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What about our national primary-care physician shortage? June 19, 2012

Posted by medvision in health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Uncategorized.
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During America’s healthcare debate, we’ve heard many arguments for and against the various elements included in the president’s PPACA law.

A significant problem, acknowledged by all parties, is the looming shortage of primary care physicians. Primary care physician compensation has been shorted when compared to pay physicians specializing in disease categories, types of patients or methods of treatment. This has resulted in those physicians responsible for treating the whole patient, quarterbacking the complex maze of specialists, testing, procedures and hospital stays, receiving the lowest pay in the hierarchy of physician specialties.

No one should be surprised to learn students in medical school are steering away from the various primary care specialties. Given the reality of a shortage of primary care doctors, the manner in which primary care offices operate can virtually determine “life or death” outcomes for patients. The attached describes this scenario:

http://www.kevinmd.com/blog/2012/06/long-waits-access-primary-care-avoidable.html

A necessary solution to long-term primary care woes are mapped out in a program entitled “MD CEO”. Authored by Dr. Scott Conard M.D., a brilliant Dallas Texas-based primary care physician, MD CEO is a process which enables the skills of “physician extenders” to quickly and efficiently serve patients in the doctor’s office for conditions of clear “empirical medicine”. This program aligns the physician’s time to serve patients with conditions requiring “intuitive medicine” while sequentially providing medical leadership serving all patients.

www.themdceo.com

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If I want my plan to fail (pt.2): June 2, 2012

Posted by medvision in Chronic Disease, health data, Healthcare Costs, Insurance Plans, Risk Management, Rx Costs, Uncategorized.
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Health Costs, Rx Costs“I won’t question nationally published cost statistics and wonder if these “industry averages” apply to my member population.  When I read an article stating an average family of four incurs health claims in excess of $20,000, my mind closes”.  http://www.marketplace.org/topics/your-money/makin-money/family-health-care-costs-breach-20000

What does “family of four” typically denote? Most would think, mom, dad and two kids? Look outside of your house, condo/apartment and notice a family on a stroll. How many think the average family walking by incurs $20K per year in claims? So, how could Milliman publish such a high average, or high “Milliman Medical Index, MMI”?  

From a pure mathematical perspective I’d never question the validity of their result. They took millions of values (family claims) came to a total and then divided by the number of values to obtain the average or mean. We should be asking, “is this average a reasonable representation of the “central tendency” or essence of the data”? Another way to think of the Milliman average is what does this number/average tell us about health care risk?

When thinking of families of four, I find it hard to comprehend the average claims expense is in excess of $20 thousand dollars, annually? Could both be correct? The answer is yes, however I hope to convince the audience the Milliman average is unrepresentative of the “central tendency” of the values (family of 4 health claims) as this average is obviously calculated including huge claim values (high) outliers.  Here’s a very clear video explaining the manner outliers change our perception of data sets.  http://www.statisticslectures.com/topics/outliereffects/#video

Huge average claim values tend to “breed” stagnation concerning intelligent plan management actions!

When looking at “average per member per year plan cost” why let consultants define average in a different manner than the financing of the plan? Most plans re-insure specific member claims to a “specific” deductible amount and receive reimbursements for amounts over this deductible. However, when computing the annual per member/employee cost, these amounts reimbursed are included grossly inflating the average cost! In fact the top 1% of members, by claims cost, incur approximately 30% of all plan assets. Removing these as outliers would provide managers a more accurate “central tendency” of their claims data.

If I want my employer health plan to fail, I’ll — ? (Pt 1) May 15, 2012

Posted by medvision in health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Uncategorized.
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http://waysandmeans.house.gov/News/DocumentSingle.aspx?DocumentID=293471

50% of Americans receive health care coverage through their employers. Much discussion is being focused upon the extent  Obamacare/PPACA will provide financial incentives  facilitating employers to drop health coverage, and thus, sending employees/dependents into state exchanges.

Some of us foresee state exchanges as another term for “standing in the Medicaid line”. The above attachment possibly crosses line into politics and I apologize to those offended. I do believe people exist, on both sides of political spectrum, who don’t favor the elimination of employer-provided health coverage.

Granted, America does have systemic healthcare problems. Plan managers, (benefit managers, HR officials, risk managers and brokers/consultants) have huge influences on the quality and cost of care.

Recently, I’ve run across situations where plan managers appear unconcerned of the impact decisions have on their plans. I sometimes walk away wondering why they elect options of obvious detriment to the plan. Maybe its of value to write about some of the, in my opinion, incoherent decisions I stumble across. I’ll summarize these under: If I want my plan to fail

(1) If I want my plan to fail

I’d make health care purchasing decisions in a way “exactly opposite” from the manner any other goods/services are purchased by my organization. I would accept unrecognizable performance metrics, purchasing proposals by the pound and justify decisions based mainly on what my competitors, down the street. decided to. I’d allow myself to be persuaded this decision is based upon benchmarking. I don’t demand  independent data and am completely unable to measure quality of care been purchased.

(2) If I want my plan to fail:

I’d work exclusively with advisors and consultants lacking the same long-term interests as my organization. The more my plan fails, dysfunctions and produces high cost, the more we pay in compensation.  In sequence with my advisors, we fail to allow vendors/service providers with new ideas/new processes to propose for our business. After all, we only want to do business with the mainline providers who provide average benchmark results!

(3) If I want my plan to fail:

I  execute legal documents composed of provisions, definitions and terms written entirely by the vendor. Rarely do these documents align with promises and provisions made in vendor proposals. Commonly they omit our rights to audit, limit termination rights and  provide no recovery for large financial mistakes. While every other contract, apart from employee benefits, is analyzed for weeks, healthcare provisions are indeed complex and due diligence is accomplished by someone else.

Cancer is about patients and the community May 5, 2012

Posted by medvision in Cancer Care, Healthcare Costs, Uncategorized.
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America is blessed with wonderful physicians. This oncologist’s article moved me by his description of cancer’s broad impact on care givers, family and loved ones. I took this cancer-care journey with my Mom. From a healthcare perspective, my experience highlighted the importance individual members/patients.

http://www.kevinmd.com/blog/2012/04/stop-someones-oncologist.html

Economy taking a toll on healthcare spending April 19, 2012

Posted by medvision in Chronic Disease, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Rx Costs, Uncategorized.
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Health Costs, Rx CostsIn my last 8 years working with employer-sponsored self-funded health plans, and their health claims data, one common element is always a signal as to their clinical and financial health. It’s amazingly simple! The higher the total ratio of primary care cost to total cost, the better the plan performs. (Lowest trend, lowest cost and highest member compliance rates to evidence based medicine/screenings) For example, if a plan only spends 8% of total dollars on primary care, then the plan’s condition is sick/poor. Why? Because the balance, 92% is being spend due to advanced disease–in hospitals, seeing multiple specialists, utilizing high-cost technology and receiving costly drugs.

Again, why? Primary care is low-cost/high value. Primary care is preventative care or health maintenance-care, instead of reactive disease care. This makes sense and is the major reason employer sponsored on/near site primary care clinics, save so much money on disease care! (These centers charge no member co-pays or co-insurance for primary care visits and generic drugs)

Here’s an article saying the public is skipping primary care visits due to the down economy! If you are responsible for an employer sponsored health plan, you need to make member primary care compliance a critical metric. A stay-awake-at-night concerned, metric.

http://www.marketwatch.com/story/health-care-spending-takes-a-hit-2012-04-18

Independent plan data, it’s hard to manage what you cannot see! April 14, 2012

Posted by medvision in Uncategorized.
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I’m always amazed when I meet individuals responsible for managing mammoth self-funded health plans and I bring up the subject of data. I may ask, “what’s your number one procedure group by annual cost”? “Hmm, I’m not sure”. “Which hospital provided the highest value for cardiovascular patients”? What percent of your members age 50 and above have been screened for colon cancer”? “I’m not sure, let me call my broker”.

Being blind to risk and quality issues around member health is why we’re in so much trouble.  Medicare, Medicaid, and the vast majority of employer sponsored plans, are totally or partially guilty. The plans utilizing independent plan data are, interestingly, the plans running at 0 or negative trend. Here’s a few facts helping tilt toward the data route:

  • Your administrator and broker/consultants make more money as your health plan performs poorly. Why is failure profitable to your advisers? Why not make them financially suffer when the plan suffers financially?
  • Benchmarking data is similar to rear-view mirror information, it’s behind, possibly interesting but not generally actionable.
  • If other plan sponsors are failing, don’t copy them.
  • Create an environment which facilitates members receiving the right care, on a timely basis, at the best value. Value equals (safety + best medical outcomes/cost)

It all starts with data + questions!

Another HDHP rant! March 28, 2012

Posted by medvision in health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Uncategorized.
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Today we are in the middle of the arguments concerning healthcare reform before the US Supreme Court. The individual mandate is the issue of the week; however, I’d like to discuss the lack of procedure pricing in health markets. Although lack of pricing information is not the main problem with High Deductible Health Plans, the issue is amazingly resilient. First, I’d like to describe personal experience with my own HDHP.

Somehow during December 2011 my family actually met the large deductible of our plan. Given this was the first month of any reimbursable expenses over the last several years, I elected to follow my primary physician’s advice and submit to a sleep study. My physician is owned by a local hospital and I was referred to their outpatient center. I tried to check the pricing on my MCO’s website only to find no information exists for sleep studies. So, around December 30th I traipsed over to the hospital ending up in the basement in a drab, lifeless room. Subsequently, I was met by male technician who proceeded to stick wires all over my head and chest to the point I looked like Frankenstein. Somehow, I fell asleep, was awoken after four hours and drove home.

About two weeks later, I noticed the EOB in the mailbox and quickly opened it. Shock, outpatient billing $4000, BUCA allowed $2000, BUCA paid $1600, member amount due at 20%, $400. Subsequently, I start receiving calls from hospital to schedule my next delightful evening, another four-hour visit, but this time entirely subject to my fantastic $3000 deductible. I answered, “Hmm, let me get back to you”.

By now, I’m feeling pretty stupid and decide to call another facility to inquire the discounted rate for the same procedure/CPT under my MCO. The facility answers, “we don’t know what you’re MCO pays”. Then I say, “forget the MCO, I’m paying cash”. “Oh, you should’ve mentioned that at first, yes the cash price is $300 per evening or $600 for the entire procedure”. Pretty big variance? Drafty hospital, $4000 or brand-new facility $600!

Here’s a supporting posting today on Kevin M.D. The subject has a little more clinical risk significance.  Again, I’m not in the HDHP corner!

http://tinyurl.com/7ddt2a8

 

State of Georgia 2012 health enrollment guide–OMG March 11, 2012

Posted by medvision in health data, Healthcare Costs, Insurance Plans, Uncategorized.
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No wonder we are confused with employer health plans! While researching benefits available to state employees, I came across Georgia’s, State Health Benefit Guide, SHBG. (This acronym is the easiest element of the plan to understand) Now before I criticize the 1000s of billed consulting hours that produced these 13 health benefit options, please realize I have access to population claims expense distribution data which never sees the inside of the consultant’s highrise offices. Here’s an example!

I bet 40% of all Georgia employees/dependents covered (40 of 100) average incurring less than $100 in claims annually from the state health trust fund. Not accounting for the member’s required premium contributions of umpteen $1000s. 70% of all covered members spend less than $500 after their premiums and 85% incur less than $1000. So, let’s set the record straight: 85% of the population’s incurred claims average less than the payroll premiums they contribute to be covered under the plan! Now back to the options. They offer the exact same options, HRA, HSA (plus countless employer fund contributions) and HMO, all with individual wellness, yes/no from (2) national managed care organizations, MCOs. Throw in a Tricare supplement option and we have 13 options.

Maybe I’m too simplistic? 5% of Georgia’s covered employees will account for close to 60% of the plan’s $100s of millions in plan expenses. Why not make sure the sick 5% are getting the best quality, value based care in the world? For the 95%, provide all the low-cost doctor services, screenings, preventative medicines, wellness, weight loss and stress reduction to prevent their entering the top 5%? Drop all the HSA/HRA individual account stuff and their accompanying VISA cards! Many covered members don’t even have their own VISA cards in today’s weakened economy!

These plan designs look to be more tinkered with than a rusted 1955 Chevy in Havana Cuba! The enrollment guide covers 35 pages! I’d bet the consultants and Georgia HR staff don’t understand the options in their entirety. How’s a state trooper working nights and part-time jobs going to understand? Logical rework option: Go back a few decades and provide care to covered beneficiaries? Manage risk instead of burying it under acronyms, ink and paper! Georgia needs to realize it’s the largest purchaser of health services in the state, so act like the largest. Demand quality and value, and of most importance demand accountability from all stakeholders, providers, patients, MCOs and consultants.

http://dch.georgia.gov/vgn/images/portal/cit_1210/0/17/1766508382012_Active%20Guide%2010.1.2011.pdf

The light of free markets slipping into employer sponsored health care! March 6, 2012

Posted by medvision in Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Free market practices appear to breaking through the screens covering our American health care system. Healthcare is a unique marketplace in which our current lack of financial and quality transparency produces high cost and poor clinical outcomes. How many patients will flock to a hospital experiencing 300% increases in cardiac death for heart surgery?  Read this physician’s post: Why we are busier than we’ve ever been.

Self-Funded plan management–take a close look at disease management results February 27, 2012

Posted by medvision in Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Recently results of Medicare’s largest commercial disease management study were republished in the New England Journal of Medicine.

This study should refocus plan managers on the issue of disease management because 75% of all plan dollars are spent on chronic disease. Preventing the production of disease and the management of existing disease states is the entire ball game with respect to healthcare. Back to the Medicare pilot. In the Medicare Modernization Act of 2003, CMS was required to test the commercial disease management industries services with respect to the Medicare fee-for-service program. The program engaged eight of the industry’s DM providers, 250,000 Medicare beneficiaries with serious cardiovascular disease and spent $400 million over the four-year program. The conclusion was reported: In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

How should this be viewed in today’s environment? I’ve always felt the practice of nurses calling healthcare members they do not know, usually from a different state while attempting to offer advice concerning very personal aspects of one’s health is very problematic. Why? (1) Everyone, especially working folks, have very limited time during home hours (2) Not many are comfortable discussing their health issues with strangers and (3) nurses calling many times have limited, or worse, incorrect data about the medical conditions associated with the member.

My impressions of commercial disease management reports being delivered to clients today seem to be verified by the Medicare study as having, essentially, no positive results. But, Medicare members are very different from commercial health plan members? Yes in some ways, however they are mainly at home available so members have time to speak with nurse managers, this pilot targeted serious states of disease, and still, no demonstrable reduction. In what ways should plan managers react when delivered industry standard reports?

  1.  Don’t allow a 50 page DM document impress. DM providers have a strategy of creating member silos in which they describe all silo members as participants in the plan. A member not complaining about monthly mailings is “not” a participant! How many of us pitch 3/4ths of the mail we receive in the trash can? Probably over 90%. The only participants are the ones in continuous monthly/weekly phone calls with nurse managers. Usually this class never exceeds 1-3% of total members.
  2. Health claims metrics reported by the DM vendor probably will contain positive results. These must be verified from independent data in order to be considered valid. Many times DM providers attempt to “prove the negative’ by claiming their efforts created an absence of claims. Even worse are “vapor” attempts to prove savings by producing some type of productivity gain metrics! Sorry but this business in not akin to a college philosophy class.
  3. Each year $100s of millions are simply wasted on telephonic DM. If you cannot see the results clearly, the result didn’t happen.
  4. If you are offering a sole HDHP don’t assume a short-term claims reductions are necessarily good news. In today’s economic climate many are forgoing important medical care. As water recedes prior to a tsunami, an absence of claims this year may be indicative of an avalanche of future chronic disease.

Now the good news. If it isn’t working, try another approach. I’ve seen clients spend $250K through $500,000 with no clear results. How about using the dollars to hire, through a vendor/or directly, on site full-time nurses to reach out to members, face to face? People trust others they meet, trust and recognize!

The greatest opportunity in healthcare is for employer purchasers of healthcare to start demanding the results they want/need from vendors. Vendors which perform win should be rewarded and the many failing need to be sent packing!

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