Value-Based Reimbursement: There’s a New Player in Town

Value Based Reimbursement Webinar

 

There’s a new player in town. In case you haven’t heard, his name is VBR – value-based reimbursement. He’s smart. He’s tough. He’s out to break you down and build you up. And if you’re a healthcare provider, there is nowhere to hide.

For several years now I’ve been writing about the “coming” revolution in healthcare reimbursement as the system moves from a fee-for-service approach (ie, the more you do, the more you earn) to one based on cost and outcomes, aka, value. Well, the revolution has begun. Just consider:

➢ On April 1, nearly 70 hospital systems will switch from billing separately for each component of a knee or hip replacement to receiving a bundled payment for all care provided from the time the patient enters the hospital until 90 days after discharge. Just consider the possibilities!

➢ Two weeks ago, the Centers for Medicare & Medicaid Services (CMS), which is driving the value-based revolution, announced a proposal to change the way physicians are paid for drugs administered in their offices (mainly oncology medications).

Today, doctors get the … Continue Reading

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Affordable Care Act healthcare costs healthcare reform healthcare system; Value-based reimbursement

Ladies: Stop Cutting Off Healthy Breasts

bra_breast_cancerReally scary story in The Wall Street Journal this week about a dramatic increase in double mastectomies in this country — and not for women who need them.

Most women diagnosed with breast cancer only need a lumpectomy in the affected breast or, more rarely, a mastectomy. There is no evidence that removing the healthy breast reduces the risk of recurrence or increases survival.

Yet rates of double mastectomy among women diagnosed with breast cancer have skyrocketed in the past 13 years, from 2 percent in 1998 to 12 percent in 2011. And no, it’s not because women have been diagnosed with more severe breast cancer or some major study showed that slicing off healthy breasts keeps cancer at bay.

As one plastic surgeon quoted in the Journal article tells his patients: “Why don’t we simply remove your foot? It will have the same effect on survival.”

Don’t take my word for it; check out this study of 190,000 women with breast cancer that compared survival rates in those who had a double mastectomy vs those who underwent lumpectomy followed by radiation. Bottom line: … Continue Reading

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cost health insurance waste

How Much Is That CT Scan In the Window?

transparencyDo you know how much that 50-inch, flat-screen TV cost? How about your car? The cashmere cardigan you just had to have?

So how much did that visit with your gyn because of your painful period cost (men: substitute whatever you want here)? The ultrasound to see if you had a fibroid? The myomectomy to remove the fibroid?

A few years ago it didn’t matter so much; most of us only had to handle relatively small copayments and many of us didn’t even have deductibles. Fast forward to today, when the cost job-based health insurance has grown faster than our incomes, essentially eating up any salary increases over the past 10 years. In fact, the average deductible has more than doubled for most employees regardless of the size of their companies.

Note I said the past 10 years. Which means you can’t blame the five-year-old Affordable Care Act entirely. In fact, out-of-pocket payments would likely be higher without the ACA; a recent report from the Commonwealth Fund found a “marked slowdown in premium growth in 31 states and the District of Columbia.” However, that same report also found that premiums increased about … Continue Reading

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cost health insurance healthcare costs healthcare reform payment

Who’s In Charge? You or Your Doctor?

babyshowerSunday was the first baby shower I’d been to since. . . well, let’s just say that my youngest kid turned 19 a few days ago. There were the mandatory sherbet-colored decorations; a watermelon fruit bowl designed to look like a sleeping infant (complete with pacifier); infused water; chattering ladies; a table piled high with gifts. Only one thing was missing: the guest of honor. For even as everyone arrived for the shower, she was already in labor. And, ever the obliging young woman, she delivered a healthy baby boy before the shower ended.

I’m assuming she had great care in the hospital. Most women who have babies do. But far from the cozy, wood-floored, prettily painted maternity suites lies the healthcare system the rest of us have to deal with. Like another young woman at the shower, 26-year-old Mary.

I happened to overhear her talking to someone else and caught the words “migraine,” and “doctor,” and “frustrated.” Manna to my ears. “What’s up?” I asked.

Turns out she’d been having horrific, daily migraines and vertigo for months. The urgent care doctor told her … Continue Reading

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blog healthcare reform healthcare system; patient-centered healthcare

A Letter to a Friend (or, I’m Sorry I Lost My Temper Last Night”)

Sibling RivalrySo I did something last night that I’m not proud of. I got into an argument – complete with raised voices – with a friend. Over health care and the Affordable Care Act (ACA), of course. (Note that he continually called it “Obamacare” in a somewhat sneering tone, which, as those of you who read my blog regularly or know me, know I consider a derogatory term for a very important piece of legislation).

I felt terrible after we left and tossed and turned all night coming up with things I wished I said (not to mention wishing I hadn’t lost my temper).

So I decided to write my friend a letter via this blog.

Dear Friend:

I am really sorry about last night’s discussion, er, argument. I should have remained calmer (I’m blaming it on the martini you made me, which, by the way, was very, very good). So here is a cooler version of responses to some of the points you made.

The government should not be paying for health insurance.

Well, I notice that you are quite happy to … Continue Reading

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Affordable Care Act blog health insurance healthcare costs healthcare reform healthcare system; Obamacare

Why Repealing the Affordable Care Act Won’t Stop Healthcare Reform

So the election is over. The Republicans now control both houses. And several are promising that one of their first jobs is to repeal the Affordable Care Act (ACA). I’m sure there are lots of people jumping up and down with glee.

This reaction reminds me what one doctor told me a couple of weeks ago after I spoke to his group (abdominal surgeons) about healthcare reform (you can read more about the experience here). “This (the ACA) is going to go away and things will return to normal.”

Um, not quite.

Sure, if the ACA goes away we’ll return to more than 40 million uninsured Americans who can’t afford health care. States that have expanded Medicaid will have to pick up the full tab for those expansions (instead of 10% beginning in 2020). Young adults who are still covered on their parents’ policies will now have to buy their own — if they can afford them. Women will once again be discriminated against in terms of premiums and plan designs. People with preexisting conditions will be unable to find affordable health insurance on the individual market. We’ll have no guarantee of a basic set of benefits (for instance, some … Continue Reading

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Affordable Care Act cost health insurance healthcare costs healthcare reform healthcare system;

Doctors Are Angry. I Get That. But . . .

surgeonI knew this would be the toughest audience yet in my three years of teaching/speaking about the US healthcare system and healthcare reform. I even put on a flak jacket at the beginning of my talk as a way of breaking the ice (and protecting myself; I mean, these guys pack scalpels!). And I made it through the two-hour talk and their anger without losing my composure or my sense of humor (thank god for that sense of humor).

Now I’m sitting in the airport waiting for my flight home and find myself tearing up. Not because the doctors were mean or cruel — they weren’t — but because of how much distance there is between  reality and perception, how much anger is out there, how too many people rely only on anecdotes and commentary instead of facts to develop opinions, and how scary it is to look at where we are and where we need to be — and realize that, more and more, it is unlikely we will ever get there given the rhetoric and anger in this country.

The doctors this morning, most of whom have been in practice … Continue Reading

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ACA Affordable Care Act health insurance healthcare costs healthcare reform healthcare system; malpractice insurance Obamacare patient-centered care patient-centered healthcare Uncategorized

Why You Need a Second Opinion

Early in the summer I wrote about a good friend who was diagnosed with ovarian cysts and endometriosis. She saw a gyn oncologist because there was a small chance it was cancer (thankfully, it wasn’t). The doctor drained the cyst and started my friend on  oral contraceptives to control the hormonal shifts that contribute to endometriosis (which contributes to the cysts).

A couple of weeks ago, however, my friend texted me to say that her leg/foot was really hurting. She thought she might have a deep vein problem. I immediately told her to go to urgent care because it might be a blood clot, which can be quite serious. Her own primary care physician had left his practice, so found another that took her insurance.

Here’s her story:

“I went to the primary care physician my insurance company recommended. I specifically asked her if my leg problem could be a blood clot and she said “no” and sent me to a sports medicine doctor who then sent me to physical therapy. My leg still hurts and I thought they were wrong so I decide to go back to the gyn oncologist  who sent … Continue Reading

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healthcare costs healthcare system; ineffective procedure

Should You Listen to Your Doctor?

moneyWhen I speak about the US healthcare system, I always like to tell the story of my mother. A couple of years ago, she emailed my sisters and I. “Good news!” she wrote. “My nuclear stress test was normal!” (The test  involves injecting a radioactive dye into a vein after which a special camera scans the heart to determine if there are any blockages).

At the time, my mother was 70 and, with the exception of very-well-controlled high blood pressure (that she’d had all her life), extremely healthy. No sign of heart disease. No angina. No shortness of breath. In short, no indications for an expensive, invasive, potentially dangerous, test. So why, I asked her, did she have the test? “Because my doctor told me it was time,” she said.

At which point I began banging my head against the wall.

Even regular stress tests (where you run on a treadmill or ride a bike) are only recommended in people with heart disease or symptoms of heart disease, same with an EKG. Yet a survey of nearly 1200 people ages 40 to 60 with neither found that 39 percent had an EKG … Continue Reading

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healthcare costs healthcare reform healthcare system; patient-centered care patient-centered healthcare Unnecessary tests waste