THCB

Categories

Tag: Insurers

POLICY/HEALTH PLANS: Clowns to the left of us, jokers to the right…..

• 7

Yet another study showing that even if you’re insured, because of the structure of our insurance system even the insured have trouble paying bills.  Now I know I should leave this well alone. It’s ground that I’ve trampled to death before, such as this story about the insured parents of the sick kid who’ve declared bankruptcy. But when the magic four letter acronym of certain industry trade group pops up (even without a certain lobbyist’s name mentioned) I just can’t help myself.

Along with deductibles and co-payments, The Access Project found other factors associated with medical debt were annual or lifetime "caps" on benefits; extra charges for "out of network" care, even when admitted to in-network hospitals; and complex billing systems by insurers and hospitals that left patients confused about what they owed.

Mohit Ghose, spokesman for the industry trade group, America’s Health Insurance Plans, says the study unfairly blames insurers for rising costs. He says there are many reasons spending on health is going up, including new treatments and drugs, rising demand as the population ages and "defensive medicine" by providers worried that they will be sued if they don’t run every test or offer every alternative to patients. "For too long, people have found it convenient to put any and all problems with the health sector at the doorstep of health insurance plans," says Ghose.

Not actually a direct lie this time, you’ll note. But excuse me again, but if it’s not to sort out that stuff—the over use, the defensive medicine, assess the correct use of technology—then what do AHIPs members do for their customers other than slap on 20% and send them the bill? Not much is the answer.

But I guess AHIP is doing its job. They’ve been getting idiot libertarians from no-name universities to write ridiculous op-eds about the value private insurers bring to the system and than has succeeded in getting them placed in that bastion of Marxism The New York freaking Times!! I’ll spare you the whole thing (although this post at Economist’s View  explains largely what a pile of crock Cowen writes. But this choice piece of outright idiocy has to make an appearance at THCB:

It is precisely because competing insurance companies spend money evaluating the appropriateness of claims that they are willing to pay for so many heart bypasses, extra tests, private hospital rooms and CT scans.

Given what Ghose says in the line above about how insurers aren’t able to do that stuff because it’s just too hard for them, someone at AHIP has clearly not been communicating well with their pet blogger, or at least Cowen has no idea what a health insurer does. Perhaps he should try to get a job at HBS? He’d fit in well there

And given that Cowen is an out-there libertarian nut with no basic chops in health care, and for whom this is his second recent appearance in the Times, it’s worth asking how many op-eds has the Times featured from Alain Enthoven, Vic Fuchs, or anyone else with half a brain on the topic this year? You know my guess as to the answer.

HEALTH PLANS/QUALITY: Setting up high performance networks leads to lots of trouble

Hmm…mistakes in health care data? Who’d have imagined that. Which leads to lots of politics in the setting up and creation of these “high-performing networks” and of course the ability for the baby of improvement to be thrown out with the bathwater of data incompetence, if poorly introduced.

What am I talking about? Well you’ll have to read Jeremy Smerd at Workforce.com on what went wrong when Regence tried to introduce a high-performance network for Boeing. And then too about how Group Health of Puget Sound Puget Sound Health Alliance did it in a rather kindler, gentler and less lawsuit attracting way.

It’s in the end the employers’ fault. There the ones who told their plans to back off from doing this when costs were (apparently) under control in the 1990s. So the plans gave up on limiting their networks, and as a partial consequence, costs went up, and then the cycle starts again. Of course, the same thing will be true for the whole P4P movement.

HEALTH PLANS: Guess who said this?

• 10

"Health insurers are committed to improving health care choices for small businesses and bringing costs under control for all Americans,"

A woman who’ll say anything in absolute opposition to the facts, so long as it makes her patrons look better. Don’t you think she’d make a good next attorney-general?

HEALTH PLANS: UnitedHealth keeps gobbling

• 10

United is buying Sierra Health Services, a regional HMO in Nevada for $2.6 billion. Sierra is a more traditional HMO than most of the health plans United’s bought in recent years (Golden Rule et al). The price is a modest 15% increase over Sierra’s current stock price, which last month was hit by the rather interesting news that it was taking a bath on its new Part D plan—mostly because a certain other plan (hint: it’s one of united’s big competitors) was shunting its sick people onto Sierra’s plan.

PODCAST/TECH: John Capobianco, President of Medecision “making the unknown known”

• 1

Here’s the transcript from interview with John Capobianco from Medecision talking mostly about the “payer-based health records” they’re developing with several big health plan customers, and distributing to providers. The audio podcast is here.

Matthew Holt:  Matthew Holt with The Health Care Blog, still at HIMSS. Now I’m meeting with John Capobianco, who is the President of MEDecision, and also with Tracey Costello, who is the VP of marketing. So welcome to you both, hi John.

John Capobianco:  Hi.

Matthew:  Hi, Tracey.

Tracey Costello:  Hello.

Matthew:  John, tell us a bit about MEDecision. As some of the readers of the blog know, I’ve had folks from ActiveHealth Management and Click4Care do podcasts. I was thinking about the whole space around payers and data, and analyzing what’s going on in that world is something that probably most of our readers don’t know that much about. So give me a brief overview of what you guys do, where you fit in the space generally, and how you compare yourself to those guys, or other competitors.

John:  Hi, Matt. I’d be happy to do that, Matt. MEDecision started about 18 years ago creating a solution to a mission statement that was put forth. That was:  how to improve the relationship amongst payers, patients, and providers. We started out going after the payer community because it was not only where the money is, but where the data is, to create clinical records for patients. If you want to improve the outcome, you want to improve the health of patients, what you have to do is to get health information exchange to actually work.By spending the first 18 years going after providing the right information for care managers, for utilization in case and disease management, we figured out how to analyze and gather the data together that was inherent within the only currently available digital systems in the industry that have a lot of data. That’s from the payer’s claims data. We also then created the workflow applications for the case disease utilization mangers. We’ve now recently added the clinical overlays for both utilization as well as case and disease conditions, and what the best practices and processes are around that. Then just a few years ago we started to create the communication vehicles from those inside the walls of the payer to the outside, to the provider communities.About a year ago now, we entered into what we think is probably the most important phase of that. That is, above and beyond the great work we’ve now been able to do with authorizations and referrals and extensions as communication vehicles, we’re actually now starting to take what we call the patient clinical summary. That summarized view of this patient and all their conditions and move it out to the point of care.With several of our clients now, we are not only populating the personal health records, or personal health management systems that they choose, but we’re also providing that data out to either their provider portals or through the standard vehicles we put in place to do authorizations and referrals. Delivering that patient clinical summary right to the provider at the point of care.

Continue reading…

HEALTH PLANS/POLICY: Sierra– a case study of needed insurance reforms

• 1

Now and again there’s a real world case that reminds you why the only solution for keeping private health plans is managed competition, with the emphasis on managed. Remember as you read this story that Alain Enthoven always said that there should be community rating, with standardized benefits between plans and risk adjustment between them to override the impact of chance-driven uneven risk selection.

So the story (hat-tip to Rick Byrne for this) begins with Part D, which allows significant disparity in benefits between plans—something that it’s claimed causes few problems for enrollees. What happens next is that one plan with particularly rich benefits finds that it is adversely selected against. But this doesn’t become clear until late in 2006. Meanwhile Sierra Health Services, a Nevada based for-profit HMO with a pretty good record at cost containment, thinks that it can launch a PDP (stand alone drug plan) that covers the donut hole and has rich benefits. It has to file the paper-work by mid-2006, it charges a hefty premium and it waits for the money to roll in. 42,000 seniors sign up.

Continue reading…

PODCAST/CONSUMERS/TECH: HealthFacts

• 1

BCBS of Minnesota has set up an interesting approach to transparency and measuring provider performance. They’ve created a site called HealthCareFacts.org for consumers to look at and compare provider details, set up a subsidiary called Consumer Aware to run it, and are now marketing it to the world. The model is nutritional labeling. I met Amelia Schultz (the VP of Sales at Consumer Aware) and she set up this interview with founder and CEO MaryAnn Stump. (The interview was recorded on Feb 14, but posting was delayed because I had to fix some technical problems with it. All better now, I hope!)

POLICY/POLITICS: Will Medicare Advantage get slashed? with UPDATE

• 10

Bob Laszewski has been, correctly, all over the issue of Medicare Advantage payments and what the Dems will do to them. And he’s at it again CBO Pours Gasoline on the Democratic Plans to Cut Medicare Advantage Payments to HMOs.

It just blows my mind that UNH is up 20% since the election. But the evidence is right here that Wall Street doesn’t believe Bob, or just doesn’t care. Maybe someone smarter (and richer) than me can explain why. I’m just glad I was too chicken to short UNH after the election.

Unh

 UPDATE: Bob has answered my question. He thinks that Wall Street is short-termist and doesn’t believe that there’ll be cuts in 2007.

TECH: Quick KP HealthConnect update

• 5

Of course the other big non-HIMSS tech news is that KP dumped interim CIO Phil Bruce Tukstra and brought in another outsider. While the LA Times says that Tukstra ran Health Connect, I’m not so sure. Andy Weisenthal told me that he (on the TPMG side) and Louise Lang (on the plan side) ran it, and expressly said that Dodd (the CIO who went a few months back) had not much to do with it. And I’m a little cynical about the LA Times reporting on this last week too.

However, I have extracted a promise from a senior TMPG regional CMIO to go on the record about what he’s seeing—so hopefully I’ll have more details for you all soon but suffice it to say that not everyone was too happy about the Citrix approach

Meanwhile there was an interesting session I sat in on at HIMSS Monday from the CIO of Kaiser Hawaii about how to deal with down-time when you have an EMR. What he said was that every hour a mirror of the latest data is made and that it’s on a separate system that can be accessed if the main HealthConnect goes down. And then he said that most doctors would dream of having that level of data (i.e. what’s in the backup) and he’s probably right! But I guess the real question is was the low uptime (the Times says 80% only in some cases) a function of the power failures last year, or is it still going on? My understanding is that it’s the former.

Finally, I’m going to be on a panel in Vegas on April 30th with two one leading Kaiser basher”* (Justen Deal and Gadly) and apparently Kaiser has declined an invite <sigh>. Which I guess means that I’m going to be their tame blogger and be castigated for defending HealthConnect….

* term adopted from “Japan basher”

UPDATE: Justen emailed me to point out that not only had I called Bruce, Phil (hey it was 6 am!) and that he was not going to be on the Vegas panel (should have checked, his name was on an earlier agenda I saw but he never agreed) but also this:

Bruce was, without question, the "architect" of HealthConnect.  Before he became
interim CIO, he was the VP specifically for HealthConnect.  Dr. Liang has always
handled making sure HealthConnect improves the "quality" of our hospitals, while
Andy Wiesenthal’s job is to work with the physicians to make sure the system
meets their needs.  Turkstra was in charge of designing and implementing the
system, while Dodd was in charge of making sure the infrastructure was in place
to support it. Finally, I hope you’ll consider not calling me a "basher"
("Japanese" or American) of Kaiser Permanente. Trying to paint someone as a
"basher," frankly, only makes you look like a "cheerleader." Since neither, as
far as I know, is true, I hope you’d consider not using it in the future.

I don’t know about who did within HealthConnect, so hopefully someone who does will tell me if Justen’s right or not.

As for the "basher" term, this is a little inside baseball, but the "Japan bashers" of the late 1980s actually felt that they were very pro-Japanese but that Japanese politics and society needed to become more open. So I think the reference to Justen as a Kaiser-basher is extremely correct in that context.