2010 Potpourri VII

A preferred provider organization is a collection of providers who have contractually agreed to provide services to certain patients at a set price or fee schedule.  An issue which has created problems for providers and occasionally patients is the application of preferred provider discounts to payers whom the provider did not know were eligible for the reduced rate.  This has been a concern both in group health and workers’ compensation contracts.   These circumstances are sometimes referred to as “silent PPOs”.  The American Association of PPOs has weighed in on the subject, opposing the formation and use of silent PPO techniques, but endorsing PPO “rental” contracts, which may not be much different from a provider’s perspective.  (AAPPO Paper) It would be best if all PPOs clearly informed the network providers in writing or by email of any payer who is going to be allowed to access the network and if the PPO ensures that providers understand before signing a rental-type contract that the PPO may give any payer access to the network discounts.

America’s Health Insurance Plans regularly surveys its members for performance on administrative functions like claims processing.  The most recent survey has been released.  (AHIP Survey) It indicates that enormous progress has been made in electronic claims submission, from 44% in 2002 to 82% in 2009.  Claims automatically adjudicated went from 37% to 75% in that time period.  Interestingly, many providers continue to be very slow in submitting claims, which makes little financial sense but may reflect continuing inefficient operations.  Over 20% of claims are received more than 30 days after the date of service.  About 93% of “clean” claims are processed within 30 days of receipt.

A news story relates the increasing use of telemedicine in California’s prisons, which are currently under receivership, partly because of poor health care delivery.  (Cal. TeleMed. Article) Prisons were an early and notable telemedicine success story and expansion continues.  Over 100,000 patient appointments have been conducted by telemedicine since 1997, saving the state about $13 million last year alone.

Further to our post earlier this week, at least one newspaper article indicates a better understanding of why individual premiums are increasing and why some supposed fixes may only exacerbate the problem.  (LA Times Article) The article focuses on New York State, where requirements that insurers cover any individual without underwriting and charge everyone the same price have led to the highest premiums in the country and even fewer people with insurance than before the mandate was enacted.  It is pretty obvious, at least to anyone except politicians apparently, that if you let people buy insurance only when they want to then only unhealthy people are likely to purchase policies, especially when they are expensive.  The cycle this creates is well-known, and again, the end result–very high prices and very few people covered–should surprise no one.

The Veterans Affairs Department has been another proponent of telemedicine, especially to reach rural veterans.  The current federal budget anticipates a large increase in the use of telemedicine, growing from $72 million in 2009 to $163 million in 2011.  The program services over 35,000 patients and is the largest in the world.  (VA Release) (VA Telehealth Article)

The Atlantic Monthly has a column by Megan McArdle which effectively debunks the notion that tens of thousands of Americans are dying because they don’t have health insurance.  (Atlantic Column) Proponents of reform have used old studies on 1980s data, which were relied upon by more recent Institute of Medicine and Urban Institute research, to suggest that 20,000 Americans die every year because they don’t have insurance.  As McArdle points out, not only are the studies old, they probably weren’t very well done to begin with.  These were obviously observational studies, drawing inferences from data, but not controlling for or exploring all possible factors and causal relationships.  The studies assumed that if at the time of interview a person didn’t have insurance, they never got it.  The studies also ignored the fact that the uninsured tend to have poorer health status and therefore be more likely to die whether or not they have insurance.  More recent research at UC San Diego does not find any such link between insurance and death.  As has unfortunately become the norm, this is just another example of finding the most misleading statistic and research to support one’s position, as opposed to trying to really understand the facts.