Dental eHR Controversy Continues

Posted on November 28, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Response to Valerie Powell, PhD

By Darrell K. Pruitt; DDS

Dear Valerie,

This is a response to statements in www.ModernHealthcare.com, although to address all of the issues will probably be more space than they will want to devote to this. So, I’ll leave it to them to decide how much, if any, they would like to post.

Starting from the Top

Valerie Powell asks whether a dentist would face liability under HIPAA if electronic health data were stolen. Of course they would. And in six months the FTC will be interested in data breaches as well. The “Red Flag Rules” were not eliminated, they were just delayed.

Practice Interference

She asks whether the thefts would interfere with the dentist’s practice. Yes again – in many unpleasant ways. For example, if there is a data breach connected to a series of identity thefts from a dental office, the HHS Office of Civil Rights, state investigators or even the FBI can confiscate the dentist’s computer to investigate. A search warrant would shut down an office much more unexpectedly than paper floating away in a hurricane. By the way, using Hurricane Katrina as a reason for dentists to go digital is merely a weak rationalization commonly used by those who would de-value paper records to increase the relative value of digital.

Self-Reporting

If the dentist is able to self-report the breach before finding out from law officials, even before the inspectors arrive, ready to teach the careless dentist a good lesson as an example to others, the dentist would be obligated to contact every one of his or her patients as soon as possible to tell them, “I am terribly sorry to inform you that your social security number, date of birth, health insurance information and other valuable items have been stolen from my office. However, I will assist you in watching for identity thefts for the next few years at my expense.”

The Ponemon Institute Report

A couple of years ago, the Ponemon Institute estimated that it costs almost $200 per patient to do this. For a small dental practice with only 2500 active patients, that is half a million dollars – even before the fines arrive.

Economic Costs

But wait, there is more. If the immediate financial costs do not bankrupt the practice, Ponemon once estimated that 20% of the clients will never return to a business that fumbled their identity. I think Ponemon is an optimist. Ponemon’s estimate is not based on breaches from dental practices. I think at least a third of dental patients would immediately leave and probably seek out a dentist who uses paper records. And that is when they will find me.

Conclusion

And so, your thoughts and comments on this Executive-Post, and continuing discourse, are appreciated.

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

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Filed under: Health Insurance, Information Technology, Op-Editorials, Practice Management | Tagged: EHRs, EMRs, HIT | 5 Comments »

Pondering the Health Insurance Overhaul

Posted on November 27, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Mandates Include All Patients and Pre-Existing Conditions

Staff Reporters

According to the New York Times, November 20, 2008, the health insurance industry would support a health care overhaul requiring insurers to accept all customers, regardless of illness or disability, if Congress requires all Americans to have coverage.

Industry Trade Groups

In separate actions, the two trade groups, America’s Health Insurance Plans and the Blue Cross and Blue Shield Association, announced their support for guaranteed coverage for people with pre-existing medical conditions, in conjunction with an enforceable mandate for individual coverage.

Assessment

In the absence of such a mandate, insurers said, many people will wait until they become sick before they buy insurance. Members of Congress said that they wanted to pass legislation next year to expand coverage and rein in health care costs, while the new position taken by the insurance industry could ease the way for passage of such legislation.

View Video [“Future of American Healthcare” by Uwe Reinhardt; PhD]: http://vodpod.com/watch/852139-uwe-reinhardt-future-of-american-healthcare-who-will-manage-the-system?pod=drdemmba

Conclusion

As always, your thoughts and comments on this Executive-Post are appreciated.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: Health Insurance, Health Law & Policy, Practice Management | Tagged: health insurance reform, national healthcare | Leave a comment »

The National Health Care-Scare

Posted on November 24, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

The Markets and Health Economics

By Dr. David Edward Marcinko; MBA, CMP™

As a centrist fiscal conservative – social liberal – I tend to side with libertarian issues and not political parties. Nevertheless, I was dismayed with the recent presidential election and wondered what impact it would have on the stock markets. Mr. Market replied with haste.

The Question

In the short term, the stock market collapsed back in September when most pundits opined that President-elect Barack Obama would become our new leader. In fact, the DOW has not seen its current lows since 1998, or so.

More specifically, according to one analyst from Wall Street – Paul Shread – “the Dowshould have strong support between here and 7000, which would cover the 1998 and 2002-2003 lows (7200-7400), the 50% decline mark (7100) and the October 1997 low (6971). This would be a very important place for the market to make a stand.” But other chartists see the markets falling even further, with the S&P dropping as low as 400. Why is this?

The Answer is Uncertainty, Doubt and Fear

While the mounting credit default swap and mortgage crisis has had a major role in sinking stocks, some speculators worry that Obama will follow through on promises to raise income taxes on dividends and capital gains; eliminate the estate tax exemption, rescue the auto-industry and the: airlines, home builders, furniture, footgear and apparels, textiles, glassware, tobacco, beer brewers and perhaps a few others, and generally make it difficult for private employers to resist unionizing drives. In other words – there is a rising level of fear, doubt and uncertainty over the seeming potential of Keynesianism and governmental guarantees and protectionism – rather than the opportunities of capitalism. All disguised in the “cloak of change”.

Enter the Politicians

Some economists – tax and policy experts – fear that if Obama, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid bailout these manufacturing segments instead of filing for Chapter 11, the country may face a very long recession. Just look to Japan some two decades ago, when the country bailed out its failing banks and corporations instead of letting them fall so that innovative competitors could take their place.

According to Niall Ferguson, a scholar who has studied the relationship between political, banking and financial fortunes –”you can stick money into every orifice of the big banks — their mouth, their nose, their ears, wherever — but if they can’t make loans because they have to reserve against future losses, and if they won’t make loans because there’s a recession, it won’t do any good,” Ferguson says. “If they can’t lend, there’s no money multiplier — they’re stuck, they’re zombies. It’s Japan all over again.” And, some ghoulish traders are indeed hoping for a deep recession. Today, Japan is still in worse shape than we are.

Phoenix Rising

Following such a debacle, the failed companies might then re-organize with some of their current workers under revamped union contracts. Reorganization, new labor contracts and new employee and retiree health benefit plans would make them competitive and profitable after emerging from bankruptcy; much like the proverbial Phoenix.

National Health Insurance, et al

Our physician clients and investors also are also worried that if national health insurance becomes a reality, defense spending is reduced and/or onerous regulations imposed on the surviving banks and Wall Street, the economy will be in for ride rougher than the one we have experienced to-date. No wonder a recent poll suggested that more than half of all doctors did not encourage their offspring to follow their career footsteps.

Other pressing issues for the medical profession, according to the HealthCare Group – Co-Chaired by Angela Braly of Wellpoint Inc., Dr. Denis Cortese of the Mayo Clinic, Jeffrey Kindler from Pfizer Inc., and Dr. Daniel Vasella from Novartis AG – include tort reform,defining and measuring medical value, payment reform, and building the health care workforce of the future with an emphasis on primary care, nursing and other allied health professionals. Moreover, true healthcare reform must involve integrating issues like Single Payer Systems, Consumer Directed Health Plans, Pharmaceutical Price Competition, Advanced Electronic Medical Records, and Quality & Outcomes Disclosure, etc.

The Obama Cabinet

President-elect Obama’s staff and cabinet appointments will also offer important clues for the markets, going forward. In addition to Rahm Emanuel, as the President-elect’s Chief of Staff, hearsay suggests Laura Tyson or Bill Richardson for Secretary of Commerce, Hillary Clinton as Secretary of State and Timothy Geithner as Treasury Secretary. Other considerations include Renee Glover for Secretary of Housing and Urban Development [HUD], Max Cleland as Secretary for Veteran’s Affairs, Janet Napolitano for Homeland Security, Jim Jones as National Security Advisor; and Richard Danzig and/or Chuck Hagel for other Cabinet Posts. Yet, Tom Daschle as Secretary of HHS is not exactly an “agent of change”, as the term is commonly understood.

Assessment

As the world’s markets sink, the pressure on our new administration will be to clarify these issues. Only then, will a stock market bottom be reached, and the dismal economy begins to reverse itself. Hopefully, the health care-scare will then be mitigated.

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated.

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: Health Economics, Health Insurance, Health Law & Policy, Insurance Matters, Managed Care, Research & Development | Tagged: economy, markets, national healthcare | 2 Comments »

Medicaid MD Acceptance Slows

Posted on November 22, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Delayed Reimbursements Cited as Root Cause

Staff Reporters

According to the Wall Street Journal, November 18, 2008, fewer doctors are accepting Medicaid patients. And, it’s not just because fees are so low – but because it often takes months to get paid.

Health Affairs Analysis

An analysis by the Center for Studying Health System Change says Byzantine bureaucracies can delay Medicaid payments for months. Using data provided by Athenahealth, a specialist in processing claims and payments for doctors, researchers at the Center for Studying Health System Change found that even in states with relatively high Medicaid payments yet long delays, only 50 percent of doctors took all new Medicaid patients.

Assessment

By contrast, in states with higher and speedier payments, doctor participation was 64 percent. Variations in payment delays varied wildly state to state – from a low of 37 days in Kansas to a high of 115 days in Pennsylvania.

Conclusion

What do you think is the reason for the Medicaid patient slowdown; delayed cash-flow or some other cause? As always, your thoughts and comments on this Executive-Post are appreciated

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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Filed under: Career Development, Health Insurance, Practice Management, Research & Development, Surveys and Voting | Tagged: Medicaid | Leave a comment »

The Healthcare Capital Budgeting Crisis

Posted on November 21, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Your Vote Counts

Staff Reporters

Did you know that South Carolina’s Department of Health and Environmental Control [SCDHEC] will likely close some of its rural health clinics due to the state’s budget woes? It’s true; according to reports from The State of Columbia, SC. Moreover, the SCDHEC would also offer early retirement to its employees.

Hospital Bankruptcies

On another front, hospitals filing bankruptcy last quarter included: a two-hospital system in Honolulu; one in Pontiac, MI; Trinity Hospital in Erin, Tennessee; Century City Doctors Hospital in Beverly Hills, Lincoln Park Hospital in Chicago, and four hospital system Hospital Partners of America, in Charlotte.

Private Medical Practice Impact

And, according to consultants from the Institute of Medical Business Advisors, in Atlanta [www.MedicalBusinessAdvisors.com], similar negative impacts have occurred in private medical practices, and clinics, as well.

Assessment

Will the current economic crisis have a chilling effect on your healthcare organization’s capital spending?

Conclusion

Please vote.

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Surveys and Voting, Uncategorized, Voting Polls | Leave a comment »

Consumer-Driven Healthcare

Posted on November 20, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

An Emerging Trend Vital to Hospitals

[By Staff Reporters]

According to Associate Professor Gregory O. Ginn; PhD, MBA, CPA, MEd., of the University of Las Vegas, an important emerging trend today is consumer-driven healthcare [CDHC] as patients become more knowledgeable and demanding about the quality of care they receive.

Definition

According to the Dictionary of Health Insurance and Managed Care, CDHC refers to health insurance plans that allow members to use personal Health Savings Accounts (HSAs), or similar medical payment products to pay routine health care expenses directly, while a high-deductible health insurance policy protects them from catastrophic medical expenses. High-deductible policies cost less, but the user pays routine medical claims using a pre-funded spending account, often with a special debit card provided by a bank or insurance plan. If the balance on this account runs out, the user then pays claims just like under a regular deductible. Users keep any unused balance or “rollover” at the end of the year to increase future balances, or to invest for future expenses.

Benefits Managers and Corporate America

Benefits managers in particular are proponents of consumer-driven healthcare. They argue that employers should focus on which plans create the most value, go with quality, get employees to pay more, and move to a defined contribution approach. The concept of consumer-driven healthcare is being implemented in employer strategies to change participant and provider strategies. This trend stimulates competition among providers based on both price and quality and forces providers to offer more information about cost and quality. Providers who successfully differentiate their strategies to respond to this trend may benefit financially.

Hospital Operations

Consumer-driven healthcare will have major ramifications for the operations management function in hospitals. In order for hospitals to compete on both price and quality, they will need to develop greater flexibility in order to differentiate their service offerings. Such flexibility is not likely to occur without sophisticated information systems that allow for data integration.

Assessment

Of course, considerable staffing and training changes may be in order to provide this type of service.

***

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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: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: CDHC, consumer driven health care | 6 Comments »

State Mandated Health Insurance Laws

Posted on November 19, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

A Growing List

By Staff Reporters

State laws inform health insurers what health coverage they must offer as state mandates. For example, if a state says “behavioral health coverage,” then health insurance policies issued in that state must provide coverage for behavioral health benefits for the insured and dependents But, recall that no two states impose the same set of mandates, and coverage changes regularly. So, here is a list:

Alabama

Alcohol treatment
dependent coverage (from the moment of birth, including abnormalities)
mammograms
open selection of pharmacy

Alaska

Alcohol/drug treatment
dependent coverage (from the moment of birth, including abnormalities, and those who are adopted)
mammography
pap smears
prostate cancer screenings
phenylketonuria

Arizona

Dependent coverage (from the moment of birth, including those who are physically or mentally handicapped, and those who are adopted) mammography
outpatient care
home health care
mastectomy reconstruction
emergency care
diabetes self-management; mail-order pharmacies may not be required
prescription contraceptives (exceptions exist for religious employers)

California

Alcohol/drug/nicotine treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
lead screening for children
preventative care for children
home health care
infertility treatment
mastectomy and other reconstruction
diabetes self-management
pap smears
temporomandibular joint disorder
prosthetic devices
osteoporosis
off-label drugs
DES effects
prostate cancer screening

Colorado

Alcohol treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, and those who are adopted)
mammography
home health care
hospice care
maternity coverage for women
pregnancy complications
prostate cancer screenings
coverage may not be denied to an individual solely on the basis that the individual casually or professionally participates in skiing or snowboarding activities

Connecticut

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
mammography
home health care
comprehensive rehabilitation
occupational therapy
long-term care
metabolic disorders
mastectomy reconstruction
breast implant removal
diabetes
ambulance services
cancer
accidental ingestion of controlled drugs

Delaware

Mental health coverage
dependent coverage (from the moment of birth, including abnormalities)
cancer screening (including Pap tests, mammograms, ovarian cancer, and prostate screenings)
lead screening
children’s immunizations

District of Columbia

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities and preventive care)
mammography
Pap tests

Florida

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
second surgical opinions
HIV testing/infection
fibrocystic breast disease
ambulatory surgical care
mastectomy
reconstructive surgery
home health care
acupuncture
mammograms
diabetes
temporomandibular joint disorders
osteoporosis

Georgia

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
pregnancy complications
mammography
Pap tests
bone marrow transplants
prostate cancer screening
diabetes
heart transplants
outpatient services
osteoporosis
chlamydia screening
pharmacy open choice

Hawaii

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities, those who are mentally or physically handicapped, and those who are adopted,)
maternity expenses if employee covered for past nine months
mammography
in vitro fertilization
contraceptive services
emergency services
telehealth

Idaho

Dependent coverage (from the moment of birth
including abnormalities
those who are mentally or physically handicapped, and those who are adopted)
if mastectomy covered so must mammography be
elective abortions must be excludable
involuntary complications of pregnancy

Illinois

Alcohol treatment
mental health coverage
dependent coverage (from the moment of birth, including those who are mentally or physically handicapped, and those who are adopted)
mammography
examinations of criminal assault or abuse victims
infertility when maternity is covered
mastectomy
reconstructive surgery
nonexperimental organ transplants
treatment for DES children
blood processing
temporomandibular joint disorders
ambulance service
off-label cancer drugs
fibrocystic breast disease
breast implant removal
colorectal cancer screening
diabetes

Indiana

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
mastectomy reconstruction
diabetes self-management
off-label drugs
infant screening exams where maternity is covered
prostate cancer screening
colorectal cancer exams
morbid obesity
pervasive developmental disorders
mental health

Kansas

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities, and adopted children)
mammograms
Pap smears
emergency care

Kentucky

Alcohol treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities)
mammography and reconstruction where mastectomy is covered
ambulatory surgery care
home health care
long-term care
bone marrow transplants
temporomandibular joint disorders
endometriosis
diabetes self-management
off-label cancer drugs
hearing aids and related services

Louisiana

Dependent coverage (from the moment of birth, including abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
Pap tests
ambulatory surgery care
immunizations for children
mastectomy reconstruction
diabetes self-management
prostate cancer screening
emergency care
off-label cancer drugs
outpatient surgery
use of mail-order pharmacies cannot be mandatory

Maine

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities, and those who are adopted)
mammography
home health care
AIDS coverage (cannot be more restrictive than for other illnesses)
mastectomy reconstruction
diabetes self-management
Pap tests
outpatient services
off-label cancer and HIV drugs
prostate cancer screening
breast prostheses for mastectomies
clinical trials
emergency services

Maryland

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities, and adopted children or grandchildren)
hospice care
home health care
child wellness
metabolic disorders
mammograms
infertility if maternity is covered
certain blood products
mastectomy reconstruction
diabetes
prostate cancer screenings
temporomandibular joint disorders
outpatient care
osteoporosis
pharmacy of choice
tuberculosis
off-label drugs
contraceptives
chlamydia screening
hospice care
emergency care

Massachusetts

Alcohol/drug treatment (only if you have more than five employees)
mental health coverage
dependent coverage (from the moment of birth, including abnormalities, and those who are adopted)
mammography
infertility treatments
home health care
pregnancy and childbirth
hospice care
ABMT (treatment for breast cancer)
preventive care for children
enteral nutrition
DES-related conditions
diabetes management
Pap tests
off-label drugs for HIV/AIDS
scalp hair prostheses
cardiac rehabilitation

Michigan

Dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped)
mastectomy reconstruction and prosthetics
emergency care
off-label cancer drugs
hospice care

Minnesota

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
home health care
well-baby care
emergency care
some diabetes treatment
prenatal care
mammograms and other cancer screening
breast-implant-related conditions
reconstructive surgery
exposure to DES
phenylketonuria
port wine stains
Lyme disease
Pap tests
temporomandibular joint disorders
outpatient care
off-label cancer drugs
fibrocystic breast disease
scalp hair prostheses

Missouri

Alcohol/drug treatment
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
mammography
preventive care for children
bone marrow transplants
reconstructive surgery after mastectomy
phenylketonuria
diabetes self-management
speech or hearing loss
elective abortions may be covered only under separate policy riders for which additional premiums are paid

Mississippi

Alcohol treatment
dependent coverage (from the moment of birth, including abnormalities and those who are physically or mentally handicapped)
temporomandibular joint disorders
open choice of pharmacy
off-label cancer drugs
mammography
diabetes
dental anesthesia

Montana

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
mammography
home health care
inpatient care for breast surgery
mastectomy reconstruction
phenylketonuria
metabolic disorders
open choice of pharmacy

Nebraska

Mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped)
childhood immunizations
mammograms
emergency care
off-label cancer and HIV/AIDS drugs
temporomandibular joint disorders
diabetes
abortions only to prevent death of mother
use of mail-order pharmacies can’t be mandatory

New Hampshire

Mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
nonprescription enteral formulas
mammograms
bone marrow transplants
mastectomy reconstruction
diabetes self-management
certain hair-loss prostheses
dental anesthesia

New Jersey

Alcohol treatment
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped)
mammography
Pap smears
second and third (sometimes) surgical opinions
reconstructive breast surgery and prostheses
home health care
blood tests
glaucoma tests
adult immunizations
wellness examinations
childhood immunizations for plans with over 49 enrollees
metabolic disorders
bone marrow transplants
maternity care
hemophilia blood products
diabetes self-management
lead poisoning screenings
prostate cancer screening
colon screening
open choice of pharmacy
off-label drugs
dental anesthesia

New Mexico

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
childhood immunizations
diabetes
Pap tests
ambulance service for childbirth

Nevada

Alcohol/drug treatment
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
mastectomy
reconstructive surgery and prosthetics
enteral formulas and special food products ordered by a physician
diabetes self-management
Pap tests
temporomandibular joint disorders
pregnancy and childbirth

New York

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped and those who are adopted)
mammography
home health care
preadmission tests
second surgical opinions
infertility treatment
preventive pediatric care
prescription enteral formulas
mastectomy reconstruction
maternity care
diabetes self-management
Pap tests
emergency care
nursing home care
hospice care
off-label cancer drugs

North Carolina

Dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted or foster children)
mammography
Pap tests
mastectomy reconstruction
diabetes self-management
prostate cancer screening
open choice of pharmacy
off-label cancer drugs

North Dakota

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
free choice of pharmacy
prostate cancer screening
temporomandibular joint disorder
dental anesthesia

Ohio

Alcohol/drug treatment
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammograms
Pap tests

Oklahoma

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
childhood immunizations
mastectomy reconstruction
diabetes
bone density tests
dental anesthesia
prostate surgery side effects
prostate cancer screenings

Nevada

Alcohol/drug treatment
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
mastectomy
reconstructive surgery and prosthetics
enteral formulas and special food products ordered by a physician
diabetes self-management
Pap tests
temporomandibular joint disorders
pregnancy and childbirth

Pennsylvania

Alcohol/drug treatment
dependent coverage (including those who are mentally or physically handicapped)
annual gynecological exams and Pap smears
mammograms
mastectomy reconstruction and prosthetics
phenylketonuria
diabetes self-management

Rhode Island

Alcohol/drug treatment, mental health coverage, dependent coverage (including those who are adopted)
home health care
pediatric preventive care
mammograms
mastectomy reconstruction and prosthetics
new cancer therapies
diabetes
Pap tests
second surgical opinions
infertility treatments
bone marrow donor testing abortion may be covered only under a separate rider, and only if mother endangered, rape, or incest

South Carolina

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
off-label cancer drugs
gynecological exams
mammograms
mastectomy reconstruction
Pap tests
prostate cancer screenings
emergency care
open choice of pharmacy

South Dakota

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
phenylketonuria
open choice of pharmacy
diabetes self-management
emergency care

Tennessee

Dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
mammography
mastectomy reconstructions
phenylketonuria
diabetes
prostate cancer screening
emergency care

Texas

Alcohol/drug treatment
dependent coverage (from the moment of birth, including those with abnormalities, those who are physically or mentally handicapped, and those who are adopted)
coverage for AIDS (including HIV and HIV-related conditions)
infertility including in vitro fertilizations where pregnancy/childbirth is covered
childhood immunizations
mammograms
mastectomy reconstruction
diabetes
prostate cancer screening
temporomandibular joint disorders
free choice of pharmacy
home health care
telemedicine
emergency care

Utah

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
metabolic disorders
maternity benefits for birth mothers in adoptions
genetic information may not be used for purposes other than treatment

Vermont

Alcohol treatment
mental health coverage
dependent care coverage (from the moment of birth, including abnormalities, those with physical or mental handicaps, and those who are adopted)
mammography
certain cancer therapies
diabetes self-management
home health care
metabolic disorders
craniofacial disorders

Virginia

Alcohol/drug treatment
mental health coverage
dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)
mammography
pregnancy treatment after rape or incest
HDC/ABMT (breast cancer treatment)
Pap tests
temporomandibular joint disorders
emergency care
early intervention therapies for children
open choice of pharmacy
off-label drugs
contraceptives
mastectomy reconstruction
hemophilia
diabetes
prostate cancer screening
cancer pain
hospice care

Washington

Alcohol/drug treatment
dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
home health care
mammography
breast reconstruction
hospice care

West Virginia

Dependent coverage (from the moment of birth, including abnormalities and those who are adopted)
home health care
primary care nursing
rehabilitation services
mammograms
diabetes
Pap tests
temporomandibular joint disorders
emergency care
childhood immunizations
cannot cancel if diagnosed with AIDS

Wisconsin

Dependent coverage (from the moment of birth, including those with abnormalities, those who are mentally or physically handicapped, and those who are adopted)
mammography
diabetes supplies
HIV drugs
home health care
kidney disease treatments
skilled nursing care
maternity care
emergency care
open choice of pharmacy

Wyoming

Dependent coverage (from the moment of birth, including abnormalities and those who are mentally or physically handicapped, and those who are adopted)

###

Alcohol Treatment: http://www.altamirarecovery.com/alcohol-treatment/

Conclusion

What do you think? As always, your thoughts and comments on this Executive-Post are appreciated.

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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Filed under: Health Insurance, Health Law & Policy, Insurance Matters, Managed Care, Quality Initiatives, Uncategorized | Tagged: state health insurance mandates | 6 Comments »

A National Health Insurance Proposal

Posted on November 18, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Transitioning from HIE-to-HIE

Staff Reporters

Did you know that according to the New York Times, on November 12, 2008, Senator Max Baucus (D- Montana) would eventually require everyone – not just children – to have health insurance coverage, with federal subsidies for those who could not otherwise afford it, and possible enforcement through the federal tax-system?

The Proposed Health Insurance Exchange

The proposal would create a nationwide “health insurance exchange” [HIE] where people could compare and buy insurance policies, with an option of private insurance and a new public plan similar to Medicare. Insurers could not deny coverage to people who had been sick, and would be limited in their ability to charge higher premiums because of a person’s age or prior illness.

Adults also Insured

Adults aged 55 to 64 would be able to buy Medicare coverage if they do not have access to a public insurance program or a group health plan; Medicaid would be available to everyone below the poverty level. The State Children’s Health Insurance Program [SCHIP] would also be expanded to cover all uninsured youngsters in families with incomes at or below 250 percent of the poverty level; and legal immigrants would no longer be barred from Medicaid and the children’s health program in their first five years in the United States.

Small Business Assistance

The plan would also offer tax credits to small businesses to help them defray the costs of providing health benefits to employees, and would offer tax credits to individuals and families with incomes at or below four times the poverty level who buy coverage on their own.

Assessment

According to the Dictionary of Health Information and Technology, a health information exchange [HIE] may be defined as:

the mobilization of healthcare information electronically across organizations within a region, community or national infrastructure; especially disparate systems with the aim to facilitate access to – and retrieval of – clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.

So, now it seems that we may be progressing from a health information exchange, to a health insurance exchange [www.HealthDictionarySeries.com]

Conclusion

What do you think? As always, your thoughts and comments on this Executive-Post are appreciated.

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

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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

Filed under: Health Insurance, Health Law & Policy, Information Technology, Insurance Matters | Tagged: HIE | 1 Comment »

Evidence-Based Medicine

Posted on November 18, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

An Emerging Trend Vital to Physicians

[Staff Reporters]

According to Associate Professor Gregory O. Ginn, PhD; MBA, CPA, MEd., of the University of Las Vegas, an emerging trend for all medical providers is evidence-based medicine that offers the promise of improving the quality of clinical services. And, some argue that evidence-based medicine is a trend that will prevail for the foreseeable future.

Definition

According to the Dictionary of Health Insurance and Managed Care, EBM involves the judicious use of the best current evidence in making decisions about the care of the individual patient. Evidence-based medicine (EBM) is meant to integrate clinical expertise with the best available research evidence and patient values. EBM was initially proposed by Dr. David Sackett and colleagues at McMasters University in Ontario, Canada.

Expert Driven Standards of Care

In the past, standards of care were often set by panels of experts. Today, however, there is a greater demand for empirical evidence to establish the efficacy of clinical protocols. Evidence-based medicine can directly affect financial performance because it facilitates the elimination of therapies that cannot be demonstrated to be effective.

Example:

For example, evidence-based medicine can reduce a hospital’s prescription drug costs. Evidence-based medicine may also affect operations management if it shows that multiple approaches to treatment can be efficacious. Of course, in order to accommodate different modalities of treatment, hospitals will need more sophisticated information systems that allow for data integration.

Assessment

Evidence-based medicine may also be used to support another trend, the development of alternative and complementary medicine.

Channel Surfing the ME-P

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: Health Insurance, Managed Care, Practice Management, Research & Development | Tagged: EBM, evidence based medicine | 3 Comments »

Health Economists and the Economy

Posted on November 12, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

“The Not-So-Dismal Science”

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Economics was labeled the “dismal-science” by Thomas Carlyle a century ago. Since then, its tradition of negativity carries into the present recessionary environment. As the corporate credit and home mortgage crisis escalates, the financial and pharmaceutical industries implode and the population ages, hospitals are shuttered, re-sized or merely struggle onward with trepidation. And, daily, the media focuses on the increasing number of our citizens without health insurance.

To “Afflict the Comfortable and Comfort the Afflicted”

Such media coverage is expected entering into a general economic contraction, recession and/or depression for the healthcare sector, and economy as a whole.

But, in their zeal to “afflict the comfortable and comfort the afflicted”, the media victimizes the for-profit class, while it champions public hospitals, not-for-profit clinics and nanny-state medical care. The news is pre-occupied with calamity even when the health sector is fundamentally strong.

A Print Guide for us All

OK, premium print guides like Healthcare Organizations [Financial Management Strategies] know that bad news draws more subscribers than good news.

When all is well, physicians, executives and administrators are not keen on constructive change. There are also fewer reasons to log-on to this Medical Executive-Post blog. It’s all a matter of perspective!

Q: But, why is the media’s take on economic issues so important?

A: Because it has significant impact on how patients view the entire healthcare industrial complex! It influences how doctors, insurers and politicians adjust their own lobbying and legislative initiatives. And, it governs how CFOs invest in capital expenditures, as well.

Historical Review

Yet, media glare on our industry is not new. It began in 1963 with the article “Uncertainty and the Welfare of Medical Care,” and again in 1972 when Nobel Laureate Kenneth J. Arrow PhD shocked academe’ by identifying health-economics as a separate and distinct field. He codified seemingly disparate insurance, econometric, statistical, business and financial management principles for us all. And, he argued that the marketplace was incapable of insuring against the uncertainties we face in the healthcare arena.

Another View

Of course, the opposing viewpoint argues that, without the existence of a competitive market, individuals lose their freedom to choose, or are allowed to consume medical care for “free.” Therefore, the marketplace cannot learn what an individual values most. Nevertheless, to informed executives and our readers and subscribers, Arrow served as progenitor to the modern strategic health advisory era. In 2004, he was awarded the National Medal of Science for his innovative views.

Economy as Excuse for Self-Pity

Unfortunately for some hospitals, disinformation and exaggeration about health economics is just the excuse needed for self-pity, or to reduce or cease operations. “It’s not our fault, we can’t compete in a free-market economy and our patient satisfaction rates are falling. The malaise is sapping our morale”; etc, and ad nausea

A More Positive Approach

For others, there is the more positive proactive track of your editors, contributing authors and enlightened consultants.

Example:

In a recent budget meeting, one young hospital CFO cautioned physician-executives and healthcare administrators to watch every dollar in anticipation of a softening economy. Yet, his more seasoned CEO responded:

“Fiscal prudence is important, but if you are asking me to take my foot off the gas pedal, my position is that we should choose not to participate in this recession.”

He further opined that we all must anticipate changing cycles, recessions and adverse demographics. But, let’s not make it a self-fulfilling prophecy. It is the astute CEO who realizes that strong financial statements lie in effective negotiation skills and the management of revenue cycles.

Subscribe

And conversely, that strong entity management and informed decision-making is the basis of an enhanced revenue cycle. In practical terms, this means understanding the process and targeting core aspects revenue growth to fine-tune and support the entire healthcare enterprise.

And so, if you are not a subscriber to this blog, or to our print journal, we trust you will review, communicate, use and profit from both. Let Healthcare Organizations [Financial Management Strategies] enhance your knowledge of modern [new-wave] health-economics, finance and collaborative medical management and avoid its confusion with the traditional [non-Healthcare 2.0] dismal-science.

PS: Don’t forget to review-read-rave and rant online at this communications forum.

Conclusion:

Your thoughts and comments are appreciated; especially from our print journal guide subscribers and all readers of this professional network.

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

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: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: kenneth arrow | 3 Comments »

Barack Obama and Health Policy

Posted on November 6, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

What Do -U- Think?

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

First it was Nixon’s supply-side national healthcare proposal; then it was managed care and HMO’s; next came HillaryCare, and finally the Republican’s “Contract with America”. So, will the next domestic healthcare policy initiative be; “Obama Care?”

Number 44 is Official

Now, that the United States has officially elected Barack H. Obama – the 44th president with 62 million popular votes – what does it mean to you as a doctor, financial advisor, politician, healthcare administrator, CEO, physician or nurse executive? And, what will this mean for – healthcare policy and administration – patients and virtually all of us going forward?

Election

After nearly two years of campaigning – countless debates about McCain versus Obama’s health plan – and the possibility of reform; the US has a president-elect and put Democratic majorities in both the House of Congress and the US Senate.

Opinions Vary

And so, what do you predict the next four years will bring? This is your chance to reflect, comment, opine and debate. Please share your thoughts, and let’s get a vigorous discussion going. Medical practitioner input is especially appreciated.

Assessment

Don’t forget to integrate your opinions with the current dismal economic scene; include challenges like the aging population, personal biomedical and genetic engineering initiatives, and related competitive healthcare 2.0 concepts. As an inside – or outsider – what is the future?

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated.

Conclusion

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

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Surveys and Voting | Tagged: barack obama | 1 Comment »

Healthcare Business Information Review

Posted on November 5, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Breaking News – “U Can Use”

Staff Reporters

Mental Health Policy: The Senate adopted HR.-6049 with mental-health parity. Bipartisan lawmakers are working to make the bill law before 2009.

Regulations: Under new Medicare regulations, doctors, with a financial stake in hospitals, must tell referred patients about ownership links.

Compliance: CMS proposed October 1, 2011, for full implementation of the International Classification of Diseases, Tenth Revision (ICD-10), code sets.

Policy: Congress [S. 2041 and HR 4854] is considering changes to the False Claims Act that could lead to more vigorous qui tam litigation.

Accreditation: CMS approved Norwegian company Det Norske Veritas [DNV] to accredit hospitals for Conditions of Participation [COP] standards. Authority to also certify ISO 9001 compliance runs, through 2012.

Bankruptcy: Hospitals filing bankruptcy this quarter include: a two-hospital system in Honolulu; one in Pontiac, MI; Trinity Hospital in Erin, Tennessee; Century City Doctors Hospital in Beverly Hills, Lincoln Park Hospital in Chicago, and the four-hospital-system Hospital Partners of America, in Charlotte.

Insurance: First Professionals Insurance Company told the SEC that it held securities with an amortized cost of $4.1 million in Lehman Brothers, $2.1M in American International Group, $2.5M in Morgan Stanley, $2.1M in Washington Mutual and $300,000 in Fannie Mae.

Business: Emdeon, a developer of revenue and payment cycle health management products, acquired the patient statement business of GE HIT.

Finance: Minnesota’s HealthPartners new Web tool provides prices for 83 procedures in its primary care and radiology network.

More info: www.HealthcareFinancials.com print-journal and November 2008 – February 2009 issue: http://healthcarefinancials.com/Nov08Jan2009.aspx

Disclosure: Dr. David Edward Marcinko is the editor of Healthcare Organizations: [Financial Management Strategies].

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Filed under: Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: healthcare business, healthcare economics, Healthcare Finance | Leave a comment »

Exposing Medicare and Insurance Sales Commission Scams

Posted on November 3, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Some Agents and Brokers May Be Cashing-In

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

According to the Associated Press, on October 25, 2008, Medicare Advantage’s agents stand to make $500 to $550 this year. This happens by enrolling a beneficiary into one of their HMO type managed care type plans, while the agents could make another $500 for every year the beneficiary stays with the plan. It represents a financial reward that is raising concerns that agents and brokers will work too aggressively to enroll people into HMO plans that don’t meet their health needs; or where traditional Medicare may be a better personal fit.

CMS to Take Action

Representative Peter Stark (D-California) has urged the Centers for Medicare and Medicaid Services [CMS] to consider capping the commissions, while Kerry Weems, the acting administrator for CMS, said the agency plans to take action soon.

Insurance Policy “Twisting” and “Churning”

According to the Dictionary of Health Insurance and Managed Care, and others:www.HealthDictionarySeries.com:

Policy Twisting is the use of trickery to get someone to lapse an insurance policy and purchase a new one; usually in another company.
Policy Churning is a related fraudulent practice where an agent tricks a policy holder to fund a new one with the same insurer. Important information about the full consequences of their action is dishonestly withheld.

Both tactics are typically done to increase sales agent/broker commission income.

Scam Alerts

Although much more common with life insurance policies, each state has an insurance department that will help you if you think you’ve been scammed. Visit their website or office and you’ll get help on what to do. Many reputable insurance companies will quickly compensate you once it’s established that you were a victim of such fraud. Make sure you don’t waste you time by complaining to an insurer’s branch office. Contact the main office for swift response.

Assessment

America‘s Health Insurance Plans [AHIPs], the trade group representing insurers, encouraged CMS to develop clear and consistent standards, while two of the major players in the program, Humana Corporation and UnitedHealth Group both said that they welcomed regulation of insurance agent commissions. WellPoint and Cigna are the two other major health insurance companies in this country.

Conclusion

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FINANCE:Financial Planning for Physicians and Advisors
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Filed under: "Advisors Only", Health Insurance, Insurance Matters, Managed Care | Tagged: Add new tag, CMS, commissions, insurance agents, medicare | 2 Comments »

Healthcare, Medicine and AIG

Posted on November 1, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Hospitals, Doctors and Insurance Companies Affected

Staff Reporters

The federal government recently announced a $100 billion rescue of American International Group [AIG], the largest insurer in the nation. Those involved in the business of insurance should know that it was the financial services operations and other non-insurance operations of AIG, and not its insurance companies, that forced the federal government to bail them out. Medical professionals should be aware, as well.

How it Happened

According to experts, the reason for AIG’s problems is two-fold. It is partly based in its dealings with credit default swaps, complicated financial instruments that investors use to protect themselves from bond defaults—which also caused the collapse of Lehman Brothers.

Insurers try to keep premiums low and profits high by investing. And while all insurers invest premiums in different forms of assets, AIG invested much of its enormous income in securities that were backed by sub-prime mortgages. As the mortgage-crisis came to a head, the value of those securities fell, creating financial problems for AIG. Insurers, like AIG, who attempted to profit from high risk investments found those investments to be so risky that they failed completely. When the investments failed, the insurer’s operating assets were reduced and it needed a major infusion of working capital. The federal loans, although enormous, are fully backed by saleable assets.

I Have AIG Insurance – Should I be Worried?

Generally no; because of the corporate structure of AIG. The holding company can be experiencing financial problems while the individual insurance company subsidiaries that agreed to insure you remain secure. They have more than adequate reserves to pay the claims anticipated. Each AIG branded insurer is a separate corporate entity that, by law, must maintain funds in secure reserves to pay claims presented.

And yet; First Professionals Insurance Company [FPIC] of Florida, recently told the SEC that it held securities with an amortized cost of $4.1 million in Lehman Brothers, $2.1M in American International Group, $2.5M in Morgan Stanley, $2.1M in Washington Mutual and $300,000 in Fannie Mae.

Will AIG Claims be Paid?

Probably, yes. If the insurer has maintained adequate reserves, as required by state laws, there will be sufficient funds to pay all claims reasonably presented. If the individual insurer should fail, it will be taken over by the state where it is domiciled. If the insurer is faced with a catastrophe that it cannot cover and if your insurance is with an AIG company that is admitted to do business in your state, the state’s Insurance Guarantee Fund will pay your claim up to a limit that is usually no more than $500,000. Of course, there is no absolute certainty in any situation relating to insurance, but the AIG companies are well-funded and very capable of handling all predictable claims.

On the one hand, if the insurer is put into receivership, the state regulator will use the insurer’s own assets to make payments before seeking funds from the insurance guarantee fund which is financed by assessments on all insurance companies that do business in the state. If, on the other hand, the AIG insurer is not admitted to do business in the state but does business through the surplus lines market, you are not protected by a guarantee fund and must be certain the insurer has the assets sufficient to cover any potential losses.

How Do I Determine That My Insurer Has Adequate Assets?

Contact your state department of insurance to determine if the insurer is admitted to do business and is protected by the Guarantee Fund. Also, check your policy; the insurer must tell you in writing if it is not admitted. Contact your state department of insurance to obtain financial documents filed by the insurer.

Assessment

The credit-crunch is on everywhere, and hospitals filing bankruptcy this quarter include: a two-hospital system in Honolulu; one in Pontiac, MI; Trinity Hospital in Erin, Tennessee; Century City Doctors Hospital in Beverly Hills, Lincoln Park Hospital in Chicago, and four hospital system Hospital Partners of America, in Charlotte [See www.HealthcareFinancials.com; November 2008 issue].

Assessment

Finally, conventional wisdom suggests a ratings reveiw of any policy provided the insurer by Bests. It should be at least “A” rated. Review financial ratings of the insurer issued by Standard & Poors. Of course, these have become suspect of late, too! So, search the Internet with a query including the name of the insurer and the words “financial problem.” Be sure to ask your insurance agent or broker.

Conclusion

Your thoughts and comments re appreciated.

Disclosure: Dr. David Edward Marcinko is the editor of Healthcare Organizations: [Financial Management Strategies] www.HealthcareFinancials.com

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

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Filed under: Breaking News, Financial Planning, Health Insurance, Health Law & Policy, Insurance Matters, Investing, Op-Editorials, Risk Management | Tagged: AIG, bankruptcy | 6 Comments »

Long Term Care Insurance [LTCI] Meltdown

Posted on October 8, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Only the Beginning

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

As a Certified Financial Planner™ and licensed insurance agent for more than a decade, I am aware of how much the industry is promoting long term care insurance [LTCI] as one solution to the aging baby boomer crisis. And, there is no doubt that a legion of agents and “advisors”, along with readers of the Medical Executive-Post, are aware of the fat commissions these products produce. Of course, I have been criticized for opinions against this product for some time now, along with a philosophy of personal accountability.

Only the Beginning

And so, it is no surprise that Penn Treaty American Corporation [PTAC], a long-term-care insurance company, recently said it would stop issuing new LTCI policies. PTAC said its primary insurance subsidiary will be considered insolvent unless it can raise at least $100 million by January 1st, and that it will accept letters of interest from prospective investors and purchasers through mid-October, while deciding on a course by the end of the year.

Assessment

According to the Philadelphia Inquirer on October 4, the company needs about $100 million to $120 million to cover reinsurance agreements it intentionally dropped because the cost to keep them was more than the value of the agreements.

Conclusion

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Filed under: Health Insurance, Insurance Matters, Retirement and Benefits | Tagged: LTCI | 15 Comments »

Hospital Charge Reports

Posted on September 26, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Charging the Poor – More?

Staff Reporters

According to a new report from the Agency for Healthcare Research and Quality [AHRQ], on September 18, 2008, hospital charges increased in 2005 – the latest reporting period.

Charges; Not Actual Costs

Hospital charges – what patients are billed for their rooms, nursing care, diagnostic tests and other services; and not actual costs – jumped from $873 billion in 2005 to $943 billion in 2006.

www.HealthDictionarySeries.com

Data Summary and Survey Results

Between 2005 and 2006, hospital charges increased by:

$38 billion to $44 billion – 15 percent for people with no insurance.
$124 billion to $135 billion – 9 percent for Medicaid patients.
$411 billion to $444 billion – 8 percent for Medicare patients.
$272 billion to $287 billion – 6 percent for patients with private insurance.

Assessment

The steep increase occurred even though hospitals admissions increased only slightly, from 39.2 million to 39.5 million. And, it is interesting to note that charges for uninsured and Medicaid patients, those presumably least able to pay and/or protest, rose more than charges for those with private insurance or Medicare?

Conclusion

Your thoughts and comments are appreciated. Is this fair, not fair, an example of “reverse-charge” shifting, or something else?

Related Information Sources:

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

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Surveys and Voting | Tagged: AHRQ | Leave a comment »

The “Balance-Billing” Conundrum

Posted on September 17, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Doctors versus Patients

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Recently, it was reported to the public that millions of patients are paying medical bills they don’t actually owe after being confused about the practices of “balanced billing.” .

Formal Definition

According to the Dictionary of Health Insurance and Managed Care – and others – balance billing [BB] may be defined as:

“The practice of a physician, medical clinic, hospital, ASC or medical provider billing a patient for all charges not paid for by an insurance company or healthcare plan. Balance billing is generally prohibited by managed care plans”.

The story in Business Week, on page 40 by Chad Terhune in the September 8, 2008 issue, goes on to discuss how it’s illegal for doctors, hospitals or labs to bill patients for the difference if they deem the insurance payment too low, but that it happens routinely to the tune of $1 billion each year.

And, healthcare journalist Sarah Arnquist similarly noted the practice with more patient BB horror stories in The Health Care Blog [THCB], a policy and political e-periodical not unlike this Executive Post in format; but not content.

Not a New Problem

However, long before the threatening horror-stories first ran about doctors aggressively pursing collections, maybe even as much as a two decades ago, our network of physicians, attorneys, insurance and risk management experts have been writing about this situation in both peer-reviewed and non-peer-reviewed print and traditional publications.

So, the conundrum is not really a new one. In fact, Medicare first prohibited BB, in 1991. But, its ferocity; pitting patient against doctor, might indeed be an emerging issue. And, it is deeply distasteful on many levels.

Managed Care Contracts

Over the years, managed care has replaced usual, customary and reasonable [UCR] fee-for-service [FFS] medicine with a contracted fee-schedule. Essentially under managed care, an MD can “charge” just about anything s/he might want, but the managed care organization (MSO) will only reimburse up to its maximum contractual allowance as determined by a previously set fee schedule; known as a managed care legal-contract.

In other words, medical providers have pre-accepted a fee schedule and have agreed and been contracted to accept “payment-in-full” for services rendered. And, the greater the difference between the MD charge and the allowable reimbursement, the more the MD will eventually write off as artificially inflated accounts receivables [ARs].

Therefore, there is no “balance-bill” to pay [sans fine print specials, out-of-network provider and venue clauses, etc].

Physician Mindset

Yet, the balance billing mindset continuers by some, especially older, doctors and patients! Why mature docs and patients? It’s because the current and next-generation of doctors, and patients, never practiced or worked in a FS environment, and know little of it?

Now, this might occur benignly; but more often than not today – and in my experience as a multiple-hat wearing medical provider, insurance agent, physician-executive and health economist – it occurs maliciously and greedily; pitting the doctor against patient.

Of course, a common physician defense ploy is the cry: “I didn’t know it was wrong” – or – “my staff was doing the balance-billing; not me.”

Staff Education and Training

So, the doctor’s medical staff is an extension of the physician. And, the physician can become vicariously liable for staff transgressions.

Furthermore, several federal regulations, including HIPAA, the False Claims Act, and OSHA have specific staff training requirements. Failure to provide the required training not only subjects the physician to the risk of employee transgression, but also to the risk of administrative discipline for failure to conduct proper training of staff.

Patient Mindset

Now, since most patients receive health insurance their employers, it seems odd that some remain so naive about this conundrum; ethics aside. I mean, managed care has been around for almost 20 years now, and its risks and benefits are well known. Contract-medicine did not begin yesterday.

And so, where have such gullible patients been living? In a hole void of newspapers, magazines, TVs and the internet? What about their neighbors, gossip, HR advisors or benefits departments at work? I know of Corporate America, and have participated in several educational programs where employees are informed of their duties and responsibilities in this managed care contracted world.

And so, at the risk of sounding harsh, I often wonder where have these souls been?

In other worlds; naiveté has a price and if you don’t look out for yourself; who will ultimately look out for you? No one! So, get a clue, already! It’s 2008; not 1988.

The Offensive Plan

As a patient, if this occurs to you, as it did to me when I once visited an out of state optometrist who tried to BB me while on vacation, you might consider the following pre-emptive strike. Forewarned is forearmed and it is far better to play offense, than defense, with these aggressive and greedy docs:

Read and understand your managed care plan contract. Know your duties and responsibilities. Follow the rules.
Privately inform your medial provider that you are aware of the “contract-medicine” concept.
Confidently tell the provider to put the BB invoice in writing, under his personal signature.
Whisper to him/her you will fax it to your employer, third-party payer, attorney, IRS, OIG, DOJ and/or insurance commissioner for a collegial second-opinion check.

Finally, once the problem has been resolved, politely inform the provider that true BB is illegal; and suggest that if your health plan’s compensation is too low, he/she should not re-enlist on the plan.

Outcome

This was all I had to do, as the flustered provider apologized to me, citing personal and staff ignorance. Of course, I then told him of my credentials and my doubt about his “excuse”; but was willing to give him “benefit-of-doubt” this time. No harm-no foul, I reckoned.

Assessment

By personality – maternal side – I tend to employ the passive-aggressive posture of conflict resolution. So, always be knowledgeable but respectful, polite and most of all ‘umble; just like David Copperfield’s fictional character, Uriah Heep.

And, although there will always be miscreant doctors who try to game-the-system, according to David McKalip MD, Chair, Council on Medical Economics [CME] for the Florida Medical Association [FMA], “A free market with price transparency, quality accountability and private contacting between patient and doctor, is the answer” to the unfortunate balance-billing conundrum.

Conclusion

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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: Health Insurance, Practice Management, Research & Development | Tagged: balance-billing | 15 Comments »

How Doctors Get Paid

Posted on September 12, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

It’s all about Flow [Part 1]

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Most patients don’t have a clue about how doctors get paid; it’s not by magic.

Yet, a number of different steps occur during the processing of a medical claim as can be seen in the flow chart below. Each step within the process can be mapped out and each is subject to claim payment-or-claim abortion or rejection.

The steps can also be subjected to a number of variables, depending on a number of different factors including staff competency, time, outside vendors, information management, management decisions in general, or regulatory requirements.

Flow Chart

Of course, any one of these points could lapse, causing the entire process to break down. Like treating patients, when the process has no variables, the end result is very predictable, such as in the flow chart below. When there are variations the end results can be very different.

Treatment is Only the Beginning

Doctor gets the chart

↓

Doctor evaluates patient

↓

Doctor documents visit

↓

Doctor marks billing slip

↓

Doctor gives slip to patient

↓

Patient gives slip to billing clerk

↓

Billing clerk enters information into computer

↓

Office staff submits claim to insurer

↓

Third party payor/Insurance company receives claim

↓

Insurer adjudicates claim

↓

Reimbursement transmitted (electronic or mail) to practice

↓

Reimbursement entered (posted) into practice management system by office staff.

There are two things that you need understand in order to implement an efficient compliance program.

1] The first is the processes needed to run the organization and the desired outcome of those processes.

2] And second, if the process needs improvement, what can be done to make the process function better?

Office Efficiency Checks

Most small medical and dental practices or clinics have a number of checks and balances in place to control variation.

In an example of an inefficient operation, one practice had the physician-executive open every envelope that came into the office. This was done because of a concern that if someone else did it, then something could go missing.

However, the doctor would then turn the mail over to the payment posting person, who would enter claims into the system. Sometimes the person who entered the claims would become busy with other duties and would not be able to enter claims for a couple of days. This proved to be an inefficient method of managing the billing process for the organization.

Assessment

A possible solution is to have one person in the front office to open the mail, organize the contents based on who needs to deal with the information (such as claims, refusals, or requests), and then distribute them accordingly.

More on how physcians get paid.

Part 2: https://medicalexecutivepost.com/wp-content/uploads/2010/02/how-doctors-get-paid-in-2010.pdf

Conclusion

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***

Invite Dr. Marcinko

Filed under: Health Economics, Health Insurance, Healthcare Finance, Practice Management | Tagged: super bill | 18 Comments »

Determining Medical Fees

Posted on September 11, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Reflecting Worth and Reality

By Dr. David Edward Marcinko; MBA, CMP™

Despite changes in insurance models, a healthcare provider’s fees should reflect what the doctor feels his or her services or procedures are worth. The type of insurance that the patient has should not play an influencing factor in either the fee determination or services rendered.

Additionally, fees should not vary based on the patient’s insurance type, or what the patient’s managed care contract determines is the maximum payable allowance.

Deterring Factors

Determining a professional fee for a given service takes into account many factors including the professional work performed, non-clinical work performed, unusual skills required, time for service, practice expenses (e.g., staff salaries and benefits, disposable items, rent, utilities, etc.), risk, as well as direct (surgical global care) and indirect (communicating with other health professionals, laboratory finding evaluation, review of x-rays, etc.) follow-up care.

Provider Determined

In establishing professional fees, the operative phrase is “provider determined.” While the input from knowledgeable experienced staff is certainly desirous, the ultimate responsibility for determining fees rests on the shoulders of the healthcare professional providing the service. Of course, the medical treatment administered, and for which reimbursement is sought, is assumed to be performed on the basis of medical necessity and effectiveness.

The Import

So why are reasonable fees and reimbursement for services important?

Well, medicine is a business whether physicians like to admit it or not. Businesses that are not profitable do not remain businesses for long. Today, most healthcare professionals will admit they are working harder, more hours, seeing more patients to maintain practice revenues. Even so, in many cases, expense increases are outpacing revenue increases. In an age of managed care, even Marcus Welby, MD would have to work harder.

Getting Started

Actually reviewing the annual Medicare rules and regulations found in the year ending Federal Register is a good place to start. That issue printed between November 1 and December 15 of each year lists all the CPT® codes and their Centers for Medicare and Medicaid Services (CMS) (formally Health Care Financing Administration-HCFA) determined relative value units (RVUs). The RVUs are procedure comparable.

Case Example:

You can assume if, for example, a free muscle flap procedure using microvascular techniques is valued at 68.65 total RVUs, it would be relatively more complicated procedure than a simple repair of a small laceration at a total 4.34 RVUs. You would price your procedure fees accordingly.

Generally, if a managed care allowance exceeds what you have billed; your fee is unreasonably low. The true test of reasonableness is your comfort (emotional as well as economic) level in charging the cash patient the same fee. If you feel it is in the “reasonable” range, and you are not consistently writing off 98% of your charges, it probably is reasonable. Under a managed care fee schedule, the service billed amount generally only has significance when the fee charged is less than the contract allowance.

Assessment

In that case, the MCO allowance is reduced to the lesser amount billed. The physician’s fees should not be lower than the highest contractual reimbursement rate.

Conclusion

Your informed opinions and comments are appreciated. How do you determine professional medical provider fees?

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Practice Management, Practice Worth | Tagged: medical fees | 1 Comment »

Medicare Benefits Report

Posted on September 11, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

2007 Payment Services Review

Staff Reporters

In 2007, benefit payments for the four parts of Medicare totaled $426 billion and allocated as follows:

Part A: Hospital Insurance = 41% (includes home health which is partially funded under Part B)

Hospital Inpatient = 30%
Skilled Nursing Facilities = 5%
Home Health = 4%
Hospice = 2%

Part B: Supplemental Medicare Insurance = 28%

Physicians and other suppliers = 20%
Hospital Outpatient = 4%
Other Part B benefits = 4%

Part C: Medicare Advantage (private health plans) = 18%

Part D: Prescription Drug Benefit = 12%

Payments to Drug Plans = 7%
Low-Income Subsidy Payments = 4%
Payments to Union/Employer-Sponsored Plans = 1%

Note: Does not include administrative expenses such as spending for implementation of the Medicare drug benefit and the Medicare Advantage program. Total is net of $8.1 billion in recoveries for 2007.

Data Source: Congressional Budget Office, Medicare Baseline, March 2008.

Publication: Medicare Spending and Financing Fact Sheet; September 2008. The Kaiser Family Foundation.

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Filed under: Drugs and Pharma, Health Insurance, Healthcare Finance, Monthly Reports, Research & Development | Tagged: medicare | 1 Comment »

Medical Coding Definitions

Posted on September 10, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding CPT® Methods

By Patricia Trites; PhD

www.HealthcareFinancials.com

The American Medical Association Physicians’ Current Procedural Terminology manual (commonly known as the CPT® manual) is the recognized coding manual used by healthcare providers to bill third party payers.

CPT Codes

No quantitative values are assigned the CPT® codes contained within the CPT® manual. Each third party payers determines a value, whether a direct dollar or unit value, for each CPT® code. Each CPT® code represents a service, procedure, test, or study.

The CPT® manual attempts to define each of the codes specifically by individual descriptive phrases, and generally utilizing guidelines, rules, and definitions related to code groupings: medical, surgical, pathological, and diagnostic services. Third party payers develop for internal use additional protocols, guidelines, rules and definitions.

Assigned Values

The value assigned to each CPT® code is based on a determined amount of work, practice expense and risk inherently bundled into the service or procedure. Each procedure or service is further defined as a body of work made up of multiple lesser components all valued within the main CPT® code.

Case Example:

As an example, if the surgical lengthening of a leg tendon is the main procedure to performed, it would be assigned a unique CPT® code. Within the tendon lengthening code definition and assigned value would be included (bundled or “packaged”) seemingly obvious lesser procedures available to the surgeon in achieving the ultimate goal of the tendon lengthening. These lesser procedures include the incision itself, retraction of vital structures, tying off small vessels, suturing the tendon in a lengthened position, closing the soft tissue in layers, suturing the skin, application of a dressing, and application of a posterior splint.

Modifications

While some surgeons in a particular case may not need to tie off small vessels because no vessels interfered with the surgical exposure, or maybe they had to tie off two more vessels than they usually have to do, or they may elect not to apply a posterior splint, or the procedure takes twenty minutes more because a required instrument falls on the floor and needs to be re-sterilized, the overall code value of the tendon lengthening procedure does not change.

Essentially with the exception of minor modifications, one way or another, the main procedure remains essentially the same. Those minor modifications or variations in technique would be included in what would be called the global surgical description and allowance. Not all potential secondary or minor procedures need to be performed to fully reimburse the primary procedure.

Billing Fragmentation

The fragmentation, breakdown or unbundling of the main or primary procedure through the billing of each secondary procedure is billing abuse at best, intentional double billing at worse. Bundling is also addressed in the Correct Coding Initiative [CCI] issued by the Centers for Medicare and Medicaid Services [CMS]. This is a quarterly publication that lists the procedures and/or services that cannot be billed on the same day for the same patient.

Assessment

Healthcare providers intentionally billing unbundled services may be committing fraud or abuse.

Conclusion

Your thoughts and comments are appreciated.

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Managed Care, Practice Management | Tagged: CPT codes | 1 Comment »

Health Insurers Secrets

Posted on August 31, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Seven Things you don’t Know about Health Insurance

By Staff Reporters

“Myth Busters”

Wrapped up in all the noise these days are myths on health insurance that were perhaps once true – or maybe never were.

So, here’s a look at seven things you probably didn’t know about your health insurer.

Link: http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/7SecretsOfHealthInsurers.aspx

Conclusion

Your thoughts are appreciated; especially from insurance agents, industry insiders and medical providers; please opine and comment.

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The NPI and One DDS’s Opinion

Posted on August 25, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

A Dentist Offers his View on the NPI Deadline Issue

By Darrell Pruitt, DDS

I have a unique perspective of the National Provider Identifier [NPI] issue.

As a dentist who has no contracts with any insurance company, I refuse to apply for an NPI number. Legally, I am not compelled to “volunteer” for the number, regardless of whether it is a mandate or not. HHS does not license dentists. States do. Texas says that it is fine by them for me to practice here on the east side of Fort Worth.

Why Volunteer?

Why should I volunteer for the NPI mess?

The NPI does nothing to improve the quality of care I provide. It benefits only payers, and any time anyone fouls up at National Plan & Provider Enumeration System [NPPES], it can only mean one thing – payments will be delayed, earning insurers even more interest on money meant to pay for work already done and long gone out the door.

I should remind you that inflation is due to soar soon as well, making the reimbursement worth even less to the provider the longer it is delayed.

The IRS

And, there is more.

I assume you heard about the IRS sticking their fat fingers into the pie. That happened just recently, completely unexpectedly.

Now the IRS can delay claims as well if one has an NPI number. What a mess. Why would I want to be part of it? If having an NPI forces me to raise my fees, it hurts my patients.

Part of the Hippocratic Oath is to do no harm. It is clearly unethical for a doctor to have an NPI number. Allow me to show you how far ethics will take a Texas dentist these days.

My Situation

Since I am not on any managed care plans, my BCBSTX-covered dental patients who I have treated for years did not pick me off of BCBSTX’s annual preferred provider list. They chose my practice as a consistent dental home, year after year, because they were more than likely referred by a satisfied patient.

When the BCBSTX agents sold my patients’ employers their dental plans, the insured was told to tell employees that they could see any dentist they choose. This is called a traditional indemnity plan, which honors freedom of choice as opposed to the cheaper managed care plans that penalize clients for not going to dentists that the insurance company prefers.

The Managed Care Misnomer

Calling managed care in dentistry “insurance” is a misnomer. It is actually nothing more than a discount dental brokerage service with annual lists of the lowest bidders in the market, and there is no quality control.

Until recently, I have had an unwritten agreement with BCBSTX that I would honor their insurance by allowing their clients to pay only their estimated part of the dental bills, and I would wait for BCBSTX’s share to come later in the mail – however long that takes.

That is called “accepting assignment,” and it is based on trust between dentists and BCBSTX, and is a favor to patients, not a requirement.

I have to say that BCBSTX is so slow at paying their part of their clients’ bills that patients would soon become very impatient if they had to wait as long for their money as I have to wait for mine. My practice, as well as my patience, can tolerate delays … up to a point.

In the end, if a claim is unreasonably delayed by an insurer, I can ultimately call on the state insurance commission to fight for fairness for my patient. Who can I complain to if payment is delayed by the IRS?

Assessment

In the last week, BCBSTX rejected three of my claims because I don’t have an NPI. What am I to do?

Ultimately, I may have to go against my own ethics and apply for an NPI number in order to stay in business.

The NPI does nothing to improve the quality of care I provide to my patients. It only delays payment.

Conclusion

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Filed under: Health Insurance, Information Technology, Op-Editorials, Practice Management | Tagged: NPI | 6 Comments »

Physician Owned Hospitals

Posted on August 24, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

New Patient Disclosure Rules

Staff Reporters

According to Bloomberg News, August 19, 2008, doctors with financial stakes in hospitals where they work must tell patients being referred to those facilities about the ownership link, under new rules from Medicare.

Patient Queries

Patients who ask about investors in a physician-owned hospital must be furnished with a list of all doctors, and their immediate family members, who own or have an investment interest and make referrals.

Assessment

Medicare is seeking to make it harder for doctors to boost their payments by referring patients to their own facilities; and it already bars self-referrals for 11 services. The agency said it would end reimbursement agreements with physician-owned hospitals that don’t follow the new disclosure requirements.

Conclusion

What do you think about this, “if they don’t ask – don’t tell” policy; your informed opinions and comments are appreciated. Is it too much disclosure, or not enough?

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Domestic Healthcare Access Survey

Posted on August 9, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Still an Elusive System for Many

[By Staff Reporters]

Access to health care in the United States continues to elude more and more Americans, and the nation’s health care system hasn’t improved overall, even though the U.S. spends more on medical care than any other industrialized nation, a new Commonwealth Fund survey shows.

The Study

The authors compared average performance in the United States to those of top-rated performers across the country and abroad. Overall, the U.S. score averages just 65 out of a possible 100, falling far short of benchmarks with wide gaps in all dimensions of the health system, while the score was lower than that achieved in the Commonwealth Fund’s 2006 scorecard, according to HealthDay, on July 17, 2008.

Efficiency Scores Low

For example, scores for efficiency were particularly low, held down by fragmented, poorly coordinated care; lack of access that leads to avoidable hospitalizations; variations in costs with no return in quality; lack of investment in information technology; and very high insurance overhead costs.

USA is Dead-Last

Although no pun is intended, the United States is now “dead-last” among 19 industrialized nations in premature deaths that might have been prevented by better access to health care. In 2006, the United States was 15th on the list.

The scorecard also found that health care varies widely from state to state, region to region, and from one hospital and health plan to another, while the difference between the best and worst performers can be as much as fivefold.

On the positive side, mortality rates in hospitals improved 19 percent over the past five years, the result of concentrated public-private efforts to improve hospital safety.

Related Findings also Disappoint

Related other findings of the scorecard included:

Basic preventive care hasn’t improved, with only 50 percent of all adults receiving recommended preventive care, such as cancer screenings.
Health insurance premiums continue to rise faster than wages. In 2007, 41 percent of adults said they had medical debt or trouble paying medical bills, up from 34 percent in 2005.
The number of primary care doctors using electronic medical records rose from 17 percent in 2001 to 28 percent in 2006, but this gain still lags some other countries where 98 percent of doctors use electronic records.

Assessment

Disparities in health care continue to be pervasive, with minority, low-income and uninsured adults more likely to wait to see a doctor and encounter delays and poorly coordinated care. Also, they have worse dental care, more uncontrolled chronic disease, more avoidable hospitalizations, and worse outcomes.

Conclusion

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Prescription Data-Mines and Insurance “Credit-Reports”

Posted on August 7, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

The End to “Rx” Privacy?

[By Staff Reporters}

Collecting and analyzing [HIPAA protected?] personal health information [PHI] in commercial databases is a fledgling, but exploding industry, despite privacy concerns.

Industry Leaders

For example, Milliman’s IntelliScript provides personal drug profiles to insurers. And, Ingenix’s MedPoint is owned by UnitedHealth, the corporation that owns UnitedHealthCare. UHC is also the nation’s second-largest health insurance company.

Large Data Bases

Both firms created their large profiles by mining rich databases of prescription drug histories [eRXs], kept by pharmacy benefit managers [PBMs], which help insurer’s process drug claims. The data-base then aggregates and ranks the information, based on the drugs and dosages, dates filled and refilled, therapeutic class, and the name and address of prescribing doctor; etc. Higher scores imply higher health insurance premium costs.

Thus, prescription data is used to “rate” or economically judge potential insured patients via these “health credit-reports.”

***

Assessment

And so, while politician’s debate how to regulate electronic medical records [EMRs], and attorneys monitor HIPAA policies, some health insurers have already begun tapping into other information sources such as clinical and pathological laboratories, as well. And, other sources are sure to follow.

Conclusion

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Filed under: Health Insurance, Health Law & Policy, Information Technology, Risk Management | Tagged: credit reports, HIPAA, PBMs, PHI, prescription privacy | 2 Comments »

Medicare GAO Report on Radiology

Posted on August 5, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Prior Imaging-Authorization Suggested

Staff Reporters

As reported in the Wall Street Journal, on July 14, 2008, Medicare may be soon requiring prior authorization to curtail unnecessary utilization of CT scans, MRIs and other forms of medical imaging, a new Government Accounting Office [GAO] report suggests.

The Medicare Report

To cut imaging costs, Medicare has been reducing certain physician payments, sifting through its data to spot improper claims, and educating medical practitioners about the issue. But, the GAO reported that post-payment claims review alone is inadequate to manage medical imaging – one of the fastest growing parts of Medicare – and suggests that Medicare include prior authorization as a possible front-end tactic.

The Findings

The GAO pointed to new evidence of imaging overuse in physician practices, including:

The proportion of Medicare spending on in-office imaging rose from 58 percent to 64 percent from 2000 to 2006.
Imaging became an increasingly large slice of doctors’ revenue pie. For example, cardiologists got 36 percent of their total Medicare revenue from in-office imaging in 2006, compared with 23 percent in 2000.
In-office imaging spending per Medicare patient varied widely nationwide in 2006, from $62 in Vermont to $472 in Florida.

Assessment

What might proponents of the classic Dartmouth Study on healthcare quality say about these findings?

Conclusion

Please comment on the above; opinions from health economists, actuaries and our radiology colleagues are especially welcomed.

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: Career Development, Health Insurance, Health Law & Policy, Healthcare Finance, Insurance Matters, Managed Care, Practice Management, Quality Initiatives, Surveys and Voting | Tagged: GAO, radiology | 2 Comments »

Patients Challenging Medical Invoices and Bills

Posted on August 5, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Root Cause is Money, Failure-to-Disclose and Frustration

[By Staff Reporters]

Patients are challenging their medical bills with lawyers and lawsuits, out of frustration about the lack of up-front disclosure over costs by doctors and hospitals.

Involve More than a Few Cases

For example, after being charged $82,282 for a 23-hour stay in doctor-owned Westfield Hospital for two operations on her abdomen, a 56-year-old West Penn Township woman called the hospital and her insurer for an explanation.

Not satisfied with the response, she hired a lawyer and notified a reporter, after which Westfield officials said she was overcharged due to human error.

In another 2006 class-action Seattle lawsuit that was expected to have a ripple effect on consumers and hospitals, two patients of the Virginia Mason Medical Center filed suit against the center and won, after which Virginia Mason agreed to pay back an estimated $60 million to more than 3,200 patients who over six years had been charged ”overhead” for procedures performed in hospital-owned clinics – in some cases adding 60 percent to the price patients would have been charged for the same procedure performed by the same doctors in their offices.

Assessment

Although private legal action over medical bills is hard to track, the number of billing and coverage complaints filed with the Pennsylvania Attorney General’s health care unit has risen steadily, with the 2,000 or more complaints so far this year representing a five or six percent increase over last year; according to Morning Call, July 13, 2008.

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: Health Insurance, Health Law & Policy, Healthcare Finance, Professional Liability, Risk Management | Tagged: Add new tag, medical bills, medical invoice | 3 Comments »

Blue Cross – Blue Shield Administrative Survey

Posted on August 3, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Cost Trends Demonstrate a Decline in 2007

By Douglas B. Sherlock; CFA

PRESS RELEASE REPORT

Gwynedd, Pennsylvania

The per-member [pm] administrative cost growth for BC/BS declined from 6.1% in 2006, to 4.3% in 2007. Adjusted to eliminate the effect of a shift in product mix, administrative expense growth declined from 6.5% in 2006 to 2.5% in 2007. Administrative expenses were 10.4% of premium equivalents in 2007. And, plans reported total administrative expenses of $25.36 PMPM.

All cited values exclude investment and non-operating income and expense, income taxes and miscellaneous business taxes.

Sherlock Expense Evaluation Report

These results are excerpted from the Sherlock Expense Evaluation Report, a benchmarking study comprising the results of 23 Blue Cross Blue Shield Plans surveyed by the Sherlock Company. More than 90% of participants also participated in the prior year’s survey and nearly 80% have five or more years of experience participating in our benchmarks.

Benchmarks and Metrics

The Sherlock Company benchmarks include thousands of operational and financial performance metrics. Besides Blue Plans, other universes include Independent / Provider-Sponsored plans, Medicare Advantage plans, Medicaid plans and larger plans. Collectively, the 46 plans serve approximately 36 million insured Americans.

Administrative Growth

The growth in administrative expenses ranged from a high of 10.0% for Medical and Provider Services to a low of 0.2% for Corporate Services.

In fact, the Sherlock Company said that, “The increasing emphasis of these Plans on Medicare Advantage had a profound effect on their expense trends. After holding constant the product mix, corporate service costs per member declined by 6.2% and provider and medical management costs increased by 2.2%.”

Assessment

Additional information is available in the Sherlock Expense Evaluation Report. We have also published a summary in July 2008 edition of the Plan Management Navigator accessible at www.sherlockco.com/docs/navigator/navigator-08-07.pdf

Conclusion

Your thoughts and comments on the above findings are appreciated? Do they agree, or disagree, with your factual or heuristic cost impressions of this institutional space?

###

The Sherlock Company www.sherlockco.com based in Gwynedd, Pennsylvania, provides informed solutions for health plan financial management. Since its founding in 1987, Sherlock Company has been known for its impartiality and technical competence in service to its clients.

Contact: Douglas B. Sherlock; CFA for more information.

215-628-2289, sherlock@sherlockco.com or visit www.Sherlockco.com

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Monthly Reports, Surveys and Voting | Tagged: Sherlock Company | Leave a comment »

Consumer Health Plan Satisfaction Survey

Posted on July 20, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

New Deloitte Center for Health Solutions Survey

Staff Reporters

Nine out of 10 Americans are not completely satisfied with their health plans, according to “The Deloitte Center for Health Solutions 2008 Survey of Health Care Consumers.”

The Survey:

According to the survey of what more than 3,000 Americans thought about a variety of healthcare issues; these findings were reported:

73 percent are interested in accessing information about quality or price from their health plans,
78 percent would rather customize their insurance by selecting the benefits and features they value, rather than choose their plans from a few pre-packaged options,
78 percent are interested in online access to medical records and test results,
76 percent want e-mail communication with doctors,
72 percent support online office visit scheduling, and
46 percent would like a software program or web site [cloud computing] to create a personal health record.

Assessment

Tommy Thompson, senior advisor at Deloitte and former secretary of health and human services in the Bush Administration, said dissatisfaction with health plans should serve as a wake-up call for health insurers to offer more quality and transparency information; according to HealthLeaders Media, June 20, 2008

Conclusion

Is there a disparity-gap in this study between provider and patient opinions; or is it more accurate than not? Please comment?

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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Filed under: Health Insurance, Managed Care, Quality Initiatives, Surveys and Voting | Tagged: health plan satisfaction, healthcare consumer, patient satisfaction | Leave a comment »

RAC Contractors to be Identified

Posted on July 19, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

CMS Aims to Reduce Fraud

[By Staff Writers]

This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.

The RAC Program

Under the so-called Recovery Asset Contractor [RAC] program, CMS pays auditors a fee based on the amount of improper payments discovered.

Hospital officials worry this “bounty hunter” approach – the second for CMS after medical practice audits – will create a bias in auditors to focus only on collecting government overpayments, reported the Pittsburgh Business Times on June 16, 2008.

Pilot Program Results

Some hospitals point to a pilot audit program in New York, Florida and California, which found $357.2 million in overpayments and just $14.3 million in underpayments. Medicare estimates its error rate at 3.9 percent in 2007, down from 9.8 percent in 2003, but still totaling $10.8 billion in improper payments

Assessment

Is this another instance of brute intimidation or just honest review?

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: Health Economics, Health Insurance, Healthcare Finance, Insurance Matters, Practice Management | Tagged: CMS, Health Economics, health fraud, Healthcare Finance | 7 Comments »

Doctors Unite!

Posted on July 10, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

On the “Open Letter from America’s Physicians”

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

As we have seen in this healthcare-charged election season, almost every form of political activism or debate has moved online. So, it is no surprise that a coalition of disgruntled physicians would electronically socialize and network together, as seen with www.sermo.com

About Sermo – Peer 2 Peer Doctor Network

First billed as a physician’s only online community, where 65,000 doctors around the nation exchanged the latest medical insights with each other to improve patient clinical outcomes, some portions of the Sermo community have morphed into a kind of political action committee [PAC] representing a particular flavor of zealot doctor activist.

Political Activism

And, not to miss out on a marketing opportunity, Sermo has allowed itself to be used as a vehicle for an open letter signed by physicians, decrying the state of domestic healthcare, that’s only going to get more public.

According to Mr. Matthew Arnold of Medical Marketing & Media, the letter is a physicians’ manifesto of sorts, composed by selected Sermo doctors demanding an end to intrusive insurers and overzealous regulators. To date it has garnered 5,200 signatures in the several weeks since it was posted on www.mmm-online.com

So, You Want a Revolution?

According to Arnold, “There’s a sense of revolution in this,” said Dr. Daniel Palestrant, founder and CEO of the physician social networking site, which boasts around 70,000 members. “It’s doctors coming together for the first time, voicing discontent with the representation they’ve had to date, and making it clear to the public that the quality of care is going to be suffering based on some of these outside forces.” http://www.mmm-online.com/Fed-up-Sermo-docs-draft-manifesto/article/112006

Doctors Unite

The “Open Letter from America’s Physicians,” hosted at www.doctorsunite.org blames “The insurance industry’s undue authority and oppressive control over healthcare processes,” “Excessive and misguided government regulation” and “The practice of defensive medicine in response to a harmful and costly legal environment” for America’s healthcare crisis, and vows: “We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients’ health have absolute control.”

Assessment

As almost every other form of political activism has moved online, don’t be surprised to see more websites, blogs, wikis or social e-communities like this. Of course, if the details get specific, it’s tricky to know whether the coalition of disgruntled doctors will stay together, and/or whether Sermo will emerge as representing a new breed of doctor “turned-political-pundit.”

Conclusion

And so, is political activism an appropriate initiative for the medical community; why or why not?

Might it be considered more self-serving; or more patient centric? Your thoughts and comments are appreciated.

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

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 or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Filed under: "Doctors Only", Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Op-Editorials | Tagged: Add new tag, sermo | 3 Comments »

The Cure for Claims Campaign [CCC]

Posted on July 9, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Reducing Healthcare Administrative Burdens and Costs

Staff Writers

To help reduce the administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association [AMA] recently launched the “Cure for Claims” Campaign [CCC] and unveiled the first AMA National Health Insurer Report Card on claims processing.

Goals

The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, as physicians divert substantial resources – as much as 14 percent of their total revenue – to ensure accurate insurance payments for their services.

The National Health Insurer Report Card [NHIRC]

The AMA’s new National Health Insurer Report Card provides physicians and the public with information on the timeliness, transparency and accuracy of claims processing by health insurance companies. Based on a random sample pulled from more than 5 million electronically billed services, the NHIRC examines the claims processing performance of Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.

Study Results

According to the June 16, 2008 AMA study:

There is wide variation in how often health insurers pay nothing in response to a physician claim (from less than 3 percent to nearly 7 percent), and in how they explain the reason for the denial. There was no consistency in the application of codes used to explain the denials, making it expensive for physician practices to determine how to respond.
Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
More than half of health insurers do not provide physicians with the transparency necessary for an efficient claims processing system.
There is wide variation among payers as to how often they apply computer generated edits to reduce payments (from a low of less than .5 percent to a high of over 9 percent). Payers also varied on how often they use proprietary rather than public edits to reduce payments (ranging from zero to as high as nearly 72 percent).

Assessment

The use of undisclosed proprietary insurance claims edits, only serve to inhibit the flow of transparent information to physicians, adding additional administrative costs to reconcile their health insurance claim issues.

Conclusion

Your thoughts and comments are appreciated. Will likely outcomes of the CCC and NHIRC be real, or illusionary?

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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Filed under: Health Insurance, Healthcare Finance, Quality Initiatives, Surveys and Voting | Tagged: health claims, Health Insurance, medical billing, medical invoice | 1 Comment »

Survey on Convenient Care Medical Clinics

Posted on June 8, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Possible Solution to the Healthcare Dilemma?

Staff Reporters

Another new survey suggests that convenient care medical clinics (CCMCs) could be a potential solution to health care issues, if fears can be alleviated; at least in the Keystone State.

The Survey

The survey by Widener University in Elder Pennsylvania, found that while baby-boomers aged 43 to 64 were most interested in using these clinics, many also expressed concerns regarding the quality of care likely to be delivered.

Aged played a significant role in a person’s likelihood of using a CCMC: among respondents aged 43 to 49, more than half (54 percent) were very likely or somewhat likely to use the clinics, while that number dropped to a mere 25 percent among those over 80 years of age.

Assessment

Access to health insurance influences an individual’s likelihood of using a CCMC: the percentage of respondents who were very likely or somewhat likely to use a CCMC was higher among individuals without health care insurance, than among those with insurance (65 percent versus 40 percent).

Women in the survey indicated they were very likely to worry about misdiagnosis (25 percent), yet they were more inclined to use these types of facilities than men (43 percent versus 37 percent).

Please visit related Executive-Posts for more information on this emerging topic.

Conclusion

Your thoughts and comments on the above survey are appreciated? Is the CCMC concept revolutionary, or merely evolutionary, and how do DNPs fit in the model?

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

Referrals: Thank you in advance for your electronic referrals to the Executive-Post.

Filed under: Career Development, Health Economics, Health Insurance, Insurance Matters, Managed Care, Quality Initiatives, Surveys and Voting | Tagged: retail clinic surveys | 1 Comment »

Paying for Health Care and Insurance

Posted on June 6, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

New Survey Reveals 28% Report Financial Problems

Staff Reporters

A new survey by the Kaiser Family Foundation recently asked this question.

Q: As a result of recent changes in the economy, have you and your family experienced any of the following problems, or not? Was this a serious problem, or not?

A: Results are included in the summarized chart below.

	Percent saying each was a “serious problem”
Problems paying for gas	44%
Problems getting a good-paying job or a raise in pay	29%
Problems paying for health care and health insurance	28%
Problems paying your rent or mortgage	19%
Problems paying for food	18%
Problems with credit card debt or other personal debt	18%
Losing money in the stock market	16%

Source: Kaiser Family Foundation Health Tracking Poll: Election 2008 (conducted April 3-13, 2008). www.kff.org.

Conclusion

Your thoughts, opinions and comments are appreciated?

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

Referrals: Thank you in advance for your electronic referrals to the Executive-Post.

Filed under: Health Insurance, Healthcare Finance, Research & Development, Surveys and Voting | Tagged: Health Insurance, Healthcare Finance | 1 Comment »

Milliman Medical Index Components of Spending

Posted on May 22, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Components of Medical Costs

Staff Reporters

According to the just released Milliman Medical Index Components of Spending [MMICS], the total medical costs for a domestic family of four reached $15,609 in 2008, as allocated below.

2008 MMI Component of Spending	Total Medical Cost*	Percentage
Physician	$5,435	35%
Inpatient	$4,724	30%
Outpatient	$2,516	16%
Pharmacy	$2,302	15%
Other	$633	4%
Total	$15,609	100%

*Includes both the portion of the costs paid by an employer’s benefit plan and the portion paid by the family in the form of out-of-pocket cost sharing.

Full report: http://www.milliman.com/expertise/healthcare/products-tools/mmi/pdfs/milliman-medical-index-2008.pdf

Conclusion

Your thoughts and comments are appreciated?

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

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact him at: MarcinkoAdvisors@msn.com or Bio: http://www.stpub.com/pubs/authors/MARCINKO.htm

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Filed under: "Ask-an-Advisor", Health Insurance, Surveys and Voting | 2 Comments »

Convenient Medical Clinics in Wal-Mart

Posted on May 5, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Survey Profile of Customers

[By Staff Reporters]

Demographics:

· 79% are visits for Adults

· 21% are visits for Children

Insurance Status:

· Approximately 55% uninsured

Alternative Considerations:

· 40-50% Primary Care Provider

· 20-35% Urgent Care

· 10-15% ER

· 5-10% would have foregone treatment

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
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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: Career Development, Health Insurance, Surveys and Voting | 2 Comments »

Genworth Financial Reports on LTC

Posted on May 2, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

LTC Survey Results

[By Staff Reporters]

A new study by Genworth Financial Inc., suggests that costs for nursing homes, assisted living facilities and some in-home care services have increased for a fifth consecutive year, and could rise further if a shortage of long-term care workers isn’t resolved.

Results

The survey found that the average annual cost for a private room in a nursing home rose to $76,460, or $209 per day, this year. This was a 17 percent increase over the $65,185 cost in 2004. Meanwhile, nursing home costs this year ranged from $515 per day in Alaska to $125 per day in Louisiana.

###

Assessment

The cost for assisted living facilities averaged $36,090 nationally, up 25 percent from $28,763 in 2004, while costs ranged from $4,921 per month in New Jersey to $1,981 per month in Arkansas. Obviously, this far exceeds the inflation rate.

Conclusion

And so, does LTC insurance still make sense; or is it better to save and invest privately for eldercare? Please opine, for-or-against this risk transfer insurance vehicle.

Related Information Sources:

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

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

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

Filed under: Health Economics, Health Insurance, Retirement and Benefits, Surveys and Voting | 1 Comment »

HD-HCPs Gaining Ground

Posted on February 27, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Popularity of Consumer Driven Plans Increasing

Staff Writers

Filed under: Health Insurance | Tagged: High Deductible-HCPs | 7 Comments »

New Health Insurance Compliance Issues

Posted on February 3, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Implications of US Patriot and Bank Secrecy Acts on Hospitals

By Dr. David E. Marcinko; MBA, CMP™

By Hope R. Hetico; RN, MHA, CMP™

With the recent popularity and growth of personal health insurance plans (PHIPs), health savings accounts (HSAs) and / or medical savings accounts (MSAs), compliance with the USA PATRIOT Act has become an important issue for these new health insurance products.

These insurance plans place financial services organizations into relationships with shared information institutions like hospitals, healthcare organizations, medical clinics and patient clients.

The Online Connection

This happens because many, perhaps even the majority of health insurance plans are opened online as patients and insurance company clients use Internet search engines to find the “best” policy type to meet their needs.

Appropriately, banks, healthcare entities, and hospitals are working with insurance companies, trust companies, banks and broker-dealers to offer identity-compliant and integrated insurance plan products.

Verifications that these clients are who they say they are, is as paramount as monitoring their activity.

Example:

Section 314(b) of the US Patriot Act permits financial institutions and health insurance companies – upon providing notice to the United States Department of the Treasury – to share patient and related information with one another in order to identify and report to the federal government activities that may involve money laundering or terrorist activity.

The US Patriot Act

The US Patriot Act aims to partially accomplish this through three critical goals:

First, it gives investigators familiar tools to use against a new threat.
Second, it breaks down a wall that has prevented information sharing between agencies.
Third, it updates U.S. laws to respond to the current Internet environment.

Bank Secrecy Act, PHIPs, MSAs and HSAs

For additional compliance security, The USA Patriot Act also amended the Bank Secrecy Act [BSA] to give the federal government enhanced authority to identify, deter and punish money laundering and related terrorist financing activities.

Assessment

Whatever the financial outlays required for insurance/financial organizational compliance, it may result in very large savings later if affected hospital assets and patient health insurance information is safeguarded against attacks of virtual or real assets.

Conclusion

And so, what is your opinion on the above health law and policy?

Institutional information: www.HealthcareFinancials.com

Terminology: www.HealthDictionarySeries.com

Related reference: Marc B. Royo and David B. Nash. “Sarbanes-Oxley and Not-for-Profit Hospitals: Current Issues and Future Prospects.” American Journal of Medical Quality: Vol. 23, No. 1, 70-72, February 2008.

Filed under: Health Insurance, Practice Management, Risk Management | Tagged: Bank Secrecy Act, banks, david marcinko, hope hetico, hospitals, HSA, money laundering, MSA, Patriot Act, personal health insurance plans, PHIPs, Sarbanes, terrorist, trust companies, US Treasury Department, USTD | 1 Comment »

Values-Based Health Insurance

Posted on December 19, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

Another New Idea?

[By Staff Writers]

According to Mark Fendrick MD and Michael E. Chernew PhD, instead of the one size fits all approach of traditional health insurance, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible.

The Model

In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit.

Benefit Product Packages

Smarter benefit products and packages are then designed to combine disease management with cost sharing to address spending growth.

Assessment

What do you think of this new health insurance business model; is it revolutionary or evolutionary?

Conclusion

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Filed under: Health Insurance | Tagged: ACOs, Chernew PhD, Mark Fendrick MD, vales based healthcare | 3 Comments »

Supply and Demand in Medical Care

Posted on December 19, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

The Imperfect Competitive Medical Marketplace

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™

The issue is not how to fill or reuse empty beds. In this changing environment, hospitals and health systems must focus on streamlining and simplifying operational processes, facilitating case management, promoting the least costly setting for care delivery, and optimizing resource sharing among departments. When hospitals have addressed these issues, then solutions to the “bed problem” will be obvious.

-Cynthia Hayward, 1996

How and why the current healthcare imbroglio happened is very complex, but here is a brief synopsis of current supply-demand inequalities.

A Definition of Medical Care

Medical care is defined as the finite examination and treatment of patients, for monetary compensation. Among other reasons, changes in patient demand may occur as a result of the absence or presence of health insurance plans or the encouragement of additional treatments by profit maximizing providers.

Health Economics 101

Changes in supply occur as a result of physician shortages or surpluses and a host of other factors. Until recently, a glut of physicians has caused them to become “price takers,” selling a homogenous service.

How else could aggregate HMO fee schedules drop to some percentage below prevailing Medicare or Medicaid rates in some instances? Or, how else could otherwise qualified physicians be de-selected from managed healthcare plans because of large (successful equates with expensive) practices?

The Supply-Demand Curve

A graphical representation of this economic relationship produces the classic downward sloping demand curve and the upward sloping supply curve. At some point in time however, the treatment plan is completed, the patient is satisfied, and additional services are not needed. This is known as market equilibrium.

When an industry becomes more competitive – either by too much supply or too little demand – market equilibrium fees tend to become elastic while patient volume becomes very sensitive to even small changes in price. This may be where we have arrived, right now relative to medical price elasticity.

Medical Price Elasticity

In a managed care environment, every covered service has a low price ceiling and every “non-covered” service has its own price elasticity.

Traditionally, medical services were inelastic to price changes and considered a growth industry since a fee increase would also increase revenues. Now, the marketplace has become resistant to pricing pressure by physician oversupply and managed care.

Generally, a pricing coefficient greater than one is considered elastic, while a coefficient less than one is inelastic.

Interestingly, exact unity prevails when elasticity of supply is exactly equal to one.

In the golden days of medicine, the price elasticity of medical care was greater than 1, now it is about .35 and diminishing

Meaning to Doctors

Financially, all this means that many doctors are “taking what they’re given (by HMOs, CMS, etc), because they’re working for a living”.

Younger doctors under 40 are especially inclined to work for less since they have had little exposure to fee-for-service compensation. Older doctors are retiring. Middle-Agers are frustrated.

Additionally, physicians have an increasingly smaller share of the medical marketplace because of so-called medical care extenders, such as PAs and nurse practitioner’s.

Some health plans have even done away with many true allied healthcare professionals, such as RN’s or CRNAs, in favor of trained, not educated, and less costly technicians.

Conclusion

Despite the financial impact of managed care on doctors, patients may also be hurt physically as the economic cost of medical re-intervention is often much more than the cost of the proposed initial professional care.

For example, a study by Deloitte & Touche a few years ago, reported employee satisfaction was decreasing about 10 percent per year, as healthcare coverage represented a fiscal and economic time bomb on corporate books.

How would you comment on the above in light of the IOM on medical errors and mistakes, findings a few years back?

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Managed Care, Practice Management | Tagged: CMS, competition, CRNA, health competition, Health Economics, HMO, medical supply-demand, non-covered medical care, price elasticity, RN | 10 Comments »

A Decade of Desperate Patients

Posted on December 18, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

Patients Disenfranchised from the System

Staff Writers

“When was the last time you had freedom of choice in, of all places, a hospital? One choice is no choice at all, and it only makes people feel frustrated and powerless. People have a fundamental need to choose for themselves-give your customers the power of choice.”

-Roger Dow and Susan Cook, 1996

Examples of patients disconnected form the domestic US healthcare system abound. Here are just three for consideration from the past decade:

The Disconnected and Disenfranchised

An HMO cost cutting measure, known as the Drop in Group Medical Appointment (DRGMA) is particularly onerous to some patients. In this largely still voluntary model, group visits of 10-15 patients take place simultaneously. During each visit, patients are examined in the group or privately, charts are reviewed, vital signs are taken, medications adjusted, tests are ordered and results discussed.
Virtual e-health visits took a step forward recently as the First Health Group became the first managed care organization to establish another voluntary cost cutting program that eventually will pay doctors about $25 for online consultations with disembodied patients conducted via their web site.
In a most unusual court case, a physician and six patients covered by Kaiser Permanente file suit accusing it of endangering patients’ lives by forcing them to accept double size pills. The plaintiffs alleged that the HMO forced them to buy medication at a higher dose and then split the pills in half. Some pharmaceutical and medical experts opine that the practice is harmful to patients; others support it.

More Patient Concerns

And, according to Charles S. Lauer, publisher of the Modern Physician, through a study conducted by ARA Marketing and HBOC McKesson which appeared in the Harris Interactive Healthcare News a few years back, other pressing patient concerns include:

· 60 percent: “forgetting to ask all my questions when I am with my doctor, and

· 29 percent: “not having enough time with my doctor”, since the amount of face time between patient and doctors now amounts to about three-five minutes.

In a more recent study, Harvard University reported that half of U.S. physicians believe their ability to deliver quality healthcare has deteriorated in the past five years.

In yet another example, according to a survey of the Employee Benefits Research Institute (EBRI):

· Only 23 percent of employees considered themselves familiar with managed care.

· Fewer than 27 percent said that healthcare has gotten better in the last five years.

· Only 43 percent of those who received care expressed high satisfaction with its quality.

· Almost 40 percent said they were not pleased with healthcare costs, despite HMOs.

Conclusion

Is it no wonder that patients, along with their healthcare providers are increasingly becoming despondent over the domestic healthcare imbroglio?

Please, send us your comments, examples and most importantly – your solutions to the disconnect?

For related info: The Business of Medical Practice [Advanced Profit Maximization Techniques for Savvy Doctors]
http://www.springerpub.com/prod.aspx?prod_id=23759

Filed under: Health Insurance | Tagged: Managed Care | Leave a comment »

2008 CMS Updates for HDHCPs

Posted on December 9, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

HDHCP Minimum Deductibles

[By Staff Writers]

For 2008, the minimum annual deductible amounts are unchanged from 2007:

Single Minimum Deductible: $1,100
Family Minimum Deductible: $2,200

HDHP Maximum Out of Pocket Expense:

The 2008 maximum out of pocket amounts are:

Single Annual Maximum: $5,600
Family Annual Maximum: $11,200

Maximum Annual HSA Contributions:

The 2008 maximum for HSA contributions are:

Single Annual Contribution: $2,900
Family Annual Contributions: $5,800

Conclusion

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Filed under: Health Insurance | Tagged: High Deductible-HCPs | 6 Comments »

One Health Insurance Policy Solution

Posted on November 28, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

A Real Insurance Solution

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

Market Driven Health Insurance Alternatives

According to Michael K. Evans, former chief economist for the American Economics Group, Washington, DC, a real market driven insurance model may be a solution to the current health insurance coverage crisis.

It would work like a Medical Savings Account [MSA], or Health Savings Account [HSA] or any other insurance plan; by self-payment for routine visits and medications and using the insurance only for catastrophic illness.

Ironically, this was the plan in the original Medicare legislation and the reason prescription drug costs were not covered until the adoption of Medicare Part D, a few years ago.

However, many older or sickly patients claim that the cost of doctors, hospitals and medications has risen so much that they are often forced to choose between food and medical care, since the CPI grossly understates the cost of living for the elderly. And, some experts therefore believe a one-time adjustment is needed to put those payments back where they actually cover the average market basket of goods and services they buy.

But, with adjustments must come an ironclad agreement that government aid for medical care should be used only for major costs associated with catastrophic illness, not routine care.

Furthermore, we believe that when drug companies, hospitals and physicians find that consumers are spending their own money, they will then work out more reasonable price schedules — or they won’t get paid.

Just, as not everyone can live in the most expensive neighborhood, not everyone can afford to see the most expensive doctor. As lower prices work their way through the system, employers who offer health-care benefits will find their financial situation also will benefit because costs incurred by employees will rise less rapidly.

In the long run, even though the initial effect will be to boost government spending, the net result will be lower medical-care costs, more covered recipients, less bureaucracy, more competent physicians, smaller government outlays and a greater chance that some medical manufacturing firms, or big pharma companies, will remain in the U.S. instead of outsourcing to countries where labor costs are much lower.

Your thoughts are appreciated – but it sure sounds like a HDHCP to me?

Filed under: Health Insurance | Tagged: High Deductible-HCPs | 3 Comments »

Beware “Faux” Health Insurance Models

Posted on November 27, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

The Proliferation of Fraudulent Silent (“Mirror”) Healthcare Models – Should I Join?

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Beware the Silence

A silent, faux, or “mirror” PPO, HMO or other provider model is not a formal managed care organization. Rather, it usually is simply an intermediary attempt to negotiate practitioner fees downward by promising a higher volume of patients in exchange for the discounted fee structure.

Of course, the intermediary then resells the packaged contract product to any willing insurance company or other payer, thereby pocketing the difference as a nice profit. And, sometimes these virtual organizations are just indemnity companies in disguise.

Physicians should not fall for this ploy, since pricing pressure will be forced even lower in your next round of “real” PPO negotiations!

Occasionally, an insurer or bold insurance agent will enter a market and tell its practitioners that they have signed up all the local, or many major, employers. Then, they’ll go to the employers and give them the same story about signing up all the major providers. The true story is that they haven’t signed up either and a Ponzi like situation is created!

As an active fiduciary Certified Medical Planner™, insurance agent and licensed medical provider, I urge you to be on guard for silent HMOs, MCOs and any other silent insurance variation, since these virtual organizations may not exist except as exploitable arbitrage situations for the middleman.

So, has anyone been duped out there?

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Filed under: Health Insurance | Tagged: Insurance Matters | 2 Comments »

High Deductible Health Care Plans

Posted on October 8, 2007 by Dr. David Edward Marcinko MBA MEd CMP™

Providing Health Care in a High-Deductible World

By Steven Podnos MD, CFP®

With the increasingly common use of High Deductible Health Care Plans (HDHCP) (often combined with a Health Savings Account), health care providers are seeing a growing population of health care consumers that are paying “out of pocket” in some fashion for the first several thousand dollars of health care expenses each year.

Q: What is the impact of this for health care providers and hospitals?

Consider that historical pricing for health care services are much higher than providers expect to receive. Many “fee schedules” hark back to a day in which reimbursement bore some relationship to charged fees-almost unheard of now.

Let’s illustrate

Enter the consumer with a high deductible plan. Last year, with his old more traditional health insurance, he sees a physician for an initial visit. With ancillaries, the office bill might be $300, but the patient pays his $20 co-pay and leaves. The physician is contracted with the insurer to provide that level of service for a total of $110, and collect the remaining $90 from the carrier. Everybody is happy.

This year however, no one is happy. The consumer with the HDHCP gets a $300 bill for the same service that cost him $20 last year. He doesn’t know or doesn’t remember that his health care insurance premiums are lower than last year (as he may not pay them).

The result is one very unhappy patient. Clearly, health care providers need to adapt to the new world of HDHC plans. Hospitals and physician offices should have a list of charges for patients paying cash or having these plans. The charges would fairly approximate what they expect to receive from patients with Medicare and/or managed care plans for the same services.

Conversely, patients with these HDHC plans must learn to ask up front for a “cash” price on health care services.

Dr. Podnos is a fee-only financial planner in Brevard County, Florida.

Filed under: Health Insurance | Tagged: High Deductible-HCPs | 9 Comments »

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Such media coverage is expected entering into a general economic contraction, recession and/or depression for the healthcare sector, and economy as a whole.

A Print Guide for us All

OK, premium print guides like Healthcare Organizations [Financial Management Strategies] know that bad news draws more subscribers than good news.

When all is well, physicians, executives and administrators are not keen on constructive change. There are also fewer reasons to log-on to this Medical Executive-Post blog. It’s all a matter of perspective!

Q: But, why is the media’s take on economic issues so important?

A: Because it has significant impact on how patients view the entire healthcare industrial complex! It influences how doctors, insurers and politicians adjust their own lobbying and legislative initiatives. And, it governs how CFOs invest in capital expenditures, as well.

Historical Review

Another View

Economy as Excuse for Self-Pity

A More Positive Approach

For others, there is the more positive proactive track of your editors, contributing authors and enlightened consultants.

Example:

In a recent budget meeting, one young hospital CFO cautioned physician-executives and healthcare administrators to watch every dollar in anticipation of a softening economy. Yet, his more seasoned CEO responded:

“Fiscal prudence is important, but if you are asking me to take my foot off the gas pedal, my position is that we should choose not to participate in this recession.”

He further opined that we all must anticipate changing cycles, recessions and adverse demographics. But, let’s not make it a self-fulfilling prophecy. It is the astute CEO who realizes that strong financial statements lie in effective negotiation skills and the management of revenue cycles.

And conversely, that strong entity management and informed decision-making is the basis of an enhanced revenue cycle. In practical terms, this means understanding the process and targeting core aspects revenue growth to fine-tune and support the entire healthcare enterprise.

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Implications of US Patriot and Bank Secrecy Acts on Hospitals

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-Cynthia Hayward, 1996

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Patients Disenfranchised from the System

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