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Just another reminder in the news that Big Insurance isn't worried about getting super-sized and that United Healthcare Corporation isn't the only burgeoning beast at the table: Human shares reported today as being up by more than 4%
Rob
My wife and a couple of my kids have been on a healthy-food focus (craze would be too strong a word) the past couple of months, while one of my other kids and I have been somewhat, shall we say, more passive about the topic.
Last night one of my healthy-food focused kids got me to watch the docu-drama "Super Size Me!" with her. Whew........eye-opening to say the least (and a bit disgusting at times).
I awoke this morning a bit more focused on healthy foods, something all of us can relate to this time of year right after Christmas and New Years, while resolutions are still a bit more than faded memories. The problem is that there is so much information out there you may not know where to start or how to filter the sites so as to best spend your time looking for dieting and nutritional information (that refrain sounds familiar, doesn't it?).
Healthratings.org lists the top 20 most popular sites for dieting information (ranked in order of popularity) and then rates them based on quality of information.
Bon Apetite!
Rob
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The Evidence in Motion Team
I think it was the leadership guru Warren Bennis that said "it is easier to kill a large organization than it is to change it." I find myself wondering if that statement isn't somewhat applicable to where we stand as a profession. I don't want to imply that we need to die as a profession - but it seems that we are being pushed as a profession to figure out how to change or face some level of death.
History is full of businesses (private practice PT is a business as well as a profession) that where forced to change or die based on demands that were externally placed on them. Some didn't make it, others suffered greatly. The Railroad industry thought they were in the railroad business but outside changes left them behind because they didn't realize they were in the transportation business. If they had realized this how might they have changed what they did and would they have continued to be a force in their area of influence? What business are we in? Do we have to expand how we see what business we are in? - not just from the patients point of view and the MD but also of the insurer? Are we partly in the business of making health care more effective and efficient - not just providing what we determine to be quality care?
The US auto industry is facing serious issues today - can they change and refocus on quality and listen to what the Toyota's of the world are hearing the consumer say? (Hearing the CEO of Ford say they are refocusing on innovation tells me they still don't get it - Toyota seems to be winning on quality not innovation) The design of a new car used to be very long process taking months or years - competition has forced them to greatly reduce the time it takes to do many parts of their business. Not unlike when DRG's first came on the scene for hospitals - I remember the uproar then as providers where up in arms that insurers where going forcing them to shorten hospital stays. In a few years we have many outpatient procedures that used to be hospital stays. We may be facing a similar situation in PT where some of the responses of the insurance company are to force change in our general non-evidence based beliefs/actions. As one person commented in a past blog - they now have less profit because they now provide higher quality in less visits. Sound familiar?! Or what about the Virginia Mason Hospital in the WSJ article. Would PT's be concerned about the reduced profit of the hospital if we are the PT's getting the LB pts as depicted in the graphic? Or is it just better medicine? Then why do we expect the insurer to care about our profit? But if we can pro actively as a profession reduce the "waste" in the system might we be in a better position to get them to care if we are profitable?
Lastly, what have we done (in the words of Tom Peters) to "reinvent" ourselves to meet the demands of our customers? I believe there are many former pts of PT that do not look forward to having to go to PT due to their rising co-pays. What have we done to overcome that negative perception that some (I'd argue many) PT's have left them with. I see effective EBP practices as practices that can re-define PT in the minds of the MD, former pts and the insurer. What would re-defining ourselves look like in the minds of our consumers - the 3 primary consumers of our services (MD, pts, insurers)?
My rant for the day...As usual more questions than answers! Your thoughts?
No doubt most PTs reading the headline of this post immediately got a warm flash and thought about what procedures to add to their already onerus administrative burden so as to avoid making a billing mistake; understandable, just a natural reaction due in part to the "Peace-Corps gene" so often found in PTs.
Not to worry though, most of the primary perps in this report here weren't PTs.....they were physicians (and in one case cited uscrupulous PT co-conspirators)!! On second thought, worry because it seems PT billing will be under closer scrutiny (due in large part to physican violations).
You can access the report directly via the link above, but I pasted the pertinent citation text below for ease of access and so it is out in the open on this blog for all to see......very ugly laundry indeed.
Question: Wouldn't we all be better served (ironically, including the third party payors in this case) by just doing the right thing-- having PTs be the only ones billing for PT codes?
Rob
"Your physical therapy billings could be a major hot button in the new year, judging from the HHS Office of Inspector General’s (OIG) semi-annual report on fraud & abuse.
A Texas physician received an 11-year, three-month sentence for taking part in schemes to defraud Medicare and Medicare, the OIG notes. He accepted money from clinic owners in exchange for signing charts for physical therapy, helping the clinic owners to submit false claims. In another scheme, the doctor ordered motorized wheelchairs for patients whom a company transported to his office and performed unnecessary medical services for those patients.
The number of physicians billing more than $1 million for physical therapy per year more than doubled from 2002 to 2004, the OIG found in a recent study. Claims for physical therapy increased from $353 million to $509 million during that period, and the OIG found “significant and persistent compliance and quality-of-care problems.” Doctors’ offices overbilled for services, used unskilled staff, and billed for services that didn’t meet Medicare coverage requirements."
Over the last several weeks, we have received numerous questions in reactions to many of our posts, presentations, and comments. The increasing frustration of private practice PT’s who are being cut across the country by large payors has been the biggest contributor to the questions.
In this first part of a 2 part series, we will attempt to address the most common questions that we have been getting lately.
Ques #1 Why do insurance company’s pay hospital based providers more than freestanding?
Hospital’s (the Have’s) provide a bundle of other services that are important to payors that freestanding providers do not (the “not’s”). In essence, hospitals are either monopolistic or oligopy's in their respective geographic areas. Largely protected by regulations giving them exclusitivity (e.g. CON laws), they have the ability to negotiate rates as part of their “bigger picture” in their relationship to payors. AND hospital CFO’s are not genetically coded with peace corps genes like PT’s-they know how to say “NO”.
Ques #2 Why do insurance companies offer rates to PT’s that are well below their costs and roughly 30% of medicare rates?
Payors believe that PT is a “black hole”. They don’t know what they pay for and they are not sure what they get and they are not sure what determines when a patient has reached medical improvement. Therefore, treat them all like plankton and pay low rates. The more simple answer is that “the can” because they realize most markets are oversaturated with therapy providers and many are willing to take rates below their costs.
Ques #3. Why do PT practices take rates below their costs?
This is not as simple question as it appears. History would reveal that PT’s and their natural predisposition towards doing good things for patients (part of that genetic thing) have unwittingly not charged for all of their service time which has resulted in a natural undervaluing of services from an economic and pricing standpoint. When one set of “physical therapy” is charging and receiving substantially less than another set of “physical therapy”, data analysis and pricing naturally falls to the lowest denominator.
This phenomenon has traditionally caused PT practices to just continue to take falling rates. PT is also a referral oriented business where we count on receiving patients from sources. Practices don’t like to confuse the referral train by making their referral sources decide based on reimbursement where to send patients. Of course, their is always the mistaken belief that taking rates below costs gives you an edge in the marketplace. Lastly, PT’s just don’t know how to say “NO”.
Ques #4. What about all this talk from payors about evidence-based practice, outcomes, P4P, and patient satisfaction?
These are all euphemisms for “we want you to do more but pay you less”. When the difference between performance and underperformance is undetermined, rates fall to their lowest common denominator.
Ques. #5. Why do insurance companies pick on PT?
Great question, glad you asked. PT represents at best 2–3% of the health care premium. However, musculoskeletal costs are rising and soon to be higher than cardiac and oncology (for some payors they may be already). Part of musculoskeletal costs include PT (along with imaging and pharmacy but we won’t go there right now). Because of the nebulous nature of PT (the “black hole” thing), it is an easy captive market to pick on. A more simpler answer is “they can”.
More to come in Part II. Thoughts?
Larry
This short commentary by Dr. Jonathon Adler of Mass. General addresses several issues and concepts related to clinical practice guidelines and clinical prediction rules (the term clinical prediction "instruments" is now being used).
Although most of us have known about practice guidelines for some time, some may view clinical prediction rules (CPRs) as a recently new phenomenon. And those who do little reading outside our field may view CPRs as being something primarily relgated to the field of physical therapy. Not so on either account. The New England Journal of Medicine discussed CPR methodology as early as 1985 and numerous examples of CPRs in the medical literature exist (streptoccol pharyngitis, febrile neutropenia to name a couple). Although there are many issues and concerns related to clinical practice guidelines, I will say that CPRs have the potential to greatly improve clinical decision and reduce unwanted practice variation.
On a related note, congratulations to Dr. Josh Cleland and colleagues recently published a CPR for the identification of patients with neck pain who respond to thoracic manipulation, exercise, and patient instruction. Also, congratulations to the Dr. Rebecca Craik and all the folks at PTJ for taking the journal to the next level. The improved format and online intiatives are great, thank you!
Rob
The story behind the Susan G. Komen Foundation (now named "Susan G. Komen for the Cure") is an inspiring story of what the efforts of a single person can accomplish.
I have participated in a race before but never really knew how this organization got started. Now I do. Pause and take the opportunity to read and find out too: Be inspired!
Rob
"Row, row, row your life-boat, across the health-care stream.
Merrily, merrily, merrily, merrily makes you want to scream.
Cut, cut, cut our cost, what is that you say?
Must be crazy, margins are high, and we'll make sure they stay that way!
-Sincerely, UHC"
OK, just when you thought you had seen everything check this out. Seems like physicians in the Medford area got tired of getting the shaft from UHC and got together to form their own coalition called "Prime Care" to negotiate contract rates with UHC. As it turned out no agreement was made (physicians lost round 1) and agreed to just doing business under the same rates as the previous year. Same thing happened with negotiations this year and the result was the same. So guess what? The physicians bailed on the contract and now UHC covered patients in that area have to drive at least 30 miles to be seen by a provider who takes UHC patients.
What was UHC's responsible answer to their premium paying customers? A letter sent informing them that "You will be covered by out-of-network coverage", which of course means higher out of pocket costs. Geez, I haven't seen the letter but why not save some extra expense and just send a post-cared that says "What, Me Worry?" complete with a smiley face. Hmm, as I think about it now and given the cost of mass mail, that solution would be a way to add to the 1.2 Billion (with a B) margin for UHCs most important stakeholders--the Shareholder (and CEO?)
The really disappointing thing in this case (at least as this was described) is that even good faith efforts to engage UHC by other important stakeholders (physicians in this case) appear to be met with a level of arrogance and indifference that appalling to say the least. I wonder if a similar attempt by the PT community would be met with this attitude and yield the same results? Given the evidence, that is obviously a rhetorical question.
Rob
One thing that doesn't seem to be changing are the huge profits experienced by Big Health Insurance (like the 1.2 billion (yes, with a "B") 4th quarter earnings reported by UnitedHealth)
The chess-boarding in an attempt to stream-line and cut-costs (which these days seems to always mean more profit for the Insurance Industry) always seems to have a predictible results: most patients get the short end of a stick and providers get the other, like the new Medicare Advantage Plan in KY expemplifies.
Of course, during this process the providers look like the bad guys because they refuse to take a plan that jeoprodizes thier viability, patients miss out on care, and the Insurance Company rationalizes their actions as the need to control costs which is belied by the size of their bulging coffers. Just a couple of the reasons providers in KY decided to stop taking long-standing patients who were transfered to the plan were 1) more adminstrative hassle than Medicare and 2) more work for less money.....these are direct quotes.
Not sure how to stem this ongoing trend that affects providers of every sort (including PTs; don't forget many of our colleagues were given the privilege of a $35 a visit per diem rate), but it appears that more and more are just saying "No". The unfortunate part is that unless a viable solution that benefits all parties is worked out, then just like the lowest ranking soldiers, sailors, and airmen, we are going to see our patients be the first to suffer before change is brought about.
Rob
