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

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

Welcome to the Roller Coaster Ride of the Affordable Care Act

I’m behind in the blog, I admit it. Last week I was planning a blog on all the good news about the Affordable Care Act (ACA), including the 10 million people who signed up; the lower-than-expected premiums; the lower-than-anticipated medical inflation predicted for the coming year, the result of which is due, at least in part, to the ACA.

Then came the ruling from a federal circuit court that the government could not provide subsidies for people to buy health insurance in states that did not set up their own exchanges. The ruling comes from a couple of sentences in the huge bill (about 900 pages) that states that the subsidies are available for people who sign up through state exchanges. Of course, that was when we thought the states would all set up their own exchanges (since the feds were paying for it).

How naïve were we?

Today, just 16 states and the District of Columbia run their own exchanges, with residents of the remaining 34 states buying insurance through the federal exchange. That means that about 5 million people who bought health insurance on the federal exchange and received subsidies may find themselves back where they started – … Continue Reading

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ACA Affordable Care Act Obamacare

Help! I’ve Lost My Insurance and I Can’t Get Up!

indexThe serendipity of the universe never ceases to amaze me. A couple of days ago I gave the keynote speech on healthcare reform at the Texas Medical Association’s CME Association’s annual meeting in Austin. A physician in the audience brought up an issue that was trumpeted in the press when the health care exchanges rolled out for open enrollment; namely, that people had lost their insurance and couldn’t see their doctors. I knew that a very small minority of people had actually “lost” their insurance, and that, in most cases, that insurance provided pretty bad coverage at fairly high prices. But I didn’t want to get into it with him, so I just agreed that yes, the Affordable Care Act certainly has flaws, then moved on to the next question.

If only I’d checked the news before my talk. I could have told him about a Kaiser Family Foundation survey of non-group enrollees (ie, they don’t have employer-provided insurance and bought their own insurance, most on the Exchanges). Among the findings:

About  two-thirds of those with non-group coverage are now in ACA-compliant plans, while three in 10 have coverage they purchased before … Continue Reading

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ACA Affordable Care Act health insurance health insurance exchanges healthcare costs healthcare reform healthcare system; Obamacare Obamacare

The CT Scan Cost HOW Much??

So a couple of months ago I saw my doctor about this chronic pain in my lower right abdomen. I’d had it for about a year, sometimes barely noticeable, sometimes more noticeable, and, being a medical writer, I was certain it was ovarian cancer (don’t ask my why, but I’m convinced that this is the cancer lying in wait for me, even though I have no risk factors. Medical writers are only second to med students in terms of hypochondria).

Anyway, my doctor thought it was probably gynecologic and told me to see my gyn. But he also suggested a CT scan to rule out a kidney infection or stone. Sure, I said, and off I went to radiology.

Long story short, we still don’t know why I have this sometimes pain, but it’s not that bad and I’ll just live with it (until it turns out to be something serious and it kills me [see, I told you medical writers were hypochondriacs]).

But the pain got much worse last week when I received a bill from the radiology center for $778.62. Turns out that’s what I owe after my insurance company paid it’s part of the charge. Here’s how … Continue Reading

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

Would You Walk Away from $2 Billion? Then Why Is Virginia (and 26 Other States)?

Hey, I just won the lottery! Two billion dollars! But you know what? I think I’ll just refuse it.

That, dear readers, is what my much beloved state of Virginia is prepared to do. On March 24, the General Assembly meets in a special session to consider the new budget — which is tied to expanding Medicaid. The Republican-led body has already voted against the budget because of the Medicaid requirement.

The expansion is part of the Affordable Care Act. If states expand Medicaid eligibility to those making up to 138 percent of the federal poverty level, including childless adults, the feds will pay for 100 percent of the expansion for the next five years, after which it picks up 90 percent. That’s a big bonus given that the state and the feds split the cost of traditional Medicaid.

Currently, Virginia covers children up to age 19 and pregnant women with  family incomes  up to 133 percent of the poverty level, and parents with family incomes up to 31 percent of the federal poverty level. No matter how poor you are, if you don’t have kids and you’re not pregnant, you’re out of luck.

So let’s take a look at … Continue Reading

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Affordable Care Act

Reigning in the Cost of Health Insurance, or, Why We Can’t Have Granite Countertops on a Laminate Budget

This blog comes to you courtesy of a nasty exchange on Facebook. It started with a posting about the fact that an insurance plan offered through the state exchange did not include the regional children’s hospital in its network.

This is happening around the country as insurers limit provider networks in order to keep premiums within  prescribed limits, whether those limits are mandated by the Affordable Care Act or by the employer paying for the health insurance. And it’s no secret that specialty hospitals like children’s hospitals and teaching hospitals have far higher costs than community hospitals. Reasons include the cost of training medical residents and fellows, the high percentage of Medicaid patients they see as well as the high percentage of uncompensated care they provide, and their mission to do research as well as provide patient care. They do receive additional federal and state funding to compensate — at least partly — for those expenditures, but in this day of shrinking budgets it doesn’t cover it all.

On the other hand, insurers offering policies on the exchanges must keep premiums within a certain limit based on actuarial data in their region. In addition, employers are looking for ways to … Continue Reading

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Affordable Care Act cost health insurance healthcare costs healthcare reform high-deductible health plan Obamacare