The Amazing Maze of US Health Care

Hoops

The recently passed Patient Protection and Affordable Care Act (PPACA) does much to promote long term reform of the way physicians are paid for their services.

But could something be done now to simplify the system for both patients and their doctors?

Many health care policy experts tout the current payment system as a major contributor to distorted incentives within the current health care delivery system

Fee for service reimbursement promotes more procedures, surgeries, images, etc. at the expense of patient listening time.

So the PPACA implemented a number of pilot programs to promote efforts to develop more global approaches to reimbursement.  I have discussed some of these in previous posts.

Payment reform now

But there may be intermediary steps that can be taken now to simplify a system that makes sense to no one; sometimes not even the insurers who administer them.

Example one – payment confusion.

A patient, someone I know well, gets a referral from their doctor for physical therapy.  Since I have had some experience with physical therapy and with health insurance, she asks my opinion.  I advise her to go on line to her insurance carrier’s webs site and check if certain physical therapists are in her network.  She does that and identifies a physical therapists in the network and close to her home.

Again, acting on my advice, she calls in advance to confirm that the practitioner still is contracted with this insurance carrier.  She is reassured and schedules a series of appointments.  Several weeks later she gets an Explanation of Benefits (EOB to the cognoscenti) and the insurer has paid nothing.

Her immediate reaction is to cancel all of her remaining appointments.  I persuade her to contact customer service and she if she can get a better explanation than that offered by her Explanation of Benefits.  She is told that the doctor is an out of network doctor and consequently she is liable both for an out of network deductible and for “balance billing” – charges over and above the amount negotiated and approved by the insurance carrier.

“How can this be?” she says to me.  “I looked the provider up on the carrier’s web site, I called the therapist, I don’t understand.”

We got on the phone together and I was able to learn from the customer service agent that this therapist was, in fact, signed up as an HMO provider, a PPO provider, but not as an “Open Access” provider.  Many carriers have developed “open access” networks that are less restrictive than the traditional HMO networks.

The patient contacted the therapist who was more than willing to clear this administrative oversight.

But why should she?

This was a small physical therapy office with only two full time professionals.  They need to hire a support staff that will keep track of all of these different provider reimbursement agreements for each of the countless insurance carriers that she may or may not encounter.

Each reimbursement arrangement will have its own peculiarities, its own administrative procedures and its own customer service contacts.

For whom does this make sense?  Certainly not the patient and certainly not the provider.  Yet, isn’t that who this system is supposed to serve?

Example two – payment confusion

A patient goes for his annual heart check up with the same practice he has always used.  Only this time, the bill is not paid in full as it has been in the past.

The initial inquiry to customer service yields a response similar to patient one – this is an “out of network” provider and the patient must pay the out of network deductible.  Further probing by me elicits some additional information.  This practice is a “participating” provider, but not a “preferred” provider”.  This is more than a bit confusing, because this member has always had PPO coverage.  PPO means Preferred Provider Organization.  What is going on?

What changed is the patient.  He got older, he retired and he enrolled in Medicare.  He still retained the same insurance.  He is one of the lucky few who have employer sponsored health insurance as a retiree.

But some clause somewhere in those provider reimbursement agreements means that the same insurance paid when he was under 65, but not over 65.

A better approach

It is time we developed a single reimbursement methodology for all providers.

That does mean that all providers get paid the same.

It does mean that each provider is paid the same amount regardless of who he or she treats.  Within that system, there can be different degrees of patient responsibility for different groups.

The system may decide that a provider in a rural area may get paid more or less than a similar doctor in an urban area.  It would endeavor to pay those providers with better performance more than those who could not meet the outcome targets.  There could be many other differentiators but one theme will prevail – doctors will know and understand the system they are getting reimbursed by.  And it will not inconvenience patients.

Doctors can opt out of the system, but they cannot pick and chose insurance carriers.  If they are outside of the system their patients will be 100% responsible for all expenses they incur.  The insurance carriers will have no responsibility.

That is the kind of payment reform that would make a real difference.

Photo Credit: Flickr, The Smithsonian Institute

A reader responded to my recent post about accountable care organizations with the question, “How do you measure quality in an accountable care organization?”

Good question!

In other words, if a health care organization is accountable, what do you measure and how do we know that this organization is actually responsible for what is measured?

Vitality as performance

These are the two top challenges with the accountable care organization initiative.  How does one define and measure the desired outcomes, and how does one define the group of practitioners that are responsible for those outcomes.

In my post I wrote  the following:

The study first grouped physicians and patients around their primary hospitals.  What it revealed is that when the hospital performed well, the physicians and physician practices affiliated with that hospital or hospitals also performed well.

Mortality – the ultimate performance measure

The reader appears to be asking:  How do you know that a hospital is performing well and how do we know that the physicians are performing well? Read the rest of this entry »

Accountable care organizations.  Patient centered medical homes.  Episodes of care.

What do they have in common?

They each attempt to use payment incentives to encourage disparate practitioners to collaborate to achieve quality outcomes.

A common purpose

Socialized medicine is progress

The key word is collaborate.  Countless research indicates that when doctors work in teams, they achieve better results at lower costs.  It is this transition from doctor as solo practitioner to doctor as a member of a team that is the key challenge to reforming our health care delivery system.

This transition from solo craftsman to a member of a team is not new to the evolution of our economy.

It is how Karl Marx differentiated capitalism from the mercantilist economy that preceded it.  He called it the socialization of work.  It was this contradiction between the socialization of work and the private ownership of the means of production – capital –that was supposed to be resolved by the socialist revolution.

Karl Marx recognized that this socialization of work brought tremendous increases in productivity to the world economy. Read the rest of this entry »

The term medical home prompts associations with George Carlin and his comparison of baseball and football.

In baseball the object is to go home! And to be safe! – I hope I’ll be safe at home!

In football, we’re down in enemy territory

Reaching for the end zone

What would George offer as the medical counterpoint to “home”?  End zone might be a bit extreme.  But “homeless” could surely fit.

Can health care reform offer help for the medically homeless?

Safe at home

Medical home demonstration projectts

Shortly after the Patient Protection and Affordable Care Act was passed in March of this year, Mr. Vince Kuraitis, writing for the e-caremangement blog noted that the word “pilot” appears 80 times in the law, and the word “demonstration” is used 312 times

He might have also noticed that the term “medical home” appears 11 times,  exactly the same as “accountable care organization” that I discussed last week. Read the rest of this entry »

The Society for Human Resource Management (SHRM)has approximately 250,000 members representing the varied disciplines and commercial interests within the  human resource profession.   As a benefits professional with expanded human resource responsibilities, I recently joined SHRM.

No one there {Photo by JLM}

So I was disappointed to learn that SHRM does not support the recently passed House health care reform bill, HR 3962, The Affordable Health Care for America Act.

My readers will know I consistently argue that relying on employment as the primary gateway to the health care system is outmoded and ultimately harmful to the American economy.   Part of that argument is because employer sponsored health care limits the flexibility of employer human resource policies and the mobility of the workforce.

Does SHRM share those views?

Apparently not.

What does SHRM say? Read the rest of this entry »