Public versus Private Healthcare

Around the World

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Please review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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January 2012 [Health] Plan Management Navigator

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With 2012 Benchmarking Study Invitation

By Marco Georeno

Health Care Analyst

Dear Dr. Marcinko and ME-P Readers

At the risk of appearing overwhelmed with New Year’s enthusiasm, we think the attached edition of Plan Management Navigator is especially interesting:

1. We report on the cost decisions made by low cost Blue Cross Blue Shield plans. Low cost plans make decisions that differ from their higher cost peers. Hallmarks of these decisions include levels and distributions of expenses between functions, the levels and distribution of staff between functions, the levels of compensation and its distribution between functions and the distribution between functions, and levels of, non-labor expenses. Overall, low cost Blue Cross Blue Shield Plans have “tactical” administrative expenses that were $5.63 PMPM, or 29%, lower than their higher cost counterparts. These tactical expenses are all administrative expenses excluding medical management and sales and marketing.

2. We provide an update on the most recent operating and financial results for firms participating in our monthly Dashboard.

3. We invite appropriate ME-P readers to participate in the 2012 benchmarking study. Participation is very timely given that the weak economy is placing great pressure on commercial enrollment, creating the risk that administrative expenses could be a source of negative operating leverage.

Assessment

A more detailed version of this analysis is available to licensed users of Blue Cross Blue Shield Sherlock Expense Evaluation Report (SEER). Please call us for further information if you have an interest.

Link: Navigator Late January 2012

Sherlock Company

mgeoreno@sherlockco.com

Ph: 215-628-2289

Fax: 215-542-0690

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Please review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Broadening the Strategic Value of Integrated Medical Provider Management‏

How Health Plans Can Create Scalable and Competitive Products that Enable Affordable and High-Quality Care

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By Sam Muppalla – Vice President, McKesson Health Solutions Network Performance Management

[Part 6 in a 6 part series]

Over the past few weeks, I’ve covered a lot of ground in this ME-P series of six essays. We looked at the pressures on health plans and the ways in which those pressures are forcing a new dynamic in how the plans create new, scalable competitive products that enable affordable, high-quality care. We talked about some of the innovations that leading health plans are bringing to the areas of product, network, care model and reimbursement designs.

The pilot initiatives in these areas continue to show positive results. The next level of scaling requires an integrated and automated approach to enable health plans to deploy, manage and maintain these innovations in a much more rapid fashion. This all has to be done without increasing health plan costs while delivering new value to a health plan’s customers, providers and members.

Affordable Care Can be Achieved

It is our position at NPM that achieving this alignment will deliver affordable care. Additionally, through this alignment, health plans will gain a competitive and cost savings leadership position. Through collaborative and independent research with our health plan partners, we have identified three main areas of competitive and cost savings leadership. The potential cost savings of achieving alignment are impressive. For example, working with a regional Blues plan with three million members, the potential cost savings due to achieving an integrated approach to network design were projected to be:

Administrative Cost Savings [Total Potential Annual Savings = $13 million to $25 million]

  • Provider data administration cost reductions: $5 million to $10 million
  • Provider outreach cost reductions: $0.75 million to $1.25 million
  • Contract management cost reductions: $1 million to $3 million
  • Administrative reimbursement cost reductions: $3 million to $5 million
  • Provider service cost reductions: $1.5 million to $2.5 million
  • Credentialing cost reductions: $1.5 million to $3 million

Medical Cost Savings [Total Potential Annual Savings = $45 million to $100 million]

  • Streamlined member health advocacy: $5 million to $10 million
  • Pay for Performance: $15 million to $40 million
  • Network design and performance improvements: $25 million to $50 million

Provider IT Cost Savings [Total Potential Annual Savings = $.5 million to $2.5 million]

  • Redundant system consolidations: $0.25 million to $2 million
  • IT change management cost reductions: $0.25 million to $0.5 million

The total aggregated annual potential for savings is between $59 million and $127 million.

Some Final Thoughts

In 2009, the National Health Expenditure (NHE) rose to $2.5 trillion or 17.6 percent of the Gross Domestic Product (GDP) with private health insurance accounting for 32 percent of the NHE. Yet all of this spending is not translating into any measure of higher quality care as the World Health Organization (WHO) also ranks the U.S. as 72nd in overall level of health in the world. To affect high-quality, affordable care, health plans must be able to harness innovative product, network, care model and reimbursement designs. Network design is the critical element that will orchestrate the operational scaling of innovation. Therefore, automation of network design and efficient implementation of it through end-to-end integration will be crucial to success of health plans in the post reform world.

Assessment

Thanks for taking the time to follow me, and the ME-P, on this journey. If you’ve joined us late in the discussion, fear not. We’ve collected all the related threads in the Unlocking Affordable Care by Aligning Products white paper, which you can download by visiting our website at http://ow.ly/7MFKb.

MORE: Strategic Management Improvement

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Please review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Barriers to Performance Based Healthcare Networks and Medical Cost Savings

 Understanding the need to align care models, payment, products and networks

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[Number 4 in a series of 6]

By Sam Mupalla – Vice President, McKesson Health Solutions, Network Performance Management (NPM)

I wanted to follow up on last month’s ME-P discussion about Performance-based Networks and Medical Cost Savings. I wrote about the need to align care models, payment, products and networks, and then promised to address some of the barriers standing in the way of achieving alignment. Well, that’s what I’m writing about today.

Strategic Difficulties

Health plan operations responsible for supporting the intent of the provider network designs will find it increasingly difficult to maintain strategies that provide affordable care by applying existing methods and systems.

Currently, the systems and processes that enable these operations are frequently based on systems that are neither integrated nor automated, rather relying on various manual interventions to achieve some scale of efficiency. Creating and maintaining innovative value-based offerings in this environment requires process excellence coupled with tight coordination executed across multiple departments. As the complexity and frequency of demand for these offerings increase, this approach becomes more challenging to sustain, thus risking long term success of the affordable care promise.

Figure 1: Today’s operational engine interactions are not optimized for enabling innovation.

The traditional systems and processes that health plans have used to respond to specific client demands appear in Figure 1.

For example, product demands from consumers may come in through the sales team, which manually interacts with the product management, care management, network development, and health economic teams to design a product to meet the market need. This first set of interactions, in effect, becomes the innovation engine for value-based product designs. Additionally, it becomes the starting point for a myriad of manual and highly paper-based interactions that ripple throughout the enterprise.

The interactions within this innovation engine then set forth a series of parallel and independent sequences with three different operational engines: the provider contracting department, the provider management department and the claims operations department. Each of these areas relies heavily upon their own set of manual and paper-based processes and interactions. The inefficiency of this current approach suggests the potential for an annual administrative cost savings opportunity of $5-25 million, depending on the health plan’s size and current system architecture.

In addition to administrative costs, this approach creates inefficiency and waste in IT costs and medical costs that could be between $40-100 million.

Assessment

So, how can you unlock these savings and eliminate this waste? We’ll discuss that next week. I’ll say only three words here: Integrated Building Blocks. I’m not going to say a word more — but if you can’t wait for next week you can read the entire Unlocking Affordable Care by Aligning Products white paper; it’s available on our website now.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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Controlling Health Care Spending [An NIHCM Foundation Webinar]

The Imperative to Act and Diverse Views of the Road Forward

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The U.S.now spends $2.5 trillion annually on health care, accounting for well over 17 percent of GDP and growing rapidly with challenging fiscal consequences. Despite the imperative to control spending, we face much uncertainty about how to move to a more sustainable path.

Political opposition threatens implementation of the Affordable Care Act, and many of its cost-control measures are still unproven. A long-term fix for Medicare physician payment remains elusive. The trigger mechanism activated by the failure of the Super Committee is poised to affect myriad health programs, but decisions on the specific cuts await sure-to-be intense congressional negotiations.

And, the many ideas for entitlement reform that were advanced during deficit reduction talks continue to generate much debate but little consensus.

Topics

To shed light on these complex issues, this webinar will feature leading health policy experts discussing topics including:

  • health spending growth and the implications for government budgets, employers and individuals
  • the societal trade-offs we face as health spending grows and as we think about ways to control spending
  • alternative viewpoints on the viability of cost control approaches now being tried and the most promising options for the future.

Assessment

Visit NIHCM Foundation’s website to view an agenda and additional resources on health care spending. And, please register by noon (EST) on February 1st.

Conclusion        

And so, your thoughts and comments on this ME-P are appreciated. Please review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Apply AcademyHealth / NCHS Health Policy Fellowships

How to Apply – January 9th Deadline Looming!

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Vision

AcademyHealth seeks to improve health and health care by generating new knowledge and moving knowledge into action.

Mission

As the pre-eminent professional society for health services researchers and health policy analysts, AcademyHealth collaborates with the health services research community and other key stakeholders to support the development of health services research by:

  • Expanding and improving the scientific basis of the field;
  • Increasing the capabilities and skills of researchers;  
  • Promoting the development of the necessary financial, human, infrastructure, and data resources;
  • Facilitate the use of the best available research and information;
  • Translating research findings and the lessons of experience into useful information for clinical, management, and policy decisions;  
  • Enhancing communication and interaction between health services researchers and health policymakers;
  • Assist health policy and practice leaders in addressing major health challenges;
  • Providing high quality policy and technical assistance;
  • Offering educational programs that advance the use of policy analysis and research; and
  • Identifying areas where additional research and information are needed.

Assessment

Link: http://www.academyhealth.org/Training/content.cfm?ItemNumber=1435&navItemNumber=2332

Conclusion      

And so, your thoughts and comments on this ME-P are appreciated. Please review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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On Performance Based Health Networks and Medical Cost Savings‏

Achieving Proper Healthcare Alignment

[Number 3 in a Series of 6]

By Sam Muppalla – Vice President, McKesson Health Solutions, Network Performance Management (NPM)

Last week, on this ME-P, I wrote about Health Plans and the Three Levers of Innovation for Affordable Care. We looked at a number of innovations taking place in the areas of products, care models, reimbursement, and network designs. It’s vitally important to be able to innovate in each of these areas, but even more important to be able to align these network elements properly. The key to affordable care is enabling every member to get the right care, at the right time, from the right provider, and for the right price. But, when you look at what it takes to deliver such care, the interdependencies of design of care models, payment, products and networks become apparent, as you can see in Figure 1 below:

 Figure 1: Affordable care requires alignment of product, network, care model, and payment design.

Steering the member to the right provider at the right setting is influenced by the member incentives built into the product design and the provider choice component of the network design. The right care is dependent on the care model design and the provider reimbursement design. Overall affordability of care is obviously tied to payment design. Not so obvious are the dependencies between product design and payment design. The member behavior targeted by product incentives should be reinforced by the provider engagement influenced by reimbursement design. All these interdependencies necessitate alignment between product, care model, reimbursement and network design. Alignment is fundamental to scaling innovation.

Network Design Drives Alignment

As shown in Figure 2, network design drives alignment between product, care model, and payment approaches. As an illustration, it facilitates the alignment of products and care models by enabling steerage of members to the appropriate care teams or sub-segments of the network. This steerage can only occur if member benefits and incentives (which are embodied in the product design) and the structure of care teams (which are described in the network design) are systematically matched. This systematic matching has to be governed by network-level guidelines for provider performance management.

Figure 2: Network design drives the alignment that delivers affordable, high-quality care.

Focusing on the alignment between products and payment, network design enables this by ensuring that the goals of member incentives are supported by the provider behavior driven by payment design. This enablement is achieved through network-level reimbursement guidelines being automatically enforced during provider contracting.

Finally, network design incorporates network-level reimbursement guidelines to drive alignment between care model and payment design by ensuring that provider behavior envisioned in the care model design is incented by payment design.

As health plans productize new care models and payment innovations, the complexity and the frequency of the abovementioned alignment efforts will mushroom. Customer segmentation and the need for tailored products to serve these customer segments will further amplify the alignment challenge.

The approach of using network design automation to efficiently operationalize alignment is a critical core competency for health plans. By innovating with this approach, it will be possible for health plans to strike the optimal balance between the value to their customers (competitive premiums, high-quality care) and the value to themselves (revenue enablement, reduced medical and administrative cost).

Assessment 

Are there barriers to operationalizing alignment? Of course! But stay tuned: Next week, I’ll be writing about the barriers to alignment — and after that, I’ll go into more detail about why it takes an integrated approach to remove these barriers. As before, if you don’t want to wait to read more, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
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Health Plans and the Three Levers of Innovation for Affordable Care

Unlocking Affordable Care

Number 2 in a Series of 6

By Sam Muppalla – Vice President, McKesson Health Solutions, Network Performance Management (NPM)

Last week, for the ME-P, I wrote about the increasing Pressure to Deliver Affordable, High-Quality Care.

In the face of those pressures, many health plans have begun to explore innovative approaches to product, care model, and reimbursement designs. What are they doing?

In this second installment of our series about unlocking affordable care, I’d like to take look at how some of the pilots in these areas show promise.

Product Innovation

One path health plans are using to achieve affordable care is through the deployment of value-based insurance designs (VBID). At the heart of this approach is the utilization of member incentives to reduce barriers to high value Rx and services. Conversely, it also incorporates disincentives for low value services or Rx. Typical member incentives include premium reduction, co-pay/coinsurance waiver/reduction, and health reimbursement accounts (HRA). Co-pay increase or cost sharing are typical disincentives. Member steerage to high value providers is another typical goal of VBID. The design of the supporting networks is critical to the success of VBID products. The network design has to ensure that the composition, the quality and the value of the participating providers can fulfill the benefit design and match steerage goals of the member incentives. Furthermore, the network level provider reimbursement guidelines should be complimentary to the member incentives.

For example, member incentive for a preventive exam during a Primary Care Physician (PCP) office visit could be matched by a Pay for Performance (P4P) provider incentive (on top of regular capitation) to perform the examination. Without the incentive, the Per Member Per Month (PMPM) capitation might be a disincentive for the PCP to perform the preventative exam.

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Figure 1: Network steerage is a critical component of product innovation.

Care Model Innovation

Innovative care models provide another approach to the delivery of affordable, high-quality health services. Population management-based care model designs, such as Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) designs, are an important advancement towards affordable care. These designs deploy a care team-based approach rather than a traditional siloed services approach to ensure a continuity of care.

The PCMH care model results in continuity of care via a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. The emphasis for PCMH is about collaboration to manage a population’s health.

Another example of a care model with a team-based approach is the ACO care model. In this care model, the emphasis is on accountability for providing the required healthcare services for a defined population. Health plans are rolling out ACO pilots across the nation.

For example, the Pension System (of the California Public Employees’ Retirement System) formed a partnership with the Blue Shield of California Health Maintenance Organization, Catholic Healthcare West, and Hill Physicians Medical Group with the goal of improving quality of care while reducing costs. Some of the early findings are showing positive results:

  • 17 percent reduction in patient re-admissions since the pilot began
  • Length of stay reduced by one half day
  • Almost a 14 percent drop in the total days patients spend in a facility
  • 50 percent reduction in the number of patients who stay in a hospital 20 or more days

These results show that it is possible to utilize care models to improve the quality of outcomes while reducing the cost of healthcare.

It is worth noting that health plans are not limited to adopting one care design innovation over another. Greater benefits can accrue to both consumer and provider by combining approaches—leveraging both collaborative and accountable care designs.

Adoption of population management is forcing a change from paying for individual providers’ services to paying for health management of a population across a team of providers. Supporting this requires the reimbursement systems to understand the structure of the care team, role of the various providers within the care team and the relationships between the providers in the care team.

In other words, it will need to understand the provider network structure to calculate the reimbursement. Another complexity is that providers participating in PCMH or ACO care models may also be directly contracted with the health plan. Selecting which payment arrangement to use in these scenarios will require an understanding of providers’ relationships with the plan.

Reimbursement Innovation

Along with innovations in product and care model designs, health plans are also innovating in the area of provider reimbursement. These innovation efforts primarily focus on enabling incentives for quality and performance, while controlling the rate of medical cost growth. These objectives reflect the need to move away from a healthcare system that bases provider reimbursement on volume to one that bases provider reimbursement on the value of the outcome. Within this approach, a variety of different models are evolving (see Figure 2). 

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Figure 2: Mixing and matching payment models.

Evolving in parallel with individual models is an understanding that the ability to mix and match different reimbursement designs will deliver greater value than the utilization of just one design. Health plans are mixing and matching different reimbursement methodologies to optimize provider performance. This implies that a provider is likely to have multiple valid payment arrangements at any given time. Picking the appropriate payment arrangement will require the reimbursement engine to understand the role of the provider in the network and the full context of all of the provider’s relationships.

Assessment

Next week, I’ll be discussing why the alignment between products, care models, provider reimbursement, and network design is so important when it comes to scaling these innovative approaches.

If you can’t wait that long for that discussion, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest ME-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

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Health Plans Under Pressure to Deliver Affordable and High Quality Care

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US Healthcare Expenditures Reaching Unsustainable Levels

[By Sam Muppalla]

Vice President: McKesson Health Solutions, Network Performance Management (NPM)

Expenditures on healthcare in the United States continue to increase and are rapidly reaching unsustainable levels. Pressures by businesses, households and the government to address these escalating costs and ensure high-quality healthcare are multiplying.

This is the first in a series of six essays that examine the challenges facing health plans and the ways that network design can unlock affordable care by aligning products, care models, and reimbursement.

Health insurance companies are faced with addressing a rapidly changing healthcare environment on multiple fronts. These changes are being driven by the goal of achieving a more affordable, higher quality healthcare system. Shifting market needs, increased regulatory initiatives, and a demand for administrative efficiency are requiring innovative approaches to unlocking affordable care. These pressures are originating from key healthcare stakeholders—employers, members and the government (Figure 1).

Employer Pressure

As the competition for the group insurance market increases, health plans need to respond to employer demands for products that deliver greater value. Delivering high value requires products which are tailored to the health of the employer’s specific population and emphasize wellness and prevention. An employer that can offer benefits and programs tailored to meet their employee needs can both improve their workforce productivity and optimize their healthcare spend. The employer’s insistence for reduction in premiums and decrease in the rate of premium growth is challenging health plans to develop more innovative strategies.

Consumer/Member Pressure

With the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA), the Congressional Budget Office (CBO) estimates (Figure 2) that approximately 32 million more individuals will require access to healthcare services. This represents a significant increase in the number of new healthcare consumers at a time when health insurance companies are required to guarantee issue and re-newability of coverage. Steering this influx of new members to the right care teams will be a very critical core competency for health plans to develop. It is one of the few risk management tools left in the plan’s arsenal in a guaranteed access world. The growth of the individual market is also being accompanied by an increase in member financial responsibility. Members are increasingly demanding greater transparency into their provider quality, performance and cost information.

Government/Regulatory Pressure

Evolving healthcare regulation puts still more pressure on health plans. New regulations within the PPACA Section 9016, stipulate an 80% MLR cap for small groups (fewer than 100 lives) and an 85% Medical Loss Ratio (MLR) cap for large groups (more than 100 lives). These regulations also cap the percentage of revenues that can be earmarked for operational and administrative expenses at 15-20%. This poses a unique challenge for health plans; it requires plans to innovate in the areas of products, care models, and reimbursement designs without increasing the administrative and operational overhead.

There are roughly eighteen additional PPACA provisions that put further pressure on health plans by promoting increased collaboration (sections: 6301, 4201, 3027, 3011, 3021, 10333, 3022, 3024) and accountability (sections: 2705, 3006 & 10301, 3001, 3025, 2706, 2704, 3023, 3004, 3008 and 3002). The Bureau of National Affairs best summarized these provisions by stating,

“The comprehensive provisions in the act regarding payment and delivery reform reflect both the payment system continuum—from fee-for-service to bonus incentives for quality to bundled payments to partial and full global payments as well as the delivery system continuum—from independent clinicians and hospitals to small group practices to multi-provider networks to partially or virtually integrated organizations to fully integrated systems with common ownership and employment.”

These demands mean that health plans need to offer new high-value products that incorporate outcome-based reimbursement to drive quality outcomes and not pay for potentially avoidable costs.

According to studies by the Robert Wood Johnson Foundation and Prometheus Payment (2009), “Up to 40 cents of every dollar spent on chronic conditions and 15 to 20 cents of every dollar spent on acute hospitalization and procedures are attributable to potentially avoidable complications (PACs).”

With evidence like this health plans are taking a new, hard look at when and how care is delivered.

Assessment

Next time, we’ll be looking at how health plans are responding to these challenges with innovations in products, care models, and reimbursement structures. Visit the blog next week for “The Three Levers of Innovation for Care Affordability.”

If you can’t wait, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

A Webinar 

On December 8th, we’ll be hosting a webinar on Lean Provider Lessons for Post Reform Success. Plan to attend this free webinar for more insights into designing for affordable high-quality care.

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More Evidence of the Association between Hospital Market Concentration and Higher Prices and Profits

NIHCM Expert Voices in Health Care Policy

By James C. Robinson, PhD

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In this essay, Dr. James Robinson presents results from his latest work showing that the prices hospitals charge to private insurers for 6 common procedures are 30 to 50 percent higher when the hospital is located in a market where it faces less competition from other hospitals.

These findings add to the already substantial body of research showing that consolidation in hospital markets confers market power that enables hospitals to secure higher prices.

When seen in the context of current policies encouraging additional provider consolidation through accountable care organizations [ACOs], this work serves as an important reminder that ongoing vigilance of the potential anti-competitive effects of these new delivery systems is needed along with other measures to counteract growing market power of providers.

About the Author:

James C. Robinson, PhD is the Leonard D. Schaeffer Professor of Health Economics and Director, Berkeley Centerfor Health Technology, University of California, at Berkeley.

Conclusion

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How the Economy is Hurting Americans

Doctors and Medical Professionals, Included

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The stock market was down 389 points yesterday! With the current state of the economy, depressed housing and jobs market, Americans are cutting back on basic necessities; clothing, healthy nutrition habits and food. Even doctor visits and medical practices are declining; and stress and anxiety are on the rise for all.

See how the economy is really affecting our quality of life with this somber look at our mental, physical and financial health in this infographic.

 

Assessment

Source: www.creditloan.com

Conclusion     

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The Eight Types of Waste in Healthcare Processes Today

 The Industry Must Identify and Avoid These Traps

By Mark Matthews MD

www.Creative-Healthcare.com

Operative Definitions:

Noun:
Processes: A series of actions or steps taken to achieve an end.

 

Verb:
  1. Perform a series of mechanical or chemical operations on (something) in order to change or preserve it: “the stages in processing the wool”.
  2. Walk or march in procession: “they processed down the aisle”.

 

Waste in healthcare processes can be classified into 8 different subtypes:

  • Overproduction: This term refers to the performance of redundant work. Examples include duplicate charting, multiple forms with the same information, copies of reports being sent automatically, and multiple caregivers asking the patient for the same information.
  • Motion: This term refers to the extra steps taken by employees in order to complete a task (part or all of a process). People working in healthcare facilities or offices often spend a large part of their day moving around the environment searching for people or information, gathering supplies, moving items, dropping off records, etc.
  • Waiting: This is epidemic in most healthcare settings and is often referred to as “queuing.” Waiting for items like medical records or radiographs, or a patient waiting for providers is simply inactive time with no value content at all.
  • Transport: The unnecessary movement of patients, supplies or materials that are necessary for, involved in or produced by a process. Examples include delivery of medication from a distant central pharmacy, procurement of an unexpected surgical pack to the operating room, staff needing to travel a great distance to retrieve supplies, or transporting patients large distances from the emergency room to obtain diagnostic tests. This movement adds time to a process and contains no value.
  • Over-processing: Excess processes that do not add value from the patient’s perspective. The most prevalent example of this in healthcare is the processing of regulatory paperwork or the inclusion of extra steps merely to satisfy a regulatory condition. Also included are activities like order clarification due to poor handwriting or erroneous abbreviations, missing medications from a pharmacy area leading to a delay in treatment, and redundant charting or paperwork.
  • Inventory waste: Seen when too much product is acquired ahead of actual demand. This leads to a risk that items may become outdated or expired, leading to waste and excess cost. This is most often seen in healthcare in association with poor inventory management. Inspection of the average hospital storeroom will yield many items that will not be needed for months to years ahead. In addition, catering to the individual needs of all surgeons in the operating room leads to the accumulation of multiple trays and costly instruments that are used infrequently.
  • Rework: This term refers to work that contains errors or defects that require correction. In healthcare, this is seen in coding and billing errors requiring reprocessing, medication errors requiring additional reconciliation, patient mishaps requiring reporting and perhaps additional treatment, and surgical errors requiring re-operation.
  • Not using people to their full potential capabilities: This is often referred to as the “8th form of waste” because it was described after the original 7 forms of waste related to manufacturing were defined. It refers to a mismatch of a particular task to the skill set of the person assigned to perform that task. It is common to see significant variation in the ways different people will perform the same task. This often arises when there is an unclear expectation set forth by management or a lack of standard processes. Matching tasks to skill sets can lead to improved quality of work, employee satisfaction, and employee loyalty.

Pre-Order Book Now [more from this author]

We are now preparing the next edition of our book:
“Healthcare Organizations” [Management Strategies, Tools, Techniques and Case Studies].

In-Process from: (c) Productivity Press 2012
http://www.crcpress.com/product/isbn/9781439879900

About the Author

Dr. Mark Mathews has 20 years of active clinical practice in the field of Anesthesiology. Located in Scottsdale, Arizona, he has served on the management board of his large multi-specialty anesthesiology group in the Phoenix area as well as various committees within the Scottsdale Healthcare System. Currently, he is developing simulation models mimicking various medical inpatient and outpatient processes with an emphasis on improving Patient Safety through the application of Lean and Six Sigma analysis. After receiving his Bachelor of Science and Medical Degrees from the University of Arizona, Dr. Mathews completed his residency training in Anesthesiology at the University of Minnesota. Subsequently, he received specialized fellowship training in Neuroanesthesiology from the Barrow Neurological Institute in Phoenix, Arizona. Currently, he is a Diplomat of the American Board of Anesthesiology and maintains numerous memberships in professional medical societies. 

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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About Healthcare Financials.com

WELCOME ALL HEALTH 2.0 COLLEAGUES

[An Open Invitation]

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All hospitals and healthcare organizations, both emerging and mature, face a daunting financial scenario in today’s volatile healthcare reimbursement environment.  Decreasing revenues, increasing costs, and high consumer expectations present a complex challenge for CEOs, CFOs, physicians and nurse executives, administrators, financial advisors and department managers who must not only lead in today’s climate, but also position their organizations for tomorrow’s financial tumult and potential political changes of the Obama Administration.

Produced by a team of leading doctors, physician executives, nurses, medical professionals, economists, administrators, lawyers, and accountants, skilled business leaders and IT consultants, among many others; Healthcare Organizations [Journal of Financial Management Strategies] on CD-ROM, or SaaS, looks at ways to manage assets, costs, human resources and healthcare claims.  Everything – from inventory management to hybrid and activity based cost analysis in order to accelerate the cash conversion cycle – is scrutinized.  And, modern health economic themes like competitive strategy, workplace violence and financial benchmarks, for both public and private entities, are included.

We also examine contemporaneous topics such as the lessons learned from the corporate healthcare market competition and the PPMC imbroglio of the early 2000’s, and the domestic financial meltdown of 2009. This includes current methods for achieving hospital objectives, negotiating and analyzing cost-volume-profit contracts, and understanding the financial impact of regulatory requirements under HIPAA, STARK I-III, OSHA, the US Patriot Acts, the Deficit Reduction Act [DRA], the often contentious Sarbanes-Oxley Act, ARRA and HITECH Acts, and the Fair and Accurate Credit Transactions [FACT] Act.

In addition, information technology issues like electronic medical records (eMRs), RFID controls, RSS feeds and blogs, Health 2.0 initiatives and computerized physician order entry (CPOE) systems are examined in detail. Virtually no  operational, strategic business, health economics, or financial management topic is omitted.

“This wide-ranging examination of the fiscal

management scene for hospitals, healthcare

organizations, clinics and outpatient centers 

includes case models, extensive appendices, 

and detailed checklists and templates that

step the reader through a review of main

issues for each chapter.”

Health Care Organizations [Journal of Financial Management Strategies] on CD-ROM, or SaaS, is dedicated to meeting the administrative needs of our nation’s healthcare organizations in order to help them maintain a competitive edge in the markets they serve; and to take advantage of emerging business opportunities. We therefore invite you to be the first health economics cynosure in your hospital, facility, or healthcare system to join us for the journey.

Let Health Care Organizations [Journal of Financial Management Strategies] be your guide. 

Subscribe today … Succeed tomorrow!

Dr. David Edward Marcinko MBA, CMP

[Founder, CEO and Editor-in-Chief]

iMBA Inc – Suite #5901 Wilbanks Drive

Norcross, GA 30092-1141

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Pregnancy and Birth Trends in the USA

Teen Birth Rates Lowest in US History

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After declining 2% between 2007 and 2008, birth rates for 15 to 19-year-olds decreased again between 2008 and 2009 for all races and for Hispanics. This indicates that the steady decline in teen birth rates from 1991 through 2005 has resumed, after briefly increasing between 2005 and 2007.

In 2009, 409,840 live births occurred to mothers aged 15-19 years, a birth rate of 39.1 per 1,000 women in this age group (down from 434,758 births and a birth rate of 41.5 in 2008). The Hispanic, American Indian/Alaska Native, and non-Hispanic black teen pregnancy rates are more than twice as high as the non-Hispanic white teen birth rate. 

Assessment

Source: http://www.sonogramtechnician.org/

Conclusion

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Multi-Hospital System Executive Summary [2001-2009]

Number of Hospitals In and Out of Multi-Hospital Systems

By Staff Reporters

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This .PDF details key demographics measures, including hospital breakouts by size, ownership type, region and multihospital system (MHS) affiliation.

Link: http://www.managedcaredigest.com/pdf/MCD11HospInstDemoPgs.pdf

Assessment

The data measures outlined come directly from Managed Care Digest Series print digests and related materials. As always, these data are available at the state and local levels by contacting your sanofi-aventis account manager.

Conclusion

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Practice Management: http://www.springerpub.com/product/9780826105752

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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How Lifetime Benefits and Contributions Point the Way Toward Reforming Our Senior Entitlement Programs

By Staff Reporters

From Expert Voices

By C. Eugene Steuerle PhD [Institute Fellow and Richard B. Fisher Chair, The Urban Institute]
By Stephanie Rennane [University of Maryland]

For August 2011

Reforms to Medicare and Social Security will likely be debated over the next few months as the new “super committee” formed by the debt ceiling agreement works to develop its long-term deficit reduction plan.

The Essay

In this essay, Dr. Eugene Steuerle and Stephanie Rennane help to inform this debate by presenting findings from their newly updated analysis showing that seniors retiring today can expect to receive dramatically more in entitlement program benefits during retirement than they contributed to the programs while working.

For example, the average Medicare beneficiary can expect $3 in benefits for every $1 paid in payroll taxes.

Link: http://nihcm.org/images/stories/EV-Steuerle-Rennane-FINAL.pdf

Assessment

The authors posit that the magnitude of the resources involved when viewing these programs in tandem over a lifetime gives policymakers new impetus and flexibility to develop coordinated entitlement reforms that promote a coherent, equitable and sustainable support system for current and future generations of seniors.

Conclusion

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Physician Advisors: www.CertifiedMedicalPlanner.com

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Benchmarks of Health Plan Administrative Costs

2011 Edition‏

[By John Park]

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Recently, we began the release of our fourteenth annual edition of administrative performance benchmarks for health plans. It is the culmination of 515 health plan years of experience with all major sectors of the health plan industry. The attached brochure briefly describes our 2011 benchmarks.

First Universe Release

The first universe to be released was comprised of data of Blue Cross Blue Shield plans. Nearly 70% of all Blue Cross Blue Shield licensees participated this year.  A summary of the results for this universe is here:

http://www.sherlockco.com/docs/navigator/Navigator%20July%2011.pdf.

Results

In short, per member administrative expenses increased by only 1.0% in 2010 and only 1.8% when you adjust to back out changes in product mix.

This growth rate is very low by any standard.

Sherlock Company’s Benchmarks

Between the MLR provisions of the Accountable Care Act, which are intended to “create incentives for” health plans” to become more efficient,” and a weak overall economy, health plans face greater pressure to optimize their administrative costs. Sherlock Company’s benchmarks of administrative expenses enable your plan to quickly determine whether it is operating at best practice and to identify which functional areas provide the highest return on management’s efforts to improve performance.

Accordingly health plans serving more than one-half of all insured Americans are users of our benchmarks.

Assessment

Additional information can be found at http://www.sherlockco.com/seer.shtml

Sherlock Company

Douglas B. Sherlock, CFA

Senior Health Care Analyst

sherlock@sherlockco.com

Ph:  215-628-2289

Fax: 215-542-0690

Conclusion

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The ACO Prescription?

Cure or Disease?

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Accountable Care Organizations are the ACA’s [Obamacare] answer to skyrocketing Medicare costs, but who wins besides the government? Doctors take on the financial risk, and patients could suffer as a result.

Here’s a look at how Accountable Care Organizations could affect the quality of healthcare in the near future. Brought to you by gplus.com

Conclusion

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***

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Understanding US Health Care Spending

Dear ME-P Colleagues,

Nancy Chockley, President and CEO

The NIHCM Foundation is pleased to announce the release of a new data brief, Understanding U.S. Health Care Spending.

In it, we examine why we spend more than $8,000 per person on health care and the factors driving spending growth. Our analysis documents the extreme concentration of expenditures, with just 5 percent of the population responsible for almost half of all spending, and demonstrate the importance of rising spending for hospital and physician services as the primary drivers of expenditure growth.

Findings are based on NIHCM analysis of the most recent data from the National Health Expenditure Accounts and the Medical Expenditure Panel Survey.

We hope that you find this publication helpful for your own work.

Sincerely,
Julie Schoenman [Director of Research and Development]

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[Health] Plan Management Navigator

For July 2011

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By Douglas B. Sherlock, CFA

Please find attached below the July 2011 Edition of Plan Management Navigator. In this month’s edition, we summarize the administrative cost trends of Blue Cross Blue Shield Plans participating in our recently completed benchmarking study. The 27 plans, nearly 70% of total Blue plans, collectively serve 38.3 million members with comprehensive products.

Results 

The median administrative expense ratio for this peer group in 2010 was 9.2%, down from 9.7% in 2009, 9.9% in 2008 and 10.4% in 2007.

While per member Sales and Marketing cost trends increased, Corporate Services costs decreased. Provider and Medical Management and Account and Membership Administration cost growth, per member, sharply declined.

Managed Expenses 

Health plans are heavily committed to the management of administrative expenses. To adapt to the weak economic environment, they are taking steps to assure that the effects of premium rate pressures and enrollment weakness do not amplify reductions operating profits. They do this by not treating their administrative expenses as substantially fixed. In addition, the Patient Protection and Affordable Care Act’s increased scrutiny of premium rates, and enforcement of medical cost minimums (relative to premiums), elevates administrative expense control as the central aspect of managerial discretion.

Assessment

Link: Navigator July 11

Conclusion

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Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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About The Healthcare Blue Book

A Free Consumer Guide to Healthcare Services

By Staff Reporters

What it is?

The Healthcare Blue Book is a free consumer guide to help you determine fair prices in your area for healthcare services.

How it works?

If you pay for your own healthcare, have a high deductible or need a service your insurance does not fully cover, they can help. The Healthcare Blue Book will help you find fair prices for surgery, hospital stays, doctor visits, medical tests and much more.

Assessment

So, give em’ a click and tell us what you think?

www.HealthCareBlueBook.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Healthcare Organizations: www.HealthcareFinancials.com

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RUC versus RUC

Bill Seeks Outside Review of Relative Values in Medicare Services

The AMA, AOA and others defend the RUC process, but some primary care societies support bringing in contractors for a second opinion.

By ME-P Staff Reporters

PRO: http://www.familymedicine.medschool.ucsf.edu/pdf/cepc/0406_pres/BodenhPPTslides.pdf

CON: http://www.nhpf.org/library/handouts/Levy.slides_03-05-10.pdf

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

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Private v. Public Healthcare

A Look Around the World

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By MPH Degree Programs.com 

 

Conclusion

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

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The Cost of a Cared For-Nation

By Infographics

Courtesy Medical Billing and Coding

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There’s nothing cheap about medical care expenses. In fact, there’s only one constant when it comes to the price of healthcare and medical treatment: it’s expensive.

Now Just imagine picking up the tab for an entire nation. The price of Medical services are rising at a faster rate than any other service and far exceed the pace of inflation. The following graphic breaks down the most expensive medical procedures by cost and takes a closer look into the rising cost of healthcare in our country.

Assessment

Have you ever wondered which states pay the highest premiums or how much the average premium has gone up in recent years? Take a look to learn more.

 

Source: http://carrington.edu/cccblog/carrington-college-california-news/health-care-cost/

Conclusion

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Practice Management: http://www.springerpub.com/product/9780826105752

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Healthcare Organizations: www.HealthcareFinancials.com

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Cost Conflicts-of-Interest in Medicine

Clinical Care versus Finance

By Render S. Davis MHA CHE

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Conflicts of interest are not a new phenomenon in medicine. In the fee-for-service system, physicians controlled access to medical facilities and technology, and they benefited financially from nearly every order or prescription they wrote. Consequently, there was an inherent temptation to over-treat patients. Even marginal diagnostic or therapeutic procedures were justified on the grounds of both clinical necessity and legal protection against threats of negligence. 

Costs Rarely Considered

While it could be construed that this represented a direct conflict of interest, it could also be argued that most patients were well served in this system because the emphasis was on thorough, comprehensive treatment – where cost was rarely a consideration.  It was a well known adage that physicians “could do well, by doing good.” 

Managed Care

In managed care, the potential conflicts between patients and physicians took on a completely different dimension.  By design, in health plans where medical care was financed through prepayment arrangements, the physician’s income was enhanced not by doing more for his or her patients, but by doing less.  Patients, confronted with the realization that their doctor would be rewarded for the use of fewer resources, could no longer rely with certainty on the motives underlying a physician’s treatment plans.  One inevitable outcome was the continuing decline in patients’ trust in their physicians.  This has been exacerbated to some degree by revelations of significant financial remuneration to physicians by pharmaceutical and medical products firms for their services as researchers or active participants on corporate-funded advisory panels, calling into question the physician’s objectivity in promoting the use of company products to their peers or patients.

Conflicts of Interest

Conflicts of interest may also create concerns at a much higher level, as evidenced by the issues raised in 2008 litigation against Ingenix, a company that for more than a decade, provided information to the insurance industry on payments to out-of-network physicians for their “usual and customary rates (UCR).” As noted in court documents, Ingenix was a wholly-owned subsidiary of United Healthcare and the UCR information sold by the company to insurers may have been fundamentally biased in favor of the insurers, causing patients to pay larger out-of-pocket fees.

Assessment

As a result, New York attorney general Andrew Cuomo filed suit against Ingenix.  This action was followed by suits brought against major insurers by the American Medical Association and several state medical groups for systematic underpayment to members, based on the biased data.  To date there have been monetary settlements, but the issue continues to raise growing concerns regarding conflicts of interest among the key payers for health care.

Conclusion

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Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Why Your Stitches Cost $1,500 [Part II]

InfoGraphics – Part 2

Courtesy Medical Billing and Coding

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The United States has fallen behind other nations, failing to provide affordable health care to its citizens. Americans spend $477 billion a year MORE on health care than other advanced countries.

So why do we pay so much compared to other wealthy nations?

Part 2 of 2 in a Series

This Infographic is part two in a two part series which dissects the state of our health care system and presents some alarming numbers.

Assessment

Link: http://www.medicalbillingandcoding.org/medicals-costs-2/

Part 1: https://medicalexecutivepost.com/2011/04/25/why-your-stitches-cost-1500/

Conclusion

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Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Pod-Casts from the Institute of Health Economics [IHE]

Seeking an International Flavour for the ME-P

By Staff Reporters

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About The Institute

The Institute of Health Economics (IHE) is a Canadian non-profit organization committed to producing, gathering, and disseminating health research findings from health economics, health policy, health technology assessment and comparative effectiveness to improve the delivery of health care and support a sustainable future.

Vision 

The IHE vision is to be an international center for excellence for health economics, health outcomes, and health policy research, and be recognized nationally and internationally for our contributions towards the efficient and effective use of health care resources.

Mission

The IHE mission is to deliver outstanding health economics, health outcomes, health policy research, and related services to governments, health care providers, the health industry, and universities, for the betterment of society. 

Objectives 

  • Facilitate partnerships among government, academia, industry and health care providers  to address important issues in health care
  • Assess the clinical, economic, social, and ethical implications of both established and new health technologies and practices
  • Support health service delivery with evidence from research in health economics and health technology assessment.
  • Provide relevant economic research to guide policy makers in ensuring high quality care and cost-effective care.

Values
IHE’s values are: Partnership, Creativity, Independence, Quality, Relevance, Accountability, Transparency and Trust

Assessment

Visit Website: www.IHE.ca

Three podcasts released within the last 48 hours:

View PodCasts: http://vimeo.com/ihe

Conclusion

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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The Great Health Care Challenges [A Slide show]

The US Health Care Crisis and the Complexities of Reform

By Austin Frakt PhD

Dr. Austin Frakt blogs over at The Incidental Economist which contemplates health care with a focus on research, and an eye on reform. It is about economics, health policy, health services, health care and – yes – politics. And, Austin is a health policy wonk that we admire here at the ME-P

 www.TheIncidentalEconomist.com 

Last fall he created a slide show on the challenges presented by our health care system. He has updated it circa March 11 2011 and has now allowed us, and others, to post freely. We appreciate him for this educational gesture.

Thank you.

Ann Miller RN MHA

[Executive-Director]

Link: Frakt Great Healthcare Challenges

About Austin Frakt PhD

Austin is the creator, manager, host, and primary author of The Incidental Economist. He is a health economist with an educational background in physics and engineering. After receiving his PhD in statistical and applied mathematics he spent four years at a research and consulting firm conducting policy evaluations for federal health agencies. Austin now has a joint appointment with the Department of Health Policy and Management at Boston University’s (BU’s) School of Public Health and Health Care Financing & Economics (HCFE) at the Boston VA Healthcare System, U.S. Department of Veterans Affairs. He studies economic issues pertaining U.S. health care policy with a recent but not exclusive focus on Medicare and the uninsured. He has authored numerous peer-reviewed, scholarly publications, many relevant to health care financing, economics, and policy. His papers have appeared in Health Care Financing Review, Health Affairs, Health Economics, International Journal of Health Care Finance and Economics, Journal of Health Politics, Policy and Law, among other journals. For over a year, he has been a regular columnist for Kaiser Health News and he has contributed commentary for the New York Times’ Room for Debate forum.

Austin’s interests include economics and health care, of course, but also politics, personal finance, and the amusements of family life. Outside of his principal work duties, he manages his household’s finances, is CFO of a small business, and looks after his two children.

You are welcome to “friend” Austin on Facebook, follow the blog via his Google Buzz feed, and subscribe to his Google Reader bundles. Austin does not have a personal Twitter account. When he has something to communicate he does it on this blog. If you wish, contact Austin with anything on your mind via the contact form. (The views expressed in Austin’s posts are his own and do not necessarily reflect the positions of the Department of Veterans Affairs or Boston University.)

Conclusion

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Why Your Stitches Cost $1,500 [Part I]

InfoGraphics – Part 1

Courtesy Medical Billing and Coding

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The United State has fallen behind other nations, failing to provide affordable health care to its citizens. Americans spend $477 billion a year MORE on health care than other advanced countries.

So why do we pay so much compared to other wealthy nations?

Part 1 of 2 in a Series

This Infographic is part one in a two part series which dissects the state of our health care system and presents some alarming numbers.

Link: http://www.medicalbillingandcoding.org/medical-costs-1/

Part 2: https://medicalexecutivepost.com/?p=30972&preview=true

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Launching Partnership for Patients

Better Care, Lower Costs

By Staff Reporters

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Doctors, nurses and other health care providers in America work incredibly hard to deliver the best care possible to their patients.  Unfortunately, an alarming number of patients are harmed by medical mistakes in the health care system and far too many die prematurely as a result.

Just Launched

The Obama Administration has just launched the Partnership for Patients: Better Care, Lower Costs, a new public-private partnership that will help improve the quality, safety, and affordability of health care for all Americans.  The Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly.

Partnership Goals  

The two goals of this new partnership are to:

  • Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
  • Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.  Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.   

Toward a More Sustainable Health Care System

Achieving these goals will save lives and prevent injuries to millions of Americans, and has the potential to save up to $35 billion dollars across the health care system, including up to $10 billion in Medicare savings, over the next three years.  Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.  This will help put our nation on the path toward a more sustainable health care system.

Institute of Medicine

In 1999, the landmark Institute of Medicine study, “To Err is Human,” estimated that as many as 98,000 Americans die every year from preventable medical errors. Despite many successful efforts, this statistic has not improved much in the following decade.  And many more patients get injured or sicker from preventable adverse events after being admitted to a hospital.  After more than a decade of work to understand and address these problems, promising examples of better practices exist, but patients too often are still injured in the course of receiving care.  At any given time, about one in every 20 patients have an infection related to their hospital care.

  • On average, one in seven Medicare beneficiaries is harmed in the course of their care, costing the government an estimated $4.4 billion every year.
  • Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – that’s approximately 2.6 million seniors at a cost of over $26 billion every year.

Assessment

There is much more work to be done to prevent unnecessary harm to patients.

Link:  http://www.healthcare.gov/center/programs/partnership/about/index.html

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Will this initiative be a success or another governmental boondoggle? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Heathcare Administraton Dictionary Series

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Understanding MCO Fixed-Rate Contract Negotiations [Case Model]

The Hope Outreach Medical Clinic

By Staff Reporters

The Hope Outreach Medical Clinic (HOMC) is a private, for-profit, single specialty medical clinic in a south-eastern state.  It submitted its bi-annual Request for Proposal (RFP) to continue its current managed care fixed-rate contract.  Upon review of the RFP, however, Sunshine Indemnity Insurance Company, the managed care organization (MCO), denied the contract request for the upcoming year.

CEO Shock

In shock, the clinic’s CEO asked the clinic’s administrator to work with its legal team to develop a defensible estimate of economic damages that would occur as a result of the lost contract.  The clinic intended to bring suit against the MCO for breach-of-contract.  However, the administrator is not an attorney and is loathe to-enter the fray.  After consideration however, he decided to assist in filing the Statement of Claim (SOC) because he realized that changes in patient services (unit) volume would be a valid economic surrogate.  He then requested the following information from his controller, in order to develop a change in economic profit [damages] estimate:

  • Change in patient visits (unit) volume
  • Fees (price) per patient (unit)
  • Marginal (incremental) cost per patient (unit)
  • Change in current fees (prices)
  • Patient volume (units) affected

Key Issues:

1) Fee (price) per patient (units) may be obtained from the fee schedule used by the MCO to pay HOMC.

2) Marginal (incremental) costs per patient (unit) are approximated using variable costs.

3) Higher cost payers exist because lower patient volumes raise the average cost per patient (unit) due to existing fixed costs. The administrator’s financial work-product to estimate monetary damages and assist the legal team is explained as follows.

Assessment

Change in profit estimate by: www.MedicalBusinessAdvisors.com

Change-in-Profit = Change in patient (unit) volume X [Fee (price per patient unit) – Incremental (marginal) cost per patient (unit)] – [Change in current price (fees) X Patient (unit) volume affected].

Conclusion

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Treatment for Plantar Fasciitis is Expensive and Ineffective

Plantar Fasciitis Truth

By Angry Orthopod, MD

There are nearly 2 million cases of plantar fasciitis in the United States every year. As an orthopaedic surgeon, I’m quite familiar with this issue since nearly 20 percent of my patients come to me about plantar fasciitis.

Although there is a surefire way to fix the problem, the current treatments aren’t really addressing the issue, and they are costing millions for those who suffer from the heel pain. Many are quick to blame the chosen treatments on profit, but I’m here to set the record straight.

Two Factors

There are two main factors that are contributors to mistreatment, neither of which is profit. Many doctors dealing with plantar fasciitis think their treatment plans are the right course of action. That is, expensive surgeries, useless orthotics, and temporary relief through medicine. The other factor leading to the mistreatment is that patients are demanding these treatments; despite how medical studies have shown they are ineffective. Many believe that a surgery will fix their plantar fasciitis problems; it’s a misconception that surgery is what they need.

Expensive Treatments

Honestly, I don’t think the patients or the doctors know how expensive these treatments end up. In 2007 alone, there was an estimated $376 million in expenses for third parties. But what about the patient costs?

The authors of this study revealed that this estimate is low, and I have to agree; it’s definitely a conservative number since the patient’s expenses aren’t part of the study. The study doesn’t take into account lost time from work, OTC items, chiropractic visits, acupuncture, night splints, diagnostic studies, among other costs.

Study: 2010_American_Journal_of_Orthopedics

Assessment

So what should we learn from this? An exorbitant amount of money is spent on these treatments every year, but the real issue isn’t just the expense, it’s that most treatments are unnecessary and ineffective.

How much have you paid to relieve your plantar fasciitis problems? Were the treatments effective?

Link: http://www.plantarfasciitistruth.com/

Conclusion: The “Angry Orthopod” is an orthopedic surgeon who blogs at his self-titled site, The Angry Orthopod. And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Learning from a Hospital Cash Flow Management Case Model

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The Mackenzie Hospital Clinic

[By Staff Reporters]


The Mackenzie Hospital Clinic was offered a private fixed-rate MCO contract that would increase revenues by $50,000 for the next fiscal year. The clinic’s 30% gross margin would not change because of the new business.

However, $10,000 would be added to overhead expenses for another part-time assistant. More importantly, the AR collection time would be lengthened to one year, or paid at the end of the contract period.

The cost of services provided for the contract represents the amount of money needed to service the patients produced by the contract. Since gross margin is 30% of revenues, the cost of services is 70% or $35,000.

The financial manager had to decide whether there would be enough internally generated cash flow to accept the contract.

The Financial Facts

The manager knew that adding the extra overhead would result in $45,000 of new spending money (cash flow) needed to care for the patients. He had to further refine his calculations by dividing the $45,000 total by the number of days the contract extends (i.e., 365 days) to determine that the new contract would cost about $123.29 per day of cash flow. Now, the financial manger had to ask: where would the money come from?

He was reluctant to turn away any business for the clinic, so decided he must develop other methods to generate the additional cash. He made the following suggestions:

  • extend AP timelines and reduce AR times; and/or
  • borrow with short-term bridge loans or a line of credit; and/or
  • discuss the situation with vendors for longer or more favorable terms; and
  • do not stop paying corporate taxes.

Key Issues:

1) Consider what changes the Mackenzie Hospital Clinic might implement to ensure that it regularly makes good cash management, budgeting, and risk projection decisions?

2) If the Mackenzie Hospital Clinic is successful and attracts more long-term managed care fixed contracts, the serious nature of the cash flow problem becomes apparent. For instance, adding another nine contracts would multiply the above example tenfold. In other words, the clinic would increase revenues to $1 million with the same 70% cost of services and $100,000 increases in operating overhead expenses.

3) How much free cash flow would be required?

[Using identical mathematical calculations, we determine that $450,000/365 days equals $1,232.88 per day of needed new cash flow.]

4) What happens if the contract only pays off at the end of the year?

Assessment

Any other thoughts?

Conclusion

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Healthcare Reform at a Glance

A One-Stop-Look-See with Comparisons

By Staff Reporters

Link: Health-Care-Reform-Comparison-in-Brief

[Courtesy: BuckConsultants]

Conclusion

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Seeking Healthcare Administration Experts and Contributing Print Authors

Healthcare Organizations [second edition]

By Ann Miller RN MHA

[Executive-Director]

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Greetings ME-P Readers, Experts and Subscribers,

As you may know, we are now preparing the next edition of our book: Healthcare Organizations [Management Strategies, Operational Techniques and Case Studies]. And so, we solicit your interest in crafting new material or simply updating original chapters for subscriber, ACPE, Barnes & Noble, MGMA, ACHE and related distribution channels.

Tentative Table of Contents [400 pages]

  1. On the Origins and Development of Quality Initiatives in Healthcare
  2. Competitive Analysis of the Contemporary Healthcare Ecosystem
  3. Capital Formation Strategies for Healthcare Entities
  4. Inventory Management and Economic Order Quantity Analysis
  5. Improving Operations and Management to Achieve Objectives
  6. Financial and Clinical Features of Hospital Information Systems
  7. Managing Health Information Technology Security Risks
  8. Monitoring, Managing and Enhancing Hospital Revenue Cycles  
  9. Patient [Customer] Relations Management in Healthcare
  10. Healthcare Organization Compliance Processes and Tactics
  11. Reviewing OSHA Standards and Health Policy Practices
  12. Operational Impact of HIPAA, Sarbanes-Oxley and the USA PATRIOT ACT
  13. Understanding Continuous Healthcare Process Improvement
  14. Using Medical Informatics to Track Health Care
  15. Appreciating Six-Sigma Healthcare Quality Improvement
  16. Hospital-Flow Through Efficiency and Logistics.

Editorial support is available, and you would enjoy increasing subject-matter notoriety, exposure and public relations in an erudite and credible fashion. ME-P expert reader synergy seems ideal and our time line for submission is ample in a prose writing style that is “wide, and deep.”  Scheduled release is 2012.

Assessment [first edition]

Foreword: http://healthcarefinancials.com/aboutus.aspx

Style and format: http://healthcarefinancials.com/Documents/Clinical%20and%20Financial%20Features%20of%20Hospital%20IT%20Systems.pdf

Prior authors: http://healthcarefinancials.com/contributors.aspx

TOC: http://healthcarefinancials.com/Documents/TABLE%20OF%20CONTENTS.pdf

We look forward to working with you and appreciate your continued “crowd-sourced” interest in this important body of work. So, please advise me of your interest: MarcinkoAdvisors@msn.com

Conclusion

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Tax Exempt Hospitals Granted IRS Filing Delay

Recent Developments on Form 990 and Schedule H

By Children’s Home Society of Florida Foundation

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In Announcement 2011-20; 2011-10 IRB 1 (23 Feb 2011), the IRS granted a three-month automatic filing extension for most tax-exempt hospitals.

Form 990 and Schedule H

Following the development of a new Form 990 Return for Charitable Organizations, the IRS published a comprehensive Schedule H for medical centers. With the passage of the Patient Protection and Affordable Care Act of 2010, both the IRS and many medical centers need additional time to properly prepare for filing of Form 990 with the Schedule H for medical centers.

As a result, the IRS indicates that the earliest permitted filing date for tax-exempt medical centers filing Form 990 and Schedule H will be July 1, 2010. This is the earliest filing date whether the filing is in paper form or electronic format.

Filing Extension Form 8868

For those medical centers with return due dates before August 15, 2011, there is an automatic three-month extension of time to file. This extension is available without filing Form 8868, Application for Extension of Time to File an Exempt Organization Return.

However, there may be new organizations that have not filed Form 990 Schedule H for tax year 2009. In this case, they may choose to file Form 8868 to clarify their intention to extend the deadline. If a medical center requires an additional three months to file, then it should file Form 8868.

Assessment

Finally, for those medical centers that qualify for this automatic extension, there will be no penalty if they file within the additional three-month period.

Conclusion

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“Journal of Financial Management Strategies” for Healthcare Organizations

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Hospitals and Healthcare Organizations

[A Textbook of Financial Management Strategies]

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Meet Speaker Dr. David Edward Marcinko MBA

Management Expert, Social Media Pioneer, Journalist and Financial Advisor

www.BusinessofMedicalPractice.com

I am available for a limited number of speaking engagements each year. As social media’s leading integrated voice for medical and financial service professionals, the ME-P voice was noted by the WSJ.com in 2009, which said thatThis website is packed with great information.” And, medical information technology  and eMR guru Alberto Borges MD recently opined You do have an exceptional website”. 

The ME-P’s Reach

With over 250,000 visitors, the ME-P is among the web’s most influential and prominent platforms. I frequently discuss the precarious intersection among medical practice management, financial services, health economics and related social media in keynote speeches, panel discussions, and media interviews. 

Journalist

I also use my two decade long medical, surgical, business management and financial advisory practice and journalistic experiences to engage the private practice community, culminating in the third edition of our book: The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors].

Locale

I am based near Atlanta, GA, so travel for speaking opportunities is not problematic and very inexpensive.

Curriculum Vitae

Here is my CV: DEM Formal CV

Please contact me if you’re interested in having me engage your divese audience: MarcinkoAdvisors@msn.com

Sincerely,

Dr. David Edward Marcinko; MBA

Certified Medical Planner™
www.CertifiedMedicalPlanner.com

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Some Thoughts on the Marginal Healthcare Dollar

Can this Vital Buck be More Efficiently Used?

By Dr. David Edward Marcinko MBA CMP™

[Editor-in-Chief]

Recently, healthcare economist Austin Frakt PhD offered these points about healthcare dollars spent on the margin:

1. Spending on health is not without value. It does improve lives [See Cutler]. Yet, we spend much to get that value.

2. Price per QALY is very high [See Aaron’s series on spending and his other on quality).

3. Just staying within the realm of health, the price per QALY on another “service” might be a lot lower [like nutrition, exercise, and healthy habits, etc].

http://theincidentaleconomist.com/wordpress/could-the-marginal-health-care-dollar-be-put-to-better-use/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

Note: The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived. It is most often used in assessing the value for money of a medical intervention. The QALY model requires independent utility, neutral risk and constant proportional tradeoff behavior.

Understanding Marginal Profit

Recalling the equation: Profit = (Price x Volume) – Total Costs

We could amend it and say that:

Total Profit = P x V – (FC + VC) or: Total Profit = Price x Volume – (Fixed Costs + Variable Costs)

However, most medical office or clinic contracts today are based not on total profit, but on additional or marginal profit, because overhead costs always remain and clinic fixed costs are not important in contracted medicine.

And, for other pricing decisions, the equation can again be re-written, to emphasize variable costs, as follows: Marginal Profit = (P x V) – VC.

In other words, the marginal benefit must exceed the marginal cost of practice.

Cost-Volume-Profit Analysis

Now, once a basic understanding of marginal profit and medical cost behavior is achieved, the techniques of cost-volume-profit analysis (CVPA) can be used to further refine the managerial cost and profit aspects of the medical office business unit. CVPA is thus concerned with the relationship among prices of medical services, unit volume, per unit variable costs, total fixed costs, and the mix of services provided.

Assessment

Austin felt that if [*]od were jointly designing all health-related systems and functions of society and government – He’d look at the marginal cost/QALY over all possible ways to spend the next dollar and pick the smallest. How about you?

But, it’s not always going to be on health care services and it probably isn’t given what we’re already spending for those and what we’re getting for that spending.

Conclusion

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Understanding CPT® Code Payment Components

Determinations More Complex than Most Believe

By Staff Reporters

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Currently, there are more than 10,000 physician services designated by the current procedural terminology (CPT®) or healthcare common procedure coding system (HCPCS) codes.  Each reflects the three major cost drivers of a particular procedure:

  • Physician work effort or the relative value unit (RVUw) of medical providers’ work efforts, pre-service, intra-service and post-service time.

Patients may exhibit anxiety when examined orduring procedures resulting in the need for additional timeand effort by the physician to respond to and prepare for the examination or procedure. This uniformly adds moretime and stress to the pre-service and intra-service period as doctors respond to constantly changing behavior, questionsand level of cooperation in varying specialties.  Follow-up communicationwith employers, family, friends and concerned others requires increased post-service times.

  • Practice expenses (RVUpe), including non-physician costs but excluding medical malpractice coverage premiums.

The practice expense component of the resource-based relative value scale (RBRVS) includes clinicalstaff time, medical supplies, and medical equipment.  Often, the costsof supplies and equipment are not proportional to practicesize.  Major factorsaffecting practice expense are the volume of telephone, cell, or Internet management services, and the case management and administrative work required. For example, high patient turnover requires more examination rooms to maintain physician efficiency. High volume requires moreclerical staff to deal with larger patient-flow volume and resulting phone calls, difficultiesdressing and undressing patients, and is marked by increasedcomplexity and time in collecting laboratory specimens.  Thesefactors must be accounted for in any resource-based practiceexpense study and in the resulting practice expense calculationsfor medical services; and

  • Malpractice (RVUm) representing the cost of liability insurance.

The RBRVS system assigns RVUs to cover the malpractice expensesincurred by physicians. These malpractice RVUs, originally calculatedfor office-based physicians, may systematically undervaluethe practice liability costs for some specialties. The prolonged statutes of limitation on some legalactions may result in increased malpracticerisk exposure for physicians providing such services [i.e., pediatricians]. The differences in exposure may not be calculated in theRBRVS system, and were not included in initial studies.  Specialty specific survey data for malpractice expenseshould be used for this component when assigning final RVU valuations.  Without specialty-specific CPT® codes, however, there was no wayto do this objectively.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Update on How Physicians Get Paid in 2010-11 [A slide show]

Part 2: [A Visual .ppt Presentation]

By Dr. David Edward Marcinko; MBA

[Editor-in-Chief]

From prior posts and comments on this ME-P, we know that most patients don’t have a clue about how doctors get paid in the real world of health insurance reimbursement.

A Popular Topic

We know this because prior posts on the topic have consistently been among the most popular on this platform. For example:

Part 1: https://healthcarefinancials.wordpress.com/2008/09/12/how-doctors-get-paid

Assessment

And so, we have taken the liberty of drilling down the topic, to a more granular level, in this attached .ppt presentation.

Link: How Doctors Get Paid in 2010 

Conclusion

And so, your thoughts and comments on this ME-P special presentation are appreciated. Tell us what you think?

Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Healthcare Organizations: www.HealthcareFinancials.com

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David B. Nash MD MBA FACP

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Hospitals & Healthcare Organizations

FOREWORD 

David Nash MD MBA

It should come as no surprise to our readers that the nation faces a financial crisis in healthcare. 

Currently, the United States spends nearly 16% of the world’s largest economy on providing healthcare services to its citizens.  Another way of looking at this same information is to realize that we spend nearly $6,500 per man, woman, and child per year to deliver health services.  And, what do we get for the money we spend?  

This is an important policy question and the answer is disquieting.  Although the man and woman on the street may believe we have the best health system in the world, on an international basis, using well-accepted epidemiologic outcome measures, our investment does not yield much!  

According to information from the World Health Organization and other international bodies, the United States of America ranks somewhere towards the bottom of the top fifteen developed nations in the world, regarding the outcome in terms of improved health for the monies we spend on healthcare. 

From a financial and economic perspective then, it appears as though the 16% of the GDP going to healthcare may not represent a solid investment with a good return. 

It is then timely that our colleagues at the Institute of Medical Business Advisors, Inc. have brought us their greatest work: Healthcare Organizations: [Financial Management Strategies]; a two-volume set of nearly 1,200 pages.  

Certainly, this comprehensive manual, and its quarterly updates, is not for everyone. It is intended only for those executives and administrators who understand that clinics, hospitals and healthcare organizations are complex businesses, with advances in science, technology, management principles and patient/consumer awareness often eclipsed by regulations, rights, and economic restrictions.  Navigating a course where sound organizational management is intertwined with financial acumen requires a strategy designed by subject matter experts. Fortunately, Healthcare Organizations: [Financial Management Strategies] provides that blueprint.

Allow me to outline its strengths and put it into context relative to other policy works around the nation. 

For nearly two years, the research team at iMBA, Inc., has sought out the best minds in the healthcare industrial complex to organize the seemingly impossible-to-understand strategic financial backbone of the domestic healthcare system.   

The periodical print-guide is organized into two volumes in order to appropriately cover many of the key topics at hand.  It has a natural flow, starting with Competitive Strategy and moving through Asset Management, Cost Management, and Claims Management.  

Volume 1, most especially the Competitive Strategy section, has broad appeal and would be of interest to most people in the health insurance industry, including managed care, hospitals, third party benefit managers and the pharmaceutical industry. 

Volume 2 continues in a well-organized theme, progressing from Risk Management and Compliance to Health Policy, Information Technology, and most importantly, Financial Benchmarking. 

Volume 2 would be of greater interest to those in the policy sphere, both in Washington, DC, in state legislatures, consulting companies, medical colleges, and graduate schools of health administration, public health and related fields. Every day colleagues ask me to help explain the seemingly incomprehensible financial design of our healthcare system.  These two volumes would go a long way toward answering their queries. 

I also believe both volumes would be appropriate as text books and reference tools in graduate level courses taught in schools of business, public health, health administration, and medicine. 

In my travels about the nation, many faculty members would also benefit from the support of these two volumes as it is nearly impossible, even for experts in the field, to grasp all of the rapidly evolving details. 

On a personal level, I was particularly taken with the Competitive Strategy section and it brought back enjoyable memories of my work nearly twenty-five years ago at the Wharton School, on the campus of the University of Pennsylvania.  There, I was exposed to some of the best economic minds in the healthcare business and it was a watershed event for me forming some of my earliest opinions about the healthcare system. 

I also very much enjoyed the section on Health Policy, most especially, the section on the Sarbanes-Oxley Act for hospitals and healthcare organizations.  I believe we have not fully embraced the comprehensive nature of Sarbanes-Oxley on the hospital side, and envision a day when hospital boards will be held accountable for quality, in the same way that proprietary corporations are held accountable for the strength and comprehensiveness of their audit reports. Simply put, Sarbanes-Oxley for quality is around the corner and this volume goes a long way toward preparing our basic understanding of the Act and its potential future implications. Congratulations to all authors, but this one in particular deserves specific mention. As a board member for a major national integrated delivery system, I am happy that there appears to be a greater interest in the intricacies of Sarbanes-Oxley on the healthcare side of the ledger. 

In summary, Healthcare Organizations: [Financial Management Strategies] represents a unique marriage between the Institute of Medical Business Advisors, Inc., and its many contributors from across the nation.  As its mission statement suggests, I believe this massive interpretive text carries out its vision to connect healthcare financial advisors, hospital administrators, business consultants, and medical colleagues everywhere. It will help them learn more about organizational behavior, strategic planning, medical management trends and the fluctuating healthcare environment; and consistently engage everyone in a relationship of trust and a mutually beneficial symbiotic learning environment.  

Editor-in-Chief and healthcare economist Dr. David Edward Marcinko and his colleagues at the Institute of Medical Advisors, Inc should be complimented for conceiving and completing this vitally important project. There is no question that Healthcare Organizations: [Journal of Financial Management Strategies] will indeed enable us to leverage our cognitive assets and prepare a future generation of leaders capable of tackling the many challenges present in our healthcare economy.  

My suggestion therefore, is to “read it, refer to it, recommend it, and reap.”  

David B. Nash MD, MBA
The Dr. Raymond C and Doris N. Professor and
Chair of the Department of Health Policy
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pa, USA
 

Conclusion

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At Your Next Medical Management, Pharma or Financial Services Seminar  

Our Editor-and-Chief, Dr. David Edward Marcinko MBA CMP™ is a former medical practitioner and board certified surgeon [FACFAS], certified financial planner, stock-broker, insurance agent, Registered Rep, RIA representative, writer, editor, journalist, expert witness and healthcare economist who enjoys public speaking and gives as many talks each year as possible, at a variety of medical society, pharmaceutical and financial services conferences around the country and world.

Many Venues

These have included lectures and visiting professorships at major academic centers, keynote lectures for hospitals, economic seminars, pharma conventions and health systems, endnote lectures at city and statewide financial coalitions, and break-out lectures for a variety of internal and external yearly meetings.

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[Health] Plan Management Navigator

January 2011

By Douglas B. Sherlock, CFA
Senior Health Care Analyst

Dear ME-P Readers and Subscribers,

 Join Our Mailing List 

At the risk of appearing overwhelmed with New Year’s enthusiasm, we think this edition of Plan Management Navigator is especially interesting:

1. We report on the cost decisions made by low cost Blue Cross Blue Shield plans. Low cost plans make decisions that differ from their higher cost peers. Hallmarks of these decisions include levels and distributions of expenses between functions, the levels and distribution of staff between functions, the levels of compensation and its distribution between functions and the distribution between functions, and levels of, non-labor expenses. Overall, low cost Blue Cross Blue Shield Plans have “tactical” administrative expenses that are $5.75 PMPM, or 30%, lower than their higher cost counterparts. These tactical expenses are all administrative expenses excluding medical management and sales and marketing.

Last month we published a similar study of the choices of low cost Independent / Provider-Sponsored Plans. Low cost health plans had tactical costs that were 36% lower than their peers, or by $6.39.

A more detailed version of either of these analyses is available to licensed users of each of our benchmarks. Please call us for further information if you have an interest.

2. We introduce a new service on our website that will enable you to determine how a health plan is doing relative to the 2010 benchmarks. You can select your universe and then determine whether you are high or low and, if so, by how much.

3. We invite you to participate in the 2011 benchmarking study. We are now forming universes. We think that, under pending MLR rules, participation is very timely.

Link: Navigator January 2011

Thank you for your continued interest in our research.

Assessment

sherlock@sherlockco.com
Ph:  215-628-2289
Fax: 215-542-0690

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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Social-Norms versus Market-Norms in Healthcare Reimbursement

Rogue Thoughts on Toppling the Current Payment System

By Dr. David Edward Marcinko MBA, CMP™

[ME-P Editor-in-Chief]

Recently, I reviewed a copy of “Predictably Irrational” by fellow blogger Dan Ariely, PhD. Dan is the James B. Duke Professor of Behavioral Economics at Duke University and a founding member of the Center for Advanced Hindsight.

In the book, he examines some of the positive effects that irrationality has in our lives and offers a new look on how irrational decisions might influence our personal lives and our workplace experiences. I found the chapter on social-norms v. market-norms particularly interesting and wondered about its’ applicability to healthcare economics and reimbursement.

Example:

Dan sites the example of various fund raising charitable goods that had been set at market prices [the norm in this country – little retail negotiating takes place in the USA], but that he recently chose to experiment and make them donation-based instead. 

The Difference

What a difference it made! He cites the case of one woman who bought a cupcake and reached for a dollar bill when asked about the price.  When told there was no set price, but donations-only were accepted, she put the one bill back in her wallet and pulled out a ten-spot. 

References and Research

Assessment

So, please allow me to use this trivial example and suggest a limited switch experiment to social-norms – instead of market-norms in some cases of healthcare reimbursement – perhaps starting with non-surgical, non-specialty, primary care providers [GPs, internists, FPs, DNPs, podiatrists, etc], or any “willing provider” for that matter. What do you think would happen?

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is this idea too far out – or thought provoking enough for further consideration? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

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