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Useful Managed Care Provider, Staffing, Activity and Financial Trends

Posted on November 5, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Part Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

If you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

A recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, according to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following patterns and comparative trend information has been empirically determined and may provide a basic starting point for medical practitioners to share business management, facilities, personnel, and records information for enhanced success www.managedcaredigest.com

Mid-Level Provider and Staffing Trends

Mid-level provider use increased among multi-specialty groups, especially in those with more than half of their revenue from capitated contracts. Use also rose with the size of the practice and was highest with OB/GYN groups.
Medical support staff for all multi-specialty groups fell and was lowest in medical groups with less than 10 full-time equivalent (FTE) physicians. However, groups with a large amount of capitated revenue actually added support staff. Smaller groups limited support staff.
Compensation costs of support staff increased and the percentages of total operating costs associated with laboratories, professional liability insurance, IT services, and imaging also increased. Support staff costs increase with capitation levels and more than half of all operating costs are tied to support staff endeavors.

Managed Care Activity and Contracting Trends

More medical group practices are likely to own interests in preferred provider organizations (PPOs) than in HMOs and the percentages of groups with managed care revenue continues to rise. Multi-specialty and large groups also derive more revenue from MCOs than single specialty or smaller groups.
Managed care has little effect on physician payment methods that are still predominantly based on productivity. Physicians were paid differently for at-risk managed care contracts in only a small percentage of cases.
Most medical groups (75%) participating in managed care medicine have PPO contracts. Group practices contract with network HMOs more often than solo practices. Single-specialty groups more often have PPO contracts.
Capitated lives often raise capitation revenues in large group practices. Group practices are more highly capitated than smaller groups or solo practices. Almost 30% of highly capitated medical groups have more than 15 contracts and 22% have globally capitated contracts.
Higher capitation is linked with increased risk contracting. Larger groups have more risk contracting than smaller groups.

Financial Profile Trends

Medicare fee-for-service reimbursement is decreasing. Highly capitated groups incur high consulting fees.
The share of total gross charges for OB/GYN groups associated with managed care at-risk contracts is rising while non-managed care, or not-at-risk charges are declining.
Capitated contracts have little effect on the amount of on-site office non-surgical work. Off-site surgeries are most common for surgery groups, not medical groups.
Half of all charges are for on-site non-surgical procedures.
Highly capitated medical groups have higher operating costs and lower net profits.
Groups without capitation have higher laboratory expenses than those who do.
Physician costs are highest in orthopedic surgery group practices. Generally, median costs at most specialty levels are rising and profits shrinking.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part One: Useful Managed Care Patterns and Procedural Utilization Trends

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

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

Filed under: "Doctors Only", Book Reviews, Career Development, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Information Technology, Managed Care, Practice Management, Recommended Books, Touring with Marcinko | Tagged: Business of Medical Practice, capitation, david marcinko, healthcare administration, HMOs, hope hetico, Managed Care, PPOs, Practice Management, www.BusinessofMedicalPractice.com | 1 Comment »

Useful Managed Care Patterns and Procedural Utilization Trends

Posted on October 27, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Part One of Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

If you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

And, a recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, knowing your medical contract negotiation objectives, gathering information on the choices of contracts and discount payment systems, and understanding the pitfalls to watch for when evaluating a contract are the keys to any successful negotiation process.

Reimbursement Contract Negotiations

According to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following pattern and trend comparative information has been empirically determined and may provide a basic starting point for practitioners to share business management, facilities, personnel, and other records for enhanced contract negotiation success.

www.managedcaredigest.com

Procedural Utilization Trends

Among all physicians in a single-specialty group practice, invasive cardiologists averaged the most encounters with total hospital inpatient admissions down from the prior year. However, encounters rose for cardiologists in multispeciality group practices.
Echocardiography was the most commonly performed procedure on HMO seniors, followed by coronary artery bypass graft surgery. Group practices performed cardiovascular stress tests for circulatory problems most often.
CT studies of the brain and chest were the most common studies for HMO seniors, while MRI head studies were the most common diagnostic test on commercial HMO members.
Colonoscopy was the most common digestive system procedure on senior HMO members, while barium enemas were more common on commercial members.
Hospital admission volume decreased for allergists, family practitioners, internists, OB/GYNs, pediatricians, and general surgeons.
Internists ordered more in-hospital laboratory procedures than any other physicians in single-specialty groups.
Non-hospital MD/DOs used in-hospital radiology services most frequently, continuing a three-year upward trend.
Pediatricians averaged the most ambulatory encounters, down from the prior year.
Non-hospitalist internists ordered a higher number of in-hospital laboratory procedures than any other single medical specialty group, but allergists and immunologists increased their laboratory usage.
The number of ambulatory encounters increased for general surgeons, while group surgeons had the most cases. Capitated surgeons, of all types, had a lower mean number of surgical cases than surgeons in groups without capitation. Surgeons in internal medical groups also had more cases than those in multi-specialty groups.
The average number of total office visits per commercial and senior HMO visits fell, along with the number of institutional visits for both commercial and senior HMO members.
The average length of hospital stay for all commercial HMO members increased to 3.6 days but decreased to 6 days for all HMO members.
The total number of births increased for commercial HMO members served by medical group practices, and decreased for solo practitioners.
More than one-third of all medical groups use treatment protocols, rising from the year before. Multi-specialty groups were more likely to use them than single-specialty groups, who often develop their own protocols. The use of industry benchmarks to judge the quality of healthcare delivery also increased.
Outcome studies are most common at larger medical groups, and multi-specialty groups pursue quality assurance activities more often than single-specialty groups.
Provider interaction during office visits is increasingly coming under scrutiny. Patients approve of cardiologists more frequently than allergists and ophthalmologists.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part Two: Useful Managed Care Provider, Staffing, Activity and Financial Trends

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: "Doctors Only", Book Reviews, Career Development, CMP Program, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Managed Care, Practice Management, Quality Initiatives, Research & Development | Tagged: Business of Medical Practice, david marcinko, DOs, EHRs, EMRs, healthcare administration, HMO, hope hetico, Managed Care, Managed Care Digest Series, MDs, medical outcomes, medical practice management | 2 Comments »

New Third Party Healthcare Administrator Benchmarks Available

Posted on October 19, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Benchmark Supplement Licenses Now Available

By Douglas B. Sherlock, CFA

Managing healthcare insurance and related administrative expenses is especially important for health benefit organizations this year. Health care reform has magnified its importance: the new medical loss ratio regulations are expected to be voted on by the NAIC within a week and approved by HHS soon after the November elections.

The Economy Weakens

In addition, the economy continues to be weak, and if costs are not managed wisely, enrollment declines can have a leveraged impact on earnings. Finally, Medicaid plans are squeezed by tight state budgets, higher enrollment and the prospect of 16 million additional members under health care reform.

We offer the benchmarks you need to help you make sure your administrative cuts don’t harm your long term competitive position. Nearly 60 health plans and TPAs participate in various benchmarking universes, and health plans serving most insured Americans used the most recent editions of our benchmarks. Sherlock administrative expense benchmarks are the “gold standard” for the operational and cost information that you need.

A Comparable Universe

Our universes are designed to be as comparable as possible to your company and include Blue Cross Blue Shield Plans, Independent / Provider-Sponsored Plans, Medicare Plans, Medicaid Plans and, our newest universe, TPAs. We have attached a brochure concerning the health plan benchmarks and a one page summary concerning the new TPA benchmarks.

TPA Descriptor

Link: TPA Supplement

Assessment

At this pivotal stage, reliable information has never been so important. We invite you to consider licensing these remarkably useful benchmarks. Additional information can be found at http://www.sherlockco.com/seer.shtml

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

Conclusion

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[Health] Plan Management Navigator

Posted on October 10, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Early October 2010 Edition

By Douglas B. Sherlock, CFA

In this edition of Plan Management Navigator, we summarize the cost benchmarks of health plans focused on Medicaid.

Administrative Expenses

Core administrative expenses for selected Medicaid focused health plans was 8.4% of premiums in 2009, both overall and in the Medicaid HMO product itself. Comprehensive products had total PMPM costs of $24.90 and the Medicaid HMO product had total PMPM costs of $22.77.

The median values for core administrative expenses for the Medicaid HMO products offered by these health plans were 7.5% of premium and $21.30 PMPM.

Core Costs

Core costs declined by 5.2% PMPM on an as-reported basis compared with a decline of 1.4% last year. Holding product mixes constant, costs declined by 5.8% PMPM compared with a PMPM decline of 1.4% PMPM. Central to the decline was a 13% PMPM decline in Account and Membership Administration costs.

The peer group in this analysis consisted of ten Medicaid plans, which together served 3.9 million members. Of these members, 2.8 million were Medicaid HMO, and this product comprised on average 70.8% of the total.

HealthCare Reform

Health care reform is expected to have a dramatic effect on plans serving Medicaid-eligible members as Medicaid eligibility is expected to increase by 16 million members. But, this takes place in a weak economy which contributes to membership growth while federal and state tax revenues are under pressure. Medicaid health plans are heavily committed to the management of administrative expenses.

Web Conference

We will host a web conference on Tuesday, October 12^th from 2:00 PM to 3:00 PM East Coast Time to discuss the summary results. I will offer a brief presentation, followed by questions and answers.

To participate register here: https://www2.gotomeeting.com/register/995011459.

Once registered, dial-in information and a link to connect to the web will be provided in a confirmation email.

Assessment

Link: Navigator Early October 2010

I hope that you find this month’s Navigator of interest and we look forward to your participation on Tuesday.

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

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

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About HealthCareTownHall.com

Posted on October 2, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Informed Healthcare Reform Dialogue

By Staff Reporters

Milliman is the host of this blog to encourage an informed dialogue about healthcare reform.

Complications

Healthcare is complicated, and there is no single, silver-bullet answer to the question of “How do we best improve the current system?”

Assessment

But, thoughtful discussions will help move reform in the right direction and mend the fractured system; especially in terms of entitlements, costs and spending, etc.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Visit www.HealthCareTownHall.com and 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, subscribe to the ME-P. It is fast, free and secure.

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Information Technology | Tagged: Health Insurance, healthcare economics, Healthcare Finance, Healthcaretownhall.com, Milliman | Leave a comment »

Vote on What the US Healthcare System Needs?

Posted on September 30, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

An Opinion Poll

[Staff Reporters]

HIEs launch tomorrow. So, please vote.

Conclusion

After voting, 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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Filed under: Health Insurance, Health Law & Policy, Voting Polls | 1 Comment »

Essay on Medicare Pricing Distortions

Posted on September 17, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

In Physician Fee Schedules

By Nancy Chockley PhD
President & CEO
NIHCM Foundation

Leaving Medicare F-F-S Reimbursement

While there is near universal agreement that we need to move away from Medicare’s fee-for-service [F-F-S] physician payment system, Dr. Robert Berenson argues that in the short term we still need to focus on improving the current physician fee schedule.

Reasons Why?

Not only are the value-based payment systems that most reformers envision still many years from widespread reality, the existing fee schedule prices will serve as the building blocks for some of the newer aggregate payment approaches.

Assessment

In his Expert Voices essay, Dr. Berenson offers thoughts on how to improve the system in ways that both address current payment system woes and serve as a step toward future value-based payment systems.

Link: http://nihcm.org/pdf/NIHCM-EV-Berenson_FINAL.pdf

Contact

phone: 202-296-4426
email: nihcm@nihcm.org
website: www.nihcm.org

Conclusion

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What Does Health Reform Mean to You?

Posted on August 26, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

A Health Reform Pamphlet from the NCPA

By Staff Reporters

The new health care legislation will impact every American. The National Center for Policy Analysis [NCPA] has created a new pamphlet, “What Does Health Reform Mean for You? It explains the new legislation’s major points in a succinct and unbiased way.

Content Overview

The contents of the pamphlet are reviewed below:

http://www.ncpa.org/healthreform/

Full Report

The full report is available here.

Link: What-Does-Health-Reform-Mean-for-You-A-Consumers-Guide

Conclusion

Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Health Insurance, Health Law & Policy | Tagged: health care legislation, health reform, John Goodman, National Center for Policy Analysis, NCPA, Obama care | 5 Comments »

August 2010 Plan Management Navigator

Posted on August 5, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Blue Cross Blue Shield Plans Summary

By Erin Sawchuk

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

erinsawchuk@sherlockco.com

Dear ME-P Readers,

Please find attached the August 2010 Edition of Plan Management Navigator. In this month’s edition, we summarize the results of Blue Cross Blue Shield Plans. The 24 plans collectively serve 32.5 million members and are leaders in their communities. Because of the weak economic environment and the effects of health care reform, health plans are heavily committed to the management of administrative expenses.

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

WebCast Invitation

We will host a web conference on Thursday, August 5^th from 2:00 PM to 3:00 PM East Coast Time to discuss the summary results. Doug Sherlock will offer a brief presentation, followed by questions and answers. To participate in the web conference, please register at https://www2.gotomeeting.com/register/589960691.

Once registered, dial-in information and a link to connect to the web will be provided in a confirmation email. Please note that if more than one person from your firm would like to participant in the conference call and everyone will be in one room, only ONE person needs to register for the conference.

Assessment

We hope that you find this month’s Navigator of interest and we look forward to your participation on Thursday.

Link: August 2010 Navigator[1]

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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

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: "Doctors Only", Alerts Sign-Up, Health Economics, Health Insurance, Managed Care, Practice Management, Research & Development | Tagged: Blue Cross Blue Shield Plans, Doug Sherlock, Erin Sawchuk, Plan Management Navigator, www.Sherlockco.com | Leave a comment »

Obama Eliminates Medicare Tax?

Posted on July 29, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

‘Medicare Tax’ Now to be Called ‘Unearned Income Medicare Contribution’

By Olga Pierce

ProPublica, March 24, 12:27 pm

The payroll tax increase that was formerly known as “Medicare tax” in both President Obama’s health care reform reconciliation proposal and the original House reconciliation bill is NOT A TAX. Repeat: NOT A TAX.

Sure, individuals with earnings over $200,000 and couples with earnings over $250,000 will have to fork over 3.8 percent of their capital gains (which were not formerly subject to Medicare taxes) to Medicare, in addition to .9 percent more of their earned income.

Medical Tax Eliminated

But, among the 15 pages of changes to the Reconciliation Act [1] included in the manager’s amendment [2] released over the weekend was a wee name change: references to ‘Medicare tax’ were deleted, and replaced with the much gentler, and voluntary-sounding, ‘unearned income Medicare contribution.’

We called Speaker Nancy Pelosi’s office for more insight, and will pass along anything we hear back.

For a look at all the changes that the reconciliation bill would make in the health care reform law, check out our side-by-side comparison [1].

Assessment

Link: http://www.propublica.org/article/medicare-tax-now-to-be-called-unearned-income-medicare-contribution

Conclusion

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BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: Alerts Sign-Up, Health Insurance, Health Law & Policy, Taxation | Tagged: healthcare reform, Medicare Tax, Obama care, Reconciliation Act, Unearned Income Medicare Contribution | 1 Comment »

On Medical Pricing Transparency

Posted on July 29, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

For Hospitals, Clinics and Physicians

[By Staff Reporters]

In 2007, federal and state legislatures called for hospitals across the country to make their prices “transparent.” The term was defined as the full, accurate, and timely disclosure of hospital charges to consumers of healthcare, as well as the process employed to arrive at those fees. Moreover, transparency does not merely involve publishing a list of prices and fees. Essentially, hospital CXOs must be able to present their prices in a manner that is understandable to the general public and they must be prepared to explain the rationale behind their charges.

State Initiatives

More recently, at least 38 states have already proposed or passed legislation regarding publication of hospital charges. For example, the average cost for a hip, knee or ankle joint replacement is $38,443; while a heart valve operation is $124,561and a back fusion is $60,406. Torrance California based HealthCare Partners now notes on its Website that it charges $15 for flu vaccines, $61 for a chest X-ray, while a colonoscopy costs $424.

Assessment

Such initiatives demonstrate increased industry competition and advancing patient empowerment with CDHPs.

Current Updates for 2010

Link: http://www.govtrack.us/congress/bill.xpd?bill=h111-2566

Conclusion

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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
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: CDHPs, Medical Pricing Transparency | 5 Comments »

Independent Health Plan Management Navigator

Posted on July 16, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Mid-July 2010 Edition with Webinar Invitation

By Douglas B. Sherlock, CFA

Dear ME-P Readers

Please find attached below the Mid-July 2010 Edition of Plan Management Navigator. In this month’s edition, we summarize the results of Independent / Provider Sponsored health plans. The 17 plans collectively serve 6.0 million members and are leaders in their communities.

Status of the Economy

Because of the weak economic environment and the effects of health care reform, health plans are heavily committed to the management of administrative expenses.

Navigator Results

The median administrative expense ratio for this peer group in 2009 was 8.0%, down from 8.3% in 2008 and 9.4% in 2007.

A press release summarizing the results is found at http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20100714006308&newsLang=en.

Web Conference

We will host a web conference on Friday, July 16^th from 2:00 PM to 3:00 PM East Coast Time to discuss the summary results. I will offer a brief presentation, followed by questions and answers.

To participate in the web conference, please register at https://www2.gotomeeting.com/register/796253810. Once registered, dial-in information and a link to connect to the web will be provided in a confirmation email.

Assessment

Link: Mid-July 2010 Navigator

We hope that you find this month’s Navigator of interest and we look forward to your participation today.

Conclusion

Please comment and 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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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Health Insurance, Monthly Reports, Research & Development | Tagged: Douglas B. Sherlock, health care reform, health plans, Plan Management Navigator | Leave a comment »

Health Plan Management Navigator

Posted on July 11, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

ADVERTISEMENT

July 2010 Edition

By Erin Sawchuk

erinsawchuk@sherlockco.com

Dear ME-P Readers

Please find attached the early July 2010 Edition of our health Plan Management Navigator. In this month’s edition, we suggest an approach to quantifying best practice of administrative activities of health plans. Determining best practice for health plans is a knotty problem because of the complexity of the product and because some of what makes for best practice cannot be captured in the current year’s administrative expense line. We offer a solution that we hope to implement but we would be grateful for any insights you wish to share on this matter.

Financial and Operating Results

Navigator also summarizes some of the May financial and operating results of health plans reporting in our Dashboard. Operating earnings are weak on soft revenues and compressing margins. Enrollment trends in Medicare, Medicaid and ASO products are relative bright spots. Plans are adapting by reducing staffing ratios.

Link: Early July 2010 Navigator[1]

Web Casts

Please save 2:00 on July 16, and 2:00 on August 5 for two important web conferences. The first will summarize the results of this year’s SEER benchmarks for Independent / Provider-Sponsored plans. The second will summarize this year’s SEER benchmarks for Blue Cross Blue Shield Plans.

The Plan Management Navigators containing the respective peer group data will be sent to you a day or so before the web conference. There is no charge to participate, but we would be grateful if you would let us know in advance. Please reply back to me.

Assessment

Erin Sawchuk [Sherlock Company]

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

Conclusion

Feel free to comment and 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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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Career Development, Health Economics, Health Insurance, Healthcare Finance, Monthly Reports, Research & Development | Tagged: ASO, Blue Cross Blue Shield Plans, Erin Sawchuk, Medicaid, medicare, Plan Management Navigator, SEER, Sherlock Company | Leave a comment »

Video Introduction to HealthCare.Gov

Posted on July 9, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

“Take Health Care into Your Own Hands”

[By Staff Reporters]

This new federal government Website is managed by the US Department of Health & Human Services; located at 200 Independence Avenue, S.W. – Washington, D.C. 20201

Assessment: http://www.healthcare.gov/news/videos/tour.html

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Breaking News, Health Insurance, Health Law & Policy, Videos | Tagged: Department of Health & Human Services;, HealthCare.Gov, HHS | 3 Comments »

Benchmarks of Health Plan Administrative Costs

Posted on June 23, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

2010 Edition‏

Sherlock Company
ADVERTISEMENT

By Douglas B. Sherlock, CFA
[Senior Health Care Analyst]
sherlock@sherlockco.com

In the next few weeks we will be releasing our thirteenth annual edition of our administrative performance benchmarks for health plans. It is the culmination of 450 health plan years of experience with all major sectors of the health plan industry. The attached brochure briefly describes our 2010 benchmarks.

Weak Employment Environment

Many health plans are convinced that effective management of operating costs is central to their long-term success. This is especially the case in the current challenging environment. The weak employment environment pressures revenue yields and membership, forcing rationalization of operating costs. The weak credit environment heightens plan sponsor interest in self-insurance, which increases the visibility of administrative expenses.

Finally, health care reform heightens the interest in operating costs by external audiences. Accordingly health plans serving more than one-half of all insured Americans are users of our benchmarks.

Assessment

Our benchmarks 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. Additional information can be found at http://www.sherlockco.com/seer.shtml or by contacting me directly.

I hope you will not hesitate to contact me if I can answer any further questions.

Link: Sherlock Health Plan Benchmarks Brochure

Sherlock Company
Senior Health Care Analyst
sherlock@sherlockco.com
Ph: 215-628-2289
Fax: 215-542-0690

Conclusion

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
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: Alerts Sign-Up, Health Economics, Health Insurance | Tagged: CFA, Douglas B. Sherlock, Health Plan Administrative Costs, Sherlock Company | 2 Comments »

Customer Service in Medicare and Medicaid Plans

Posted on June 15, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

June Edition of Plan Management Navigator

By Erin Sawchuk

erinsawchuk@sherlockco.com

Please find attached by the link below, the June 2010 Edition of Plan Management Navigator. In this month’s edition, we estimate the strength of cost drivers for “Customer Services in Medicare and Medicaid Plans.”

We quantify the relationships of customer services costs to simple algebraic and other operational metrics within the Customer Services function. We also identify and test some of the potential interrelationships between customer services costs and other functions for Medicare and Medicaid Plans. This analysis draws on data from the 2009 Sherlock Expense Evaluation Report.

Benchmarks

Also included in this analysis is an update on our progress on our various benchmarking universes. Participation is up this year, we think due to public policy changes and economic weakness. While benchmarks for Independent / Provider-Sponsored plans will be published shortly, please let us know if you are interested in joining our 2010 Medicare, Medicaid or TPA universes.

Link: Navigator June 2010[1]

Assessment

Finally, we summarize the operating and financial trends identified in our recent Dashboard.

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289

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, be sure to subscribe to the ME-P. It is fast, free and secure.

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed: Credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Career Development, Health Economics, Health Insurance, Practice Management, Research & Development | Tagged: Erin Sawchuck, Medicaid, medicare, Plan Management Navigator, Sherlock Company, Sherlock Expense Evaluation Report, TPA | 4 Comments »

Ending Employer Sponsored Health Insurance

Posted on June 11, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Or … at Least as We Currently Know It

By Staff Reporters

The latest Kaiser Health News column bids farewell to employer-sponsored health insurance. It will supposedly erode. And that’s a good thing, according to some experts.

Of Criticisms

The KHN news begins by saying that one of the latest criticisms of the new health overhaul law is that it will encourage employers to stop offering health insurance. And, in fact, it may.

http://www.kaiserhealthnews.org/Columns/2010/May/052710Frakt.aspx

Alternatives Must Exist

According to economist Austin Frakt PhD, we should welcome this, provided the decline in employer coverage is gradual and good alternatives like HSAs, exist. So, there are several advantages to the way in which the new law promotes severing the connection between employment and health insurance.

http://theincidentaleconomist.com/the-end-of-employer-sponsored-health-insurance-as-we-know-it/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

[picapp align=”none” wrap=”false” link=”term=health+insurance&iid=102664″ src=”0099/8461586d-cbd6-48d8-b6bc-0620b4303fad.jpg?adImageId=13084712&imageId=102664″ width=”380″ height=”253″ /]

Assessment

One of them is that it will make more visible the biggest looming health care problem: costs.

https://medicalexecutivepost.com/2010/01/25/why-health-savings-accounts-are-no-longer-a-pariah-in-the-banking-industry/

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is there a difference of opinion between employers and employees; recall doctors and financial advisors [FAs] often are both at some career inflection point?

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

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Contact us for a rate card: MarcinkoAdvisors@msn.com

Filed under: Health Insurance | 3 Comments »

Reporting Tips for Covering High Risk Health Insurance Pools

Posted on June 8, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

A Call to all ME-P Citizen and Investigative Journalists

By Hope Rachel Hetico RN, MHA

[Managing Editor]

According to our colleagues from the Association of Health Care Journalists [AHCJ], the federal government and states are scrambling now to create temporary high-risk pools for the medically uninsurable by July 1, 2010. As one of the first provisions of the Patient Protection and Affordable Care Act to go into effect, it will serve as a test case for implementation of the new law and it should be closely followed.

[picapp align=”none” wrap=”false” link=”term=medical+professionals&iid=5271528″ src=”e/4/2/f/portrait_of_medical_aedc.jpg?adImageId=12922304&imageId=5271528″ width=”380″ height=”380″ /]

Some states with existing high risk pools are passing laws to ensure their programs comply with the new federal rules and are eligible for some of the $5 billion in federal funding. Other states are refusing to alter their programs and ceding responsibility to the federal government.

But, apart from being a policy story, it’s of great interest to all our ME-P readers, viewers or listeners who have pre-existing conditions and are struggling to find coverage.

Avoid HI Scammers

Finally, don’t be scammed into buying fake health insurance. With unemployment high and complicated health care changes under way, scammers see big opportunities. Here’s how to avoid getting hurt.

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/scams-peddle-fake-health-coverage.aspx

Assessment

And so, we now ask our ME-P citizen journalists or investigative reporters to cover this topic for story tips, suggestions, comments and related posts. We hope to add your insights and resources as the story develops.

Conclusion

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

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed

And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Experts Invited, Health Insurance, Industry Indignation Index | Tagged: AHCJ, Association of Health Care Journalists, health insurance pools, high risk health insurance pools, Patient Protection and Affordable Care Act | Leave a comment »

Win a Free iMBA Inc Dictionary

Posted on June 5, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Dictionary of Health Insurance and Managed Care

ADVERTISEMENT

Health care and health insurance have become increasingly complicated for the average citizen. While we at the Benefits Group do our best to assist individuals and businesses with their insurance needs, we appreciate and understand the value of educating yourself on the subject.

With that in mind, we’re offering a no strings attached opportunity to win a book that will provide many answers to your health care questions.

From iMBA Inc: www.MedicalBusinessAdvisors.com

The book up for grabs is the Dictionary of Health Insurance and Managed Care by Dr. David E. Marcinko; FACFAS, MBA, CFP™, CMP™ [Editor-in-Chief] and Hope Rachel Hetico; RN, MHA, CPHQ, CMP™ [Managing Editor].

Click here to read the Amazon.com reviews for Dictionary of Health Insurance and Managed Care

Beyond that, all you need to do to win is provide your email below. We will not be using this email for any marketing purposes, nor do we participate with any lists. We just need your email to contact the winner so we know where to send the book.

The only rules are that participants be at least 18 years of age and live in the residential United States. Also, only one entry per person (our software knows how to sniff you out if you cheat, so please don’t bother). We will be announcing a winner on July 1st, 2010 and will be accepting entries until midnight EST on June 30th, 2010.

ENTER TO WIN

Enter to Win: http://www.healthbrokers.com/blog/index.php?tag=hope-rachel-hetico

Any how, thanks for subscribing to the ME-P and good luck!

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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed: And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Contest Entrance, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care, Sponsors | Tagged: Benefits Group, Health Insurance, Managed Care, www.certifiedmedicalplanner.com, www.HealthDictionaySeries.com, www.medicalbusinessadvisors.com | Leave a comment »

25 or so – Unintended Consequences of Healthcare Reform

Posted on May 14, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Protean, Pervasive, Prolonged and Painful

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Definition of the Term

Much like the physical laws of nature, action begets consequences, which are usually known, unknown or disregarded by human foibles.

According to Robert Norton, the law of unintended consequences, often cited but rarely defined, is that actions of people—and especially of government—always have effects that are unanticipated or unintended. Economists and other social scientists have heeded its power for centuries; for just as long, politicians and popular opinion have largely ignored it.

My List

And so, regardless of your political affiliation or opinion on healthcare reform in America, passed on March 21 2010 [Patient Protection and Affordable Care Act], there is a plethora of unintended consequences with the [any] new law. So, please indulge me in a bit of healthcare administration prescience:

Healthcare costs will be shifted to doctors in the form of lower reimbursement with higher practice overhead costs for private physicians, and with fewer office employees and more ancillary business and service line extensions.
Hospital based physicians like pathologists, radiologists, anesthesiologists, emergency department doctors and hospitalists will demand, and receive, higher salaries.
Fewer [under populated] primary care physicians with more [over populated] PAs, nurse practitioners and DNPs; with a blunted medical establishment oligopoly.
Higher health insurance costs for employers and most patients, especially young adults without a commensurate increase in aggregate risk.
Medical care access impediments for most Americans, but improvements for those previously uninsured.
Health 2.0 electronic connectivity for the masses with medical data “internet-neutrality”.
Continued rise of evidence based medicine and crowd-sourced healthcare information.
Higher costs for DME, instruments and drugs; particularly in the filed of human genomics and personalized pharmaceuticals.
Increased acceptance of MSAs, HSAs, concierge medicine, private-pay and other direct cash payment methods for medical care.
Realization that eMRs do not improve patient care or reduce costs as “meaningful use” is diluted.
An enterprise wide health data breach of epic proportions, with in-numerable smaller security breaches despite the HIPAA laws.
Long term macro-economically induced national inflation with weakness in the US dollar
Poor quality digital manipulation of medical information with eMR specific inflation due to ARRA and HI-TECH.
Increased national unemployment with widespread underemployment for some Americans.
Modified value added taxation in addition to increased federal tax brackets, rates and related others.
Promotion of outcomes reimbursement models, values based healthcare [episodes of care] and various micro-capitation derivatives.
Many more community hospitals, which lost 12 cents/dollar spent on Medicare and 35 cents/dollar on Medicaid patients last year, will close.
Medicare will become the defacto health insurance, much like public housing, food stamps, the USPS and public transportation.
There will be fewer viable alternatives to commercial health insurance, other than Medicare and Medicaid, since the antitrust exemption for health insurers was not repealed.
The impact of changing to ICD-10 for medical records coding and billing, will be as significant across the industry, as was Y2K and will push many other HIT projects to lower priority.
New HIPAA 5010 requirements will present substantial changes in the content of the data submitted with claims as well as the data available in response to electronic inquiries.
The Obama health insurance “police” program will be a policy failure, but a job creator.
Medical practices, often a doctor’s largest financial asset, will go down in value jeopardizing personal retirement plans.
Medicine’s lost professional status will become complete as healthcare becomes commoditized and future grass-roots caregivers are neutered.
Your 2 cents here.

[picapp align=”none” wrap=”false” link=”term=healthcare+professionals&iid=99522″ src=”0095/4e612b02-300a-4dfc-b17c-f2d0d0947cfc.jpg?adImageId=12656185&imageId=99522″ width=”380″ height=”429″ /]

Assessment

In order to be politically correct – not a known trait for me – I will adopt a scientist’s perspective and omit any value judgment regarding the above [positive or negative] unintended consequences.

www.BusinessofMedicalPractice.com

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. 25 consequences not listed? Add your 2 cents. What else can you think of? Am I correct, or not, and how do you feel about the above?

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

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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Sponsors Welcomed

And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Career Development, Health Economics, Health Insurance, Healthcare Finance, Op-Editorials, Practice Management, Research & Development | 7 Comments »

On Medicare and Medicaid Cost Drivers

Posted on April 29, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Health Plan Management Navigator

By Douglas B. Sherlock; CFA

Dear ME-P Readers

Please find attached below the Mid April 2010 Edition of Plan Management Navigator.

In this month’s edition, we estimate the strength of cost drivers for claims processing in Medicare and Medicaid plans. We quantify the relationships of claims processing to simple algebraic expressions and operational metrics within the Claim and Encounter Capture and Adjudication function.

Assessment

Also included in this analysis is an update on our progress on our various benchmarking universes. Participation is up this year, we think due to public policy changes and economic weakness. Please let us know if you are interested in joining our Medicare, Medicaid or TPA universes.

Erin Sawchuk

Sherlock Company

P.O. Box 413

Gwynedd, PA 19436

www.sherlockco.com

215-628-2289 – Phone

erinsawchuk@sherlockco.com

Conclusion

Link: Navigator Mid April 2010

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

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Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

Sponsors Welcomed

And, credible sponsors and like-minded advertisers are always welcomed.

Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Health Economics, Health Insurance, Healthcare Finance | Tagged: Douglas B. Sherlock CFA, Erin Sawchuk, Health Economics, health plans, Medicaid, medicare, Plan Management Navigator, Sherlock Company | 4 Comments »

“Go Elsewhere for Health Care”

Posted on April 13, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

What One Doctor Tells Obama Supporters

By Staff Reporters

[picapp align=”none” wrap=”false” link=”term=tea+party&iid=8445957″ src=”5/e/f/6/Tea_Party_Express_6ebb.jpg?adImageId=12359612&imageId=8445957″ width=”380″ height=”253″ /]

According to Stephen Hudak, of the Orlando Sentinel, a Mount Dora doctor [Jack Cassell MD] posted a sign telling Obama health care supporters to go elsewhere for medical care.

http://startthinkingright.wordpress.com/2010/04/02/doctor-cassell-if-you-voted-for-obama-seek-urologic-care-elsewhere/

Timeline for Healthcare Implementation

Timeline of Major Provisions in the Democrats’ Health Care Package

Conclusion

And so, your thoughts and comments are appreciated; especially from our physician readers. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, Health Law & Policy | Tagged: Jack Cassell MD, Mount Dora, OmamaCare, Orlando Sentinel | 3 Comments »

Donald M. Berwick MD to Head CMS?

Posted on April 13, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Obama Selects Health Policy Scholar as the Director for Medicare and Medicaid

By Staff Reporters

President Obama has named Dr. Donald M. Berwick, an iconoclastic scholar of health policy, to run Medicare and Medicaid, the programs that serve nearly one-third of all Americans.

Assessment

New York Times: http://www.nytimes.com/2010/03/28/health/policy/28health.html?scp=1&sq=Berwick&st=cse:

Berwick on: “Reducing the Harm from Medical Care” http://www.nihcm.org/pdf/ExpertVoices_Berwick_HR_final.pdf

Berwick on: “Curing Health Care”

http://www.amazon.com/Curing-Health-Care-Strategies-Improvement/dp/0787964522/ref=sr_1_1?ie=UTF8&s=books&qid=1271007422&sr=1-1

Wachter on: “Is Don Berwick the One”

http://community.the-hospitalist.org/blogs/wachters_world/archive/2010/03/26/is-don-berwick-the-one.aspx

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is this the right man for the job? 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.

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

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Sponsors Welcomed

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Link: https://healthcarefinancials.wordpress.com/2007/11/11/advertise

Filed under: Alerts Sign-Up, Book Reviews, Breaking News, Health Insurance, Health Law & Policy | Tagged: CMS, Donald M. Berwick, Medicaid, medicare, obama | 13 Comments »

Update on Medicaid and Medicare Advantage Plans

Posted on April 9, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Impact of Health Care Reform

[By Christopher de Garay]

Please find attached below, the Early April 2010 edition of Plan Management Navigator.
Link: Navigator April 2010

Review

In this month’s edition, we review how health care reform will impact the top line of plans offering government managed care programs such as Medicare Advantage and Medicaid. Combined with new minimum health benefit ratios, these pressures will force health plans to look at their administrative expenses. In the next several issues of Navigator, we will look at specific operational metrics and their impact on functional areas such as claims processing.

2010 Benchmark Studies

This edition of Navigator also summarizes the timing for the 2010 benchmarking studies, which includes a new Third-Party Administrator universe.

Christopher de Garay
Senior Health Care Analyst
Sherlock Company
www.sherlockco.com
215-628-2289 Phone
215-542-0690 Fax
cgaray@sherlockco.com
P.O. Box 413
Gwynedd, PA 19436

Editor’s

If your plan would like to consider participation, we invite you to give Chris a call at 215-628-2289 or email him at sherlock@sherlockco.com.

Conclusion

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Filed under: Alerts Sign-Up, Health Economics, Health Insurance, Managed Care, Research & Development | Tagged: Christopher de Garay, DHHS, Managed Care, Medicaid, medicare, Medicare Advantage, Sherlock Company, TPA | 12 Comments »

Dr. Deborah Peel vs. Ms. Mary Grealy on Patient Privacy

Posted on April 6, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Physician versus Lobbyist

By Darrell K. Pruitt; DDS

On March 23, 2010 Dr. Deborah Peel, a psychiatrist in private practice and the founder of Patient Privacy Rights (www.patientprivacyrights.org) posted an opinion piece titled: “Your Medical Records Aren’t Secure” in the Wall Street Journal.

http://online.wsj.com/article/SB10001424052748703580904575132111888664060.html

Her still popular article soon picked up 217 comments – reflecting respectable interest in the conundrum. Since then, her message of caution has gained momentum on the Internet in the security industry, and has even spilled over into appearances on Fox News, MSNBC and PBS in the last week.

Dr. Peel’s Case

Dr. Peel argues that even though the President claims digital health records will reduce costs and improve quality, they could undermine safe and effective care if patients become afraid to confide in their doctors.

“The solution is to insist upon technologies that protect a patient’s right to consent to share any personal data. A step in this direction is to demand that no federal stimulus dollars be used to develop electronic systems that do not have these technologies.”

It is easy to understand why Dr. Peel’s opinions draw the ire of HIT stakeholders both inside and outside government.

Dr. Peel concludes:

“Privacy has been essential to the ethical practice of medicine since the time of Hippocrates in fifth century B.C. The success of health-care reform and electronic record systems requires the same foundation of informed consent patients have always had with paper records systems. But if we squander billions on a health-care system no one trusts, millions will seek treatment outside the system or not at all. The resulting data, filled with errors and omissions, will be worth less than the paper it isn’t written on.”

Dr. Peel is currently on a campaign to encourage Americans to sign her “Do not disclose” petition.

http://patientprivacyrights.org/do-not-disclose/

HIT Stakeholders Speak Up

Recently, the Wall Street Journal featured an opposing opinion to Dr. Peel’s in an article titled “Industry Rep Calls Patient Privacy ‘Overblown’ Worry”

http://online.wsj.com/article/SB10001424052748704094104575144110418562490.html?mod=googlenews_wsj#articleTabs%3Darticle

Ms. Grealy’s Case

Mary R. Grealy, President of the Healthcare Leadership Council, a coalition of chief executives from the health-care industry, posted her objections to Dr. Peel’s warnings about the dangers of digital records versus paper:

“Dr. Peel seeks to frighten people into believing electronic health records are more vulnerable than paper ones, which is not the case. She fails to acknowledge the important role of the HIPAA in protecting health information, or the extraordinary steps hospitals, health plans and physicians have taken to assure confidentiality. Building upon HIPAA, federal laws adopted this year strongly encourage encryption of data included in electronic health records and have imposed new criminal and civil penalties for violating an individual’s privacy.”

“More importantly, though, if Dr. Peel’s prescription for this hyperbolic problem were to be followed, it’s actually our health that will be less secure. Burdening patients with the responsibility of deciding what health information should be divulged and what should be shielded from medical professionals brings an infinite array of possible consequences. Would the average patient know what information a surgeon needs in order to perform a complex procedure? It’s highly doubtful”.

“In a broader sense, draconian restrictions on the essential flow of medical information would have society-wide repercussions. It would affect the ability of public health officials to report and track incidences of disease. It would undermine the Food and Drug Administration’s capability to monitor the quality and safety of medical products, and product recalls would be hampered”.

“Perhaps most importantly, medical research into lifesaving cures and treatments would be severely hindered by restricted access to health information. Stymieing the necessary transfer of data contained in one diagnosis, one prescription or one lab test could mean the difference between life and death. That is a very high price to pay in order to address overblown privacy concerns”.

Mary R. Grealy

[Washington]

_____________________________________

Assessment

Mary Grealy doesn’t have a petition to sign.

Whereas Dr. Peel turns to patients for support, Ms. Grealy, President of the Healthcare Leadership Council, a coalition of chief executives from the health-care industry, turns to Washington.

Conclusion

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Filed under: Ethics, Health Insurance, Health Law & Policy, Information Technology, Point-Counter Point, Pruitt's Platform, Risk Management | Tagged: Darrell Pruitt, Deborah Peel, EHRs, EMRs, FDA, Healthcare Leadership Council, HIPAA, HIT, Mary R. Grealy | 12 Comments »

Podcast: How the Health Care Bill Comparison News Application Came Together

Posted on April 4, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

A Problica Podcast

By Mike Webb, ProPublica – March 26, 2010 12:32 pm EDT

Last week, Olga Pierce and Jeff Larson created a side-by-side comparison of the health care bills [1] to help people see the exact changes in the legislation. Larson developed a news application that highlighted the changed, added or deleted provisions of the bill and Pierce had the unenviable task of going through the 2,000-plus page bill to decipher what the changes were.

[picapp align=”none” wrap=”false” link=”term=insurance&iid=8337859″ src=”9/d/c/c/President_Obama_Signs_196b.JPG?adImageId=11862302&imageId=8337859″ width=”380″ height=”454″ /]

Assessment

We talked to the pair, as well as to ProPublica’s editor of news applications, Scott Klein, about how and why they did it and the challenges they faced in turning it around so quickly.

Articles related to this podcast:

Why You Should Check Out the Health Care Bills Side by Side [2]

Eye on Health Care Reform [3]

Download this episode

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Healthcare Finance, Research & Development, Videos | 1 Comment »

Taxing Sin to Modify Behavior and Raise Revenue‏

Posted on April 2, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

NIHCM Expert Voices

By Nancy Chockley PhD [President & CEO]
[NIHCM Foundation]

Sin taxes on tobacco and alcohol have a long history in the U.S., and many credit cigarette taxes as being the single most effective strategy in achieving our dramatic reductions in smoking. Similar taxes have been proposed in recent years as one weapon in our fight against rising obesity rates, and a new study has just added support for this policy by showing that higher prices for sweetened sodas are associated with lower caloric intake, lower weight, and better health.

Rationale Reviews

In his essay, Dr. Jonathan Gruber reviews the rationales for and experience with sin taxes for cigarettes and alcoholic beverages, and offers his insights on using sin taxes to combat obesity.

http://www.nihcm.org/pdf/ExpertVoices_Gruber_April2010.pdf

Related Others

Other recent “Expert Voices” essays on health reform include:

William Vogt, RAND Corporation, “Hospital Market Consolidation” (November 2009)http://www.nihcm.org/pdf/EV-Vogt_FINAL.pdf
Genevieve Kenney, Urban Institute, “Uninsured and Eligible for Public Coverage” (November 2009) http://nihcm.org/pdf/EV-Kenney_FINAL.pdf
Eric Jensen, Consultant, and Lenny Mendonca, McKinsey & Company, “Why America Spends More on Healthcare” (November 2009)http://nihcm.org/pdf/EV_JensenMendonca_FINAL.pdf

Assessment

I hope you enjoy reading these essays and those that follow, down-line.

Phone: 202-296-4426
email: nihcm@nihcm.org
Website: www.nihcm.org

Conclusion

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Filed under: Ethics, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Taxation | Tagged: alcohol tax, cigarette tax, Dr. Jonathan Gruber, Eric Jensen, Genevieve Kenney, Lenny Mendonca, Nancy Chockley, NIHCM Foundation, William Vogt | 8 Comments »

As the Health Care Vote Passes

Posted on March 28, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Another Troubling Insurance Story

By Marian Wang, ProPublica – March 17, 2010 2:03 pm EDT

[picapp align=”none” wrap=”false” link=”term=health+insurance&iid=8337843″ src=”c/e/5/3/President_Obama_signs_baf7.JPG?adImageId=11734822&imageId=8337843″ width=”380″ height=”484″ /]

Reuters filed a stunning report [1] recently about a health insurance company that targeted policyholders with HIV to drop their coverage. It opens with the case of Jerome Mitchell:

Patient Jerome Mitchell

Previously undisclosed records from Mitchell’s case reveal that [health insurance company Fortis [now known as Assurant Health] had a company policy of targeting policyholders with HIV. A computer program and algorithm targeted every policyholder recently diagnosed with HIV for an automatic fraud investigation, as the company searched for any pretext to revoke their policy. As was the case with Mitchell, their insurance policies often were canceled on erroneous information, the flimsiest of evidence, or for no good reason at all, according to the court documents and interviews with state and federal investigators ….

Insurance companies have long engaged in the practice of “rescission,” whereby they investigate policyholders shortly after they’ve been diagnosed with life-threatening illnesses. But, government regulators and investigators who have overseen the actions of Assurant and other health insurance companies say it is unprecedented for a company to single out people with HIV.

The Three Minute Rule

A South Carolina judge who ruled on the case noted that in the meeting in which the rescission committee [2] reviewed Mitchell’s case and decided to cancel his policy, there were more than 40 other customers whose cases were up for review, and “an average of three minutes or less” was spent per customer. Assurant Health told Reuters [1] it doesn’t comment on individual customer claims, while a spokesman added the company disagreed with “certain of the court’s characterizations of Assurant Health’s policies and procedures.”

Link: http://www.propublica.org/ion/blog/item/as-health-care-vote-nears-another-troubling-insurance-story

Assessment

As the story notes, it’s not just this one insurance company that has been engaging in aggressive rescission. In California, state regulators fined five major health insurance providers—Health Net, Anthem Blue Cross, Blue Shield of California, PacifiCare and Kaiser Permanente—for dropping more than 6,000 sick policyholders. The terms of those settlements, reached in 2008 and 2009 [3], have yet to be implemented in most cases, according to news reports [3] from last week.

Industry Indignation Index: 39

Conclusion

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Filed under: Ethics, Health Insurance, Industry Indignation Index | Tagged: Anthem Blue Cross, Assurant Health, Blue Shield of California, Fortis, Health Insurance, Health Net, HIV, Jerome Mitchell, Kaiser Permanente, Marian Wang, PacifiCare, rescission | 5 Comments »

Need a New Career in Dentistry – Become a Consultant

Posted on March 26, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Or – Maybe Just a Hobby

By Darrell K. Pruitt; DDS

One might ask how much knowledge of dentistry is required before a person is qualified to call oneself a “dental practice management consultant” – beyond maybe being able to spell HIPAA with only one P, and Hippocrates with two.

Meet Jill Coon, Inc

An anonymous management consultant who works for Jill Coon, Inc of Florida posted this brave suggestion on the company Facebook today:

“Why not take 3 max anterior PA’s and 1 mandibular PA once a year with bitewings to check for caries in front teeth? We actually bill insurance for 3 PA’s not 4. Hygiene production just increased!”

My Translation

Here is a translation of her question from dental-speak to English:

“Why don’t dentists take routine x-rays of front teeth like they do for back teeth, when doing so increases hygiene production and payments from the insurance companies?”

[Dental team members, please sit on your hands for this one].

Bonus Round

Bonus question: Can anyone think of any reason why one might not want additional routine x-rays – even if insurance pays for it at 100% (of usual and customary fees)?

Hint: It can be trickier to avoid irradiating the thyroid when taking anterior x-rays than while taking routine bitewing x-rays.

Assessment

I’ll be back soon with the tricky opinion I will have posted on Jill Coon, Inc Facebook. It will be her first if nobody beats me to it.

http://www.facebook.com/home.php#!/pages/West-Palm-Beach-FL/Jill-Coon-Inc/125510596754?v=wall&ref=mf

Conclusion

Is there anyone out there with almost no knowledge of dental care who wants to match wits with a sales rep for a consulting company that “specializes in dental insurance billing and treatment planning for dental practices”?

Industry Indignation Index: 47

How about it – HHS Secretary Kathleen Sebelius, JD?

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Filed under: Career Development, Ethics, Health Insurance, Industry Indignation Index, Practice Management, Pruitt's Platform | Tagged: ADA, bitewing X rays, Darrell Pruitt, DDS, dental consultants, dentist, dentistry, HIPAA, ionizing radiation, Jill Coon Inc, Kathy Sebelius, thyroid gland | 5 Comments »

VOTE: New Healthcare Reform Legislation

Posted on March 23, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Vote on Healthcare Reform and Tell us What you Think?

Now that healthcare reform is law, tell us what you think and give us your vote.

You may wish to review this synopsis guide first: http://www.msnbc.msn.com/id/34609984/ns/health-health_care/?GT1=43001

Feel free to answer these queries, in prose form, as well:

1. How will the new law affect the practice of medicine?

2. How does it affect the condition of the national economy?

3. Where do you go to seek succor and support?

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Do you agree with the new healthcare law?

Filed under: Ethics, Health Insurance, Health Law & Policy, Voting Polls | Tagged: ACA, healthcare reform, Obana Care, PP-ACA | 3 Comments »

What’s Next with Health Care?

Posted on March 23, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

And, Why the Process was Madness

By Staff Reporters

With the House passing health care reform yesterday, resident ProPublica blogger Marian Wang explains what’s next for the bill, and why the process keeps on changing.

Main Concerns

Sometimes things are a little clearer in retrospect. Now that health care reform has passed in the House, it seems there are two main questions in people’s minds:

What’s next?
Why, procedurally, was the legislative process so confusing and painful to watch?

So, Marian will answer that second question first with some helpful infographics.

Assessment

http://www.propublica.org/ion/blog/item/whats-next-with-health-care-and-why-this-process-was-madness

Conclusion

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Filed under: Breaking News, Health Insurance, Health Law & Policy, Research & Development | Tagged: healthcare reform, Marian Wang, Obama care, Pelosi, ProPublica | Leave a comment »

A New Survey on Dental Insurance

Posted on March 22, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Come on out Kim E. Volk – CEO of Delta Dental

By Darrell K. Pruitt; DDS

Today, Julie Frey posted “Dentist & Dental Insurance: No Love Lost” on Jim Du Molin’s Blog.

http://www.thewealthydentist.com/blog/1186/dentist-dental-insurance/

Frey hosts dentists’ frank criticism of dental insurance – their harsh sentiments backed up with fresh results from yet another of the blog’s timely studies that nobody else can compete with. Frey writes “Half of dentists have mostly or completely stopped accepting dental insurances, according to this survey.” One dentist captured the mood of the dentists with the statement, “Do the math … somebody is making hell of a lot of money on these plans, and it is not the dentist!” I smelled blood and posted the following comment.

Bloody Sunday

Anonymous members of the obscure National Association of Dental Plans (NADP) are losing the fat, collective thumb they once oppressed us with – even using our own ADA News to present their non-negotiable terms. Apart from common sense appearing in the marketplace about the same time as transparency, multiple other interconnected factors are causing dental insurance companies to lose business. The bad economy, corporate greed and pride are a few of their more serious handicaps that come to mind. Wasteful, deceptive insurance practices have aggravated my patients and me for decades before modern networked recourse became available on the Internet through progressive Websites like Jim Du Molin’s Blog. I’ll go out on a limb and say it is not unprofessional for us to enjoy protecting those we serve by showing no mercy to unfair stakeholders like the NADP.

There. I said it. In fact, as US citizens and taxpayers I think blowing the whistle on unneeded expense and danger in the nation’s healthcare delivery is the least we can do for meaningful healthcare reform. I say do your part. Make an insurance CEO like Delta Dental Plans Association’s Kim E. Volk feel discomfort on the Internet. Do you know that Kim E. Volk is the only person who has ever refused to accept me as a friend on Facebook?

http://www.jbpub.com/catalog/9780763733421/

Assessment

We really don’t want to allow Delta Dental, UnitedHealthcare, United Concordia and others to dictate fees for non-covered dental services, do we? I also don’t think they deserve continued protection from FTC anti-trust litigation. I say we punish the NADP hard every chance we get until the repeal of the McCarran-Ferguson Act and finally make such in-your-face collusion illegal for crying out loud.

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Filed under: Career Development, Ethics, Health Insurance, Practice Management, Pruitt's Platform | Tagged: ADA, Darrell Pruitt DDS, DDS, delta dental, dental insurance, eDRs, FTC, Julie Frey. Jim Du Molin, Kim E. Volk, McCarran-Ferguson Act, NADP, National Association of Dental Plans, United Concordia, UnitedHealthcare | 13 Comments »

A Petition to the US Federal Government

Posted on March 20, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

For an Individual Opt-Out Request for Healthcare

By MyMillionSite

We The Undersigned Wish To Convey By Their Signatures Below That They Wish To Have The Same Rights Under The Current Health Care Legislation.

That Allows The Individual States That If This Would Place An Economic Burden On That State They Have The Option To Opt Out Of This Mandate.

Currently Over 35 Of The 50 States Have Or Will File A Legal Action Against Washington To Claim This Is An Unconstitutional Bill.

If The States Are At 35 against and 15 Not Yet Heard From, It Would Seem That “We The People” Are More That 51% Against This Health Care Bill.

THIS WOULD BE A CLEAR STATEMENT THAT IF AN UP OR DOWN VOTE WAS HELD TODAY BY THE GENERAL POPULATION OF REGISTERED AMERICAN VOTERS THIS BILL WOULD NOT EVEN SEE THE LIGHT OF DAY AND ANY LEGAL ACTION FILED BY THE INDIVUDAL STATES WOULD NOT EVEN BE REQUIRED.

IF THIS BILL WOULD Place an ADDITIONAL ECONOMIC BURDEN ON THE STATE, it Would Seem Logical That It Should Also Be AVAILABLE TO THE INDIVIDUAL PERSON AS WELL.

We the Undersigned Wish To Opt Out Of the Average $12,000.00 per Year Price Tag The Current System We Have In Place by Law Already Mandates That Any Hospital Cannot Refuse Medical Treatment to Anyone That Is In Need Currently Any One Who Asks For Help Will Receive It.

This Bill Will Be Imposed By A Federal Mandate On Each Man, Woman, Child, And Even Unborn Children That Live In This The United States If This Bill Passes.

That This Mandate Is Actually an Unconstitutional Bill in Many Ways:

The Federal Government Does Not Have the Right to Mandate that it’s Citizens Will Have to Purchase a Product Such As Health Insurance Policy.

To Mandate That An Unborn Child Will Have To Purchase This As Well Is The Same Taxation Without Representation.

We As Citizens Are Now Already Over Taxed the Federal Government It Takes the First 4 Months of Our Income and The States Take Another Two Months Of Our Income.

If You Live You Pay Sales Tax on All Purchase’s And Even More On Other Taxes Such As Property Taxes, City Taxes, Cigarettes, Alcohol, Death Taxes, And Soon Even A Carbon Tax On Breathing.

At The Present Time With All Of The Visible Taxes And The Taxes That Are Hidden In Every Item That Is Purchased We Are Taxed At If Not More Than 50% Of Our Income’s An Additional $1000.00 Per Month $12,000.00 For A Federal Health Care Product That Once Implemented Will Only Cover 60% Of Medical Expenses After An Already High Deductible This Will Place A Large Burden On Any If Not All United States Citizen’s.

WE CITIZENS OF THE UNITED STATE RESPECTFULLY REQUEST TO OPT OUT OF THE CURRENT HEALTH CARE BILL

PLEASE COPY AND EMAIL TO ALL OF YOUR CONTACTS AND ON SUNDAY WHO EVER HAS A COPY FORWARD IT TO THE HOUSE, SENATE, AND THE WHITEHOUSE

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Filed under: Breaking News, Ethics, Health Insurance, Health Law & Policy | Tagged: healthcare reform, MyMillionSite, obama, Obama care | 7 Comments »

On Employer Based Health Insurance Premium Costs

Posted on March 15, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

One Client’s Comparative Expense Analysis Experience

By Dr. David Edward Marcinko; MBA

[Publisher-in-Chief]

A colleague posted an interesting essay recently on his blog The Incidental Economist. Austin Frakt PhD is a health economist with an educational background in physics and engineering. After receiving a PhD in statistical and applied mathematics, he spent four years at a research and consulting firm conducting policy evaluations for various federal health agencies. Here is the post.

Link: http://theincidentaleconomist.com/index.php?s=Kaiser%2FHRET+

The Survey

In his essay, Austin reported these figures from a cited survey:

“The 2009 Kaiser/HRET employer health benefits survey found that employees pay 17% of the $4,824 annual premium for single coverage and 27% of the $13,375 annual premium for family coverage (all average figures)”.

Case Report Model

So, if the survey is correct, it got me thinking about how much a long-time client paid as a doctor-employer, when she last practiced in a certain medical group back in 2000. And, especially about how much she would be paying today if still in business with the same group. This brief case-report with comparative expense analysis [CEA} is the up-shot.

My Client’s Story

Her health insurance premium costs including doctor-partners, was about $13,500 annually, per employee. This was a sunk cost, but an above the AGI line deductible business expense to the practice and entirely employer paid as a fringe benefit [all valid corporate expenses are deductible as there is no AGI line on a business tax return]. She and her three partners were both very magnanimous to their employees, and naïve. They became virtually insolvent a few years later and were bought out by a larger medical group for a pittance. Today, they are grunt employee doctors in a 25 plus physician group practice.

My Numbers

Now, if I crunched the numbers correctly as an citizen economist, on my HP12-C calculator, using health insurance inflation rates of 3%, 5% and 7% respectively for a decade [low], she would be now be paying somewhere between $18,143 and $21,990 and $26,556 in 2010 [dangerously assuming linear economics]. Each of her 15-18 employees at the time was a female, head of household, with 1-4 dependents of their own; no singles. Her own family unit included a professional husband and young daughter in private elementary school. They were the most health conscious of the bunch.

Her Situation

So, she left the group in 2000, and we transitioned her to solo private practice with a HD-HCP indemnity-styled [better] plan that pays 100% after her $5,000, and later $10,000, deductible. She has 100% prescription drug coverage, no OB coverage and no networks, second opinions or pre-certification requirements. Today, she has more than $50-K in the savings portion [cash account earning 3.5%, tax deferred].

Her Reaction

As she just turned age 55, there as was significant jump in her family coverage premiums from about $1,350/quarter to $1,650/quarter! Of course, her carrier offered a ten percent discount to $1,485 quarter, when she pitched a fit, and completed a health and wellness survey which “they” verified.

My Intervention

So, I used my “insider” knowledge as a doctor, financial advisor and insurance agent and went back to the open market place for coverage. Her new direct halth insurance coverage [she used a non-fiduciary insurance agent intermediary previously] is better, and her premium is only $1,248/quarter or about $5,000 annually to age 58. Bye, bye insurance agent. Link: www.CertifiedMedicalPlanner.com

Now, if we use the non-inflated [a conservative unlikely scenario] 27% employee premium contribution for the present value projections of $18,143 and $21,990 and $26,556 today – each employee would be responsible for about $4,898, $5,937 and $7,170 respectively [please again recall both our conservative nature and the repeat danger of linear economic assumptions].

Where Did the Money Go?

So, under the 3-5% health insurance inflation scenario, my client would have been contributing about $5,417 for her heath insurance. This is very close to what she is annually paying now! So, where did the much larger employer’s contribution portion of the money go? Probably to overhead costs, marketing, advertising, sales and commissions, HR, high-risk pool premiums, ie … down the drain?

What did my client do with the monetary difference? Well, she paid all family doctor and drug bills that were under the high-deductible threshold; some went to her annual family health club membership dues, covered extras and various “wants and nice-to-haves”, and the remainder of course, went into her savings account portion. In other words … not down the drain.

There is an additional $1.000 “catch up” savings provision for those over age 55. She paid it – to herself.

The Road Ahead – More Expensive

I informed my colleague-client that there likely will be another big premium jump when she turns 58, 60 and age 62 respectively. We will report back to ME-P readers on market competition and related health insurance pricing at that time, ceteris paribus.

Assessment

Does the competitive open marketplace find a way to reduce HI costs– sooner or later? High Deductible HealthCare Plans were launched as a temporary pilot project in 1997 and initially sold poorly. In the past few years however, there has been a boom in HD-HCPs and the pilot project was made permanent. What other HI innovations may be in the future?

Of course, President Obama was against them in his original healthcare reform plan. But, now in his weakened political position, they seem acceptable to him. So, go figure. Utility depends on political winds, not economic efficacy, I suppose.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: CMP Program, Health Insurance, iMBA, Investing, Practice Management | Tagged: AGI, Austin Frakt, CMP, CMP Program, CMP www.CertifiedMedicalPlanner.com, david marcinko, fiduciary, HD-HCPs, Health Insurance, high deductible health care plans, HSAs, incidental economist, insurance agents, Kaiser/HRET, MSAs | 7 Comments »

About the Managed Care Digest Series

Posted on March 14, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Where Information Becomes Intelligence™

By Staff Reporters

The sanofi-aventis Managed Care Digest Series^® is part of their continuing commitment to provide the healthcare industrial complex with the latest and most essential information on the evolution of medical care.

The Series, available online or in print, provides key benchmarking data that can help assess value, control costs, and develop business strategies.

Assessment

According to ME-P Publisher-in-Chief, Dr. David Edward Marcinko:

I have been a user of the Managed Care Digest series for more than a decade. The depth and breadth of information is astounding. I especially appreciate the data driven and graphical interface nature of the publication; as well as its’ cost—free!

I suggest all medical professionals, healthcare economists, business experts and financial advisors – read it and reap!

And so, give em’ a click www.ManagedCareDigest.com and tell us what you think?

Conclusion

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Filed under: Book Reviews, Career Development, Health Economics, Health Insurance, Healthcare Finance, Managed Care | Tagged: david marcinko, Managed Care Digest, sanofi-aventis | 1 Comment »

On New York’s Medicaid “Rip-Off” Artists

Posted on March 11, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Or … Just Accidentally Billing Dead Patients?

By Staff Reporters

Sixty-six New York state healthcare providers billed Medicaid for services provided to 287 patients they later admitted were “deceased at the time of service,” says the office of state Medicaid Inspector General James Sheehan.

Assessment

The inappropriate billings, which the providers attributed to clerical mistakes, totaled less than $1 million.

Now, read the entire New York Post article, complete with identifiers; and then page Dr. Frankenstein.

Link: http://www.nypost.com/p/news/local/rai_ing_the_dead_in_medicaid_rip_Ocmt6BxwUyL8WO3OwwmCVI

Conclusion

Industry Indignation Index: 24

And so, your thoughts and comments on this ME-P are appreciated. Could this only happen in the bi-polar State of New York? How about at Manhattan’s famed Bellevue Hospital?

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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

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Filed under: "Doctors Only", Breaking News, Ethics, Health Insurance, Industry Indignation Index, Quality Initiatives | Tagged: Bellevue, James Sheehan., New York Medicaid | 2 Comments »

I’m Not Economically Bashing JHU … But!

Posted on March 9, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

In My Opinion … Hospital Charges Not 4 Me

Dr. David Edward Marcinko; MBA

[Editor-in-Chief]

On February 09, 2010, journalist Maggie Mahar posted an excellent op-ed piece on The Health Care Blog. In fact; I am now compelled to address one aspect of it. The essay was titled: “Massachusetts’ Problem and Maryland’s Solution”.

Assuredly, I’ve no beef with Maggie, her economic machinations or reporting. In fact, I am a fan and encourage all ME-P readers and subscribers to “read it and reap.’

Link: http://www.thehealthcareblog.com/the_health_care_blog/2010/02/massachusetts-problem-and-marylands-solution-we-dont-have-to-wait-for-washington-part-2.html#comments

Maggie Speaks

In her essay, Maggie says the following to which I agree. It is well known to me as a Balti-moron. For, I lived in the bowels of inner-city Baltimore when this legislation went down, back-in-the-day:

“While health care reformers argue about what it would take to “break the curve” of health care inflation, the state of Maryland has done it, at least when it comes to hospital spending. In 1977, Maryland decided that, rather than leaving prices to the vagaries of a marketplace where insurers and hospitals negotiate behind closed doors, it would delegate the task of setting reimbursement rates for acute-care hospitals to an independent agency, the Maryland Health Services Cost Review Commission. When setting rates, the Commission takes into account differences in labor markets and how much a hospital pays in wages; the amount of charity care the hospital does; and whether it treats a large number of severely ill patients.

For example, the Commission sets the price of an overnight stay at St. Joseph Medical Center in suburban Towson at $984, while letting Johns Hopkins, in Baltimore Maryland, charges $1,555. For a basic chest X-ray, St. Joseph’s asks $81 and Hopkins’ is allowed to charge $155. The differences reflect Hopkins’s higher costs as a teaching hospital and the fact that it cares for generally sicker patients.”

Of Invoices, Charges and Cost Shifting – Oh My!

I do have a beef with the above charges, which are not necessarily costs, which are not necessarily what is ultimately paid by a third-party insurer, or patient. This cost shifting is not unique to JHU, of course, but mention of the “Johns” just caught my eye as I admit that I’ve been away from my hometown of Baltimore, Maryland for 35 years.

Oh my; don’t get me wrong. I loved the place and played stick-ball in JHU’s parking lot on Broadway in Upper Fells Point when I was a kid. I was seen in the ER, at a young age, for a forehead laceration. I even met two of the greatest physicians in the world there.

J. Alex Haller Jr. MD – the world famous Children’s-Surgeon-in-Charge of Johns Hopkins Hospital, and pectus excavatum surgical pioneer, from 1964 until 1997. As well as pediatric heart surgeon Helen Brooke Taussig MD (1898 – 1986), developer of a famous operation to alleviate “blue baby” syndrome, and who first warned the public on the dangers of thalidomide.

Link: https://healthcarefinancials.wordpress.com/2009/09/01/off-road-touring-with-dr-marcinko-part-vii/

However, as a health insurance agent and advocate of HD-HCPs for more than a decade, who has direct economic “skin-in-the-insurance game”, I would rather go to suburban St. Joe’s medical center for non-traumatic, non-emergent care – if I had my druthers. The neighborhood is safer and the quality can’t be much different. After all, a basic chest x-ray … is a basic chest x-ray, and an uncomplicated overnight stay … is an overnight stay etc, ceteris paribus.

RememberParetto’s 80/20 economic principle of the “vital few and trivial many”? Most of us [trivial many] will not need JHU care [vital few]. And, that’s a good thing!

The fact that JHU is a teaching hospital that generally cares for sicker patients has tremendous societal implications with positive “trickle-down” innovative benefits for the masses. But, not for me as one doctor-purchaser of healthcare services who knows better. I refuse to pay freight charges for the “full JHU monty”.

I just can’t afford it under my definition of medical / business school derived quality health care.

The correct diagnosis, necessary care and proper treatment with f/u and ancillaries; at the most convenient venue; by the appropriate level medical provider; in an appropriate time-frame, and at the right price.

Assessment

JHU is an outstanding healthcare entity in Baltimore, but perhaps even more so for the poor and/or rich; not us “tweeners”.

For the middle class, it is expensive care whose reputation for quality may actually be declining.

In fact, some JHU employee’s still living “back in the hood” tell me that it is “getting larger, but not better.”

Link: https://healthcarefinancials.wordpress.com/2010/01/10/a-story-all-doctors-and-patients-should-re-read/

Quality guru, Bob Wachter MD, where are you?

http://community.the-hospitalist.org/blogs/wachters_world/about.aspx

PS: I am a former CPHQ myself [Certified Physician in Healthcare Quality].

Conclusion

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FINANCE:Financial Planning for Physicians and Advisors
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Filed under: Health Economics, Health Insurance, Op-Editorials, Quality Initiatives | Tagged: david marcinko, Edward Miller MD, hospital cost shifting, Johns Hopkins University, Maggie Mahar, Maryland Health Services Cost Review Commission, medical care quality, Robert Wachter, The Health Care Blog, www.thehealthcareblog.com | 6 Comments »

Risk Assessment of Medical Coding Services

Posted on March 3, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Office of Inspector General

By Pati Trites MPA CHBC, with Staff Reporters

Any readers considering enrolling in a medical coding school should read this ME-P.

Why? Because the written policies and procedures concerning proper health insurance and Medicare coding should reflect the current reimbursement principles set forth in applicable statutes, regulations and Federal, State or private payer health care program requirements, and should be developed in tandem with organizational standards.

Furthermore, written policies and procedures should ensure that coding and billing are based on medical record documentation; which is now the “reality” rather than just a “reflection” of the reality.

Focus on the Codes

Particular attention should be paid to issues of appropriate diagnosis codes, CPT, DRG and MS-DRG coding, individual Medicare Part A and B claims (including documentation guidelines for evaluation and management services) and the use of patient discharge codes. The billing company should also institute a policy that all rejected claims pertaining to diagnosis and procedure codes be reviewed by the coder or the coding department. This should facilitate a reduction in similar errors.

Problem Areas

Among the risk areas that some billing companies who provide coding services should address are:

Internal coding practices;
“Assumption” coding;
Upcoding and Downcoding;
Alteration of medical records and documentation;
Coding without proper documentation of all physician and other professional services;
Billing for services provided by unqualified or unlicensed clinical personnel;
Availability of all necessary documentation at the time of coding; and
Employment of sanctioned individuals.

Assessment

Billing companies that provide coding services should maintain an up-to-date user-friendly index for coding policies and procedures to ensure that specific information can be readily located.

Similarly, for billing companies which provide coding services, the physician-executive and billing company should assure that essential coding materials are readily accessible to all coding staff.

Finally, billing companies should emphasize in their standards the importance of safeguarding the confidentiality of medical, financial and other personal information in their possession.

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Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Accounting, Health Insurance, Health Law & Policy, Practice Management | 3 Comments »

Risk Assessment of Medical Practice Billing Companies

Posted on February 28, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Office of Inspector General

[By Pati Trites MPA, CHBC with Staff Reporters]

The Office of Inspector General [OIG] believes a medical billing company’s written policies and procedures, its educational program and its audit and investigation plans should take into consideration the particular statutes, rules and program instructions that apply to each function or department of the billing company.

Co-ordination Needed

Consequently, coordination between these functions is needed, with an emphasis on areas of special concern that have been identified by the OIG through its investigative and audit functions.

Furthermore, the OIG recommends that billing companies conduct a comprehensive self-administered risk analysis or contract for an independent risk analysis by experienced health care consulting professionals. This risk analysis should identify and rank the various compliance and business risks the company may experience in its daily operations.

Risk Analysis

Once completed, the risk analysis should serve as the basis for the written policies the billing company should develop. The OIG provides the following specific list of particular risk areas that should be addressed by billing companies. It should be noted that this list is not all-encompassing and the risk analysis completed as a result of the company’s audit may provide a more individualized roadmap. Nonetheless, this list is a compilation of several years of OIG audits, investigations and evaluations and should provide a solid starting point for a company’s initial effort.

Problem List

Among the risk areas the OIG has identified as particularly problematic are:

Billing for items or services not actually documented;
Unbundling;
Upcoding, such as, for example, “DRG creep;
Inappropriate balance billing;
Inadequate resolution of overpayments;
Lack of integrity in computer systems;
Computer software programs that encourage billing personnel to enter data in fields indicating services were rendered though not actually performed or documented;
Failure to maintain the confidentiality of information/records;
Knowing misuse of provider identification numbers, which results in improper billing;
Outpatient services rendered in connection with inpatient stays;
Duplicate billing in an attempt to gain duplicate payment;
Billing for discharge in lieu of transfer;
Failure to properly use modifiers;
Billing company incentives that violate the anti-kickback statute or other similar Federal or State statute or regulation;
Joint ventures;
Routine waiver of copayments and billing third-party insurance only; and
Discounts and professional courtesy.

Additional Risk Areas

The physician-executive should understand that a billing company’s prior history of noncompliance with applicable statutes, regulations and Federal health care program requirements may indicate additional types of risk areas where the billing company may be vulnerable and may require necessary policy measures to prevent avoidable recurrence.

Additional risk areas should be assessed by billing companies as well as incorporated into the written policies and procedures and training elements developed as part of their compliance programs.

Assessment

Billing companies that do not code bills should implement policies that require notification to the provider who is coding to implement and follow compliance safeguards with respect to documentation of services rendered.

Moreover, the OIG recommends that billing companies who do not code for their provider clients incorporate in their contractual agreements the provider’s acknowledgment and agreement to address the above coding compliance safeguards.

Conclusion

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Filed under: Career Development, Health Insurance, Health Law & Policy, Professional Liability, Risk Management | Tagged: ARs, CPT codes, DRG, healthcare fraud, medical billing firms, medical invoicing, OIG, Pati Trites | 7 Comments »

Political Primer on Healthcare Reconciliation

Posted on February 27, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

What it is – How it Works

By Staff Reporters

Several ME-P readers have contacted us for a definition of the term “reconciliation” and what it means in the current political debates and the recent Healthcare Summit in Washington, DC.

Definition,

According to Wikipedia, Reconciliation is a legislative process intended to allow consideration of a contentious budget bill without the threat of filibuster. Introduced in 1974, reconciliation limits debate and amendment, and therefore favors the majority party. Reconciliation also exists in the House of Representatives, but because the House regularly passes rules that constrain debate and amendment, the process has had a less significant impact on that body.

Healthcare Significance

“In 2009 the House and Senate each passed separate healthcare reform bills. The Senate bill passed only after all 60 members of the Democratic caucus voted for cloture to stop an attempted Republican filibuster. Negotiations to produce a compromise bill acceptable to majorities in both houses were thrown off track by Republican Scott Brown’s victory in the Massachusetts.

After Brown’s victory, the Democratic caucus no longer had enough votes to stop a Senate filibuster of the compromise bill. An alternative plan was for the House to pass the Senate bill verbatim, and for each house to pass another bill that would embody the compromises agreed to in the negotiations. This separate piece of legislation, which might possibly include a public option, would require use of the reconciliation procedure in the Senate.”

Of Minutia

No matter whether the House votes on reconciliation or the Senate bill first, the Speaker can ensure that the health care bill is signed into law before reconciliation. (The dirty little secret of Congress is that even if the House votes to pass the Senate health care bill tomorrow, the Speaker has unilateral power to hold that bill at her desk until January 3rd of next year before sending it to the President and starting the 10-day Constitutional veto clock).

Assessment

The Republican leader in the Senate, Mitch McConnell, said: “Using reconciliation would be an acknowledgment that there is bipartisan opposition to their bill, another in a series of backroom deals, and the clearest signal yet that they’ve decided to completely ignore the American people.” according to the New York Times, February 19, 2010.

Other opponents of Democratic legislative initiatives in the 111th Congress began to refer to reconciliation as the “nuclear option, although that term had previously been used to refer only to a majoritarian procedure to effect a formal change in Senate rules.

[picapp align=”none” wrap=”false” link=”term=politics&iid=8096056″ src=”4/f/a/7/Obama_Hosts_BiPartisan_83e0.jpg?adImageId=10759098&imageId=8096056″ width=”380″ height=”257″ /]

Note: Cloture is the only procedure by which the Senate can vote to place a time limit on consideration of a bill or other matter, and thereby overcome a filibuster. Under the cloture rule (Rule XXII), the Senate may limit consideration of a pending matter to 30 additional hours, but only by vote of three-fifths of the full Senate, normally 60 votes.

Conclusion

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: cloture, fillibuster, healthcare reform, Healthcare Summit, obama, reconciliation, Scott Brown | 7 Comments »

Reality TV or Healthcare Summit?

Posted on February 25, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Preparing for the Debate and a TV Audience

By Staff Reporters

In convening today’s bipartisan health session, President Obama is angling to recreate the kind of spontaneous, unscripted debate that gave him a decided advantage when he took questions on live television at a House Republican retreat in Baltimore Maryland, last month.

Link: http://www.nytimes.com/2010/02/25/health/policy/25summit.html?ref=health

[picapp align=”none” wrap=”false” link=”term=healthcare+summit&iid=5340228″ src=”3/c/1/8/Members_Of_White_56fc.jpg?adImageId=10712340&imageId=5340228″ width=”380″ height=”527″ /]

Assessment

Or, will the meeting be like the summer’s flu summit; much ado about nothing?

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Watch, listen and tell us what you think about the President’s ideas; new innovations or more of the same? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too.

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Filed under: Breaking News, Health Insurance, Health Law & Policy | 6 Comments »

The Almost Brand New Obama Healthcare Reform Proposal [Again]!

Posted on February 23, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Fallback Version Now More Likely than Ever

By Staff Reporters

President Barack Obama put forward a nearly $1 trillion, 10-year healthcare reform bill compromise yesterday that would allow the government to deny or roll back egregious insurance premium increases that infuriate consumers. Of course, all ME-P readers are aware of the recent Wellpoint scenario, and Anthem rate increases at such an inauspicious time. Nevertheless, it is unlikely that such sweeping political legislation can pass.

Bi-Partisan Opposition Brewing

Most political pundits view Republicans as opposing the new Obama plan along with some Democrats who previously supported healthcare reform and are having second thoughts in an election year. And so, after a year in pursuit, Obama may still have to settle for a crippled fallback version of what once was his top domestic priority.

Assessment

Feel free to review the attached summary report [The President’s Proposal – February 22, 2010 – Puts American families and small business owners in control of their own health care].

This revised Obama health plan costs $1 trillion. No public option is proposed to cover 31 million uninsured, or limit health insurance rate hikes.

Link: summary-presidents-proposal

Conclusion

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Filed under: Breaking News, Health Insurance, Health Law & Policy | 3 Comments »

Health Care and the Economy

Posted on February 22, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The National Governors Association Meeting

By Staff Reporters

The National Governors Association (NGA)—a bipartisan organization of the nation’s governors—promotes visionary state leadership, shares best practices and speaks with a unified voice on national policy.

Healthcare Politics

The nation’s governors gathered this weekend to address critical issues, including health care reform and the economy. The Governors met with President Obama, members of the Administration, business executives and other experts for discussions on a host of issues and challenges facing states.

Opening Session

This 2010 winter meeting began with a robust opening plenary session highlighting the role states can play in improving health care delivery systems to provide cost-efficient and effective health care to all Americans.

http://www.nga.org/portal/site/nga/menuitem.b14a675ba7f89cf9e8ebb856a11010a0

Conclusion

And so, your thoughts and comments on this ME-P are appreciated; especially our colleague Somnath Basu, PhD. Be sure to visit and watch the online video discussions, as well.

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Filed under: Breaking News, Career Development, Health Economics, Health Insurance, Health Law & Policy | Tagged: CMS, Health Economics, Health Insurance, healthcare, healthcare financing, healthcare reform, National Governors Association, obama | 2 Comments »

Save Fewer Lives or Save Lives More Efficiently?

Posted on February 15, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

An Economics Argument

By Austin Frakt PhD

The Incidental Economist

Originally Posted: 14 Feb 2010 03:58 AM PST

Let’s say the cost per saved life due to providing an additional individual with health insurance is X dollars (Tyler Cowen says X = $9 million; I say that’s an overestimate). If one thinks X is too high, what’s the right policy response? One answer is to extend insurance to fewer people. The other is to try to reduce the cost of care so that X is lower.

The Differential

There is a huge difference between these two responses. I won’t go into all of them now. One important difference I want to highlight is that if we simply reduce the number who will become insured then the rest of us are still left paying exorbitant health care costs. Thus, two problems remain, many are left uninsured and health care costs are still too high.

Cost Reductions

On the other hand, if the policy response is to reduce the cost of care then we all win. More of the uninsured can be insured for some level of funding and the rest of us can benefit from lower health care costs. That’s a double victory.

Assessment

That health reform is too expensive is not a good argument for doing less of it*. It is an argument to do more. The provision of health care will not become more efficient under the status quo. And, the status quo (with perhaps minor tweaks to it) is what we will get if health reform does not pass this year. But, if reform does pass it sets the stage for more reforms, and ones that focus on costs.

*Note: I’m not saying I think it is too expensive. But if you do think it is I do not find that a convincing argument not to do it.

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On the Elimination of Medicare Consultation Codes

Posted on February 8, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Is it Budget Neutral?

By Brian J. Knabe MD, CFP, CMP

http://www.CertifiedMedicalPlanner.org

The New Year 2010 has brought some changes in the Medicare Physicians Fee Schedule. For many specialists, the most significant change is the elimination of consultation codes, 99241-99245 in the outpatient setting and 99251-99255 for inpatient care. Physicians can still provide consultations and bill for these services – using codes for routine new or established patient visits (99201-99205 and 99211-99215).

Reported Revenue Neutrality

It has been reported that this change has been made in a revenue neutral manner. Reimbursement for all E/M codes has been increased in order to make up for the removal of consultation codes. The increase is approximately 6% in the outpatient setting and about 2% for inpatient codes.

Of Averages and Outliers

The result of these changes might be revenue neutral overall, but the outlier effect on many specialties and individual physicians can be significant. Specialists who obtain most of their income from procedures will see less of an effect on their income. This includes dermatologists, surgeons, and gastroenterologists. Less procedurally-oriented specialists, particularly those who rely upon Medicare as a primary payor, are seeing the most significant effect. For example, neurologists and hematologists will likely see double-digit declines in revenue.

Private Payers

While private payers have not yet adopted these changes, billing codes must be adjusted when filing a claim with a commercial insurer when Medicare is the secondary insurer. If a consultation code is used in these instances, the primary payer will pay their portion of the bill, but Medicare will deny secondary coverage. There is no indication yet that commercial insurers are dropping the consultation codes altogether, but if history is any indication, they will likely eventually follow the lead of Medicare.

Assessment

Physicians can take certain measures to decrease the impact of these changes on their revenue stream. It is increasingly important to understand how the complexity of a patient visit affects the appropriate level to be billed. Prolonged service codes are also available (99356 and 99357) to enable physicians to bill appropriately for more complex and time-consuming evaluations.

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Practice Management | Tagged: brian knabe, CPT codes, EM codes, medical billing codes, medicare, physician fee schedules | 5 Comments »

The Scott Brown versus Healthcare Reform Poll

Posted on January 20, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

The Sott Brown Opinion Poll

By Staff Writers

In what some pundits are calling the “Boston Massacre” in liberal Massachusetts, Republican Scott Brown rode a wave of voter anger to win the US Senate seat held by the late Edward M. Kennedy for nearly half a century, leaving President Barack Obama’s health care overhaul in doubt and marring the end of his first year in office.

Our ME-P Audience

As a financial advisor, we know you are aware of the rise in healthcare stocks yesterday. And, as a medical executive or healthcare professional, we know you have been against the public option, and healthcare reform, in its current version. The AMA is not your friend – nor does it represent you.

The Question Is?

And so, do you believe that last Tuesday’s Republican victory in Massachusetts means the current Democratic health care bill will not be on the President’s desk in 2010?

Please VOTE:

Filed under: Health Insurance, Health Law & Policy, Surveys and Voting, Voting Polls | Tagged: AMA, Edward Kennedy, FA, financial advisor, healthcare reform, obama, public option, Scott Brown, Ted Kennedy | 4 Comments »

Healthcare Reform and the US Constitution

Posted on January 17, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Consider this Proposed 28^th Amendment

Submitted by Cecelia T. Perez; RN

Author Unknown

For too long we have been too complacent about the workings of Congress. Many citizens have no idea that Congress members can retire with the same pay after only one term, that they didn’t pay into Social Security, and that they specifically exempted themselves from many of the laws they have passed (such as being exempt from any fear of prosecution for sexual harassment); while ordinary citizens must live under those laws.

The Healthcare Reform Exemption

The latest is to exempt themselves from the Healthcare Reform that is being considered … in all of its forms. Somehow, that doesn’t seem logical. We do not have an elite class that is above the law. I truly don’t care if they are Democrat, Republican, Independent or whatever. The self-serving must stop. This is a good way to do that. It is an idea whose time has come.

Proposed 28th Amendment to the United States Constitution:

“Congress shall make no law that applies to the citizens of the United States that does not apply equally to the Senators and Representatives; and, Congress shall make no law that applies to the Senators and Representatives that does not apply equally to the citizens of the United States.”

Assessment

Each person contact a minimum of twenty people on their address list, in turn ask each of those to do likewise. Then in three days, all people in The United States of America will have the Message. We ask you to pass this idea to your friends for their consideration.

Channel Surfing

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Op-Editorials | Tagged: congress, healthcare reform, public option, social security, US Constitution | 2 Comments »

Around the Healthcare Financial Blog-O-Sphere

Posted on December 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

News and Economics Updates in Thirty Minutes or Less

By Staff Reporters

1. Unions pressure Democrats on health insurance tax
Associated Press via Google, December 10, 2009

2. Is there a doctor in the corporation? Maybe soon
Reuters, December 9, 2009

3. Sebelius Statement on Benefits of Health Insurance Reform for Businesses
HHS Press Release, December 3, 2009

4. Majority of employers would reduce health benefits to avoid proposed excise tax
Mercer Press Release, December 3, 2009

5. U.S. unemployed face higher healthcare premiums
Reuters, December 2, 2009

6. Public support for health-care reform is high, but some CFOs take a different view
CFO.com, December 1, 2009

7. Survey: Growing worker stress seen in benefits use
Associated Press via Google, November 30, 2009

8. Employers Play Dr. Mom to Limit Swine Flu Impact
Associated Press via Google, November 30, 2009

9. Health Care Savings Could Start in the Cafeteria
The New York Times, November 28, 2009

10. Ford, GM Face $2.5 Billion First VEBA Bill
Workforce Management, November 24, 2009

11. Plan credits healthy habits – Employer cuts costs by allowing workers to ‘earn’ lower rates
Business Insurance, November 23, 2009

12. Health Care: GE Gets Radical
Business Week, November 19, 2009

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Filed under: Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Monthly Reports | Tagged: Health Insurance, healthcare business, healthcare economics, Healthcare Finance | 4 Comments »

Take the ICD-10 Survey Poll

Posted on December 10, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

ICD-10 Survey Poll

By Ann Miller; RN, MHA

[Executive Director]

The Department of Health and Human Services [DHHS] recently released the final rule for implementing the ICD-10 [International Classification of Diseases] CM [Clinical Modification] and ICD10-PCS [Procedure Coding System] insurance coding initiatives.

Shifting Deadlnes

The compliance deadline was shifted from October 1, 2011; as proposed in the original rule; to October 1, 2013. And so, how prepared are you for the transition to ICD-10?

Please VOTE:

Filed under: "Doctors Only", Health Insurance, Research & Development, Voting Polls | Tagged: CM, CMS, DHSS, ICD-10, ICD-9 | 7 Comments »

Kathleen Sebelius Please Pay Attention to Dr. Darrell Pruitt

Posted on December 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Deferred Investment [An Incentive to Access]

By D. Kellus Pruitt; DDS

On Friday, the editor of the Chicago Dental Society’s [CDS] blog “Open Wide” posted a progressive, brief article titled, “State of Illinois offers incentive for dentists to treat Medicaid patients” (no byline).

http://chicagodentalsociety.blogspot.com/2009/12/state-of-illinois-offers-incentive-for.html

CDS says that last week, Governor Pat Quinn signed a law which allows Illinois dentists who treat Medicaid patients to accept payment deposited into a tax deferred investment portfolio instead of the traditional delayed, unpredictable payments that offer no tax advantages – only headaches.

Illinois Governor Quinn is a vast improvement over his predecessor. What was his name? He’s gone on to become a TV personality …. Oh yeah. Blagojevich!

I don’t know about you, but for me, Quinn’s incentive to access could offer not only more relief for those who cannot afford dental care in Texas, but it could also be a more or less painless way for dentists to fund IRAs – rather than having to do it at the last minute like I’ll do in a few months – just like every year. Instead of having an IRA hanging over my head, all I would have to do is donate my skills to help a few more people every now and then. That’s noble, charitable duty, friends – even with the Quinn incentive.

I especially respect current Medicaid dentists who work for nothing at all on the more profitable days.

To HHS Secretary Kathleen Sebelius

Pay attention. You only think you run the show.

The nations’ dentists you need aren’t being paid what they deserve, yet they put up with expensive and threatening CMS bureaucracy and struggle on – simply because they wish to ease suffering everyone else chooses to ignore.

Medicare dentists are American heroes to be sure. But let me warn you, Ms. Sebelius, they will turn on you hard and cold if you try to push them around. It’s time that you welcome real dentists to the bargaining table instead of ambitious ADA-approved stakeholders. You need us more than we need you, Ms. Sebelius. Forget the ADA. That is a foundation on which we can build … or not.

And this is for my stunned dentist colleagues in Texas who cross the street to ignore grandiose special bastards like me. Most of you detest the messy stuff I drag around, but nevertheless can’t stop watching from a safe distance. Rather than get your own hands messy, most of you simply pay the TDA to quietly and ineffectively hide or delay huge approaching problems. So what’s the trade-off? To remain “In the Loop,” you must obediently take up your differences with leadership in the approved, professional manner through designated ADA representatives. And. that’s so cute.

Now that you read about Quinn’s incentive, don’t you also hope that a TDA committee has already approved a draft of a deferred investment proposal to be offered to state lawmakers as soon as possible? After all, similar plans are already being tried in not only Illinois, but in four other states as well: Louisiana, Florida, Mississippi and Arkansas.

Hope as we may, nimrods, I fear those in Austin who should be paying attention to legislative opportunities such as this only heard about Quinn’s incentive to access law a minute or so ago at best.

Of Face Book Accounts

Both the TDA and the ADA desperately need functional Facebook accounts like Chicago Dental Society’s. By the way, it is the CDS which will be hosting their annual mid-winter dental conference in Chicago – reliably a tremendous meeting. This year it is Thursday-Saturday, Feb. 25-27, 2010 in the McCormick Place West Building.

http://www.cds.org/mwm_2010/

The TDA’s Facebook Wall is pristine white and graffiti-ready, and the spray paint is free to any artist who walks by. Not unexpectedly, it’s a mess. Nobody is joining, and whoever is in charge of managing the site is busy deleting unacceptable comments from a jerk who has no respect for anyone. (It’s not me). The TDA Facebook is in trouble, and it has been suggested that it should be shut down. It is indeed an embarrassment.

Assessment

Here’s something we’ll all laugh about later: The one dentist in Texas who could have sent the rogue artist on down the road (me), was kicked off for badmouthing BCBSTX and the NPI number as well as 13 other listed allegations, including posting pornography. I’ll let the TDA Director of Membership explain that and the other allegations if you are curious. I was not provided access to the evidence on which the sudden and uncontestable revocation of my TDA benefit was based. But there’s still hope because a friend of mine resented the way I was treated and complained to the TDA using the approved channels. That was 2 months ago. I wonder how well that one is progressing from the Austin City dump.

The ADA Facebook is no better. Over 1600 fans have piled up at the door waiting for the ADA’s grand opening, yet nothing is happening. What do you think is going on there?

If you’ve missed hearing from me for the last 2 weeks and have an inquisitive mind, I’ve been pursuing answers for such questions about ADA and TDA transparency on Twitter. They call me Proots.

Conclusion

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Filed under: Breaking News, Funding Basics, Health Insurance, Health Law & Policy, Pruitt's Platform | Tagged: ADA, BCBSTX, Blagojevich, Chicago Dental Society, CMS, Darrell Pruitt, DDS, dentists, IRAs, Kathleen Sebelius, Medicaid, NPI, Pat Quinn, Proots, TDA, Texas Dental Association, twitter | 10 Comments »

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