The Latest Issue of Health Affairs

Health Affairs is a monthly magazine which supposedly covers health care research and policy.  For many years it was an outstanding source of fairly unbiased research on a variety of topics, although it always leaned a little left.  Then of course over the last decade in particular it went off the ideological deep end and spends a significant amount of time pursuing the DIE agenda.  There are still occasional useful pieces of research.  I thought it might be interesting to take a little spin through the current December issue, which was focussed on risk adjustment and insurance markets as primary topics.

The first research piece is actually quite useful, on “upcoding” and its impact on perceived health trends.  Here is the background.  When you see a doctor, go to a hospital, or visit another health care provider, a very detailed bill is produced regarding the services and products you received.  This bill has two sets of codes on it.  One set is used to describe what was wrong with you–your diagnoses and is based on the International Classification of Disease code set.  The second set describes what was done to you, and is based on the Current Procedural Terminology code set, which interestingly is owned by the American Medical Association.  There are other code sets, for example, the Healthcare Common Procedure Coding System, which has some greater level of detail than the CPT set and was initially used by Medicare.

As you might imagine, because the combination of ICD and CPT or HCPCS codes has everything to do with what providers get paid, providers have invested extensively in software systems which attempt to maximize coding–make you look as sick as possible and like you needed as many services as possible; and payers have invested in software to “edit” providers’ claims to eliminate inappropriate diagnosing and service coding.  Now Medicare Advantage and other payer programs also may pay health plans based on how sick a member is, so to some extent providers and payers share a common interest in maximizing coding–“upcoding”.  And a lot of health plans also are or own provider systems–Kaiser and UnitedHealth Group are examples–so they have mixed motives.

Anyway, the Health Affairs research finds that the supposed trend in more intense hospital says is largely the result of provider upcoding.  In other words, the patients aren’t actually in any worse health, they are just being coded at a higher level of intensity.  Guess what, the hospitals get paid for more patients that are sicker!!  Think that might provide an incentive for upcoding?  I am not sure there is a perfect method of provider reimbursement, but the current health adjustment methods are resulting in a lot of excess payment.  (HA Article)

You may recall President Trump’s recent claim about a huge increase in autism.  Another wonderful example of upcoding.   The reality is there isn’t a huge increase in autism, there probably isn’t any; what has increased enormously is autism diagnoses.  All kinds of money is available to treat autism, some schools even get paid more for autistic children.  Autism is the fuzziest kind of “disease” imaginable.  So providers are calling every child who has any difficulty in life autistic.  And RFK, Jr. gets to spread his absurd lies about vaccines and autism.

Another article in the issue discusses Medicare Advantage upcoding in regarded skilled nursing facility assessments.  These help raise the risk scores on which the MA plans are paid.  But another article supports a point I have made frequently on the other side, which is that providers in fee-for-service Medicare often don’t completely code all of a patient’s issues, so some of the risk-score gap is because FFS patients aren’t coded as high as they should be.  And the FFS providers often are not proactively identifying all of a patient’s health needs.

Another article discusses the growing concentration of Medicare Advantage members in a few national health plans.  Another describes how these same national plans are the primary force in the self-funded market.  Additional articles discuss relative payments to providers by different types of insurance, the use of hospital payment caps to limit spending by state employee health plans, putting an inflation factor in Medicare physician payments, the intergenerational effects of adverse childhood experiences (with a DIE twist), the cost of cancer meds.

This issue has a lower than average DIE content, but here comes one, about pharmacy closures.  Gosh, guess what, they disportionately affect minority communities.  Gee, wonder if just like every other kind of store, that could actually be attributed to higher crime rates in these communities.  If you owned a business, would you put it where you couldn’t make money due to theft and your employees were at risk of physical harm?

Anyway, as I said, a lot of useful research, with only a smattering of DIE in this issue, but if you are interested in health research and policy, this remains an important journal.