FY2015 Budget Proposes $400 Billion in Cuts to Medicare Reimbursement
March 10, 2014 –
On March 4, President Obama announced his proposed 2015 fiscal budget of $3.9 trillion beginning October 1, 2014. As we know, much of this budget may not be passed, but it certainly sets benchmarks of where the administration would like to go, particularly with the mid-term election.
I'll continue to look at how Affordable Care Act dismantles Medicare and moves 80% of Americans and growing to what is basically Medicaid for All----a gutted Medicaid. As always I like to begin with the real problem in health care costs----fraud and profiteering----and the fact that nothing more than a bandage has been applied to this flood of fraud. Remember, Obama and Clinton neo-liberals do not need Republicans or funding to recover fraud----it pays for itself. They simply want to stop and recover fraud and they do not.
Why Health Care Fraud Is Still Growing in 2013
By Dan Mangan,CNBCSeptember 23, 2013
Deep staff cuts are hitting a federal agency responsible for investigating health-care fraud just as Obamacare is due to kick in, leaving less people to investigate an ever-growing crime that costs taxpayers billions of dollars.
And in a perverse twist, the funding cuts at the Health and Human Services Department's Inspector General's Office might save money in the short term for the U.S. taxpayer. But over the long run, more money that could have been recouped from the fraud cases now going unpursued, is being left on the table, the agency said.
For every $1 spent on health-care fraud probes, nearly $8 is recouped in fines, restitution or settlements, according to HHS.
"With fewer agents we investigate fewer cases, and with fewer cases we're likely to have fewer convictions, few civil settlements, which will likely translate into less recoveries," said Gary Cantrell, deputy inspector general for investigations at HHS, which investigates Medicare and Medicaid fraud.
"The problem is certainly growing . . . yet our resources are declining."
RELATED: INFLATING THE DEFICIT WITH FUTILE HEALTH THERAPIES
The Office of Inspector General is halfway to its goal of reducing staff by a total of 400 people from a previous level of about 1,800 employees. The cuts, which may continue into 2015, are being made because OIG is faced with $30 million in expiring funding streams, another $25 million in funds that have been authorized but not appropriated since 2009, and about $15 million in cuts as a result of the federal government's sequestration spending reductions.
Staff for Sen. Tom Harkin, D-Iowa, noted that the Appropriation Committee subcommittee on health that he chairs "is trying to make up for the expiring funding streams" by including tens of millions of dollars in spending increases for OIG.
But there is no guarantee those increases will make it through the Senate, much less be approved by a Republican-controlled House of Representatives.
The dollar amounts being cut from OIG's budget are a pittance compared to the amount of money that can and has been recovered by the government in health-care fraud cases, and compared to the tens of billions of dollars lost in Medicaid and Medicare fraud each year. Millions on the line
The money at stake varies. In 2012, drug giant GlaxoSmithKline agreed to pay the U.S. government a whopping $3 billion for, among other things, promoting antidepressant prescriptions to children despite those drugs not being approved for kids.
RELATED: MEDICARE WANTS YOU TO HELP IT FIGHT FRAUD
While the GSK case is a high-water mark, it is not unusual for health-care fraud cases to recoup millions of dollars.
Earlier this year, for example, a judge slapped a $17.3 million fine on corrupt Detroit-area pharmacist Babubhai Patel as he sentenced Patel to 17 years in prison for fraud involving Medicare, Medicaid and private insurance.
With the roll-out of Obamacare, which will expand Medicaid enrollment rolls, as well increase the number of people with private medical insurance, Cantrell and others expect there to be even more opportunities for fraud.
"We already turn down work that we can't proceed on. It's only going to increase with the continued expansion of the Medicaid program because of the Affordable Care Act," Cantrell said.
"Last year, we closed over 1,200 complaints because of lack of resources," Cantrell said. "That number's going to be pretty high this year as well, likely to exceed 1,000."
RELATED: MAKING A MINT ON MEDICARE: PRIVATE BUSINESS
Louis Saccoccio, president of the National Health Care Anti-Fraud Association, a private-public partnership, said the cut to OIG's budget "doesn't make any sense."
"You're spending close to half a trillion dollars on Medicare, and another $400 billion or so in Medicaid. You have to invest in ensuring the integrity of these programs," Saccoccio said. "When you have this amount of investment, it just doesn't make much sense to cut."
Former U.S. Senate Majority Leader Bill Frist, a Tennessee Republican who is also a cardiothoracic surgeon, predicted, "Substantial cuts will translate into greater abuse, waste and fraud."
HEALTH AT RISK
At stake in those cuts is not just the dollars lost. "The bottom line to all this is, besides the money, the public health," said Lauren Mack, who heads health-care fraud prosecutions for the Brooklyn District Attorney's office in New York City, which often partners with federal authorities.
"We find doctors who are diluting flu shots, pharmacists putting out tainted pills," Mack said. "We have had people giving pacemakers to people who don't even have heart problems."
"There are 774 pharmacies in Brooklyn," Mack said. "There are a lot of bad little shops. Those little frauds, those little crimes add up. That's a constant bleed. If you don't have these people closed down by agents, that amounts to a big bleed—that's a gusher."
OIG's Cantrell said that while his office's value often is measured in fines and settlement amounts in the millions of dollars or more, another measure is reductions in unnecessary Medicaid and Medicare reimbursements.
Cantrell noted that in 2011 Miami resident Lawrence Duran was sentenced to 50 years in prison for a $205 million Medicaid scam involving his community mental health company American Therapeutic. Duran also was ordered to pay $87 million in restitution.
Duran's scheme, which involved bogus Medicaid claims, was brought down by the Medicare Fraud Strike Force, a joint HHS and Justice Department effort that operates in nine metropolitan areas and has lead to charges against more than 1,500 people for more than $5 billion in false billings since the unit began in 2007.
"We saw this scheme, and others like it in south Florida and Louisiana," Cantrell said. "Largely as a result of law-enforcement efforts, we saw significant reductions of Medicare outlays."
In other words, after Duran was busted, other community mental health centers reduced their billings to Medicare, a possible sign that at least some of them may have been engaging in fraud.
The supporters of Affordable Care Act are still shouting the bogus propaganda of how ACA helps the middle/working class and poor but as we are seeing------none of it is true. All of the 'progressive' policies that made it into the ACA have been eliminated or were allowed loopholes to avoid coverage responsibility. I spoke last time of how these high deductibles and co-pays will keep most people with chronic illness from actually accessing that care------but here is the second path corporations new they would take as these ACO's ----managed care groups -----merge to create what are called 'narrow networks'. It's the gerrymandering of health access exclusion.
Pre-Existing Conditions With Health Insurance May Be Gone But Narrow Networks Are Providing The Same End Result For Many Ill Patients With Not Being Able To Get Care - Extreme Cases Of New Killer Algorithms Popping Up With Insurance Business Models…
That was the huge selling point of Obamacare with people not being eliminated with pre-existing conditions and that was popular with everyone it seems no matter what political party one was. Now through another model of reducing available networks for care, we are starting to see the same end result. This story below is about a woman in New York that has a neurological disease and has had brain surgery. She bought an Obamacare policy and can’t get in to see a new doctor and is now denied her medications. There are 6 doctors in her network that will take her plan, but she can’t get an appointment for what ever reason with any of them. Her prescriptions are denied. She had to get a Congressman to intervene to get some of her prescriptions and there are others in the same boat. Top cancer centers are now no longer on the list either so we have these new models that are being used with restrictive networks that are netting the same results, no care. Even within their own business intelligence, and here’s one example below where United goes out and bids and finds their restrictive networks they established didn’t allow for any doctors to see patients. This was a Medicare Advantage contract they bid and were awarded for a retiree plan. The county has to rescind it because they had restricted the network of available providers down to such a definitive list of criteria, that there were none left to keep in network, but as we are always told “this is a business decision”.
Howard County School Board in Maryland Rescinds United Healthcare Contract As Retirees Didn’t Want the Medicare Advantage Plan, No Providers Available.. As I wrote in a recent post at the link below, in essence the “death panels” are not gone, they have taken a new shape and are now algorithmic formulas that show up and based on criteria used, care is denied, so now I guess we can say it’s a business decision made by the criteria of the algorithms that run on servers 24/7 making life impacting decisions about all of us. This is how modeling and math formulas work. I urge you to watch the 4 videos in the footer of this blog to get a better idea of how you get duped on some of this and how models work for profit. The information is a lot about the financial markets but you have the same thing with models with insurers and they too are hiring new Quants to create risk assessment models for profit.
Death Panels Have Not Vanished, Just “Re-invented” As Powerful Algorithms That Run On Servers 24/7 Making Life Impacting Decisions About All of Us - Flawed Data Driven Attacks of the Killer Algorithms Persist This is what worried me way back when the law was created that the government would be “out foxed” by insurers as that’s what they do as we have years of denials due to pre-existing conditions that denied care and now with smaller networks they are using a new risk model for profit and people don’t get care. Whether you want to see how this works or not, this is it and how and why this happens. Government is outdone with for profit business models and this is what banks and insurers do all the time, work the models and we are not able to see exactly how it all computes as that’s proprietary computer code making the decisions as the formulas run on servers 24/7. Here’s the latest on United Healthcare kicking doctors out of network that see Medicare Advantage patients too, their business intelligence algorithmic formulas. Right in New York where this patient is located, here’s the scoop on doctors being dropped right and left by United Healthcare.
Medical Society of the State of New York Files Lawsuit Asking Court to Intervene To Prevent United Healthcare From Dropping Around 2000 Doctors From Medicare Plans But if you happen to be the wife of banker, the company seemed to have no problem paying over $175,000 for a hammer toe procedure, so again what type of business intelligence are insurers using here. The money sent to that doctor sure would have been a welcome sight for this patient who has been denied.
The game just like what happens on Wall Street is fixed here too and thus I call this yet one more Attack of the Killer Algorithms. Here’s a former Wall Street Quant that now does a lot of work with the Occupy movement that did a video that explains how this works too, it’s all modeled. Killer Algorithms exist when math and formulas deny consumers access to care, money, etc. when the data is all wrong and/or flawed or just modeled for profit and my series shows every day events where this occurs and hurts consumers.
Modeling for Inequality With Segmentation, Insurance Industry Uses Backwards Segmentation As Some Models Stand to Threaten Overall Democracy I also asked the question recently too on how long before we begin calling health insurance a “science” as that’s what we seem to do today is call everything that has become complex with extreme business models, a science. Again with all the talk about the markets today being “rigged”, well this too is rigged but in a different fashion but using the same mathematical types of models to do it.
How Long Before We Proclaim Complex “Health Insurance” As A “Science”? Some Economists Think “Risk is a Science” And Mistake Laws For Just A Theoretic Framework or Idea…”The Grays” I call this “The Grays” to where people are not able to tell the difference anymore on what is a virtual world value versus a real world value. The real world has people that are sick and need care and the virtual worlds and models make it appear that this risk factor doesn’t really exist if you will and we are given tons of statistics to drive you over to that type of belief. So every day now we get some story with jaws dropping accountings on “how can this happen”..it’s the math and the subsequent algorithmic business models that do it. You are sold one perception while in fact another real world crisis is taking place, so you get blinded. Check out the 100 bottles of beer videos clip here and you can see why it end up maybe being 80 or 200 and in this model the numbers of bottles is like one or two. In essence your care that you need is never going to be 100 bottles if you will, and this how it works today in the “modeled” business world. This is the #1 Quant in the world, Paul Wilmott sharing some words of wisdom and if you want to see the entire video, it’s #2 in the footer.
Virtual Worlds, Real World We Have A Problem And It’s A Big One With A Lot of Gray Areas Finding Where The Defining Lines Exist, Confusing Many With A Lot of Weird Values And Strange Perceptions… So we have this issue and then let’s take a look at the priorities of CMS these days too. Patient don’t have access to so many physicians and facilities who offer the care and help, so in view of all of this taking place, we have this oxymoron mentality of having to create 5 star ratings for hospitals. See the link below, so does this make any sense at all? Just one more case of “The Grays” at CMS I might say with some strange perceptions on what they think is relative today and this is not it, but as long as they believe it is, well not much gets done back over at the real worlds as this rating system they are working on is nothing more than some virtual values to dish out.
I should maybe say here too that these algorithms have no political ties either, it’s math for profit; however insurers will tend to go in the direction of lawmakers to where they can lobby and present a marketing type of situation to where they “think” they have the entire picture when in fact they don’t and are also hanging in “The Grays”…as that’s the plan, keep this complicated, just they do on Wall Street and you keep hearing that over and over in the last couple of weeks since the release of the book, “Flash Boys”..same principles for profit here.
CMS Plans To Begin Five Star Hospital Rating System - Add A Column For “Hospital Mortality Projections” Or Stop the Ratings All Together As Lack of Money Today Is More of a Determining Factor With US Hospital Inequality That Keeps Growing.. I know how this works with profits and I’m not picking on insurers making a profit but does it have to be “that big” to where business models used are presenting this type of end result? I guess we are somewhat reach a crossroads here on where do ethics come into play with making money? From what is materializing in the news, it appears that money has the top billing for now at least. Below is a link written by a former Wall Street Quant who understand and share some of this with us and it’s important as she’s telling us to be a skeptic when we need to be and Cathy is also video #3 in the footer of this blog too, way back used to write models for Larry Summers and bonus points at the end for a couple of comments on her history there. I have a few more links and videos at the Algo Duping page too that discusses both how you get duped and the end result of bite of the Killer Algorithms as they occur. BD
“On Being a Data skeptic- Modelers Have A Bigger Responsibility Now Than Ever Before”–A Must Read Essay, Start “Sniffing the Data”… A New York woman suffering from a neurological disease that has required four brain surgeries has been dropped by all of her doctors and denied medications due to her Obamacare plan. "I've been vomiting. I lost 22 pounds. The pain is unbearable," said Margaret Figueroa, 49, on Wednesday. "My medication helps me function during the day."
Figueroa suffers from a disease known as Arnold Chiari Malformation and Syringomyelia. Even though the Obamacare plan she purchased assured her that she was covered, her insurance card was denied when she went to fill her prescriptions. Then she learned that none of her doctors accept her Obamacare plan. Figueroa says she cannot find a doctor who accepts her Obamacare plan; indeed, there are only six doctors in all of Staten Island who take her plan, none of whom she's been able to get appointments with.
Figueroa's congressman, Rep. Michael Grimm (R-NY), intervened to help her obtain some of her vital prescriptions. Grimm says he's already received calls from at least a dozen Staten Island residents facing the same problem with Obamacare's "narrow networks" – extreme restrictions to doctor and hospital access imposed by Obamacare.
Obamacare's narrow networks have also shut out access to top cancer centers. The Associated Press says just 4 of 19 nationally recognized comprehensive cancer centers offer Obamacare access through all insurance plans in their state Obamacare exchanges, and a McKinsey and Co. study revealed 38% of all Obamacare plans only allow patients to pick from just 30% of the largest 20 hospitals in their areas.
United Healthcare is of course already a global health system and as you see what will happen with all these newly forming global want-to-be health systems----United Health Care simply moves doctors away from here and places them where they profit most-----having nothing to do with public needs. So, if United Health Care owns a national chain of nursing homes and need doctors there-----just take them from the general population care and VOILA----people cannot access health care because no Medicare or Medicaid doctors are available. This is where Affordable Care Act leads and it was all planned. This is how you maximize corporate profits, take all control of health care from the public, and consolidate until competition is dead and there is no oversight and accountability.
Again-----all of this is no surprise. This is exactly how a consolidated and deregulated global health system is expected to work-----RUTHLESS. Can you imagine senior care and hospice centers by global corporate hedge funds? They will be sucking that Medicare Trust dry though!
THIS IS THE CLINTON WALL STREET BANK POLICY FOR HEALTH CARE AND IT IS ALL REPUBLICAN POLICY AND YOUR SUPPOSED 'DEMOCRATIC' NEO-LIBERAL KNOWS THIS.
Medical Society of the State of New York Files Lawsuit Asking Court to Intervene To Prevent United Healthcare From Dropping Around 2000 Doctors From Medicare Plans
This is a bit of an updated as there has already been one lawsuit filed with other states joining in, more information at the link below. The Supreme Court made a ruling earlier this year that doctors could group together to litigate and that’s what appears to be happening there.
In the meantime, New York has decided to file their own lawsuit and again this is the same situation with doctors who take care of Medicare advantage patients being dropped. Patients will either need to find another plan where their doctor is in network or look for another doctor. In addition, travel for seniors is also a factor as in many instances a new doctor could be miles away from where they live.
Anymore the big conglomerates just look at their numbers and the decisions seem to be a matter of “algorithm says” and from what I have read on the web it’s even a bit more irritating as United seems to not be communicating with the doctors they are eliminating from Medicare plans. A couple years ago United did a mass firing of around 200 employees to where they received a text message to report to the lobby, and then all were loaded on to buses and taken to a hotel and given their walking papers, so again their methodologies with the “human” element at times are certainly questionable.
The company also does hospice and palliative care for profit via a subsidiary Evercare, they own so they want want the money from Medicare for taking care of many terminally ill seniors but it seems as until you get to that point if you are an “Advantage” subscriber, there’s not enough money in your body to put down to their bottom lines. BD
The Medical Society of the State of New York has filed a federal lawsuit asking the Eastern District court to intervene to prevent United Healthcare from dropping nearly 2,000 of the society’s doctors from its Medicare plans on Jan. 1, court documents show. In a complaint filed Dec. 23, the Medical Society alleges the insurer terminated doctors’ contracts as Medicare providers in order to offset “reduced federal payments under the Affordable Care Act.”
Here is Maryland forcing their public employees onto private Medicare Advantage plans. I told you Maryland media is saturated with advertisements for these private Medicare plans and many of the largest hospitals are tying themselves to national insurers that have these private Advantage plans as a principle offering. In this case we are lucky these Retirees refused to be forced onto these Medicare Advantage plans. For those living in Maryland it is good to know that Howard County had Beilensen as its health commissioner and Beilensen is Johns Hopkins and Johns Hopkins is the neo-conservative driver of the most private of health care. A step further has Ulmann as County Executive when this plan to push public retirees onto this privatized Medicare and Ulmann was of course Anthony Brown's running mate. So, you see in Maryland the classic Clinton Wall Street global corporate neo-liberals on the same team as the Bush neo-conservatives in the state AND IT MAKES ONE BIG GOVERNMENTAL POLICY MESS.
You know your school board is packed with education privatization people when they try to push public employees onto private Medicare Advantage.
Howard County School Board in Maryland Rescinds United Healthcare Contract As Retirees Didn’t Want the Medicare Advantage Plan, No Providers Available..
This gets interesting as it’s been all over the news that Untied Healthcare is firing doctors throughout many states and the northeast is where most of it is taking place. The plan that was supposed to begin on January 1st was not accepted by medical providers in the area, so what good does that do if there’s few or no providers to see in network and the coverage was less. So for now, it’s status quo with existing plans with CareFirst and Aetna while the issues are worked out. Maybe they better open up some more Urgent Care centers if they want to make sure there’s providers available?
In the legal case in Connecticut a judge has now sent United and the physician’s groups to mediate and report back on February 4th and then there’s the separate lawsuit in New York.
When the new bidding takes place United can return and bid again. BD
The Howard County Board of Education Thursday terminated its contract with United Healthcare, officially backing out of a Medicare Advantage Health Benefits plan that many retirees had criticized. The board voted unanimously to rescind the contract award entirely and start the contract bidding process over again for a replacement to the existing self-funded Medicare Supplement plans for eligible retirees.
A Medicare Advantage Plan with Part D benefits from United Healthcare was supposed to go into effect Jan. 1, but the board decided to suspend that contract for a year after retirees said the plan wasn’t accepted by medical providers in the area, and that the coverage was less than what they had under their previous plans through CareFirst and Aetna.
'to provide the best evidence-based care'
If you heard one time you heard a hundred----the Affordable Care Act will lower costs with EVIDENCE-BASED CARE. Below is a good article that shows first and foremost that what these policies bring has nothing to do with scientific evidence and in fact are simply procedures designed to create the cheapest service vehicle possible and as we see in the article below this---the narrow networks----it is the citizens with the lower tiered insurance plans that will be subjected to this kind of care.
Greater Baltimore Medical Center has installed this kind of structure for its different departments and I can say that most of the doctors hate it. It creates fear in patients that are particularly tied with a regimented care because these kinds of facilities have a set procedure for care that staff are told not to change. It often leaves patients at risk of life for simple things like getting the right medications and getting them on time. This evidence-based care is purely experimental and they are using Americans with the lower tiered plans as guinea pigs in trying to find the cheapest system of health delivery.
IT IS CRAZY SINCE WE HAVE A FIRST WORLD TAXPAYER SUPPORTED QUALITY OF HEALTH CARE. WE PAID FOR ALL OF THESE HEALTH PROCEDURES AND WE NEED TO HAVE A SAY IN HOW WE GET OUR HEALTH CARE.
Evidence-based CARDIOVASCULARMEDICINEwww.elsevier.com/locate/ebcmGUEST EDITORIAL
Criticisms of Evidence–Based Medicine
More than twenty years after its conception,‘evidence-based medicine’ (EBM) continues to invoke polarised debate. There are several areas of disagreement between EBM supporters and detractors as well as unanswered questions about the role of EBM in modern healthcare. Proponents suggest that the goal of EBM is to rescue medicine from many of its major ills, including wide variations in clinical practice, use of unproven interventions, and failure to apply consistent practice guidelines. Opponents disagree that EBM adequately addresses these issues, and dismiss EBM on the grounds of philosophical and practical flaws.This editorial briefly summarises the criticisms of EBM under five main themes, to provide a starting point for more focused discussion.
The first type of criticism involves the philosophical underpinnings of EBM, which is based on empiricism. In its rawest form, EBM elevates experimental evidence to primary importance over pathophysiological and other forms of knowledge,and implicitly assumes that scientific observations can be made independent of the theories and biases of the observer. However, since the late 19thcentury, philosophers and scientists have been aware that making theory-free, objective observation is impossible. All observations are affected by the world view of the observer. In fact, the preferred situation is for ‘‘clinical trials to provide evidence in support of theory’’Clearer observations allow for theory to be challenged and eventually replaced by better theory. Better theory allows for more specific, more detailed, and ultimately more useful observations. EBM ignores this essential interplay between observation and theory, disregarding the history and philosophy of science.
The second theme is that the definition of evidence within EBM is narrow and excludes information important to clinicians. EBM grades evidence according to the methods used to collect it. Certain types of studies, such as randomised trials, are thought to be less vulnerable to bias and therefore ‘better’ evidence. However, randomised trials and meta-analysis have not been found to be more reliable than other research methods. The EBM definition of high quality evidence excludes information necessary to address many kinds of medically relevant questions. In addition,EBM does not provide a means to integrate other,non statistical, forms of medical information, such as professional experience and patient specific factors.
Third, EBM is not ‘evidence-based’ because it does not meet its own empirical tests for efficacy. Considering that EBM proposes that patient care can be improved by basing clinica ldecision-making on information from statistically valid clinical trials, it is somewhat ironic to find there is no evidence (as defined by EBM) that this is actually the case.
Fourth, the usefulness of applying EBM to individual patients is limited. Because individual circumstances and values vary, and because there are so many uncommon diseases and variants, for‘‘an increasing number of subgroups of patients we will never have higher levels of evidence’’ Clinicians must balance general rules, empirical data, theory, principles, and patient values and apply them to individual people.3,5This requires agreat deal of clinical judgment.13Lastly, EBM has been criticised for reducing the autonomy of the doctor-patient relationship by limiting the patient’s right to choose what is best in their individual circumstances. EBM could be used as a cost-cutting tool to deny treatment where interventions are not ‘proven’ effective. On theother hand, EBM could also increase costs by‘proving’ the efficacy of some expensive interven-tions. Currently, the net effect of EBM is unknown. None of the critics of EBM suggest that high-quality evidence obtained by clinical epidemiological methods should be ignored in the context of patient care. But it is only one factor of many, in acomplex context. The five criticisms described above suggest that while EBM can be a useful tool,it has drawbacks when used in isolation inindividual patient care. Modern medicine muststrive to balance a complex set of priorities. Tobe an effective aid in achieving this balance, the theory and practice of EBM must expand to include new methods of study design and knowledge integration, and must adapt to the needs of both patients and healthcare professionals in order to provide the best care at the lowest possible cost.
Below you see that the entire health system process is becoming these narrow networks and this is what was planned all along. You'll see they use all the right words-----Quality, high-value, coordinated patient care team etc. What this is for those old enough is HMOs on steroids. HMOs did not last as the rule in health care because a public free to choose which hospital and doctor they wanted did not want to tie themselves to HMOs. Fast-forward to today where people have no say and corporations decide all that is policy-----we have the Affordable Care Act requiring people attached to these HMO, or now they call them ACO structures. It is the middle and working class that become entrapped in this narrow network policy as they are exposed to these corporate health plans you see described below. Now, if you have a cardiac, cancer, or end-stage renal failure are you going to feel like being shipped across the country to a hospital that 'specializes' in performing these procedures cheaply? OF COURSE NOT. Why would PepsiCo for example partner with Johns Hopkins in sending all of its employees by plane with hotel lodging for example rather than simply having a health plan that allows that employee to go down the street to a local hospital?
CALL ME CRAZY BUT IT APPEARS THAT PEPSICO HAS INVESTED IN THE GROWING HOPKINS GLOBAL HEALTH NETWORK AND WILL PROFIT FROM THIS CRAZY DEAL.
This is what profit-driven health reform looks like-----the patient or worker plays no part in these health decisions----it is purely financial. It's like Wall Street betting on when people will die vs how much a life insurance policy will have to pay. There is no thought to citizens in these policies. The reality is that people with chronic illnesses will for the most part have these kinds of plans from which to choose and they will not want to travel for this kind of care. Selling the idea that a person with a lower tiered plan across country with room and board for a routine surgery is OBSCENE.
Those living in Baltimore know Johns Hopkins is not the best at what they say they are-----US NEWS and World Report was shown to allow institutions to BUY its rankings and we know in Baltimore that Hopkins is not the best rated in orthopedics or cardiac. Yet, there you have those stats being shown to prospective consumers. This is no doubt how a hospital that does not rank locally draws people from around the country to get its business.
Maryland has one of the most deregulated public health structures in the nation and citizens here do not take going to the hospital lightly.
MANAGED CARE February 2012. © MediMedia USACover Story
Narrow Networks Found To Yield Substantial Savings
An early managed care idea that the marketplace once rejected is now being embraced by employers and offered by health plansJoseph BurnsContributing Editor In the 2011 movie Moneyball, the general manager of the Oakland A’s is portrayed as one of the smartest executives in baseball. A former player and first-round draft choice, GM Billy Beane pores over player statistics, seeking hidden gems — high-value free agents other teams might overlook but would fit Beane’s idea of low-cost, high-quality players.
For Brett Morris, president of Health Net of Arizona, health care is like baseball, especially when putting together a narrow network of providers. Hospitals and physicians are free agents that health plans add to their teams after carefully scrutinizing their ability to deliver high-value, low-cost care, he says. Since 2006, Health Net has successfully developed such narrow networks in California and now it seeks to replicate that success in Arizona.
Health Net is not alone. Aetna, Harvard Pilgrim Health Care, and Blue Shield of California, among other managed care organizations, also have developed narrow networks in response to demands from employers seeking low-cost options that do not sacrifice quality. Since 2009, a slow economy has fueled much of the desire for these low-cost networks, but other factors are at work as well.
Quality comes first when selecting doctors for tiered networks, says Aetna’s Amy Oldenburg. “Then we select according to cost efficiency.”
For employers, Aetna expects costs to be 1 to 4 percent lower with narrow networks than under more traditional plans. Health Net of Arizona predicts costs will be 10 to 20 percent lower, and Blue Shield of California predicts its first-year premiums for its Blue Groove product will be 10 to 15 percent lower than its traditional plans. Blue Shield also says costs for Blue Groove will rise by 5 percent or less in future years.
This year, Blue Shield of California is responding to demands from employers and brokers for lower-cost offerings by selling Blue Groove in Sacramento. The plan includes a narrow network in the form of a patient-centered medical home (PCMH) for patients with any of six chronic conditions, including cancer, diabetes, and heart disease. The goal is to deliver cost-effective, high quality care through a coordinated patient care team, says Chief Medical Officer Meredith Mathews, MD. (For more on this, see “Blue Shield of California Combines Narrow Network and PCMH” below)
Blue Shield of California combines narrow network and PCMH Blue Shield of California has developed an unusual narrow network that includes a patient centered medical home (PCMH) for patients with certain chronic conditions. The PCMH is one tier of a three-tier product called Blue Groove that Blue Shield is offering to large employers in the Sacramento and Modesto areas this year.
The top tier features the PCMH model for patients with chronic conditions who can choose to receive care from a narrow network team of providers who will follow evidence-based protocols, says Meredith Mathews, MD, Blue Shield of California’s chief medical officer.
The conditions are:
- End stage renal disease/chronic kidney disease
- Heart failure/coronary artery disease
He doesn’t consider the PCMH to be strictly a narrow network, but rather a center of excellence. It is narrow by nature, however, in that there are a limited number of providers and the prevalence of the six conditions will limit the number of patients as well, he says.
“The PCMH has its origin as a chronic care model with an evidenced-based approach to care,” he says. “Our goal was to form a PCMH devoted to providing better clinical care to these members. It wasn’t simply to narrow the network. It is an effort to give people better and more comprehensive care.”
Value-based design “We will ask physicians to do the best job possible with access and care coordination and to work as a team to provide the best evidence-based care to the members in this PCMH,” he says. “For the members, we are offering them value-based insurance design so that there are advantages to patients who follow best evidence-based practices.”
Even when physicians follow evidence-based practices, patients don’t always follow physicians’ recommendations, he says.
“The value-based insurance design allows us to give significant incentives through lower copayments and putting medications on a lower-cost tier so that there are no barriers to patients who want to follow evidence-based practices.”
By using value-based insurance design, providing additional funding for care coordination and financial incentives if the physicians meet HEDIS measures, Blue Shield is aligning physicians’ and patients’ incentives, Mathews says.
“All the evidence shows that if you can drive up the number of people following evidence-based practices, their costs generally will be lower in terms of inpatient days.
“In addition, the advanced-access component of a PCMH allows these patients to seek care where most of their information is at hand as opposed to going to the emergency room or other settings where physicians can’t access the patient’s information,” Mathews explains.
“Basically, we’re promoting better care,” he says. “And the earlier in a disease progression that you intervene, the more likely you are to get results that are better for patients.”
In the past year, health plans also have been developing even narrower networks. Mercer, the human resource consultant, has worked with Lowe’s, the home improvement retailer, to send workers needing heart surgery to the Cleveland Clinic and with PepsiCo to send workers needing orthopedic care to Johns Hopkins Hospital in Baltimore.
Narrow networks ”could be very popular when we have health care exchanges” that enroll people who have never been insured, says Alexander Domaszewicz of Mercer.
Ultimate narrow network All costs, including travel, hotel, and food for the worker and a companion are covered for workers who choose this option. In this ultimate narrow network, the employers pay a negotiated bundled fee for all health care services and this fee is less than what the employers would pay in hospitals close to the workers’ homes, says Alexander Domaszewicz, a Mercer principal in Newport Beach, Calif.
Health plans have been narrowing their network offerings since the mid-1990s, Domaszewicz notes. When the weak economy followed the recession of 2008 and 2009, employers demanded lower-cost options without any decline in quality. In response, plans offered networks of highly efficient providers that deliver quality care at the best price.
“It’s definitely a growing trend,” he says. “As health reform is implemented, there are only so many levers health plans and plan sponsors can pull if they want to change plan designs. That leaves the breadth of the network as being one area that is hard to manage on your own as an employer, but if health plans are building narrow networks, then it is one of the last frontiers that employers can tap into for greater efficiency.”
The economy was a factor because plan sponsors want lower costs, but a second factor is health care reform, he says. If insurers have to enroll everyone, then it makes sense to offer more efficient programs.
“Plus, narrow networks could be very popular when we have health care exchanges and health plans start enrolling patients who have previously been uninsured,” Domaszewicz says. “You can’t offer a very expensive plan to people who previously had no insurance or they are unlikely to take it. A third factor is that health plans want to steer patients to facilities and physicians in accountable care organizations or patient-centered medical homes that are delivering highly efficient care.”
Other options Amy Oldenburg, head of national provider networks at Aetna, agrees that the economy and the changes coming under health reform have forced plan sponsors to seek lower cost options. These employers want no dropoff in quality, but they want to steer employees to the most cost-effective providers, she adds.
Larger plan sponsors have always been very vocal, she says. In prior years they cared most about having the broadest possible access through very large networks. With the recession, however, everyone was thinking about what was happening under health care reform and what effect the exchanges would have on enrollment.
“The employers told us they prefer to have broad access so that all of their members can go to any physician or any hospital, but in this economy, they also need to steer employees to the most cost-effective providers,” she says. “I call it back to the future, but it is really back to the 1980s.”
When health plans introduced highly restrictive networks years ago, consumers and physicians complained. To counter this trend, some state legislatures passed any-willing-provider laws that forced plans to allow all providers willing to meet the plans’ requirements into their networks. But today low costs and high value trump provider choice, at least for some employers.
“All plan sponsors are facing rising costs, and so we offer them a number of plan designs to manage costs,” Oldenburg explains. “Plan sponsors want us to help them steer employees to facilities or physicians who are the most cost effective so that members get the same quality of care while also saving money.
“In 2009 we definitely started to see an increase in interest among plan sponsors for narrow network offerings,” she adds. “We already had specialists in our Aexcel offering for eight or more years, and so we started considering what we could do in addition to that.”
Specialists Aexcel is a network of specialists who are cardiologists; gastroenterologists; neurologists; neurosurgeons; otolaryngologists/ENTs; obstetricians and gynecologists; orthopedists; urologists; and cardiothoracic, general, plastic, and vascular surgeons. To become an Aexcel specialist, physicians must meet Aetna’s standards for both clinical performance and efficiency and provide services to Aetna members for less than they usually charge.
Hospitals To develop its narrow networks, Aetna took the idea behind its Aexcel offering of having physicians meet clinical performance and efficiency standards and applied it to hospitals.
“By the beginning of 2011, we started offering the narrow networks in 43 markets,” Oldenburg says. “We would prefer to have more than a year’s worth of data, but what we have seen to date in overall savings shows that the narrow networks are working. We are seeing the savings we anticipated and they are delivering lower costs.”
The savings are about 1 to 4 percent for plan sponsors, depending on the segment of plan sponsor involved. In the segment of large plan sponsors, they are all self-insured and their savings accrue to them differently from offerings that are not for self-insured employers, she says. The small group savings, for example, would come on the premium side, and those numbers are proprietary.
“It will be interesting to see if we gain additional adoption for 2013, and I think we will,” Oldenburg adds. “By the end of this year, if large plan sponsors participate in greater numbers, that will determine how quickly others will move to narrow networks. Plan sponsors often make benefit decisions in a two-year cycle because they like to see what experience others have before they follow suit. That’s why we’ll know more by the end of 2012.”
Aetna offers products that allow plan sponsors to steer employees into a variety of options. “I put multiple arrangements under the umbrella of narrow networks,” Oldenburg says. “One could be a tiered network, or a network that is smaller, and even ACOs fall under that umbrella.”
Domaszewicz has a more precise definition. “The first network level is defined by using cost and quality information to choose providers and this leads to the broad in-network and out-of-network designations,” he says. “Then you can use that information to develop tiered networks where you separate the most efficient physicians with better outcomes into one network and the other standard physicians into another network. How you encourage member use of one group or provider versus another defines how narrow your network is.”
If there’s a cost differential to see a physician in one group versus another, that’s a tiered network, he says. “See a regular provider and the employee would pay a little more, while a visit to one of the top providers would cost less. But in a narrow network, employees wouldn’t be able to pay extra to go to other physicians. The employee could see only those best performing physicians in the narrow network. All others would be out of network and not covered.”
Quality is a key component in each of these offerings, Domaszewicz says. “There are narrow networks that include 50 percent or less of the full network providers, but there are also ones that only eliminate a relatively small percent of full network and both are still considered narrow networks.”
Oldenburg agrees, saying, “Our ultimate goal is to maintain or improve quality. Quality always comes first and then you look at addressing cost. Low cost is an option that we consider for plan sponsors or for individuals.”
Quality counts “When choosing providers for our tiered networks, first we select according to quality then we select according to cost efficiency,” she says. “Some providers would be on a lower benefit tier, meaning members would pay more to access those providers. The individual makes the choice based on the payment arrangements that plan sponsors make.”
In its Aexcel network, Aetna makes a distinction in 12 specialties based on quality and cost efficiency. “We may define designated physicians in those 12 specialties as being on tier 1 and reimbursed at the highest level, non-designated physicians could be on tier 2 and reimbursed at a lower level. But we also have a narrow network constructed based on having only specific hospitals and their aligned physicians in that network.”
Health Net data Does the success of narrow networks so far mean that health insurers were correct in the 1980s to limit choice? “Plan sponsors were not ready to make that leap,” she says. “The way we have constructed these networks now — with the quality criteria we use — is different from the way we did it in the 1980s.”
Health Net’s Morris agrees that when developing narrow networks, sophisticated data analysis is needed to identify providers that deliver quality care while keeping costs low.
“There is no lack of data on providers,” he says. “Our narrow network here in Maricopa County represents a lot of data analysis regarding where we find the most value,” he says. “It’s cost driven, but the value component is important as well. When we put all the components together we found aspects of our full network that work at a higher value proposition, which means extraordinary quality but lower total cost.”
Health Net is different from other Arizona plans in that it has always offered HMO plans with more restrictive networks than their PPO counterparts, Morris says. “While other plans abandoned the managed care component of the HMO format a couple of decades ago, we stuck to it,” he says. “So while other plans have only a few years of data on this strategy, we have decades of it.
“Low quality is not an alternative for us. But in this economy people need money for other things, and if we can offer a high quality product and do it at a lower cost, that’s what reform is trying to accomplish.”
After reviewing data on Arizona’s providers, Health Net contracted exclusively with Banner Health Network to establish Health Net ExcelCare, a commercial HMO network for Maricopa County and parts of Pinal County. It started January 1. Health Net calls it a tailored network, but as an exclusive contract, ExcelCare fits Domaszewicz’ definition of a narrow network.
“Employers selecting ExcelCare will have premium savings of about 20 percent when compared to our most popular PPO,” Morris says.
Offered to small and large employers, ExcelCare allows members access to more than 2,650 Banner Health Network primary care physicians and specialists and such hospitals as Cardon Children’s Hospital and the recently opened Banner MD Anderson Cancer Center.
“We think 20 percent lower is compelling, and in Arizona, it needs to be, particularly in Maricopa County,” Morris adds. “Companies are struggling to provide coverage to their employees.”
Health Net introduced its tailored networks beginning in 2006 in California: the Silver and Bronze networks. While the full statewide HMO has 13,160 primary care physicians (PCPs) and 38,900 specialists in the state, the Silver network has 7,500 PCPs and 16,490 specialists, and the Bronze network has 1,900 PCPs and 3,950 specialists, Health Net says.
The Silver network can be as much as 15 percent less expensive than comparable Health Net benefits in the full network, and the Bronze network can be 10 percent lower than Silver, the company says.
In addition to the ExcelCare network in Arizona, Health Net also has introduced similar provider partnerships in Sacramento, Calif., and Portland, Ore.
Enrollment in Health Net’s tailored network grew 45 percent between September 2010 and September 2011 and now accounts for nearly one third of Health Net’s commercial enrollment in the Western states, the company says.
One factor that may foster continued growth of narrow networks is how they can serve as stepping stones to ACOs and PCMHs, says Oldenburg.
“Both narrow networks and ACOs will continue for the future, of course,” she comments. “But it’s ideal if you have a narrow network first. Everyone can develop an ACO, but not every ACO will be a good narrow network. That’s why I see us as having both for a time, and narrow networks would work well alongside PCMHs in the same way.”
Given that both ACOs and PCMHs are designed to deliver high-value, low-cost care, they will require an approach similar to that used to build narrow networks. Or, as Morris says, “It’s like bringing Moneyball to health care.
Folks, remember these US News and World Report rankings have been suspect for years-----your local hospital is no doubt just as good.
Health Net tailored network’s annual enrollment growth, by tier
Full Silver Bronze
October 2009 63% 37%
October 2010 54% 44% 2%
October 2011 48% 46% 6%
Source: Health Net, 2012
Lowe’s, Pepsi develop narrowest networks The narrowest of networks involve direct contracts between employers and large hospital systems to provide certain kinds of specialty care to specific health plan members, say Alexander Domaszewicz and Eric Grossman, Mercer health care consultants.
One example is Lowe’s, the home improvement supply company, which contracted in 2010 with the Cleveland Clinic. Under this contract, Lowe’s will fly any employee to Cleveland for cardiac surgery. Lowe’s also will pay for a spouse or companion to stay in Cleveland during the employee’s surgery. Even though the company pays for travel, hotel, and meals, the cost of this arrangement — including the surgery in one of the nation’s top cardiac hospitals -- is expected to be the same as or less than if Lowe’s employees get cardiac surgery in traditional local settings, Domaszewicz explains.
“This program is completely voluntary,” he adds. “If the Lowe’s employee wants to get surgery at Cleveland Clinic, which is consistently rated the number one heart hospital in the United States by U.S. News & World Report, then you can go there and Lowe’s will fly the husband and wife together.”
In December, PepsiCo announced a similar arrangement with Johns Hopkins Hospital in Baltimore, consistently rated the best hospital in the country by US News & World Report. This contract allows employees and dependents from anywhere in the country to travel to Baltimore for cardiac or complex joint surgeries, Grossman explains. PepsiCo also pays for travel, hotel, and meals, and covers the deductible and coinsurance for the procedures.
As you see Clinton neo-liberals are making massive cuts to Medicare at the same time they are funding structures for the Medicaid-level preventative clinic care. It is not bad to have a strong primary care structure----but if you are dismantling the stronger Medicare structure to fund this---you are simply planning to move everyone to this Medicaid-level care. Those living in Maryland saw Maryland Health Care for All backing Affordable Care Act knowing that it intended to move everyone to Medicaid for All. Your pols new as well ACA was the Republican policy to end Medicare and Medicaid. Trans Pacific Trade Pact has nations around the world dismantling their public health systems and ACA is doing that in the US. The more cuts to Federal Medicare----the less will be offered and with that -----the more private Medicare Advantage plans will offer. People will be forced onto private Medicare Advantage plans and when Federal Medicare ends----these private plans will stop the quality and selection and prices will soar.
Now, as you listen to pundits tell us why Democratic voters did not come to the polls this election -----this is why. It is also why election fraud grew as these corporate pols do not want labor and justice to reverse these policies. These Clinton neo-liberals are heavily invested in all these global corporations and you can bet they have a nice off-shore nest egg for fleecing America.
t: 877 501 1611
FY2015 Budget Proposes $400 Billion in Cuts to Medicare Reimbursement
March 10, 2014 – On March 4,
President Obama announced his proposed 2015 fiscal budget of $3.9 trillion beginning October 1, 2014. As we know, much of this budget may not be passed, but it certainly sets benchmarks of where the administration would like to go, particularly with the mid-term elections on the horizon.
Some of the major proposals affecting health care included in the 2015 fiscal budget:
More than $400 billion in cuts to Medicare, including cuts to Medicare provider reimbursement by $354 billion, affecting providers, hospitals and drug manufacturers.
$5.23 billion in payments over 10 years for 13,000 new graduate medical education residency slots in primary care and other high-need specialties
$3.95 billion in payments over 6 years for the National Health Services Corps to support expanding the program from 8,900 primary care providers to at least 15,000 annually starting in FY2015.
Extend increased payments to primary care physicians participating in Medicaid, including physician assistants and nurse practitioners, for one year at a cost of about $5.44 billion.
$629.2 million in appropriated funding for the insurance Marketplaces, along with $1.2 billion in projected user fee collections to fund the Marketplaces at a Program Management program level totaling $1.8 billion.
$1.8 billion to support health IT incentive payments, which includes $75 million for the Office of National Coordinator for Health IT (ONC), for operation of the meaningful use program, the health IT certification program and strengthening of surveillance activities.
Another important piece of the the budget proposal would eliminate the in-office ancillary service exception to the Stark self-referral law that now apply to anatomic pathology, advanced imaging, radiation therapy and physician therapy. The proposal estimates a savings of $6 billion over 10 years. At the same time, the proposal also requires that all advanced imaging services must have prior authorization approval for Medicare patients.
Although the budget praised congressional leaders for agreeing to a structural fix to the Medicare SGR, it did not mention how a repeal or fix to the SGR would be paid for.
- See more at: http://ahsrcm.com/…/fy2015-budget-proposes-400-billion-cu…/…