Friday, December 28, 2007

Pay For Performance: Physicians Pay For Insurers Better Financial Performance?

I've always been suspicious of the pay for performance movement. Thinking cynically (which I do more and more these days), it seemed to me that pay for performance has the backing of the insurance industry because they could use it as an excuse to pay physicians less. Show me a pay for performance program that actually increases costs to insurers and I'll show you an out-of-work actuary.

Mark Vonnegut, a pediatrician, has a perspective article in the December 27, 2007 issue of the NEJM titled Is Quality Improvement Improving Quality? A View from the Doctor's Office. I found the following a much better statement of the issue than I could ever come up with:

"I can't help suspecting that underneath all these quality-improvement and pay-for-performance initiatives lies yet another scheme that will work out very well for insurers and very badly for providers and patients."

Unfortunately, it's not free full text, but it should be (meaning you'll need a subscription to read the whole piece).



Friday, March 30, 2007

P4P: Are Vested Interests Pushing the Agenda?

New Data, More Doubts About Pay-for-Performance (P4P)

"Again, as we have noted before, developing performance measures that will truly benefit patients will require detailed understanding of the clinical context, keen skeptical analysis of the available relevant research data, and careful balancing of benefits, harms and costs. All this would be very hard under the best of circumstances. But the continual attempts by those with vested ideological and financial interests to influence performance measures to advance their own interests make it unlikely that the whole P4P movement will have any good effects on patients.

The first improvement needed in the P4P movement is clear, detailed disclosure of all conflicts of interest affecting those involved in the movement at any stage.

At this point, patients and physicians should be very skeptical about who is likely to benefit from any new performance measure, particularly measures that are lavishly promoted."

This nicely sums up my suspicions about P4P beyond just the fact that it rewards task completion over the exercise of medical judgement...

[Health Care Renewal]



Wednesday, March 7, 2007

Medicare To Cut Physician Fees 9.9% in 2008

It's official (pdf). The Center for Medicare and Medicaid plans on cutting the physician fee schedule 9.9 percent as of January 2008. Five percent for 2007 (which cut was postponed due to a temporary one year patch), and 4.9% for 2008.



Wednesday, February 21, 2007

DaVinci Surgical Robots. A Hospital CEO Asks Advice.

Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!

"Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?"

I just discovered this blog today via Medgadget and am already impressed. The large health system our group works in purchased a DaVinci last year. I don't know outcomes yet but it was apparent to me before the purchase that it was largely driven by regional competition in Central Pennsylvania. I think it's telling that many of the institutions which were the early adopters no longer use the systems.

I'm hoping to pick one up cheap in a couple of years so I can do labor epidurals from home. ;-p



Thursday, April 6, 2006

I'm 41....and free of student loan debt!

I turned 41 years old today. Perhaps more significant to me, however, is that I finally paid off my last outstanding student loan! I finished medical school in 1992 and residency in 1996 so it took about ten years.

My total debt amounted to about $70,000 for college and medical school combined (without interest). Here are some interesting numbers from back then:

"Median U.S. Medical Schools Tuition and Fees for First-Year Students in 1992-3:
  • $20,597 for private schools
  • $7,544 for in-state residents at public schools
  • $16, 739 for out-of-state residents at public schools

Mean level of Educational debt of indebted graduates in 1992:
  • 19.5% of medical students had no debt
  • $47,088 for public schools
  • $69,479 for private schools
"

And here's the data from 2003:

"Average Educational Debt
  • $115,218 – According to the Association of American Medical Colleges, the average educational debt of indebted graduates of the class of 2004 (including pre-med borrowing)
  • 63% of graduates have debt of at least $100,000
  • 81.4% of graduating medical students carry outstanding loans, combined with 62.4% with loans on college/premedical education
  • $91,438 – Mean per capita debt for 2003 allopathic graduates
  • $109,457 – Mean per capita debt for 2003 allopathic graduates excluding students without loans
  • $123, 800 – Mean per capita debt for 2003 osteopathic graduates, up 2.3% from the previous year
  • $7,277 – non-educational debt (allopathic)
"

One final note: If I'd stayed in academic anesthesia it would have taken at least another ten years to pay these loans off...



Saturday, January 21, 2006

Can damage caps influence premium growth and physician supply?

The Impact of Caps on Damages: How are Markets for Medical Liability Insurance and Medical Services Affected?

"[This report] provides a summary of research on the impact of caps including those on punitive and total damages in addition to those that apply only to non-economic damages. Our focus is on those papers that employ statistical techniques to control for potentially competing explanations of changes that are observed when simple descriptive statistics are used."

and concludes

"the body of research on the impacts of tort reform shows that caps have resulted in lower growth in medical liability losses in states that passed caps than in states that did not. The more recent literature on premium effects has found that caps result in lower premium growth. And, two very recent papers based on sufficiently many years of the AMA’s Masterfile data have found that non-economic caps and direct tort reforms more generally have a positive effect on the number of physicians per capita in a state."

Insurance Profits Don't Explain Malpractice Crisis

The American Medical Association has released a new article which takes to task the so-called 'Angoff Report' which claimed that the medical liability insurance crisis is caused by insurance companies booming profits, overcharging physicians for coverage, and ballooning surpluses. It refers to two subsequent analyses which point up the flaws in the approach used by Angoff. Revised analysis shows the growth rate of insurance company surpluses was only 3.9% per year, and they were profitable in only one year (2004) when they made 5%



Wednesday, January 11, 2006

Medpundit Looks At His Financials

Ugh: I just spent the better part of the afternoon...:

"Ugh: I just spent the better part of the afternoon doing my least favorite task - reveiwing the financials of my practice. It doesn't look pretty. With Congress electing to decrease my pay by 4%, and my malpractice premium set to increase by 30% you can see it's not going to be a good year. The cost of supplies has been steadily going up, too, as have the cost of services. My medical waste haulers upped their fees by 20% in the past six months due to rising gas prices.

The Medicare cut may not sound like much, but it translates into a loss of about $2-3 per patient visit. And it isn't just limited to Medicare patients. Insurance companies base their rate of reimbursement as a percentage of Medicare fees. They might, say, pay 110% of whatever the fee Medicare pays. A practice that sees 25-30 patients a day will make $50-$90 less a day in 2006. That adds up quickly. Assuming a five-day work week, that adds up to $13,000 to $23,000 less over the course of the year. And despite what you might read in the newspapers, the majority of patients who pass through a doctor's office have health insurance - so the cut goes across the board.

How does that translate into day to day life? It means that my staff didn't get a cost of living raise this year. It means that I'll have to drop their health insurance if the premiums increase. And it means that I'm working harder - double booking patients when I can and adding an extra half day to my work week. Hopefully, I'll break even and avoid a decline in my own wages."



Tuesday, December 27, 2005

Insurance Companies Trying To Curb Anesthesiologist Participation in Colonoscopies

Propofol sedation for colonoscopies is in the news today.

Colonoscopy anesthesia popular but pricey (UPI):

"NEW YORK, Dec. 27 (UPI) -- An increasingly popular and potent anesthetic makes colonoscopies more comfortable for patients but it sharply boosts the cost, reports say."

I've given lots of propofol anesthetics for colonoscopies. Patients go off to sleep before they start, wake up when it's over and ask 'when are we going to start?' The recovery is faster and cleaner than traditional opiate/benzodiazepine sedation, allowing a center to increase the number of patients it can perform an exam on in a day.

A similar report on CNN/Money goes as far as to call the insurance company involved (Wellpoint) and ask if their executives will forego propofol. Answer?

""They'll be covered by the same clinical guidelines," the Wellpoint spokeswoman said."

I have to wonder, wouldn't the same logic apply here as applies to providing epidurals for labor? Are labor epidurals medically necessary? The American College of Gynecology, together with the American Society of Anesthesiologists has opined that "there is no other circumstance where it is considered acceptable for a person to experience untreated severe pain that is amenable to safe intervention." Ask a nurse that works with colonoscopy patients how she'd like hers done. I'll bet I know the answer.

It's not just insurance companies that are clamping down on anesthetists administering propofol to colonoscopy patients. Apparently, a group representing the gastroenterologists have asked for propofol labeling to be changed by the FDA to allow them to administer it (see safepropofol.org for more info). This same group is against Wellpoint's policy change as outlined here.

[Via Yahoo Search: anesthesia]



Friday, May 27, 2005

Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005

Kaisernetwork.org--Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005, Study Says - :

" The average U.S. family of four will use $12,214 worth of medical products and services in 2005, up 45% from $8,414 in 2001, according to a new report by Milliman, the Washington Times reports (Higgins, Washington Times, 5/26). The report -- the first on consumer health care costs culled from the new Milliman Medical Index -- was based on health insurance information for more than 15 million insured U.S. residents (Whitehouse, Dow Jones/Wall Street Journal, 5/26). The report examined medical costs for a family with two adults and two children under age 10 who were covered by a PPO. It focused solely on costs for medical care at the point of service and did not include health insurance premiums (Washington Times, 5/26). The report also did not examine over-the-counter drug spending and the cost of medical treatments not covered by health insurance (Croghan, New York Daily News, 5/26).

The report found that the average family will pay about 17% -- or $2,035 -- of its total health care costs in 2005, with a health plan paying the remainder. "

The whole report is available here pdf.



Saturday, March 12, 2005

U.S. Health Spending Projections U.S. Health Spending Projections For 2004–2014

Health Affairs: U.S. Health Spending Projections For 2004–2014

"By 2014, total health spending is projected to constitute 18.7 percent of gross domestic product, from 15.3 percent in 2003."

Gulp.

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