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26 July 2016

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John Minehan

The ACA (and Medicaid) is not really built around Primary Care of getting people a "Medical Home."

One solution (which seeems to be happening by default) is expanding the use of NPs and PAs (not interchangeable, of course) to delivery Primary Care.

John Minehan

"Clearly" is in the eye of the beholder.

ERs also have issues (with PPACA) of generating out of network charges when the Hospital is in-network but the Emergency Medical Group staffing the ED does not par with the Plan.

NYS now has a legislative fix in place.

John Minehan

Hence the rise of modalities like "Urge-centers." Care in an ED still costs the Hospital more money to provide.

John Minehan

"Med-seeking"/Frequent Flyers" have been a big issue for at least 20 years and the Opioid Epidemic has not helped.

John Minehan

What you really need are price-points for care, as you have for other things.

John Minehan

The VA is a great system but it (like other government programs does not scale well. The problems in Arizona are driven by te census increasing faster than the budget.

John Minehan

Providers are consolidating. Payers are consolidating. Patients need to consolidate, also, under MEWAs as the Trump Administration has proposed.

John Minehan

"Reimbursement rates that providers can charge are negotiated by insurance companies and put in written contracts. The rates are based on massive amounts of analysis involving everything from trends in medical technology development, to demographics, to network issues, to inflationary forces, to (especially) prior years utilization and cost trends. There is nothing arbitrary about it."

Actually, in the Discounted fee-for-service model used in most places, the rates are a function of the Medicare rate in that catchment area.

John Minehan

"A lot of time also. Medicare is straightforward and billing problems rare. All of our big problems have occurred with private insurers."

Twenty years ago or so, HCFA (now CMS) proposed docs being able to opt out of Medicare. It was unthinkable! The average practice thought the reimbursement was low but it paid net 45 days on a clean claim, it was your cash flow.

All of that has been MUCH less true since the Great Recession.

Eric Newhill

John,
This is an old thread. I'm surprised to see it resuscitated - and so actively by you. I work in the healthcare insurance industry and have provided analysis to the contracting team to help them set rates. I know what I'm talking about.

When I worked for the not-for-profit Blues, we did, indeed, often just set rates at a % of Medicare. However, now that I'm in the nationwide for profit insurance arena, we have most of our business at contracted reimbursement rates determined by analysis as I described. We would not be able to establish profitable or successful networks if we went at a % of Medicare.

Currently aspects of ACA operations are in my purview. I have about $1.5 billion in revenues and expenditures go across my desk; meaning I'm not the janitor.

Your background with regards to all of this is?

Fred

You guys must be desperate to be filling a 3 year old thread with pro-Obamacare comments.

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