Category Archives: payers

What A Hospital Charges Vs. What Medicare Pays — Yet Another Case for Pricing Transparency

According to “A Study of Hospital Charge Setting Practices” by the Lewin Group, “the Medicare Payment Advisory Commission (MedPAC) has expressed concerns about the accuracy and fairness of the current Medicare hospital in- and out-patient prospective payment systems (PPSs). Payment rates for these systems are based, to varying degrees, on hospital charges. However, little is known about how hospitals set their charges.” Really? Isn’t it getting old. Why the “shell game” with hospital charges? Charging everyone the same published price –a la Walmart—is exactly what Walmart will do at thousands of outpatient clinics, so saying it can’t be done is, [...]

[More...]
 

Payer Mix Realities: Is the Tail Wagging the Dog?

A recent study published in the JAMA suggests that for patients with Medicare and private insurance, hospitals benefit financially if these same patients suffer from postsurgical complications. In other words, many hospitals have the potential for adverse financial consequences if they do a better job in decreasing postsurgical complications. Yes, the potential for a negative impact on profits that is highlighted in this study clearly depends on payer mix, but it is fair to point out that these results (and the results of other similar studies) don’t nullify the idea that certain hospitals might be gaming the system. This particular [...]

[More...]
 

Michigan Blues get Governor’s Reprieve

Thomas Finn - March 25, 2013 7:27 PM | Categories: General News and Commentary, insurance, payers, Supply Chains

The U.S. DOJ and the state of Michigan have asked the U.S. District Court in Detroit to dismiss an antitrust lawsuit filed against Blue Cross Blue Shield of Michigan (BCBSM) over its use of “most-favored nation” clauses in some of its hospital contracts. The lawsuit alleged that BCBSM pushed some hospitals into signing contracts with clauses that required them to charge higher prices to competing health insurers. If you aren’t yet  properly nauseated, read on. In a motion filed jointly with BCBSM, the parties agreed that injunctive relief is no longer necessary, however, because legislation signed into law this month [...]

[More...]
 

California –Just 1 of 36 U.S. States to Earn a D or F in Pricing Transparency

According to two studies conducted independently by Catalysts For Payment Reform and Healthcare Incentives Improvement Institute, 36 U.S. states are getting a failing grade when it comes to healthcare consumer pricing transparency. But for just a moment, forget about how many U.S. states are stinking up the joint. Wouldn’t we all be better off if the government officials responsible for “improving” this situation were being graded for their performance? Obviously, their efforts are failing so miserably that it begs us to consider if their ineptitude is intentional. Indeed, there are so many ironies related to the system’s persistent ability to [...]

[More...]
 

HMS Delivers New COB Solution –Right on Time for Commercial Insurers

We all have certain experiences that stand out in our respective memories and will forever remain vivid. For many of us, it’s the birth of a child. For me, it was a short period of time between late 1992 and early 1994 when there were actually two incomes in our household –two paychecks. My wife was gainfully employed during that time. I get wispy even thinking about it. We not only had two paychecks, but two sets of benefits. She worked for Glaxo at that time and I worked for a no-name start-up. Her benefits were gold-plated and mine, well, [...]

[More...]
 

If Fee-For-Service is Dead –What are Reform’s Essential New Attributes?

In doing my research for this morning’s post, I became more familiar with The Commonwealth Fund and the work it is doing. Definitely some practical, down-to-earth stuff designed to help everyone get on the same page. After all, time is not standing still. The “new rules” of the game are actually being implemented. And because “getting paid” has always been a favorite topic of mine, especially when dealing with complex or evolving systems, I thought the following summary –a summary of the current “ideal” pulled together by The Commonwealth Fund– might be a useful primer. As our current system (U.S. [...]

[More...]
 

Re-admissions Penalties: What the Early Adopters are Saying

We’ve all heard about Medicare penalizing hospitals that have unacceptable re-admission rates for select conditions. For obvious reasons, new types of penalties tend to stick in the front of everyone’s brain. The “new deal” for hospitals that exceed the number of expected re-admissions includes a range of penalties, with a maximum penalty increase in 2013 to 2 percent for discharges starting in 2013 and to 3 percent in 2014. Based on those penalties, Medicare may accumulate savings of up to $8.2 billion over the next seven years. More than 2,200 hospitals faced some level of penalty in the first year. The penalties amounted [...]

[More...]
 

AMA and McKesson Team-Up to Improve Molecular Diagnostic Testing

The American Medical Association (AMA) and McKesson have entered into a licensing relationship to offer the industry a more consistent and transparent way to identify and track molecular diagnostic (MDx) tests. Under the agreement, McKesson Z-Code™ Identifiers will be grouped and indexed with corresponding molecular pathology codes in the AMA’s Current Procedural Terminology (CPT®) code set. With identifiers and codes working in tandem to create a comprehensive reference for identifying and tracking MDx tests, the healthcare industry can better understand the growth in this area to support advanced diagnostics innovation. Today, over 3,000 molecular and genetic diagnostics are marketed for clinical use. According to Frost & Sullivan, MDx is the [...]

[More...]
 

Great New Lists: “Five Things Physicians & Patients Should Question”

Healthcare Matters says thanks to the American Board of Internal Medicine: U.S. specialty societies representing more than 500,000 physicians developed lists of Five Things Physicians and Patients Should Question in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures. These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation. In collaboration with the societies, [...]

[More...]
 

Insurance Exchange Contracts Getting Awarded –Unfortuantely, No Surprises

Say what you will about “the government takeover of healthcare,” but private companies are building the infrastructure of the online health insurance marketplaces –and winning contracts worth hundreds of millions to do so. Not that I have anything against the following companies that are getting all the business, but let’s hope that the same old names don’t deliver the same old, compromised solutions: Deloitte Consulting, part of the Big Four accounting giant headquartered in New York, won four state contracts to set up the information technology systems at the heart of the marketplaces. Deloitte’s contracts with Connecticut, Kentucky, Rhode Island and [...]

[More...]
 

Cardinal To Acquire AssuraMed, Direct-To-Home Distributor for $2.07B

Late last week, Cardinal Health announced plans to acquire privately held AssuraMed, another Ohio-based healthcare concern and leading provider of medical supplies to chronically ill patients in the home. The price? $2.07 billion. The acquisition will be financed with a combination of $1.3 billion in new senior unsecured notes and the remainder in cash. The deal is expected to close by early April this year. “AssuraMed is a natural extension of the Cardinal Health businesses and of our mission to be essential to care. The acquisition of this industry leader allows us to serve the growing number of Americans treated in [...]

[More...]
 

The Business of Hip Replacements Gives Used Car Industry a Bad Name

From a Medical News Today story written by Catharine Paddock: A study that used “secret shopper” techniques to find out the price of a hip replacement in hospitals across the US finds a huge variation in price, by as much as a factor of ten, with many hospitals contacted not able to give an estimated price. Reporting in the 11 February online issue of JAMA Internal Medicine, researchers at the University of Iowa (UI) Health Care and Iowa City VA Medical Center say their findings highlight the difficulties American consumers face when trying to obtain prices for a common surgical [...]

[More...]
 

It’s Alive: Watson Deployed for Cancer Diagnostics & Treatment

Watson, the namesake of IBM founder Thomas Watson, is a highly sophisticated natural language processor. It’s a computing system designed to analyze the meaning and context of human language.  We did a post on Watson more than a year ago, announcing an agreement between Wellpoint and IBM. The deal was mouth-wateringly commercially-oriented and healthcare applications were the target. In case you didn’t already know, Watson can legally tie to electronic health records, medical literature, population health data, outcomes data, etc. (most any structured or unstructured information source) “to answer profoundly complex questions” based on its world-beating natural language interface and massively [...]

[More...]
 

A.T. Kearney in the News: Heavy Hitter Joins Healthcare Practice

A.T. Kearney is on a very short list of companies that can credibly assert that it not only helped establish strategic sourcing as a discrete corporate function, but that it made strategic sourcing a CEO-agenda issue. Former execs of A.T. Kearney –much like GE—conspicuously dot the landscape in high-ranking positions across many highly regarded supply chain management consultancies and similarly focused software companies. And there’s a reason for it. They produce. Like most experienced players at the top of their game, they can spot low hanging fruit faster than a hungry predator spots wounded prey. And what do they all [...]

[More...]
 

Varian Runs a “Clinic” in Effective Lobbying –Harry Reid Rides Shotgun

When lawmakers make last minute “inserts” and/or bury curious provisions “deep in the bowels” of an otherwise huge piece of legislation, there’s usually a reason for it, and it’s not because someone was forgetful. Let me put it this way, when you deliberately bury something “deep in the bowels” of something else, that “thing” you buried will generally carry a stench with it. A story will run in today’s WSJ where Alicia Mundy looks at a last-minute provision in the fiscal-cliff bill that sharply cut Medicare payments for Sweden’s Elekta AB EKTA-B.SK -0.36%, a maker of radiation tools, while leaving unchanged those [...]

[More...]
 

A Cure for C. diff? Simple Procedure Producing Miracle Results

When I first saw this story in Modern Healthcare, “Fecal transplants Gain Ground Against C. diff,” I had to take a closer look, because frankly, it’s personal. Having lost both of my parents over the last few years, and knowing that we all face such inevitability, I understood that anything about a “cure for C. Diff” was essential reading. Basically, C. diff (Clostridium difficile) killed my mother. And to add some perspective, when she contracted it during her rehab (recovering from a stroke) in an “infected hospital” in Savannah, her doctors put it right out there and told me that [...]

[More...]