The WELL: inkwell.vue.428: Nancy Finn, e-Patients Live Longer, The Complete Guide to Managing Health Care Using Technology

#77: Nancy Finn (nfinn8421) Fri 30 Dec 11 05:15

Fri, 30 Dec 2011 05:15:00 PST

I agree with you, changes are essential and these models not only work well but deliver better quality health care for their participants. Let's hope that other organizations see their way clear to adopt the best features and make the changes necessary to provide affordable, patient-centered care going forward. [Read entire topic]

#76: Joe Flower (bbear) Sun 25 Dec 11 09:57

Sun, 25 Dec 2011 09:57:00 PST

We actually have been having quite a discussion on this very matter elsewhere on the Well. Short version: The devil is in the details, not only the details of just who is paying for what and how they are measuring what they are paying for, but the culture of the providers. It is worth noting that _all_ of the organizations that these new structures and deals are modeled after (Kaiser, Group Health of Puget Sound, Mayo, Geisinger, Cleveland Clinic, Bozeman Clinic) differ in details of structure and payment but have one thing in common: They are old. The youngest ones are about 60 years old, the oldest (Mayo) more than 100. The clinicians working in them have self-selected and been selected to fit that highly collegial culture. How that will work out with clinicians and in environments that did not select out that way will be a matter of great interest and difficulty in the coming years. But it simply must be done. [Read entire topic]

#75: Nancy Finn (nfinn8421) Sun 25 Dec 11 09:42

Sun, 25 Dec 2011 09:42:00 PST

There's been a lot of activity and some deals pending with insurers teaming up with hospitals kind of like the Kaiser arrangement. What is your take on that type of arrangement and does it solve some of these payment issues? Does this type of arragement mean better or worse care for the patients? I have mixed stories from patients at Kaiser. [Read entire topic]

#74: Jef Poskanzer (jef) Fri 23 Dec 11 17:45

Fri, 23 Dec 2011 17:45:00 PST

Once we prosecute a couple of health insurance companies and hospitals under RICO, and confiscate them, I figure the rest will fall in line pretty fast. [Read entire topic]

#73: Joe Flower (bbear) Fri 23 Dec 11 06:24

Fri, 23 Dec 2011 06:24:00 PST

Very interesting. I had not heard of that second trick.

What kind of doc are you, Gary?

You are certainly correct that regulation is more problematic than simple elimination. The kinds of regulation that will work best are the big simple ones, like rate review, the MLR cap, and eliminating the ERISA immunity, rather than micro-regulation.

As for your Blues story, once again it's all about incentives. There is no downside whatsoever to the Blues to be late in paying, whatever the reason or excuse. None. And all kinds of upside. As long as the system is built that way, that's what we'll get.

But I also see no sign that non-profit health insurers are much of an answer. I see a lot of bad behavior by many of the Blues, for instance, many of which are still non-profit. Andrea can tell you stories about the Blues of Michigan, for instance, and I think they are still non-profit. [Read entire topic]

#72: Gary Greenberg (gberg) Fri 23 Dec 11 04:23

Fri, 23 Dec 2011 04:23:00 PST

>We have to tame the insurance companies or put them out of business. >Taming them is a lot more politically viable.

I am sure that is true. And while I think the idea of criminal prosecution is a dandy one, for the most part that taming will take place not with whips and chairs, but with nuggets and praise. In other words, through regulation by captive agencies. Corporations, I think, will always be better at finding their way around regulations (especially when they in effect write the regulations) than regulators will be at controlling corporations.

For instance, I have not received any payments from Blue Cross since about September. Why not? Well, somehow the wrong tax i.d. nbumber got associated with my provider number, which ended up triggering a rejection code referring to "provider address incorrect." Which they sent to me at, you guessed it, the provider address I had supplied, which was of course correct. I figured that out with the help of the company rep in October. The solution was to create a new provider number. I won't bother telling you what kind of chaos that set off, only to poitn out I still have not gotten paid. Meantime, someone at Blue Cross is getting paid to sort this out, which helps them justify their rate hikes, and all the while they're holding onto my money.

And then there's the company that United HealthCare pays to contact me every time I submit a claim to UHC, offering me "expedited payment" if I agree to a discounted fee. They'll trade 20 percent of my fee for a 10-day increase in payment. But the letter they send is worded very cleverly to make it seem like this is the only way you'll get paid, and indeed if you don't respond, they will continue to send letters and faxes and even make phone calls until you call them back and say you're not interested in their extortion. This scam must work--UHC pays this company to run it, but clearly it increases the cost of health care.

Point is, they companies are only doing what companies do: ensuring their profit, which in the case of health insurance means holding onto money as long as possible. It's hard to imagine regulations or even laws that will stop this from happening.

A market of nonprofit health insurers might work, but as long as they are for-profit corporations, I think they're gonna waste a lot of dollars and make people nuts in the bargain. [Read entire topic]

#71: Jon Lebkowsky (jonl) Thu 22 Dec 11 18:30

Thu, 22 Dec 2011 18:30:00 PST

A new Inkwell conversation started today, and Nancy had agreed to a two week conversation, however we still have momentum, so feel free to carry on. Meanwhile many thanks to Joe and Nancy for a great two-week exploration of the e-patient's world and the future of healthcare. [Read entire topic]

#70: Joe Flower (bbear) Thu 22 Dec 11 09:56

Thu, 22 Dec 2011 09:56:00 PST

> the idea of a smorgasbord probably fits our fractured politics real well.

A key question underlying my book is: Can we reform healthcare _without_ having to win a massive political battle not only now but perpetually? In other words: Is there a change path that will stick?

> I would add to it killing the private insurance companies.

In other words, "single payer." I know this is controversial on the Well (as elsewhere), and I have a long discussion of it in the book. I have come to the conclusion that while "single payer" might be a good idea, it is neither necessary nor sufficient for reforming healthcare, and can be a huge distraction and energy sink into political battles. What _is_ necessary is much stronger controls on health plans, and alternatives to health plans. Some of the alternatives I sketched out above. _Any_ system that does not pay fee-for-service will lessen the income and power of the insurance companies, since they make their living by taking a percentage of the money paid through them as premiums. Key controls include: o ending the ERISA immunity (as I mentioned) o enforcing the MLR (medical loss ratio) rules in the PACA, which force health plans to return 80% (or 85% for large plans) of the premium dollar in payment for medical resources * a lot of your waste goes away right there, and it doesn't really matter what they do with the other 15% or 20% o enforcing the end of the "pre-existing condition" ban in the PACA - health plans must take all comers, and must pay for all covered conditions o criminal prosecution of companies and their executives for patterns of breaking their contracts and refusing payment for things they have contracted to pay for, and have approved payment for o The "Swiss Rule:" Health plans in Switzerland must pay _all claims_ within 20 days, no screwing around. If they seriously believe they are being defrauded, they can pursue the same legal remedies as any other company, but they cannot withhold payment

We have to tame the insurance companies or put them out of business. Taming them is a lot more politically viable. It's easy to attack "single payer" as a "socialist" government takeover. It's not so easy to campaign on the virtues of allowing health plans to defraud, impoverish, and kill people. [Read entire topic]

#69: Gary Greenberg (gberg) Thu 22 Dec 11 04:16

Thu, 22 Dec 2011 04:16:00 PST

Joe, that's a really interesting list, and the idea of a smorgasbord probably fits our fractured politics real well. I would add to it killing the private insurance companies. As a provider (and I;m sure every other provider in a fee-for-service setting will agree), I am constantly amazed at the waste of that system, whose overhead, according to people whom I trust on these things, is somewhere between 200 and 300 billion dollars a year. And that's not counting the time and staffing that goes into wresting money (and accountability) from them. Their job is to hang on to our money for as long as they can, and they are really really good at it.

As for this

>The majority of health care providers out there are caring >individual who have chosen this profession because they want to heal >and help people. Of course like everyone else they want to make a >living wage for their time and efforts. But I think it is extreme to >say that patients, whether they are empowered and engaged or not are >ignored.

I think that's probably true, although it is only a majority and by no means everyone. Especially when you consider that most people chooe the medical fiedl when they're very young, and before they are fully educated, which means that you get a mix of idealism and cluelessness that can be a problem down the road. And that education still doesn't include enough about how to deal with patients as people, nor does it do much to teach physicians how to use (as oppose to abuse) power. I'm sure there are pockets of practitioners who are really happy about sharing power with their patients, but they have yet to arrive out here in the hinterlands. LIke the doc, a young guy, who, having seen one elevated blood pressure reading of mine, and with no other information about me or my history (years and years of normal bp), said "Well, I'm not going to put you on blood pressure medication yet." Which is simultaneously good practice (i.e., don't jump the gun) and bad (i.e., watch your verbs.) Taht and the fact that "living wage" is not exactly the expectation of your average health care provider, especially not one with six-figure student debt, means that it's going to be a long slog to something better. [Read entire topic]

#68: Nancy Finn (nfinn8421) Wed 21 Dec 11 18:09

Wed, 21 Dec 2011 18:09:00 PST

Joe,

I do agree with everything you have described above. You do obviously know this area and your clearly stated ideas and examples will hopefully come to fruition in the New Year.

I believe, that the empowered, enlightened, engaged, educated e-Patient can and should be a part of this conversation and of the effort to bring about some of these changes so that the end result reflects what is best for the patient, somewhat for the provider and not just for the system. That is a tall order given our current political climate but with forward thinkers such as yourself and level-headed leaders such as Jon this too can happen.

Thank you for the opportunity to have this discussion with you both. [Read entire topic]