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Impact of Moving Older Adults from Employer Coverage to Medicare
Peterson-KFF’s recent brief “How Lowering the Medicare Eligibility Age Might Affect Employer-Sponsored Insurance Costs” explores potential percent reduction in employer health plan spending if all enrollees in age group leave large employer-sponsored coverage.
The brief found:
• Ages 60-64 would cause a 15% reduction • Ages 55-64 would cause a 30% reduction • Ages 50-64 would cause a 43% reduction
American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits, and facilities like the Bumrungrad Hospital in Bangkok, Thailand (cosmetic surgery), the Apollo Hospital in New Delhi, India (cardiac and orthopedic surgery) are premier examples for surgical care. Both are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology.
Foreign countries where I studied medicine and surgery, and practiced briefly, such as Finland, England, Canada and Germany are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica. Although this is still considered “medical tourism,” Mercer Health and Benefits was retained a decade ago by three Fortune 500 companies interested in contracting with offshore hospitals and The Joint Commission [TJC] has accredited 88 foreign hospitals through a joint international commission.
To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.
Capitated reimbursement is predominantly, but not exclusively, within the realm of physician providers. But, a decade ago Community Nursing Organization project examined an innovative approach to community nursing and ambulatory care services for Medicare beneficiaries. The hypothesis was that provision of such services would promote the timely and appropriate use of health care and to reduce the use of costly acute care services.
Organizations participating in the CNO demonstration were paid a fixed per-member-per-month capitated rate for covered services. But, the participating CNOs were only at risk under capitation for a subset of Medicare benefits [partial-capitation or carve-out]. The financial incentive was to minimize utilization covered under the capitated payment, but not necessarily to minimize utilization of services not covered because traditional Medicare, not the CNO, would be at risk.
Assessment
Final results indicated that the CNO model under partial capitation led to increased Medicare costs based on findings consistent across several analytic approaches. The cost differences between treatment and control or reference groups persisted after the application of increasingly complex risk-adjustment methods.
Moreover, the differences increased over time and were robust to changes in the way CNO participation was defined.
Lastly, there was no statistically significant evidence of increase in physical or social functioning of the treatment group, as compared with the control group. CNOs cost more without providing any health benefits along dimensions measured
[Source: Voluntary Partial Capitation: The CNO Medicare Demonstration Project, Austin Frakt, Steve Pizer, Robert Schmitz, and Soeren Mattke – Health Care Financing Review 2005).
Fee-For-Service Physician Reimbursement Not to be Replaced Anytime Soon!
AN EXPOSE’
By Eric Bricker MD
VALUE BASED CARE PROPONENTS?
Definition: Value-Based Care (VBC) is a health care delivery model under which providers — hospitals, labs, doctors, nurses and others — are paid based on the health outcomes of their patients and the quality of services rendered. Under some value-based contracts, providers share in financial risk with health insurance companies. In addition to negotiated payments, they can earn incentives for providing high-quality, efficient care.
VBC differs from the traditional fee-for-service model where providers are paid separately for each medical service. While quality care can be provided under both models, it’s the difference in how providers are paid, paired with the way patient care is managed, that provides the opportunity for health improvements and savings in a VBC environment.
But – During a Panel Discussion Captured on YouTube at the 2019 HLTH Conference in Las Vegas, Blue Cross Blue Shield of Arizona CEO Pam Kehaly Admitted that Only 10% of the Payments in Value-Based Contracts Were Value-Based.
NOTE: Colleagues at Health Capital Consultants (HCC) represent a team of qualified, experienced and certified healthcare valuation professionals with specific healthcare industry focus; along with in-depth understanding and extensive experience of the healthcare market on a local, regional and national basis; and strong dedication to in-depth research and analysis.
What happens when you’re a healthcare policy wonk and the pilot study for your pet program has failed miserably? You declare “Success!” in the editorial pages of the New England Journal of Medicine and demand that the program become nationwide and mandatory.
I kid you not. This is exactly what happens.
Thankfully, colleague Mike Accad MD and Anish Koka are vigilant and explain the blatant obfuscations and manipulations that the central planners engage in to have their way.
A new RAND Corporation study on bundled payments in the private sector was published in the March 2021 issue of Health Affairs. The study analyzed data from over 2,000 procedures performed as part of a direct payment program by Carrum Health between 2016 and 2020, and found significant savings from this bundled payment program, without any significant changes in quality. This study adds important evidence to the argument in favor of bundled payments and is especially important because it examines the under-studied area of bundled payment models from commercial payment systems. (Read more…)
Amazon, the largest e-commerce company in the world, has made large, strategic moves over the past several years to make a place for themselves in healthcare. This article will review Amazon’s most recent advancements in the industry, including those related to Amazon’s voice-controlled personal assistant, Alexa, and Amazon’s employee healthcare system, Amazon Care, and how this non-healthcare company is changing the industry. (Read more…)
On March 11, 2021, President Joe Biden signed into law the American Rescue Plan Act of 2021 (ARPA). The law looks to alleviate the burden felt by the millions of people who lost their employer-sponsored health insurance over the first six months of the pandemic and assist the hardest-hit communities through the extension of the Patient Protection & Affordable Care Act (ACA) and Consolidated Omnibus Budget Reconciliation Act (COBRA) subsidies, expanding Medicaid coverage, increasing funding for behavioral health, ramping up COVID-19 vaccines and testing, providing financial relief for rural providers, and enacting other individual and healthcare system protections. (Read more…)
FINANCIAL OPINIONS OF MEDICAL PRACTICE FAIR MARKET VALUE [FMV]
Courtesy: https://lnkd.in/eBf-4vY Plastic Surgery-Medical Practice Worth, Valuation, Sales & Succession Planning
For doctor-colleagues, buying or selling a practice may be the biggest financial transaction of their lives. Reasons for appraising practice worth include: sales, merger, succession, retirement and estate planning; partnership disputes and divorce; or as an important tool for organic growth and strategic planning.
However, the transaction is fraught with many pitfalls to avoid and no medical specialty seems immune; especially when it comes to contentious fair market value [FMV] appraisals.
DEFINITION: A member of a securities exchange with the essential function of maintaining a fair and orderly market, insofar as reasonably practicable, in the stocks in which he is registered as a specialist. To do this, s/he must buy and sell for his own account and risk, to a reasonable degree, when there is a temporary disparity between supply and demand. In order to equalize trends, he must buy or sell counter to the direction of the market. DHEF:https://lnkd.in/dqdbWM9 FOREWORD: https://lnkd.in/ecwZWxu
At all times the specialist must put his customer’s interest before his own. All specialists are registered with the exchange, but are not employees of that exchange. Your thoughts are appreciated.
1. I will continue to verify any statements I make about the healthcare system by talking to physicians and operators with REAL-WORLD EXPERIENCE and not rely solely on statistical comparisons.
2. I will promote that there is a correlation between cost, quality, and access in today’s healthcare system. Those who believe health systems should approach anything close to Medicare breakeven advocate for low quality and significant service reductions.3. I will continue to promote the fact that whoever affiliates with the best doctors will win in the long run.
4. I will encourage my clients to avoid the attempt by payers and many industry desk jockeys (e.g., Rand Corp.) to commoditize healthcare delivery. The best doctors, services, and ultimately the best outcomes are not commodities; they come at a price.
5. I will not stand by and watch the payers, government, and the aforementioned academic knuckleheads destroy the hospital industry using the ‘value con’– they already destroyed the rural hospital sector.
6. I will only consider a health system to be under quality leadership if market share grows and profits meet or exceed the industry benchmark. I won’t accept ‘mission’ as an excuse.
On October 29, 2020, the Centers for Medicare & Medicaid Services (CMS) released the Transparency in Coverage final rule. This long-anticipated final rule stems from President Donald Trump’s June 2019 executive order on “Improving Price and Quality Transparency” and builds upon the hospital Outpatient Prospective Payment System (OPPS) price transparency requirements released in November 2019.
These requirements came under fire in a lawsuit filed by the American Hospital Association (AHA), Association of American Medical Colleges (AAMC), Children’s Hospital Association (CHA), and Federation of American Hospitals (FAH), against the Department of Health and Human Services (HHS); the requirements were upheld by the courts in June 2020 and the lawsuit is being appealed by the plaintiffs. (Read more…)
Yesterday, The President @POTUS outlined his plans for “America First Healthcare Plan”.
In 45 min. in front of Medical Professionals he brilliantly outlined a free market, competitive and PATIENTS centered philosophy for Medical Care in America. For those who care please view the video. you can find it here:https://lnkd.in/e9pxR-U
Medicare Advantage Plans (Private Medicare) are sold on a county-by-county basis. Attached is the market penetration of MA (compared to traditional FFS Medicare) for every county in the USA.
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Wonder why Medicare Advantage Premiums are going down (on average)? Because premiums are one of the measures by which the elderly decide what to purchase. Even though premiums are declining, not all MA plans are ‘cheaper’ than traditional FFS Medicare. Caveat Emptor.
It is also interesting to note that 3 carriers – Humana, UHC and BCBS Affiliates — cover 60% of all MA plan subscribers and use national networks of providers to offer broad service availability (compared to smaller plans, PSP’s and other narrow network options).
Medicare premiums per beneficiary typically exceed $10,000 per year. With effective ingenious use of benefit design, prior authorization, incentives, PBM contract rebates, etc., — there is a lot of money to be made in Medicare Advantage plans — accounting for the rapid growth in these plans over the last decade.
On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) released two proposed payment rules for calendar year (CY) 2021: the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP). CMS included in the MPFS proposed rule adjustments to physician payment rates and an expansion of telemedicine services.
The proposed QPP rule, meanwhile, takes into account adjustments made for the COVID-19 public health emergency (PHE) and seeks to reduce unnecessary regulatory burden on providers by eliminating some requirements. These rules, which have garnered mixed reactions from stakeholders, are both open for comment until October 5, 2020. (Read more…)
On June 25, 2020 Atlanta’s Piedmont Healthcare, Inc. agreed to pay $16 million to the federal government to resolve two False Claims Act (FCA) allegations of kickbacks and overbilling. The relator, a former Piedmont physician, alleged Stark Law and Anti-Kickback Statute (and subsequent FCA) violations of paying an amount that was above fair market value (FMV) and commercially unreasonable in Piedmont’s 2007 acquisition of Atlanta Cardiology Group (ACG).
Additionally, Piedmont’s payments settle allegations that the hospital admitted patients without medical necessity in order to bill Medicare and Medicaid for inpatient procedures that were recommended to be performed at the less expensive outpatient or observation settings. (Read more…)
Assessment: Your thoughts are appreciated.
NOTE: I was on the courtesy medical staff of Piedmont Hospital in Atlanta for more than a decade = DEM.
“Medical Management and Health Economics Education for Financial Advisors”
Physicians and medical scientists have intervened in the three revolutions in triple aim since the rise of American dominance in medical training, orthopedic technology, and Nobel Prizes. How has value based care rewarded them?
The open treatment of broken thigh bone paid 85% higher in 1849 than today when adjusted for inflation.
Join our movement for technology that works every physician every patient every time.
As the coronavirus (COVID-19) global pandemic has wreaked havoc on the U.S. economy generally, and the healthcare industry specifically, the previously-active healthcare transactional environment has been largely stunted.
Despite (or perhaps because of) this economic turbulence, stakeholders expect that merger and acquisition (M&A) activity will soon resume with a vengeance. This potential opportunity, however, is not without pitfalls, due in part to the concern from stakeholders and regulators that well-capitalized entities may use this economic and public health crisis to prey on debilitated physician practices. (Read more…)
ASSESSMENT: Your thoughts and comments are appreciated.
BUSINESS, FINANCE, INVESTING AND INSURANCE TEXTS FOR DOCTORS:
“Of the 125 medical schools in the USA, only one of them to my knowledge offers a class related to saving or investing money.” – William C. Roberts, MD
Private Banker Jorge Russe; MBA CMP™ explains in this PPT Presentation on Net Worth; NOT Income.
The COVID-19 global pandemic has brought a time of grave uncertainty for U.S. healthcare and the greater economy.
While the focus of healthcare providers is, appropriately, on the access and delivery of care to those impacted by the COVID-19 outbreak, there are many providers who will require financial resources to persevere during a time when all sectors of the U.S economy are being significantly impacted.
The federal government has announced a myriad of programs in the form of grants and loans to reimburse hospitals and physicians for some expenses and loss of revenue. (Read more…)
Spurred by how unprepared the American healthcare system was for a pandemic, the current COVID-19 emergency may present the conditions necessary to commence a healthcare delivery model paradigm shift.
In response to the public health emergency, the federal government, which has a record of reducing regulatory “burdens” under the Trump Administration, has taken aggressive actions to create regulatory flexibilities for healthcare providers and suppliers.
At least some of the various actions taken to reduce provider burden as they treat COVID-19 patients are likely to stay intact following the end of this pandemic, potentially revising the fundamental tenets of U.S. healthcare delivery. (Read more…)
A belief that rational decisions can be made with quantitative data and measures alone, when in fact the things you can’t measure are often the most consequential.
Here are 3 theories and 1 “rule” for the healthcare industrial complex that may help explain how the sector may not work correctly; from trauma, to epidemiology and to Corona; all the time.
1 – Berkson’s Paradox: Strong correlations can fall apart when combined with a larger population.
For example, among motorcycle crash victims wearing helmets are more likely to be seriously injured than those not wearing helmets. But, that’s because most crash victims saved by helmets did not need to become hospital patients, and those without helmets are more likely to die before becoming a hospital patient.
2 – Group Attribution Error: Incorrectly assuming that the views of a group member, like a physician, reflect those of the whole group in a different discipline.
3 – Baader-Meinhof Phenomenon: Noticing an idea or word every where you look as soon as it’s brought to your attention in a way that makes you overestimate its prevalence.
The 90-9-1 Rule: In social media networks, 90% of users just read content, 9% of users contribute a little content, and 1% of users contribute almost all the content.
QUERY: Does Social Media really give a false impression of what ideas are popular or “average.”
THINK: Corona Virus?
ASSESSMENT: Your thoughts and comments are appreciated.
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
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
The quality-adjusted life year or quality-adjusted life-year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived.
It is used in economic evaluation to assess the value for money of medical interventions. One QALY equates to one year in perfect health. If an individual’s health is below this maximum, QALYs are accrued at a rate of less than 1 per year.
ASSESSMENT: To be dead is associated with 0 QALYs. QALYs can be used to inform personal decisions, to evaluate programs, and to set priorities for future programs
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
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
The Medicare program currently pays significantly different rates for services provided in different settings, and site-neutral payments have been considered as one way of eliminating the payment gap.
However, that option has proven to be a contentious issue.
Here are 25 things to know about site-neutral payments
Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.
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
I was fascinated with this podcast because I too co-founded an ambulatory surgery center [ASC] two decades ago. It was recorded by my neighbor and Austrian economist Peter Raymond over at “The Free Man Beyond the Wall” website.
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Now, colleague Dr. Keith Smith who started the Surgery Center of Oklahoma with the intention of providing surgical options outside of the monopolistic insurance cartel, opines for us all. LINK: https://lnkd.in/edY9swH
As an example, the SSofOK lists prices on their website that do not change. Dr Keith explains his philosophy and gives us a behind the scenes look into the broken health care system. This is the kind of basic episode anyone can listen to in order to help understand what a free market ASC can really provide.
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