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Why Pay For Performance Measures Should Also Apply To Health Insurance Companies

In a recent post entitled, “The Joys Of Health Insurance Bureaucracy” I described how it took me (a physician) over three months to get one common prescription filled through my new health insurance plan. Of note, I have still been unable to enroll in the prescription refill mail order service that saves my insurer money and (ostensibly) enhances my convenience. The prescription benefits manager (PBM) has lost three of my physician’s prescriptions sent to them by fax, and as a next step have emailed me instructions to complete an online form so that they have permission to contact my physician directly (to confirm the year’s refills). Unfortunately, page one of the form requires you to fill in your drug name and match it to their database’s list before you can continue to page two. For reasons I can’t understand, my common drug is not in their database. Therefore, I am unable to comply with my insurer’s wish that I enroll in mail order prescription refills. This will further delay receipt of my medication – and probably increase my cost as I will be penalized for not opting into the “preferred” mail order refill process.

Now, all of this is infuriating enough on its own, but the larger concern that I have is this: How many patients are not “compliant” with their medication regimen because of problems/delays with their health insurer or PBM? Physicians are being held accountable for their patients’ medication compliance rates, even receiving lower compensation for patients who don’t reach certain goals. This is called “pay-for-performance” and it’s meant to incentivize physicians to be more aggressive with patient follow up so that people stay healthier. But all the follow up in the world isn’t going to get patient X to take their medicine each day if their health insurer or PBM makes it impossible for them to get it in the first place. And shouldn’t there be consequences for such excessive red tape? Who is holding the insurers and PBMs accountable for their inefficiencies that prevent patients from getting their medicines in a timely manner?

Pay-for-performance assumes that physicians are the only healthcare influencers in the patient compliance cycle. I’ve learned that we only play a part in helping people stay on the best path for their health. Other key players can derail our best intentions, and it’s high time that we look at the poor performance of health insurers and PBMs as they often block (with intentional bureaucracy) our patients from getting the medicine they need. While insurers save money by having patients struggle to get their prescriptions filled, doctors are payed less when patients don’t take their medicines.

Not a great time to be a doctor or a patient… or both.

Pay-for-Performance Targets Hospitals Unfairly

This blog has tried to support the virtue of personal responsibility. If you smoke, don’t blame Joe Camel. If you surrender to Big Mac attacks, don’t go after Ronald McDonald. If you love donuts, and your girth is steadily expanding, is it really Krispy Kreme’s fault? And, if you suffer an adverse medical outcome, then…

Medicare aims to zoom in on hospitals, suffocating them with a variation of the absurd pay-for-performance charade that will soon torture practicing physicians. Of course, a little torture is okay, as our government contends, but pay-for-performance won’t increase medical quality, at least as it currently exists. It can be defended as a job creator as several new layers in the medical bureaucracy will be needed to collect and track medical data of questionable value.

Medical quality simply cannot be easily and reliably measured as one can do with a diamond, an athlete or a wine. Most professions resist being graded or claim that the grading scheme is a scheme. Teachers, for example, refute that testing kids is a fair means to measure their teaching performance. Conversely, any individual or profession who scores well on any quality review program will applaud the system’s worth and fairness. Shocking.

Under the government’s new program, hospitals could be financially responsible for the cost of medical care that a patient requires for up to 90 days after discharge. Read more »

*This blog post was originally published at MD Whistleblower*

Animal Metaphor Describes New ACO Regulations


The final Accountable Care Organization regulations are out, the initial flurry of commentary is out (including my own ACO webinar with simultaneous #ACOchat tweetchat - available for replay; slides here : “ACOs, Bundled Payments and the Future of Health Care“), and we can now all catch our collective breath and contemplate the draft vs. final ACO regulation comparisons, the meaning of this new, final set of regulations, guidances and statements from CMS, FTC, DOJ, OIG, and IRS on ACOs and Medicare Shared Savings Programs, and all of the attendant antitrust, antikickback, Stark, and other fraud and abuse matters, and of course tax issues.

So, now that these final regulations are out, and the mythical characteristics of the ACO will soon be dispelled (see under: unicorn), I propose a new animal kingdom metaphor for discussion of Accountable Care Organizations:

The Camel’s Nose is in the Tent.

The definition of a camel, as those of you who tuned into my ACO webinar already know, is Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

Do Patient Surveys Measure True Medical Quality?

There was an extremely popular game show where several times each episode the emcee would shout out, “Survey Said!”. Of course, this was just a game, not real life.  Now, several times each week I am asked to respond to surveys.  They pop up uninvited on the internet and are often veiled advertisements for products and services. They are on the back of receipts from coffee houses and doughnut shops.  Is it worth 10 minutes of my time clicking through the doughnut survey for either a free chocolate frosted doughnut or the chance to be entered into the grand prize drawing months later?  Hotels I stay at routinely follow-up with e-mail surveys for my feedback.  I suspect most folks delete these instantly, which skews the customer base to those who do respond. (Remember, disatisfied folks are often more motivated to give feedback than the rest of us are.) How often do we call a restaurant, a retail store, a bank or even a doctor’s office to offer hosannas about great service?

Medicare recently released fascinating patient-survey data that raises interesting issues. In over 120 hospitals, patients rated the hospitals very highly, despite high death rates for heart disease and pneumonia. So, who do we believe here, the patients or the death rates?  I wonder if the patients’ survey results were more optimistic since only the live ones were available to complete them.

Surveys are now serious bu$ine$$. Read more »

*This blog post was originally published at MD Whistleblower*

The Features Of A Bundled Payment For Care Improvement Project

Many health care provider organizations have not been overly eager to jump onto the Accountable Care Organization (ACO) bandwagon, citing high startup costs and uncertain returns on investment given the complexity of the program.  Well, recently, the CMS Center for Innovation has announced the Bundled Payment for Care Improvement initiative.  This initiative incorporates elements of earlier CMS demonstration projects — the gainsharing demos and ACE (acute care episode) bundled payments demonstrations which the HealthBlawger has helped a number of clients around the country qualify for in the past — and builds on the broad authority granted to the CMS Center for Innovation under health reform.

The advantages to proceeding with a Bundled Payment for Care Improvement project include the opportunity to participate in CMS shared savings programs while only providing limited commitment of organizational resources, i.e., limited to one or more discrete service lines or episodes of care.  Of course, investments in a culture of collaboration must be made, but the system-wide investment in IT and other infrastructure at the level called for in order to qualify as an ACO would not necessarily be required in order to proceed with this initiative.

There are a number of different models open to participants, and nonbinding letters of commitment are due as early as late September.

From the CMS Center for Innovation announcement: Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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