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Will Employers Favor Private Exchanges Over Coverage Sponsorship?

October 17th, 2014

Over the past couple years, health care exchanges probably have consumed more of corporate benefits managers’ time and psychic energy than any other topic. An outstanding question is whether the rank and file of American businesses will drop the hassle that employer-sponsored coverage represents, or default to private exchanges.

Private exchange offerings typically move employees from their companies’ previous self-funded health plans to fully-insured individual arrangements, purporting to offer more flexibility and choice that can adapt to the wide-ranging needs of employees and employers, while creating a more competitive health plan marketplace.

Several recent surveys have reported that employers plan to move aggressively to private exchanges. In a survey last year of more than 700 businesses, the Private Exchange Evaluation Collaborative, a group of regional business health coalitions working with the consulting group PwC, found that 45 percent of employers have implemented or are considering using a private exchange for active employees before 2018. Similarly, a February Aon Plc survey found that, while 95 percent of employers say they expect to continue offering health care for the next 3-5 years, and 5 percent of employers currently use a private exchange, 33 percent say they may consider using one in the future.

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Facilitating Interoperability

October 18th, 2013

A Health Affairs report on health information interoperability by staffers of the Office of the National Coordinator for Health Information Technology (ONC) provides a good enough summary of the situation. But it also is not news, and falls under the Bob Dylan Rule: You don’t need a weatherman to know which way the wind blows. From the article: “In general, limited interoperability across vendors, low motivation to share information in a fee-for-service payment environment, and the high cost of interfaces remain substantial barriers to widespread health information sharing.”

Two difficult but solvable structural problems block our exchange of health care information. The first is the “transport protocol.” Most health care data transport approaches lack the strong privacy and security safeguards that other industries now consider essential. The same industry that is moving toward clinical applications of mobile health, genomics, and nanotechnology still primarily relies on cumbersome, expensive faxes to transmit clinical information between organizations.

The second is the “semantic standard,” which would provide an agreed-upon structure for content. Stage 2 Meaningful Use calls for adoption of The Consolidated Clinical Document Architecture (or CCDA). But health care organizations have settled on different, often incompatible versions of the CCDA, perpetuating the exchange conundrum.

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Why Congress Should Pass The Accuracy In Medicare Physician Payment Act

August 9th, 2013

Editor’s note: For more on the debate over the role of the Relative Value Scale Update Committee (RUC), see “In Setting Doctors’ Medicare Fees, CMS Almost Always Accepts The Relative Value Update Panel’s Advice On Work Values,” by Miriam Laugesen, in the May 2012 issue of Health Affairs.

With the recent release of two mainstream exposes, one in the Washington Post and another in the Washington Monthly, the American Medical Association’s (AMA) scandalous medical procedure valuation franchise, the Relative Value Scale Update Committee (RUC), has been exposed to the light of public scrutiny. “Special Deal,” Haley Sweetland Edwards’ piece in the Monthly, provides by far the more detailed and lucid explanation of the mechanics of the RUC’s arrangement with the Centers for Medicare and Medicaid Services (CMS). (It is also wittier. “The RUC, like that third Margarita, seemed like a good idea at the time.”)

For its part, the Post contributed valuable new information by calculating the difference between the time Medicare currently credits a physician for certain procedures and actual time spent. Many readers undoubtedly were shocked to learn that, while the RUC’s time valuations are often way off, in some cases physicians are paid for more than 24 hours of procedures in a single day. It is nice work if somebody else is paying for it.

Two days after the Post ran its RUC article on the front page, it reported that the AMA is already visiting Congress in force, presumably to protect its role defining the value of medical services for Medicare. The question now is whether Congress will take steps to remedy the situation.

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The RUC, Health Care Finance’s Star Chamber, Remains Untouchable

February 1st, 2013

On January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.

Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.

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Medicare Physician Payment: A Hollow Victory For The RUC

May 18th, 2012

On May 9th, William Nickerson, Senior Judge in the Southern Maryland Federal District Court, issued a 15 page ruling against the six Augusta, GA primary care physician plaintiffs who challenged HHS’ and CMS’ longstanding relationship with the American Medical Association’s Relative Value Scale Update Committee (RUC). The opinion did not weigh the substance of the […]

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Adding Seats: The RUC’s Sleight Of Hand

March 14th, 2012

On February 1, the American Medical Association’s Relative Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that […]

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Trusting Government: A Tale Of Two Federal Advisory Groups

February 2nd, 2012

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how […]

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CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

October 25th, 2011

Editor’s Note: There are ongoing legal and policy debates regarding the role of the Relative Value Scale Update Committee (RUC) in advising the Centers for Medicare and Medicaid Services on relative Medicare payment rates for different types of physician services. Below, Brian Klepper and David Kibbe argue for ending the RUC’s role in the Medicare […]

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A Legal Challenge To CMS’ Reliance On The RUC

August 9th, 2011

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment […]

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Rethinking The Value Of Medical Services

August 1st, 2011

One of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and […]

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A ‘Physician Fallow’ Program To Improve Quality, Safety, And Costs

June 22nd, 2011

In a recent New York Times op-ed, Rita Redberg MD, a cardiologist and Chief Editor of Archives of Internal Medicine, described the American health system’s penchant for delivering high volumes of “procedures and devices [to] patients who get no benefit and incur risks from them.” The culprit, of course, is fee-for-service reimbursement, used by Medicare, Medicaid and commercial […]

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Creating Value-Based Incentives For Primary Care

June 2nd, 2011

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care. Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to […]

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Stifling Primary Care: Why Does CMS Continue To Support The RUC?

May 24th, 2011

Editor’s Note: In addition to Brian Klepper and Paul Fischer (photos and bios above), this article is authored by Kathleen Anne Behan, a skilled trial and corporate lawyer who provides advice to a range of individual and corporate clients. She has 20 years of experience practicing law, including as a partner with Arnold & Porter LLP, and […]

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Unfreezing The Health IT Market

January 12th, 2011

Washington Post columnist Ezra Klein recently described the Obama administration’s consistent efforts to improve troubled private markets: Isolate the eight key economic decisions of the Obama presidency: The intervention in the financial sector, the intervention in the auto sector, the intervention in the housing sector, the stimulus package, the health-care bill, financial regulation, and the […]

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