By partnering with
other healthcare sites and services such as Electronic Health Records
(EHRs) and Personal Health Records (PHRs), it can automatically
bring in a patient's medication list from a partner, run a Drug Safety
Survey on their drugs, and show them the combined risks as well as
interactions from their drug regimen. PharmaSURVEYOR then provides a
"what if" capability to "try" substitute drugs and help find those
which will reduce the adverse drug effects of greatest concern to a
patient.

To learn more about PharmaSURVEYOR go to www.pharmasurveyor.com

Two Birds With One Stone: Covering the Uninsured by Fixing Medicare

Mar 25, 2009• 31

By Victor M. Sandler, MD

As a nation, we are in a heap of trouble. Our medical system is a
disaster—overly expensive and ineffective. On average, we spend two to
three times more per capita on health care than other developed
countries. Yet on measures of quality, we rank 22nd out of 23 among
those same countries, according to the World Health Organization. Not
only that, Medicare, our national insurer for the elderly and disabled,
is facing more than $30 trillion in unfunded liabilities over the next
40 years. We have 50 million people who are uninsured in this country
and millions more who are underinsured because employers have shifted a
larger percentage of premium costs to them and increased deductibles
and coinsurance payments, causing some to forgo medical treatment
because of the expense.

The bad news is that we are on a path that is much too costly and
clearly not sustainable. The good news is we can get off that path by
cutting medical costs dramatically without negatively affecting
quality. The way to start is by acknowledging the fact that we don’t
have the best health care in the world, as former President George W.
Bush and others have touted.

What we have is the most health care in the world.

The Causes of Medical Waste
The factors that feed our obese medical system are manifold. But three
are especially troublesome. First, there is an unfortunate ethos within
American medicine and society at large called “heroic positivism.”¹
Essentially, it is the idea that the more we do to and for our
patients, the more they gain.

A Healthcare IT Primer

Mar 24, 2009• 15

By JOHN HALAMKA

Now that Healthcare IT is part of the stimulus and newsworthy, I
receive many questions from reporters
about the fundamentals of healthcare IT. Here's a primer with the Top 10 questions and answers:

1. Can you define EHR, EMR, PHR and PM in simple terms?

Electronic Medical Record – An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by
authorized clinicians and staff within one health care organization.

Electronic
Health Record – An electronic record of health-related information on
an individual that conforms to nationally recognized interoperability
standards and that can be created, managed, and consulted by authorized
clinicians and staff, across more than one health care organization.

Personal
Health Record – An electronic record of health-related information on
an individual that conforms to nationally recognized interoperability
standards and that can be drawn from multiple sources while being
managed, shared, and controlled by the individual.

Practice
Management – An application used to manage the physician business
operations including scheduling, registration, and billing …