VALUE BASED CARE: Guidelines and Best Practices?

Posted on February 11, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

http://www.MarcinkoAssociates.com

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Three healthcare industry groups—America’s Health Insurance Plans (AHIP), the American Medical Association (AMA), and the National Association of Accountable Care Organizations (NAACOS)—released the 36-page playbook on July 25th, 2023. Adoption of the best practices in the playbook is voluntary; the playbook is intended to encourage the adoption of value-based care arrangements in the private sector, according to a news release from the three groups.

CITE: https://www.r2library.com/Resource

Under a value-based care model, providers are reimbursed based on patient outcomes rather than the quantity of services provided like in the traditional fee-for-service model. The value-based care model has been around since the late 1960s. But, widespread adoption has been slow—less than half of the primary care physicians said in a 2022 survey from the Commonwealth Fund that they had received any value-based payments.

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AHIP: Botox Marked Up 78% in Hospitals Over Pharmacies 

Posted on September 27, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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AHIP: Botox Marked Up 78% in Hospitals Over Pharmacies 

•  Botox markups: 78% in hospitals, 17% in physician offices
 •  Herceptin markups: 131% in hospitals, 40% in physician offices
 •  Keytruda markups: 104% in hospitals, 21% in physician offices
 •  Ocrevus markups: 59% in hospitals, 13% in physician offices
 •  Opdivo markups: 112% in hospitals, 18% in physician offices
 •  Prolia markups: 215% in hospitals, 49% in physician offices
 •  Remicade markups: 124% in hospitals, 15% in physician offices
 •  Rituxan markups: 85% in hospitals, 7% in physician offices
 •  Tecentriq markups: 95% in hospitals, 25% in physician offices
 •  Xolair markups: 76% in hospitals, 16% in physician offices

Notes: Drugs with the highest total spend in 2019, which are also commonly delivered through specialty pharmacies. The drug cost estimate in physician offices and hospitals does not include the cost of administering the drugs.
Source: AHIP, “Hospital Price Hikes: Markups for Drugs Cost Patients Thousands of Dollars,” February 2022

CITE: https://www.r2library.com/Resource/Title/082610254
 

BUSINESS MEDICINE: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?ie=UTF8&qid=1448163039&sr=8-9&keywords=david+marcinko

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DICTIONARY: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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Healthcare Adversaries [video]

Posted on March 7, 2013 by Dr. David Edward Marcinko MBA MEd CMP™

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Of HHS and AHIP

By Darrell K. Pruitt DDS

pruitt6If HHS and AHIP continue to give doctors the bum’s rush, what languages can we expect migrant providers to speak well?

The Conference

Last week, I came across a video of a health care conference held a month ago at the University of Miami. During a discussion period, a Miami spinal surgeon named Dr. Nordham warned that more Medicare pay cuts will make small, solo practices like his unsustainable.

Karen Speaks

Panelist Karen Ignagni, who is president and the CEO of America’s Health Insurance Plans (AHIP), reacted defensively in favor of continued unsustainable discounts – but with a hasty, disingenuous response: “We’re seeing out of network charges of 95 times Medicare fees.” While as if on cue, former HHS Secretary Donna Shalala, who is also president of the university, offered her cold interpretation of the small business owner’s legitimate fears: “He’s really complaining that the price is going down [according to law].”

Shalala Speaks

After also ignoring the physician’s plea, “There needs to be more transparency,” Shalala and Ignagni continue an irrelevant, buzzword-filled discussion with each other using flowing hand gestures while shutting out the doctor’s attempts to bring the conversation back on topic. Then abruptly, without giving Dr. Nordham the opportunity to say another word, Shalala slammed the door: “…. I think we’ll take the next question, thank you.” Then she threw him a bone, “It’s a very important question, though.”

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MD with eHR

Assessment

The 4 minutes of unvarnished disrespect of Dr. Nordham is so transparent that one wonders whether Shalala and Ignagni were even aware that their half-baked PR game was being recorded for C-span.

http://www.c-spanvideo.org/event/214023 (from 2:09:53 to 2:13:42)

They probably thought nobody stays up that late.

More: Chapter 13: IT, eMRs & GroupWare

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Update on Health Insurance Claims Processing Costs

Posted on July 22, 2012 by Dr. David Edward Marcinko MBA MEd CMP™
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Paper versus Electronic

[By Matias Klein]

[Senior VP Technology Portico Systems Integrated Provider Management Solutions]

The average cost of processing a single, clean, paper-based or electronic claim can range from 85 cents to $1.58.

However, according to AHIP, nearly half of all claims (48 percent) were pended due to the submission of duplicate claims (35 percent), lack of complete information or other information needed to justify the claim (12 percent), or invalid codes (1 percent).

The manual adjudication of these duplicate or incorrect claim submissions increases the cost of administration to $2.05. The $2.05 scenario is a best case calculation. In our actual field experience the cost can be as high as $10.00 per claim.

Payment Delays

In addition to the increased administrative cost, one must not forget about the delayed payment to the provider. As stated by AHIP, a duplicate claim can take 9 days to remediate and missing information on a claim can take up to 11 days. This kind of delay damages the relationship between the provider and the health plan, which in terms of costs is priceless.

Enter ID Management

To solve this problem, some healthcare organizations are implementing Master Identity Management (IDM)—a valuable approach to creating an enterprise “source of truth” for provider identity information. But when it comes to payment integrity and claims processing, IDM without a Provider Information Management (PIM) system doesn’t work. Provider relationship and contract data are far too complex, and both types of data are needed to supplement provider identity data in support of claims administration.

Provider Information Management

When IDM is fully integrated with PIM, payers can successfully establish a single, accurate and effective source of truth. An integrated approach also:

  • Ensures quality – by standardizing, cleansing, cross-referencing and consolidating relevant data, while removing duplicate entries.
  • Mitigates risk – reducing the downstream impact of inaccurate data on all claims processing, contracting, credentialing, provider directory and connected systems.
  • Saves millions of dollars – by reducing duplicate entries by even a fraction of a percent, thus ensuring that claims are being processed in an efficient and effective manner.

Assessment

IDM plays a pivotal role in the future of healthcare. As new, collaborative and accountable care delivery models evolve, reliable provider identity management is absolutely critical. Combining IDM with PIM gives payers the most powerful solution for assuring payment integrity while improving provider identity and duplication management.

Conclusion

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Conclusion

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

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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