Big Blue and UHG’s New Health Plan Model

Posted on February 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Innovative Model -or- Just another Paradigm Shift

By Staff Reporters56372274

According to Reed Abelson, and David Kadlubowski of the electronic New York Times [NYT].com edition, on February 6, 2009, a new medical practice business plan and health care insurance reimbursement model could allow family physicians to practice medicine the way they used to practice. How so?

Exit UHG

The giant insurer UnitedHealth Group is testing a new model of health care that some policy experts say holds great promise, but has yet to prove itself. An earlier trial of the model by UnitedHealth, in Florida, never got off the ground because doctors refused to participate.

Enter IBM

This time however, the insurer is teaming up with seven doctors’ groups to make another attempt, in Arizona, at the prodding of one of the state’s big employers, and IBM. UnitedHealth will try giving doctors more authority and money than usual in return for closely monitoring their patients’ progress, even when patients go to specialists or require hospitalization.

Link: http://www.nytimes.com/2009/02/07/business/07medhome.html?_r=3&ref=health

Moving toward Value-Added Models and Episodes of Care

The insurer will also move away from paying doctors solely on the basis of how many services they provide via CPT® codes and will start rewarding them more for overall quality of patient care [value added and/or episodes of care model].

Link: https://healthcarefinancials.wordpress.com/2009/01/28/a-medical-payment-paradigm-shift

Assessment

One comment heard through the grapevine was “caveat and vendor emptor”; while another sarcastic observer wondered if this was the same “Useless Healthcare Group that we all despise?” And, who is to define the term “medical quality -or- value added care”?

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Early-adopter insight and reports from Arizona participating practitioners is appreciated.

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On Episodes of Medical Care

Posted on January 28, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Another Medical Payment Paradigm Shift

einstein

[By Ann Miller; RN, MHA]

 “Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius — and a lot of courage — to move in the opposite direction.”

Currently, the Centers for Medicare and Medicaid Services [CMS] pay hospitals a single prospectively determined amount under the inpatient prospective payment system [IPPS] for all care given to an inpatient. Physicians who provide other care to patients are paid separately – accordingly to a Medicare physician fee schedule – for each service they perform http://www.HealthDictionarySeries.org

The ACE Project

A newer project, called the Acute Care Episode demonstration, will soon test whether a global payment will better align the incentives for both types of providers leading to better quality and greater efficiency; beginning in January 2009 www.HealthcareFinancials.com.

Bundled Payment Advocates

Like Einstein’s statement on simplicity, we are believers in bundling payments for medical providers. If done correctly, episodic medical care bundling may be an acceptable compromise for all. The current Medicare payment system treats physicians like virtual offending criminals. Every potential health claim is fraud; although this situation probably wouldn’t change. Any formula that buries E&M coding is a system worth evaluating. Many docs easily double the number of patients seen if paperwork and documentation was not so onerous. Not sure this is always a good thing; however. Bundling forces physicians to reevaluate, what is necessary and what isn’t. There is a much unnecessary productivity in medical care. “Too much friction – not enough movement” 

Assessment

Fee-for-service medicine has a way of creating business that need not be created. Will less be done under bundled care – will diagnostic care be upgraded for increased reimbursements?  Will episodic coding consultants come out of the wood-work? Maybe! And, can we can look at the DRG and MS-DRG experience as a potential harbinger of the future?

Conclusion

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