In Medicare Advantage, providers are becoming payers


Payer, provider or PayVider?

Accountable Care Organizations enable providers of care to take on some of the functions of health plans and to receive some of the financial rewards as well as the risk. But at least on the Medicare side it can be fairly indirect, with patients “attributed” to providers rather than assigned and little formal ability to keep a patient within a single provider system.

So it’s not huge surprise that some integrated provider organizations are going further, and sponsoring Medicare Advantage (MA) plans themselves. That way they are literally both the payer and provider. Setting up an MA managed care plan and running an ACO are not mutually exclusive, since the MA plan applies just to those who sign up for managed care.

Avalere Health has released an interesting report on this phenomenon. Some key takeaways:

  • More than half of the MA plans that started between 2012 and 2015 were provider sponsored
  • Provider sponsored plans are much more likely than other plans to achieve the top star ratings of 4 or 5
  • In a few geographies, provider sponsored MA plans have enrolled the vast majority of MA members and account for more than 10 percent of all Medicare recipients (most of whom are in traditional fee for service Medicare)
  •  Provider sponsored plans are not limiting themselves to the Medicare market. Some are going after commercial patients as well

What does this all mean? A few things:

  • We need to reconsider the boundary between payers and providers; they are starting to overlap more
  • Commercial health plans face even more pressure than before to demonstrate that they can add value –since providers are competing with them and showing better quality results. (The Avalere report was sponsored by Aetna –I’m not exactly sure what they were expecting to hear.)
  • Even if a Republican President and Congress overturn Obamacare, the concept of providers taking risk for Medicare patients isn’t going away
  • Medicare beneficiaries who are fans of a particular provider system should consider checking whether that system offers an MA plan

By healthcare business consultant David E. Williams, president of Health Business Group.

Mass Health Quality Partners releases patient experience results

Screenshot 2016-02-02 08.15.50

Massachusetts Health Quality Partners is a national leader in reporting on patient experience in primary care. Its latest data release at provides valuable information for patients looking for a physician and for practices seeking to understand how they perform in absolute terms and in comparison with others.

You may be familiar with the adage, “What gets measured gets done,” so it really is important what we decide to measure and to publicize. Some patient experience topics, like communication, have been measured and reported for some time. The average score is now 93.5 out of 100 –which is great, but it also means that it’s hard to improve from there and that communication may not be a great way to choose between practices.

By contrast, some of the newer categories demonstrate opportunities for –and evidence of– improvement. This is just the second year asking about behavioral health screening –an important topic since so many behavioral issues first present in primary care. Scores on that measure have risen from 53.1 to 56.5 from 2014 to 2015, while some practices have shown improvements of up to 20 points.

Self-management, a new topic this year, comes in with a score of 54.0 for adult practices and 43.6 for pediatrics. Look for that one to rise in the coming years as well. Statewide results are summarized on the MHQP website.

Most of the scores are reported as Harvey balls, with four levels of differentiation. It’s easy to compare practices against one another on specific measures, but on the other hand it’s difficult to figure out how any given practice rates overall. That’s partly because unlike commercial rating sites, MHQP is a collaborative that needs to keep the providers on board.

A shorthand way to make comparisons is with the “willingness to recommend” score that’s reported as a percentage. I asked MHQP spokesman Joe Ternullo about this measure and how to use it:

How can patients use this measure to chose a physician?

People often ask others for a recommendation when choosing a new doctor. To learn more about this, MHQP asked patients:   “Would you recommend this provider to your family and friends?”  MHQP suggests that patients look at all available information before choosing a new doctor. This is because no single rating by itself can give a clear picture about a healthcare provider’s quality of care.

Can a consumer use that measure to make a decision when the information is presented at a practice level?

Yes. A consumer should use the ratings at to see how his/her primary care practice fares, or to look for practices in their region that have scored particularly well.  In either case, focus on two things. First, look at the percentage of patients who said they would recommend the doctor. Don’t focus too much on minor differences, such as between practices with scores from, say, 86 to 89. Second, look at its scores for individual aspects of performance, such as communicating with patients, coordinating care, and getting timely appointments.  These measures are a guide to help patients assess certain aspects of patient care. No single measure reveals everything about the quality of care at a provider’s office.  Different practices may excel in different areas. But a low score can point out certain aspects of care that a doctor’s office needs to improve.

And as a follow-on, how do practices use that information with their own providers?

Medical care is complex, and patient experience is only one measure of quality. For example, it is important to know how well as doctor helps patients manage conditions like arthritis, diabetes, high blood pressure or high cholesterol. But patient experiences can affect those clinical measures. Many practices have used the MHQP statewide patient experience survey results to improve how they interact with their patients.

The MHQP patient experience survey is a valuable community resource that we are fortunate to have in Massachusetts. The survey is supported by leading health plans and provider organizations.

By healthcare business consultant David E. Williams, president of Health Business Group.

Health Wonk Review is up at Managed Care Matters

Managed Care Matters has just just awoken from its post-party stupor after a wild celebration of the 10th anniversary of the Health Wonk Review. Maybe they should party more often because the writing is surprisingly crisp in the Tenth Anniversary Edition!

There are some great health policy posts from old-timers and newcomers alike. I’m proud to say I’ve been around since the very start.

Well done!

Like I said: United’s ACA exchange departure is no big deal


Robert Wood Johnson Foundation funded an Urban Institute study to determine how Obamacare marketplaces are being impacted by the withdrawal of United Healthcare and the failure of some of the CO-OP plans. I’m grateful for the data but as it turns out their findings line up with what I wrote more than two months ago (United pulls out of ACA exchanges: Should we care?)

Here’s what I said:

Recently we’ve heard what could be interpreted as bad news about the viability of exchanges:UnitedHealth is considering withdrawing from the program. In the highly politicized world of health reform, that information has Obamacare foes sounding the death knell.

I see things differently.

The big name insurers that have a large share of the corporate market are not necessarily the winners on the exchanges. Rather, the leaders in the new price-sensitive era are lesser known plans, many of which cut their teeth in the Medicaid managed care market where tight cost control is key. They have what it takes to play in this brave new world.

Compare that to the Urban Institute findings:

Co-ops and United Healthcare (United) exiting the marketplaces may not be the shake-up many predicted because Blue Cross insurers, managed care plans, and others dominate low-cost marketplace offerings.

  • Blue Cross insurers and managed care organizations previously offering insurance to Medicaid beneficiaries but new to the private market are the most price-competitive.
  • Blue Cross and Medicaid managed care organizations are among the lowest-cost insurers in 34 and 44 of the 81 regions, respectively.

Next time maybe I should apply for that grant rather than offering my instant analysis!

Image courtesy of Master isolated images at

By healthcare business consultant David E. Williams, president of Health Business Group.

Is Generally Regarded as Safe (GRAS) safe enough?


What did I eat?

Unlike most people exposed to the Frontline investigation of supplements and vitamins, I really didn’t find it shocking that a lot of supplements are dangerous and that the bottles don’t contain what they say they do. I feel sorry for people who take these products and are not helped –and are even harmed– but frankly the customers should know better.

The story got me thinking about a related topic: the safety (or lack thereof) of food additives. An NPR story from last year (Why the FDA has never looked at some of the additives in our food) sums it up well:

Companies have added thousands of ingredients to foods with little to no government oversight. That’s thanks to a loophole in a decades-old law that allows them to deem an additive to be “generally recognized as safe” — or GRAS — without the U.S. Food and Drug Administration’s blessing, or even its knowledge.

The loophole was originally intended to allow manufacturers of common ingredients like vinegar and table salt — when added to processed foods — to bypass the FDA’s lengthy safety-review process. But over time, companies have found that it’s far more efficient to take advantage of the exemption to get their products on shelves quickly. Some of these products contain additives that the FDA has found to pose dangers. And even ingredients the agency has agreed are GRAS are now drawing scrutiny from scientists and consumer groups that dispute their safety.

Basically companies have been declaring their own products as GRAS. Sometimes they let the FDA know and sometimes not. Since the GRAS concept was introduced during the Eisenhower administration the number of additives in food has gone from around 800 to over 10,000. Chances are you eat GRAS substances every day.

The FDA review process for food is cumbersome, which is a deterrent to undertaking it. But some safety testing is becoming radically less expensive and more reliable. One area I know about is cardiac safety, thanks to my role on the iCardiac Technologies board. Until recently, drugs in development were assessed for cardiac safety by a highly manual and expensive process of measuring QT prolongation. Now iCardiac’s Early Precision QT approach can provide definitive results with a much smaller and more affordable study and it is becoming the standard that is endorsed by FDA and international bodies.

So with the new approach, maybe it’s time to reconsider the cost/benefit of cardiac safety testing at least for certain food additives.

FDA’s “threshold of concern” is reached when a drug extends the QT interval by 10 milliseconds (ms). As it turns out, some food ingredients can reach or exceed this level. For example:

  • An American Heart Association study found that energy drinks could boost QT by 10 ms.
  • Licorice (also used as a sweetener in some products) can lead to long QT when “abused”
  • Ginseng can increase QT by 15 ms.

Some of the more responsible companies like Cargill are undertaking safety studies for new products. Cargill has been evaluating a new sweetener (3000x as sweet as fructose!) derived from root bark. After some initial concerns were unearthed, the company conducted a QT study to determine the ingredient’s safety. As it turned out, this ingredient was found to cause a 20+ ms prolongation of the QT interval, which will certainly give Cargill pause before continuing development. Results of the study (Detection of ECG effects of (2R,4R)-monatin, a sweet flavored isomer of a component first identified in the root bark of the Sclerochitin ilicifolius planthave been published in Food and Chemical Toxicology.

With new techniques, you don’t have to be Cargill to be able to afford to test food ingredients for safety. As consumers become more discerning it will become a good business decision to test more thorougly.

Image courtesy of David Castillo Dominici at

By healthcare business consultant David E. Williams, president of Health Business Group.


Health Business Blog named as a top blog

The MHA@GW blog has posted a list of 54 Healthcare Blogs to read in 2016. It’s a solid collection of  blogs from mainstream media, organizations and foundations, health care professionals, and other categories.

The Health Business Blog is featured alongside some of my favorites such as HealthBlawg, HealthPopuli, Not Running a Hospital and Workers’ Comp Insider.

Evidence based defensive medicine



Defensive medicine –when physicians provide or recommend unnecessary treatment or testing in order to reduce their chance of being sued– has always bothered me. It harms the patient, drives up costs, and can be self-serving by generating more income for the provider. I’m also skeptical about whether “defensive” medicine really reduces the chances of being sued.

So I was very interested in a Today’s Hospitalist article (Does defensive medicine work after all?) that reports the results of an intriguing study of hospital admissions in Florida. The study, conducted by a Harvard Medical School professor, revealed that physicians who were responsible for the most expensive hospitalizations also had the lowest likelihood of being sued (0.3% vs. 1.5%).

There are plenty of limitations –correlation isn’t causation, it’s based on hospital admissions only, maybe the doctors in the high and low spending groups aren’t comparable, etc. — and yet it does give one pause. Maybe doctors who order more tests and treat patients more intensively really do get sued less. Could it be that patients and families are less likely to sue if they feel that everything has been done for them?

The findings have serious implications, especially as we leave the era of fee for service medicine and enter the age of accountable care and capitation. Will it be possible to get physicians to be less defensive in the name of cost savings? Is it fair to do so? What role should the patient and family have? Do we in fact need some kind of liability reform?

Dr. Anupam Jena, lead author notes that malpractice is bother under and over-stated. Malpractice costs are routinely reported at only 3-5 percent of total costs, yet physicians also say malpractice is a major concern. My own suspicion is that there’s only a limited correlation between real malpractice and what physicians actually get sued for.

Image courtesy of stockimages at

By healthcare business consultant David E. Williams, president of Health Business Group.