Tag Archives: webmd

Are You on Your Game, or Is Your Game Over?

Weeks ago, Jim and I met for coffee to solve all the world’s problems. We didn’t, but he did hand me an article about Sudoku and said, “There may be a story in here.” He was right. I just didn’t realize how quickly it would appear on my computer screen.

Later that day, when I was driving down Main Street in New Iberia, La., I saw mobs of “geeks” (the politically correct term is “millennials”) playing Pokémon Go. My wife works Sudoku puzzles. I had read about Pokémon Go, but I have never even seen it played before.

See also: Pokémon Go Highlights Disruptive Technology  

I was impressed with the marketplace’s embrace of Pokémon Go. One hundred million devotees in less than a year is a game-changer.

If, like Sudoku, your business is manual, local- and pencil- and paper-dependent, your universe is limited to yesterday. If you are global and virtual like Pokémon Go, there are no boundaries — only opportunities. Your future depends on the choices you make, local or global, manual or virtual.

Now let’s quit playing around and get serious about the insurance industry and your place, if any, in tomorrow’s world.

Whether you prefer the metaphor of revolution or evolution, our world is changing. The change is going to be structural, revolutionary and transformational. The reason is that when one thing is different it’s change; when everything is different it’s chaos.

In terms of natural disasters, think 9/11, Hurricane Katrina and New Orleans, the Japanese tsunami, etc. For economic crises, consider the 2008 economic collapse, the stock market crash, the GM bailout, the demise of AIG, Lehman Brothers, etc. — and then remember the past and current reshuffling of the retail and distribution systems in our world (Amazon, Uber, Airbnb, Expedia, WebMD, Netflix, etc.) I could go on, but I won’t. I can’t remember all the changes, nor can I outrun the pace of change.

These changes from yesterday were triggered by systems, big data, technology, global competition and corruption, the internet and a marketplace that has evolved over time — from the corner store, to Main Street, to strip shopping centers, to malls, to box stores and even to a virtual presence in cyberspace. The big change now and tomorrow is not place but rather people and pace.

See also: Look Up, Look Out, Think New!

Our industry was built for a “father knows best” world. The youngest of the Greatest Generation are now 70 years old. Their progeny are the Boomers, who are 52 and older. Those in Gen X are age 32 and above, and the Gen Y and millennials are somewhere between 12 and 34.

In tomorrow’s market, age doesn’t matter — wiring does. Every preceding generation was born to analog; these Gen Yers/millennials are digital natives. What we “old” folks see as aberrations, they see as the norm — and they and the market ain’t going back ever again. By 2025 (which is nine years away) millennials will be 75% of the working people. The next nine years may bring more technological advances than we’ve seen in our collective lifetimes.

Our options are simple: We can go enjoy a smoke and a Sudoku on the bank of the nearest tar pit and wait for a meteor to end our pain and frustration, or we can shift into high gear and catch up with the roaming hordes of Pokémon Go folks and play in — and with — the world as it’s going to be!

THE MARKET IS CHANGING BECAUSE BUYERS CHANGE!

Change or die! Carpe mañana!

How to Best Use Provider Networks

We are all familiar with preferred provider organizations (PPOs), and many have utilized either subset networks (exclusive provider organizations) or other iterations to control escalating medical claim costs. While these approaches to provider networks had proven successful between 1970 and 2010, based on the impacts of the Affordable Care Act (ACA) they may no longer be sustainable in their current configuration.

There are simple strategies that build on the current model for provider networks and that may help improve a health plan’s performance, and I will get into those shortly. But first let’s develop a common understanding of how PPOs contract.

The marketability of a PPO is based on reducing the cost of claims and providing access to a large number of providers. Typically, PPOs use a variety of cost mitigation techniques including discounts, per diems, case or global rates and relative value schedules (RVS). For a PPO to negotiate its greatest savings, it must enroll a large number of members and be able to steer utilization.

When negotiating for professional services, a PPO typically works with two models, though a third could be added when specialty care is involved. The first model is a discount off billed charges. This is a relatively easy agreement to secure because it doesn’t affect the provider’s practice unless highly utilized. The second model is based on a relative value schedule (RVS), which was implemented in the late 1950s when the California Foundation for Medical Care established a cost for services and applied factors by region. This model was known as the California Relative Value Schedule (CRVS). A similar approach was implemented by Medicare under the title of Regionally Based Relative Value Schedule (RBRVS), which has become a standard for contracting of professional services today. As a result, most professional contracts are now based on Medicare RBRVS plus 10% to 30% depending on the region, type of provider and enrollment population. In some cases, specialty providers may contract based on fixed fees, or a variation of other methods.

Contracting with institutions is very different. In a traditional PPO, hospitals may contract through either a discount off what is billed, fixed per diems for room and board, ICU or CCU or a combination. The discount model is relatively straightforward. A contract that includes per diems will typically have a number of variations such as an “outlier.” The outlier or hospital deductible is a dollar threshold that, when exceeded, triggers re-pricing. In outliers’ purest form, the claim reverts back to a discount off billed charges to first dollar. Some contracts may allow the re-pricing to begin with amounts above the outlier, but this is not the standard.

In situations where treatment is standardized, such as childbirth and knee replacement surgery, a PPO may contract on a case rate basis, which establishes a fixed reimbursement for all care associated with the event. Some of the charges that may fall outside of the event would be physical therapy, durable medical equipment and medications. There will be other treatments, including transplantation, that may include case or global rates. While case and global rates may appear similar, they can vary greatly by network and provider organization. In some cases, the application of a case rate does not limit the claim liability to the contracted amount. As an example, we had an experience with a national network where the $1.8 million transplant charge was paid at $1.3 million even though the PPO had a $250,000 case rate.

This method is not characteristic of case or global rate practices, but consultants and clients should be mindful of exposure as it could affect the plan’s claim reserves and medical excess coverage.

The Affordable Care Act continues to affect claim costs in both fully insured and self-funded environments. Overall claim trends appear to be manageable, although some specialty care and acute care hospitals have changed billing practices as a result of unlimited lifetime benefits. An example is dialysis, where the total cost per patient has skyrocketed. In an audit of dialysis claim costs, we have identified two national provider groups as being abusive in the billing of services. Claims that prior to implementing ACA would average $28,000 to $40,000 per patient per month are now ranging between $60,000 and $105,000 per patient per month. These patients have not been of major concern to PPO contracting managers because of the low volume of claims. As a result, networks have settled for discounts of 15% to 35% off billed charges. Depending on the patient’s diagnosis, Medicare pricing could come into play, resulting in allowable charges closer to $10,000 per month, which may stabilize the group’s overall health plan spending. These and other tools will be discussed in future articles.

In addition to contracting for cost control, most PPO agreements include claim filing requirements and auditing authority. In today’s electronic age, the use of clearing houses such as WebMD have significantly improved claim submission and processing times. As a result, many PPO contracts may require the professional provider to submit claims within 30 to 90 days of treatment, or sacrifice reimbursement. The same principle may apply to institutional contracts, though the timeline for submission may be 90 days. In some cases, a PPO contract may allow an institutional provider to submit claims for a premature birth or transplant patient as long as 150 to 180 days following discharge. Risk managers, consultants and claim payers need to be aware of exceptions to the claim submission rules as they could create a non-reimbursable event if the medical stop loss policy run-out period ends before the processing of the claim.

As part of the due diligence process, it is in the client’s best interest to identify any barriers to audits of financial and medical appropriateness. A number of provider networks surrender the client’s audit authority to secure greater pricing concessions. While pricing concessions are important to the overall claim spending, it only takes one catastrophic claim to hurt a health plan’s performance. Many leaders in the PPO industry understand the need for transition, but it could take a few years to re-engineer existing provider contracts in the areas of auditing for appropriate pricing and care setting, cost to charge, captitation or other non-discounted approach to re-pricing, as well as a reduction in network size to efficiently manage the consumption.

Now that we have a common understanding of PPO contracts and we agree that change will take time to implement, let’s briefly discuss simple strategies using the current PPO model that may help improve a health plan’s performance. A strong PPO can assist clients in controlling costs when the plan design encourages people to use in-network providers. Therefore, when offering a PPO, it is appropriate to include a minimum 20% differential benefit between in- and out-of-network providers. Additionally, providing for deductibles and out-of-pocket amounts will drive patients to network providers. To avoid emergency room frequent fliers, a health plan should have an appropriate co-payment as an inducement to have patients seek care in a clinical setting.

In reviewing our block of business, which includes commercial employers, public agencies and healthcare clients, we have determined that over-utilization is not a significant concern. We have identified a number of areas where a properly crafted plan document coupled with specialty vendors may aid in the control of high-dollar claims. For example, implementing a dialysis management program can reduce average claim cost by 70%.

Beware of vendors who require a percentage of savings, as their fees could double the net claim amount. Consider the addition of domestic medical tourism. While medical tourism is a hot topic, and many of these vendors redirect care outside of the U.S., a number of employers are finding local solutions through direct contracting of specialty care and adding these under domestic tourism provisions.

An employer might include the addition of cost-plus or in-network allowable amounts and the maximum allowable reimbursements for out-of-network claims. One final concept is to utilize an exclusive provider organization-type plan design packaged with a PPO network. Essentially, the health plan would only offer in-network benefits unless care is on an emergency based outside the network’s service area.

This is the first in a series addressing all forms of provider networks. Future articles will introduce the reader to establishing local networks, direct provider contracting and capitation of medical groups, which generates provider engagement in health outcomes and financial management. Recent discussions with leaders of a number of national PPO networks found that many are currently attempting to apply these principles with varying success.

Care Transparency – What Employers Are Missing!

Employers are trying hard to reduce health care costs and create a healthier, more-productive workforce. They have tried to optimize employee usage of services offered by their health plans and invested in wellness programs. They are now beginning to consider (or have implemented) cost transparency tools and second opinion and telemedicine services.

All these approaches are right!

What employers are missing is an understanding of how employees are making health care decisions and how that impacts their health care costs.

A large population of health care consumers are starting with a search engine to find health care information online. In the past year, 72% of U.S internet users have gone online specifically for health related information, and 77% of them begin their research at a search engine.1

And age has nothing to do with it!

Of those who seek health information online, 73% are 50 years of age or older.

At the same time, many doctors are urging patients to not rely so much on Google for health research. Doctors lament that they often have to correct misinformation or incorrect conclusions after patients do health research online.2

Even when employees go to a reputable site such as WebMD or a health plan’s member portal, they end up with a laundry list of treatment options. Try running a search for back pain — you will end up with more than two dozen treatment options. Health care consumers don’t know what is effective, appropriate or necessary, so most follow recommendations from friends or family or go through trial and error based on what they read online. Here are a few treatment decisions for back pain:

  • Buy a heating pad
  • Buy a muscle relaxant
  • Buy over-the-counter drugs
  • Go to the chiropractor (the one Uncle Bob recommended)
  • Go get massage therapy
  • Do yoga
  • Go to a doctor
  • Go to an orthopedic specialist (because your friend swears by it)

You get the point.

Each wrong treatment decision costs employers money — $235 per treatment decision, to be specific.3

Multiply that by the number of employees in your organization (and their dependents) and number of treatment decisions they make.

This is a huge avoidable cost.

Phone consultation services such as care/disease management or health advocacy are not going to stop employees from going online for help. It doesn’t make sense for employees to be calling someone every time they have a question regarding their health issues.

Employers also need to meet employees where they are — online. Employers need to provide them with tools that can help their research and decision making process with robust, accurate, unbiased and evidence-based information.

Employers can help create care transparency by offering Treatment Selection and Shared Decision Support tools. Employers can significantly improve the quality of care consumed by their employees and reduce health care costs by focusing on creating care transparency.

In my next article, I will write about the types of tools that will be effective in supporting employee decisions and the type of tools that employees will really use in making care/treatment decisions.

Sources:

1 77 Percent Of Online Health Seekers Start At Search Engines [Pew Study]

2 Doctors Warn Against Relying Too Much On Google

3 WiserTogether, Inc research